Metabolic syndrome was associated with a fourfold rise in cardiovascular events among patients with chronic hepatitis B virus infection, according to a prospective cohort study published in Hepatology.

Over a median of 7.3 years of follow-up, 8% of patients with metabolic syndrome developed ischemic or hemorrhagic stroke, acute coronary syndrome, or congestive heart failure, or underwent revascularization, compared with 2% of patients without metabolic syndrome (P less than .0001), reported Jenny Yeuk-Ki Cheng, MD, and her associates at The Chinese University of Hong Kong.

But it was liver stiffness measure (LSM), not metabolic syndrome, that predicted hepatic events (hazard ratio, 1.6; 95% confidence interval, 1.0 to 2.5) and death (HR, 1.9; 95% CI, 1.1 to 3.2), the investigators reported (Hepatology. 2016 Sep 29. doi: 10.1002/hep.28778).

Their study included 1,466 patients with chronic HBV infection who averaged 46 years of age, with an average baseline LSM of 8.4 kPa (standard deviation, 6.3 kPa). A total of 188 patients (12.8%) had metabolic syndrome at baseline, defined as at least three of the following five factors: central obesity, hypertriglyceridemia, low high-density lipoprotein cholesterol, hypertension, and type 2 diabetes mellitus or fasting hyperglycemia.

©sarathsasidharan/Thinkstock

Metabolic syndrome was associated with a fourfold rise in cardiovascular events among patients with chronic hepatitis B virus infection, according to a prospective cohort study published in Hepatology.

Over a median of 7.3 years of follow-up, 8% of patients with metabolic syndrome developed ischemic or hemorrhagic stroke, acute coronary syndrome, or congestive heart failure, or underwent revascularization, compared with 2% of patients without metabolic syndrome (P less than .0001), reported Jenny Yeuk-Ki Cheng, MD, and her associates at The Chinese University of Hong Kong.

But it was liver stiffness measure (LSM), not metabolic syndrome, that predicted hepatic events (hazard ratio, 1.6; 95% confidence interval, 1.0 to 2.5) and death (HR, 1.9; 95% CI, 1.1 to 3.2), the investigators reported (Hepatology. 2016 Sep 29. doi: 10.1002/hep.28778).

Their study included 1,466 patients with chronic HBV infection who averaged 46 years of age, with an average baseline LSM of 8.4 kPa (standard deviation, 6.3 kPa). A total of 188 patients (12.8%) had metabolic syndrome at baseline, defined as at least three of the following five factors: central obesity, hypertriglyceridemia, low high-density lipoprotein cholesterol, hypertension, and type 2 diabetes mellitus or fasting hyperglycemia.

©sarathsasidharan/Thinkstock

Metabolic syndrome was associated with a fourfold rise in cardiovascular events among patients with chronic hepatitis B virus infection, according to a prospective cohort study published in Hepatology.

Over a median of 7.3 years of follow-up, 8% of patients with metabolic syndrome developed ischemic or hemorrhagic stroke, acute coronary syndrome, or congestive heart failure, or underwent revascularization, compared with 2% of patients without metabolic syndrome (P less than .0001), reported Jenny Yeuk-Ki Cheng, MD, and her associates at The Chinese University of Hong Kong.

But it was liver stiffness measure (LSM), not metabolic syndrome, that predicted hepatic events (hazard ratio, 1.6; 95% confidence interval, 1.0 to 2.5) and death (HR, 1.9; 95% CI, 1.1 to 3.2), the investigators reported (Hepatology. 2016 Sep 29. doi: 10.1002/hep.28778).

Their study included 1,466 patients with chronic HBV infection who averaged 46 years of age, with an average baseline LSM of 8.4 kPa (standard deviation, 6.3 kPa). A total of 188 patients (12.8%) had metabolic syndrome at baseline, defined as at least three of the following five factors: central obesity, hypertriglyceridemia, low high-density lipoprotein cholesterol, hypertension, and type 2 diabetes mellitus or fasting hyperglycemia.

©sarathsasidharan/Thinkstock

NEW ORLEANS – A fatal complication of measles known as subacute sclerosing panencephalitis (SSPE) can develop years after measles infection and appears to occur much more often than published reports suggest, according to a review of cases in California from 1998 to 2015.

The findings underscore the vital importance of herd immunity by vaccination, Kristen Wendorf, MD, reported at an annual scientific meeting on infectious diseases.

Teka77/Thinkstock

[email protected]

NEW ORLEANS – A fatal complication of measles known as subacute sclerosing panencephalitis (SSPE) can develop years after measles infection and appears to occur much more often than published reports suggest, according to a review of cases in California from 1998 to 2015.

The findings underscore the vital importance of herd immunity by vaccination, Kristen Wendorf, MD, reported at an annual scientific meeting on infectious diseases.

Teka77/Thinkstock

[email protected]

NEW ORLEANS – A fatal complication of measles known as subacute sclerosing panencephalitis (SSPE) can develop years after measles infection and appears to occur much more often than published reports suggest, according to a review of cases in California from 1998 to 2015.

The findings underscore the vital importance of herd immunity by vaccination, Kristen Wendorf, MD, reported at an annual scientific meeting on infectious diseases.

Teka77/Thinkstock

[email protected]

Sneddon syndrome (SS) was first described in 1965 in patients with persistent livedo racemosa and neurological events.¹ Because the other manifestations of SS are nonspecific (eg, hypertension, cardiac valvulopathy, arterial and venous occlusion), the diagnosis often is delayed. Many patients who experience prodromal neurologic symptoms such as headaches, depression, anxiety, dizziness, and neuropathy often present to a physician prior to developing ischemic brain manifestations² but seldom receive the correct diagnosis. Onset of cerebral occlusive events typically occurs in patients younger than 45 years and may present as a transient ischemic attack, stroke, or intracranial hemorrhage.³ The disease is more prevalent in females than males (2:1 ratio). The exact pathogenesis of SS is still unknown, and although it has been thought of as a separate entity from systemic lupus erythematosus and other antiphospholipid disorders, it has been postulated that an immunological dysfunction damages vessel walls leading to thrombosis.

Cutaneous findings associated with SS involve small- to medium-sized dermal-subdermal arteries. Histopathology in some patients demonstrates proliferation of the endothelium and fibrin deposits with subsequent obliteration of involved arteries.⁴ In many patients including our patient, histopathologic examination of involved skin fails to show specific abnormalities.¹ Zelger et al⁵ reported the sequence of histopathologic skin events in a series of antiphospholipid-negative SS patients. The authors reported that only small arteries at the dermis-subcutis junction were involved and a progression of endothelial dysfunction was observed. The authors believed there were several nonspecific stages prior to fibrin occlusion of involved arteries.⁵ Stage I involved loosening of endothelial cells with nonspecific perivascular lymphocytic infiltration with perivascular inflammation and lymphocytic infiltration representing the prime mover of the disease.^5,6 This stage is thought to be short lived, thus the reason why it has gone undetected for many years in SS patients. Stages II to IV progress through fibrin deposition and occlusion.⁵ Histological features of stages I to II have not been reported because of late diagnosis of SS. Stage I patients typically present with an average duration of symptoms of 6 months with few neurologic symptoms, the most common being paresthesia of the legs.⁵

Case Report

A 37-year-old woman with epigastric tenderness on the left side and splenomegaly seen on computed tomography was referred by a hematologist for evaluation of a reticular rash on the left side of the flank of 9 months’ duration with a presumed diagnosis of focal melanoderma. Her medical history was remarkable for a congenital ventricular septal defect and coarctation of the aorta, as well as endometriosis, myalgia, and joint stiffness that had all developed over the last year. Her medical history also was remarkable for nephrolithiasis, irritable bowel syndrome, and chronic sinusitis, as well as psychiatric depression and anxiety disorders. She recently had been diagnosed with moderate hypertension and had experienced difficulty getting pregnant for the last several years with 3 consecutive miscarriages in the first trimester. Neurologic symptoms included neuropathy involving the feet, intermittent paresthesia of the legs, and a history of chronic migraine headaches for several months.

Dermatologic examination revealed a slightly overweight woman with a 25×30-cm dusky, erythematous, irregular, netlike pattern on the left side of the upper and lower trunk (Figure 1). Extensive livedo racemosa was not altered by changes in temperature and had been unchanged for more than 9 months. There were no signs of pruritus or ulcerations, and areas of livedo racemosa were slightly tender to palpation.

We performed 2 sets of three 4-mm biopsies. The first set targeted areas within the violaceous pattern, while the second set targeted areas of normal tissue between the mottled areas. All 6 specimens demonstrated superficial perivascular lymphocytic infiltrate with no evidence of vasculitis or connective tissue disease. The vessels showed no microthrombi or surrounding fibrosis. No eosinophils were identified within the epidermis. There was no evidence of increased dermal mucin. Both the superficial and deep vascular plexuses were unremarkable and showed no evidence of damage to the walls (Figure 2).

To rule out other possible causes of livedo racemosa, complete blood cell count, comprehensive metabolic panel, coagulation profile, lipase test, urinalysis, serologic testing, and immunologic workup were performed. Lipase was within reference range. The complete blood cell count revealed mild anemia, while the rest of the values were within reference range. An immunologic workup included Sjögren syndrome antigen A, Sjögren syndrome antigen B, anticardiolipin antibodies, and antinuclear antibody, which were all negative. Family history was remarkable for first-degree relatives with systemic lupus erythematosus and Crohn disease.

Computed tomography revealed enlargement of the spleen, as well as periaortic, portacaval, and porta hepatis lymphadenopathy. Based on the laboratory findings and clinical presentation as well as the patient’s medical history, the diagnosis of exclusion was idiopathic livedo racemosa with unknown progression to full-blown SS. The patient did not meet the current diagnostic criteria for SS, and her immunologic studies failed to confirm any present antibodies, but involvement of the reticuloendothelial system pointed to production of antibodies that were not yet detectable on laboratory testing.

Comment

More than 50 years after the first case of SS was diagnosed, better laboratory workup is available and more information is known about the pathophysiology. Sneddon syndrome is a rare disorder, affecting only approximately 4 patients per million each year worldwide. Seronegative antiphospholipid antibody syndrome (SNAPS) describes patients with clinical presentations of antiphospholipid syndrome (APS) without detectable serological markers.⁷ Antiphospholipid-negative SS, which was seen in our patient, would be categorized under SNAPS. A PubMed search of articles indexed for MEDLINE using the terms livedo racemosa, Sneddon syndrome, and SNAPS and splenomegaly revealed there currently are no known cases of SNAPS that have been reported with splenomegaly and lymphadenopathy. Our patient presented with the following clinical features of SS: livedo racemosa, history of miscarriage, psychiatric disturbances, and hypertension. Surprisingly, biopsies from affected skin did not show any fibrin deposition or microthrombi but did reveal perivascular lymphocytic infiltrations. Magnetic resonance imaging did not show any pathological lesions or vascular changes.

Sneddon syndrome and APS share a common pathway to occlusive arteriolopathy for which 4 stages have been described by Zelger et al.⁵ Stage I involves a nonspecific Langerhans cell infiltrate with polymorphonuclear leukocytes. The tunica media and elastic lamina usually are unaltered at this early stage, while the surrounding connective tissue may appear edematous.⁵ This early stage of histopathology has not been evaluated in SS patients, primarily because of delay of diagnosis. Late stages III and IV will show fibrin deposition and shrinkage of affected vessels.⁷

A PubMed search using the terms Sneddon syndrome, lymphadenopathy and livedo racemosa, and Sneddon syndrome and lymphadenopathy revealed that splenomegaly and lymphadenopathy have not been reported in patients with SS. In patients with antiphospholipid-negative SS, one can assume that antibodies to other phospholipids not tested must exist because of striking similarities between APS and antiphospholipid-negative SS.⁸ Although our patient did not test positive for any of these antibodies, she did present with lymphadenopathy and splenic enlargement, leading us to believe that involvement of the reticuloendothelial system may be a feature of SS that has not been previously reported. Further studies are required to name specific antigens responsible for clinical manifestations in SS.

Currently, no single diagnostic test for SS exists, thus delaying both diagnosis and initiation of treatment. Histopathologic examination may be helpful, but in many cases it is nonspecific, as are serologic markers. Neuroradiological confirmation of involvement usually is the confirmatory feature in many patients with late-stage diagnosis.² A diagnostic schematic for SS, which was first described by Daoud et al,² illustrates classification of symptoms and aids in diagnosis. A working diagnosis of idiopathic livedo racemosa is made after ruling out other causes of SS in a patient with nonspecific biopsy findings and negative magnetic resonance imaging results with prodromal symptoms. The prognosis for such patients progressing to full SS is unknown with or without management using anticoagulant therapy.

Conclusion

Early diagnosis of livedo racemosa and SS is essential, as prevention of cerebrovascular accidents, myocardial infarction, and other thromboembolic diseases can be minimized by attacking risk factors such as smoking, taking oral contraceptive pills, becoming pregnant,⁹ and by initiating either antiplatelet or anticoagulation treatments. These treatments have been shown to delay the development of neurovascular damage and early-onset dementia. We present this case to demonstrate the variability of early-presenting symptoms in idiopathic livedo racemosa. Recognizing some of the early manifestations can lead to early diagnosis and initiation of treatment.

Sneddon syndrome (SS) was first described in 1965 in patients with persistent livedo racemosa and neurological events.¹ Because the other manifestations of SS are nonspecific (eg, hypertension, cardiac valvulopathy, arterial and venous occlusion), the diagnosis often is delayed. Many patients who experience prodromal neurologic symptoms such as headaches, depression, anxiety, dizziness, and neuropathy often present to a physician prior to developing ischemic brain manifestations² but seldom receive the correct diagnosis. Onset of cerebral occlusive events typically occurs in patients younger than 45 years and may present as a transient ischemic attack, stroke, or intracranial hemorrhage.³ The disease is more prevalent in females than males (2:1 ratio). The exact pathogenesis of SS is still unknown, and although it has been thought of as a separate entity from systemic lupus erythematosus and other antiphospholipid disorders, it has been postulated that an immunological dysfunction damages vessel walls leading to thrombosis.

Cutaneous findings associated with SS involve small- to medium-sized dermal-subdermal arteries. Histopathology in some patients demonstrates proliferation of the endothelium and fibrin deposits with subsequent obliteration of involved arteries.⁴ In many patients including our patient, histopathologic examination of involved skin fails to show specific abnormalities.¹ Zelger et al⁵ reported the sequence of histopathologic skin events in a series of antiphospholipid-negative SS patients. The authors reported that only small arteries at the dermis-subcutis junction were involved and a progression of endothelial dysfunction was observed. The authors believed there were several nonspecific stages prior to fibrin occlusion of involved arteries.⁵ Stage I involved loosening of endothelial cells with nonspecific perivascular lymphocytic infiltration with perivascular inflammation and lymphocytic infiltration representing the prime mover of the disease.^5,6 This stage is thought to be short lived, thus the reason why it has gone undetected for many years in SS patients. Stages II to IV progress through fibrin deposition and occlusion.⁵ Histological features of stages I to II have not been reported because of late diagnosis of SS. Stage I patients typically present with an average duration of symptoms of 6 months with few neurologic symptoms, the most common being paresthesia of the legs.⁵

Case Report

A 37-year-old woman with epigastric tenderness on the left side and splenomegaly seen on computed tomography was referred by a hematologist for evaluation of a reticular rash on the left side of the flank of 9 months’ duration with a presumed diagnosis of focal melanoderma. Her medical history was remarkable for a congenital ventricular septal defect and coarctation of the aorta, as well as endometriosis, myalgia, and joint stiffness that had all developed over the last year. Her medical history also was remarkable for nephrolithiasis, irritable bowel syndrome, and chronic sinusitis, as well as psychiatric depression and anxiety disorders. She recently had been diagnosed with moderate hypertension and had experienced difficulty getting pregnant for the last several years with 3 consecutive miscarriages in the first trimester. Neurologic symptoms included neuropathy involving the feet, intermittent paresthesia of the legs, and a history of chronic migraine headaches for several months.

Dermatologic examination revealed a slightly overweight woman with a 25×30-cm dusky, erythematous, irregular, netlike pattern on the left side of the upper and lower trunk (Figure 1). Extensive livedo racemosa was not altered by changes in temperature and had been unchanged for more than 9 months. There were no signs of pruritus or ulcerations, and areas of livedo racemosa were slightly tender to palpation.

We performed 2 sets of three 4-mm biopsies. The first set targeted areas within the violaceous pattern, while the second set targeted areas of normal tissue between the mottled areas. All 6 specimens demonstrated superficial perivascular lymphocytic infiltrate with no evidence of vasculitis or connective tissue disease. The vessels showed no microthrombi or surrounding fibrosis. No eosinophils were identified within the epidermis. There was no evidence of increased dermal mucin. Both the superficial and deep vascular plexuses were unremarkable and showed no evidence of damage to the walls (Figure 2).

To rule out other possible causes of livedo racemosa, complete blood cell count, comprehensive metabolic panel, coagulation profile, lipase test, urinalysis, serologic testing, and immunologic workup were performed. Lipase was within reference range. The complete blood cell count revealed mild anemia, while the rest of the values were within reference range. An immunologic workup included Sjögren syndrome antigen A, Sjögren syndrome antigen B, anticardiolipin antibodies, and antinuclear antibody, which were all negative. Family history was remarkable for first-degree relatives with systemic lupus erythematosus and Crohn disease.

Computed tomography revealed enlargement of the spleen, as well as periaortic, portacaval, and porta hepatis lymphadenopathy. Based on the laboratory findings and clinical presentation as well as the patient’s medical history, the diagnosis of exclusion was idiopathic livedo racemosa with unknown progression to full-blown SS. The patient did not meet the current diagnostic criteria for SS, and her immunologic studies failed to confirm any present antibodies, but involvement of the reticuloendothelial system pointed to production of antibodies that were not yet detectable on laboratory testing.

Comment

More than 50 years after the first case of SS was diagnosed, better laboratory workup is available and more information is known about the pathophysiology. Sneddon syndrome is a rare disorder, affecting only approximately 4 patients per million each year worldwide. Seronegative antiphospholipid antibody syndrome (SNAPS) describes patients with clinical presentations of antiphospholipid syndrome (APS) without detectable serological markers.⁷ Antiphospholipid-negative SS, which was seen in our patient, would be categorized under SNAPS. A PubMed search of articles indexed for MEDLINE using the terms livedo racemosa, Sneddon syndrome, and SNAPS and splenomegaly revealed there currently are no known cases of SNAPS that have been reported with splenomegaly and lymphadenopathy. Our patient presented with the following clinical features of SS: livedo racemosa, history of miscarriage, psychiatric disturbances, and hypertension. Surprisingly, biopsies from affected skin did not show any fibrin deposition or microthrombi but did reveal perivascular lymphocytic infiltrations. Magnetic resonance imaging did not show any pathological lesions or vascular changes.

Sneddon syndrome and APS share a common pathway to occlusive arteriolopathy for which 4 stages have been described by Zelger et al.⁵ Stage I involves a nonspecific Langerhans cell infiltrate with polymorphonuclear leukocytes. The tunica media and elastic lamina usually are unaltered at this early stage, while the surrounding connective tissue may appear edematous.⁵ This early stage of histopathology has not been evaluated in SS patients, primarily because of delay of diagnosis. Late stages III and IV will show fibrin deposition and shrinkage of affected vessels.⁷

A PubMed search using the terms Sneddon syndrome, lymphadenopathy and livedo racemosa, and Sneddon syndrome and lymphadenopathy revealed that splenomegaly and lymphadenopathy have not been reported in patients with SS. In patients with antiphospholipid-negative SS, one can assume that antibodies to other phospholipids not tested must exist because of striking similarities between APS and antiphospholipid-negative SS.⁸ Although our patient did not test positive for any of these antibodies, she did present with lymphadenopathy and splenic enlargement, leading us to believe that involvement of the reticuloendothelial system may be a feature of SS that has not been previously reported. Further studies are required to name specific antigens responsible for clinical manifestations in SS.

Currently, no single diagnostic test for SS exists, thus delaying both diagnosis and initiation of treatment. Histopathologic examination may be helpful, but in many cases it is nonspecific, as are serologic markers. Neuroradiological confirmation of involvement usually is the confirmatory feature in many patients with late-stage diagnosis.² A diagnostic schematic for SS, which was first described by Daoud et al,² illustrates classification of symptoms and aids in diagnosis. A working diagnosis of idiopathic livedo racemosa is made after ruling out other causes of SS in a patient with nonspecific biopsy findings and negative magnetic resonance imaging results with prodromal symptoms. The prognosis for such patients progressing to full SS is unknown with or without management using anticoagulant therapy.

Conclusion

Early diagnosis of livedo racemosa and SS is essential, as prevention of cerebrovascular accidents, myocardial infarction, and other thromboembolic diseases can be minimized by attacking risk factors such as smoking, taking oral contraceptive pills, becoming pregnant,⁹ and by initiating either antiplatelet or anticoagulation treatments. These treatments have been shown to delay the development of neurovascular damage and early-onset dementia. We present this case to demonstrate the variability of early-presenting symptoms in idiopathic livedo racemosa. Recognizing some of the early manifestations can lead to early diagnosis and initiation of treatment.

Sneddon syndrome (SS) was first described in 1965 in patients with persistent livedo racemosa and neurological events.¹ Because the other manifestations of SS are nonspecific (eg, hypertension, cardiac valvulopathy, arterial and venous occlusion), the diagnosis often is delayed. Many patients who experience prodromal neurologic symptoms such as headaches, depression, anxiety, dizziness, and neuropathy often present to a physician prior to developing ischemic brain manifestations² but seldom receive the correct diagnosis. Onset of cerebral occlusive events typically occurs in patients younger than 45 years and may present as a transient ischemic attack, stroke, or intracranial hemorrhage.³ The disease is more prevalent in females than males (2:1 ratio). The exact pathogenesis of SS is still unknown, and although it has been thought of as a separate entity from systemic lupus erythematosus and other antiphospholipid disorders, it has been postulated that an immunological dysfunction damages vessel walls leading to thrombosis.

Cutaneous findings associated with SS involve small- to medium-sized dermal-subdermal arteries. Histopathology in some patients demonstrates proliferation of the endothelium and fibrin deposits with subsequent obliteration of involved arteries.⁴ In many patients including our patient, histopathologic examination of involved skin fails to show specific abnormalities.¹ Zelger et al⁵ reported the sequence of histopathologic skin events in a series of antiphospholipid-negative SS patients. The authors reported that only small arteries at the dermis-subcutis junction were involved and a progression of endothelial dysfunction was observed. The authors believed there were several nonspecific stages prior to fibrin occlusion of involved arteries.⁵ Stage I involved loosening of endothelial cells with nonspecific perivascular lymphocytic infiltration with perivascular inflammation and lymphocytic infiltration representing the prime mover of the disease.^5,6 This stage is thought to be short lived, thus the reason why it has gone undetected for many years in SS patients. Stages II to IV progress through fibrin deposition and occlusion.⁵ Histological features of stages I to II have not been reported because of late diagnosis of SS. Stage I patients typically present with an average duration of symptoms of 6 months with few neurologic symptoms, the most common being paresthesia of the legs.⁵

Case Report

A 37-year-old woman with epigastric tenderness on the left side and splenomegaly seen on computed tomography was referred by a hematologist for evaluation of a reticular rash on the left side of the flank of 9 months’ duration with a presumed diagnosis of focal melanoderma. Her medical history was remarkable for a congenital ventricular septal defect and coarctation of the aorta, as well as endometriosis, myalgia, and joint stiffness that had all developed over the last year. Her medical history also was remarkable for nephrolithiasis, irritable bowel syndrome, and chronic sinusitis, as well as psychiatric depression and anxiety disorders. She recently had been diagnosed with moderate hypertension and had experienced difficulty getting pregnant for the last several years with 3 consecutive miscarriages in the first trimester. Neurologic symptoms included neuropathy involving the feet, intermittent paresthesia of the legs, and a history of chronic migraine headaches for several months.

Dermatologic examination revealed a slightly overweight woman with a 25×30-cm dusky, erythematous, irregular, netlike pattern on the left side of the upper and lower trunk (Figure 1). Extensive livedo racemosa was not altered by changes in temperature and had been unchanged for more than 9 months. There were no signs of pruritus or ulcerations, and areas of livedo racemosa were slightly tender to palpation.

We performed 2 sets of three 4-mm biopsies. The first set targeted areas within the violaceous pattern, while the second set targeted areas of normal tissue between the mottled areas. All 6 specimens demonstrated superficial perivascular lymphocytic infiltrate with no evidence of vasculitis or connective tissue disease. The vessels showed no microthrombi or surrounding fibrosis. No eosinophils were identified within the epidermis. There was no evidence of increased dermal mucin. Both the superficial and deep vascular plexuses were unremarkable and showed no evidence of damage to the walls (Figure 2).

To rule out other possible causes of livedo racemosa, complete blood cell count, comprehensive metabolic panel, coagulation profile, lipase test, urinalysis, serologic testing, and immunologic workup were performed. Lipase was within reference range. The complete blood cell count revealed mild anemia, while the rest of the values were within reference range. An immunologic workup included Sjögren syndrome antigen A, Sjögren syndrome antigen B, anticardiolipin antibodies, and antinuclear antibody, which were all negative. Family history was remarkable for first-degree relatives with systemic lupus erythematosus and Crohn disease.

Computed tomography revealed enlargement of the spleen, as well as periaortic, portacaval, and porta hepatis lymphadenopathy. Based on the laboratory findings and clinical presentation as well as the patient’s medical history, the diagnosis of exclusion was idiopathic livedo racemosa with unknown progression to full-blown SS. The patient did not meet the current diagnostic criteria for SS, and her immunologic studies failed to confirm any present antibodies, but involvement of the reticuloendothelial system pointed to production of antibodies that were not yet detectable on laboratory testing.

Comment

More than 50 years after the first case of SS was diagnosed, better laboratory workup is available and more information is known about the pathophysiology. Sneddon syndrome is a rare disorder, affecting only approximately 4 patients per million each year worldwide. Seronegative antiphospholipid antibody syndrome (SNAPS) describes patients with clinical presentations of antiphospholipid syndrome (APS) without detectable serological markers.⁷ Antiphospholipid-negative SS, which was seen in our patient, would be categorized under SNAPS. A PubMed search of articles indexed for MEDLINE using the terms livedo racemosa, Sneddon syndrome, and SNAPS and splenomegaly revealed there currently are no known cases of SNAPS that have been reported with splenomegaly and lymphadenopathy. Our patient presented with the following clinical features of SS: livedo racemosa, history of miscarriage, psychiatric disturbances, and hypertension. Surprisingly, biopsies from affected skin did not show any fibrin deposition or microthrombi but did reveal perivascular lymphocytic infiltrations. Magnetic resonance imaging did not show any pathological lesions or vascular changes.

Sneddon syndrome and APS share a common pathway to occlusive arteriolopathy for which 4 stages have been described by Zelger et al.⁵ Stage I involves a nonspecific Langerhans cell infiltrate with polymorphonuclear leukocytes. The tunica media and elastic lamina usually are unaltered at this early stage, while the surrounding connective tissue may appear edematous.⁵ This early stage of histopathology has not been evaluated in SS patients, primarily because of delay of diagnosis. Late stages III and IV will show fibrin deposition and shrinkage of affected vessels.⁷

A PubMed search using the terms Sneddon syndrome, lymphadenopathy and livedo racemosa, and Sneddon syndrome and lymphadenopathy revealed that splenomegaly and lymphadenopathy have not been reported in patients with SS. In patients with antiphospholipid-negative SS, one can assume that antibodies to other phospholipids not tested must exist because of striking similarities between APS and antiphospholipid-negative SS.⁸ Although our patient did not test positive for any of these antibodies, she did present with lymphadenopathy and splenic enlargement, leading us to believe that involvement of the reticuloendothelial system may be a feature of SS that has not been previously reported. Further studies are required to name specific antigens responsible for clinical manifestations in SS.

Currently, no single diagnostic test for SS exists, thus delaying both diagnosis and initiation of treatment. Histopathologic examination may be helpful, but in many cases it is nonspecific, as are serologic markers. Neuroradiological confirmation of involvement usually is the confirmatory feature in many patients with late-stage diagnosis.² A diagnostic schematic for SS, which was first described by Daoud et al,² illustrates classification of symptoms and aids in diagnosis. A working diagnosis of idiopathic livedo racemosa is made after ruling out other causes of SS in a patient with nonspecific biopsy findings and negative magnetic resonance imaging results with prodromal symptoms. The prognosis for such patients progressing to full SS is unknown with or without management using anticoagulant therapy.

Conclusion

Early diagnosis of livedo racemosa and SS is essential, as prevention of cerebrovascular accidents, myocardial infarction, and other thromboembolic diseases can be minimized by attacking risk factors such as smoking, taking oral contraceptive pills, becoming pregnant,⁹ and by initiating either antiplatelet or anticoagulation treatments. These treatments have been shown to delay the development of neurovascular damage and early-onset dementia. We present this case to demonstrate the variability of early-presenting symptoms in idiopathic livedo racemosa. Recognizing some of the early manifestations can lead to early diagnosis and initiation of treatment.

“SHOULD RISK-REDUCING GYNECOLOGIC SURGERY FOR BRCA MUTATION CARRIERS INCLUDE HYSTERECTOMY?”

ANDREW M. KAUNITZ, MD (WEB EXCLUSIVE, AUGUST 28, 2016)

Hysterectomy warranted?

I am wondering if Dr. Kaunitz really is recommending performing 270 hysterectomies to prevent one endometrial cancer? Is this justified given the risks from the hysterectomy itself, the economics of the disease, or any significant reductions in endometrial cancer mortality?

David O. Holtz, MD
Paoli, Pennsylvania

Dr. Kaunitz responds

I appreciate Dr. Holtz’s interest in my commentary on the role of hysterectomy as part of risk-reducing surgery in BRCA mutation carriers. Women who are mutation carriers are at increased risk for serous or serous-like endometrial cancers. Further, hysterectomy offers specific advantages for young mutation carriers for whom menopausal hormone therapy is often indicated after risk-reducing salpingo-oophorectomy. Accordingly, I would indeed encourage such women to consider hysterectomy as part of risk-reducing gynecologic surgery if such surgery can be accomplished via minimally invasive techniques.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“SHOULD RISK-REDUCING GYNECOLOGIC SURGERY FOR BRCA MUTATION CARRIERS INCLUDE HYSTERECTOMY?”

ANDREW M. KAUNITZ, MD (WEB EXCLUSIVE, AUGUST 28, 2016)

Hysterectomy warranted?

I am wondering if Dr. Kaunitz really is recommending performing 270 hysterectomies to prevent one endometrial cancer? Is this justified given the risks from the hysterectomy itself, the economics of the disease, or any significant reductions in endometrial cancer mortality?

David O. Holtz, MD
Paoli, Pennsylvania

Dr. Kaunitz responds

I appreciate Dr. Holtz’s interest in my commentary on the role of hysterectomy as part of risk-reducing surgery in BRCA mutation carriers. Women who are mutation carriers are at increased risk for serous or serous-like endometrial cancers. Further, hysterectomy offers specific advantages for young mutation carriers for whom menopausal hormone therapy is often indicated after risk-reducing salpingo-oophorectomy. Accordingly, I would indeed encourage such women to consider hysterectomy as part of risk-reducing gynecologic surgery if such surgery can be accomplished via minimally invasive techniques.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“SHOULD RISK-REDUCING GYNECOLOGIC SURGERY FOR BRCA MUTATION CARRIERS INCLUDE HYSTERECTOMY?”

ANDREW M. KAUNITZ, MD (WEB EXCLUSIVE, AUGUST 28, 2016)

Hysterectomy warranted?

I am wondering if Dr. Kaunitz really is recommending performing 270 hysterectomies to prevent one endometrial cancer? Is this justified given the risks from the hysterectomy itself, the economics of the disease, or any significant reductions in endometrial cancer mortality?

David O. Holtz, MD
Paoli, Pennsylvania

Dr. Kaunitz responds

I appreciate Dr. Holtz’s interest in my commentary on the role of hysterectomy as part of risk-reducing surgery in BRCA mutation carriers. Women who are mutation carriers are at increased risk for serous or serous-like endometrial cancers. Further, hysterectomy offers specific advantages for young mutation carriers for whom menopausal hormone therapy is often indicated after risk-reducing salpingo-oophorectomy. Accordingly, I would indeed encourage such women to consider hysterectomy as part of risk-reducing gynecologic surgery if such surgery can be accomplished via minimally invasive techniques.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

NEW ORLEANS – Ibalizumab, the first monoclonal antibody to reach a phase III trial for multidrug resistant HIV therapy, has demonstrated efficacy, safety, and a novel mechanism of action, offering promise to many patients with few remaining options.

“The drug has now shown very significant antiretroviral activity, with 83% of patients demonstrating a half log decrease after 7 days, and a mean and median decrease of 1.1 log,” Jacob Lalezari, MD, lead author of the study and medical director of Quest Clinical Research in San Francisco, said at IDWeek 2016, the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. “The big message here is the novel mechanism of action provides new treatment to patients with limited options, really offering hope to those left behind by an otherwise amazing evolution of HIV treatment.”

Damian McNamara/Frontline Medical News

Efficacy and safety

“The story is pretty simple – the drug worked,” Dr. Lalezari said. In addition to the 83% who met the primary endpoint of a half-life log decrease in HIV-1 RNA, 60% had a full log decrease or more at day 14. The mean and median HIV-1 RNA decrease for the entire cohort was 1.1 log₁₀, a significant difference, compared with the day 0 to 7 control period (P less than .0001).

Putting the findings in perspective, Dr. Lalezari said, “So 1 log is not the most potent drug we see for HIV, but it’s pretty good. And in the setting of multidrug-resistant virus, it’s very good.” Although the agent is not potent enough for monotherapy, he said it is a strong candidate for combination therapy. The goal is to “give somebody a chance, potentially their last chance, to get control of the virus and prevent the progression of disease, and importantly, prevent them from spreading it to somebody else.”

“It’s a bit of a mystery” why 7 of the 40 patients did not meet the primary endpoint, Dr. Lalezari added. None of the factors the investigators compared between responders and nonresponders were significantly different.

Ibalizumab appears safe with no discontinuations and no treatment-related serious adverse events, Dr. Lalezari said. “We have not seen anything that strikes me as concerning at all in terms of safety, and it’s in a patient population that is quite ill.”

When asked during the press conference to address cost concerns, an issue in other specialties when biologics are introduced, Dr. Lalezari responded, “The one comment I will make is that whatever this drug is, it’s not a ‘me too drug.’ It’s unique and offers a unique mechanism of action. For those patients, the patients we saw whose T cells were under 10, whose health was failing and they were getting ready to die, their viral loads got suppressed and now they’re living, so it brings great value.”

Ibalizumab’s antiretroviral activity stems from blocking post-attachment conformational changes that are required to enable the HIV virus to bind with its co-receptors and ultimately gain entry into the target T cell. “Importantly the drug is away from the binding site for MHC class II molecules, and therefore not thought to cause T-cell depletion or be immunosuppressive,” Dr. Lalezari said.

In terms of the bigger picture, unlike most HIV drugs taken daily, ibalizumab is the first of the long-acting antiretrovirals, he noted. “I do think a paradigm shift is looming for at least some patients for whom long-acting therapy might be advantageous. There is also a movement toward IM and hopefully subcutaneous therapy as well, which would be very advantageous for patient self-administration.”

Although Dr. Lalezari and Dr. Kuritzkes presented the 14-day findings, the study is ongoing and participants continue to receive 800 mg ibalizumab intravenously every two weeks.

TaiMed Biologics, the sponsor of the study, has an expanded access program. Dr. Lalezari said, “So if you [have] a patient who is in trouble, in need of rescue therapy, there is an option for you now to consider.”

Dr. Lalezari receives research funding from TaiMed Biologics. Dr. Kuritzkes had no relevant financial disclosures.

NEW ORLEANS – Ibalizumab, the first monoclonal antibody to reach a phase III trial for multidrug resistant HIV therapy, has demonstrated efficacy, safety, and a novel mechanism of action, offering promise to many patients with few remaining options.

“The drug has now shown very significant antiretroviral activity, with 83% of patients demonstrating a half log decrease after 7 days, and a mean and median decrease of 1.1 log,” Jacob Lalezari, MD, lead author of the study and medical director of Quest Clinical Research in San Francisco, said at IDWeek 2016, the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. “The big message here is the novel mechanism of action provides new treatment to patients with limited options, really offering hope to those left behind by an otherwise amazing evolution of HIV treatment.”

Damian McNamara/Frontline Medical News

Efficacy and safety

“The story is pretty simple – the drug worked,” Dr. Lalezari said. In addition to the 83% who met the primary endpoint of a half-life log decrease in HIV-1 RNA, 60% had a full log decrease or more at day 14. The mean and median HIV-1 RNA decrease for the entire cohort was 1.1 log₁₀, a significant difference, compared with the day 0 to 7 control period (P less than .0001).

Putting the findings in perspective, Dr. Lalezari said, “So 1 log is not the most potent drug we see for HIV, but it’s pretty good. And in the setting of multidrug-resistant virus, it’s very good.” Although the agent is not potent enough for monotherapy, he said it is a strong candidate for combination therapy. The goal is to “give somebody a chance, potentially their last chance, to get control of the virus and prevent the progression of disease, and importantly, prevent them from spreading it to somebody else.”

“It’s a bit of a mystery” why 7 of the 40 patients did not meet the primary endpoint, Dr. Lalezari added. None of the factors the investigators compared between responders and nonresponders were significantly different.

Ibalizumab appears safe with no discontinuations and no treatment-related serious adverse events, Dr. Lalezari said. “We have not seen anything that strikes me as concerning at all in terms of safety, and it’s in a patient population that is quite ill.”

When asked during the press conference to address cost concerns, an issue in other specialties when biologics are introduced, Dr. Lalezari responded, “The one comment I will make is that whatever this drug is, it’s not a ‘me too drug.’ It’s unique and offers a unique mechanism of action. For those patients, the patients we saw whose T cells were under 10, whose health was failing and they were getting ready to die, their viral loads got suppressed and now they’re living, so it brings great value.”

Ibalizumab’s antiretroviral activity stems from blocking post-attachment conformational changes that are required to enable the HIV virus to bind with its co-receptors and ultimately gain entry into the target T cell. “Importantly the drug is away from the binding site for MHC class II molecules, and therefore not thought to cause T-cell depletion or be immunosuppressive,” Dr. Lalezari said.

In terms of the bigger picture, unlike most HIV drugs taken daily, ibalizumab is the first of the long-acting antiretrovirals, he noted. “I do think a paradigm shift is looming for at least some patients for whom long-acting therapy might be advantageous. There is also a movement toward IM and hopefully subcutaneous therapy as well, which would be very advantageous for patient self-administration.”

Although Dr. Lalezari and Dr. Kuritzkes presented the 14-day findings, the study is ongoing and participants continue to receive 800 mg ibalizumab intravenously every two weeks.

TaiMed Biologics, the sponsor of the study, has an expanded access program. Dr. Lalezari said, “So if you [have] a patient who is in trouble, in need of rescue therapy, there is an option for you now to consider.”

Dr. Lalezari receives research funding from TaiMed Biologics. Dr. Kuritzkes had no relevant financial disclosures.

NEW ORLEANS – Ibalizumab, the first monoclonal antibody to reach a phase III trial for multidrug resistant HIV therapy, has demonstrated efficacy, safety, and a novel mechanism of action, offering promise to many patients with few remaining options.

“The drug has now shown very significant antiretroviral activity, with 83% of patients demonstrating a half log decrease after 7 days, and a mean and median decrease of 1.1 log,” Jacob Lalezari, MD, lead author of the study and medical director of Quest Clinical Research in San Francisco, said at IDWeek 2016, the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. “The big message here is the novel mechanism of action provides new treatment to patients with limited options, really offering hope to those left behind by an otherwise amazing evolution of HIV treatment.”

Damian McNamara/Frontline Medical News

Efficacy and safety

“The story is pretty simple – the drug worked,” Dr. Lalezari said. In addition to the 83% who met the primary endpoint of a half-life log decrease in HIV-1 RNA, 60% had a full log decrease or more at day 14. The mean and median HIV-1 RNA decrease for the entire cohort was 1.1 log₁₀, a significant difference, compared with the day 0 to 7 control period (P less than .0001).

Putting the findings in perspective, Dr. Lalezari said, “So 1 log is not the most potent drug we see for HIV, but it’s pretty good. And in the setting of multidrug-resistant virus, it’s very good.” Although the agent is not potent enough for monotherapy, he said it is a strong candidate for combination therapy. The goal is to “give somebody a chance, potentially their last chance, to get control of the virus and prevent the progression of disease, and importantly, prevent them from spreading it to somebody else.”

“It’s a bit of a mystery” why 7 of the 40 patients did not meet the primary endpoint, Dr. Lalezari added. None of the factors the investigators compared between responders and nonresponders were significantly different.

Ibalizumab appears safe with no discontinuations and no treatment-related serious adverse events, Dr. Lalezari said. “We have not seen anything that strikes me as concerning at all in terms of safety, and it’s in a patient population that is quite ill.”

When asked during the press conference to address cost concerns, an issue in other specialties when biologics are introduced, Dr. Lalezari responded, “The one comment I will make is that whatever this drug is, it’s not a ‘me too drug.’ It’s unique and offers a unique mechanism of action. For those patients, the patients we saw whose T cells were under 10, whose health was failing and they were getting ready to die, their viral loads got suppressed and now they’re living, so it brings great value.”

Ibalizumab’s antiretroviral activity stems from blocking post-attachment conformational changes that are required to enable the HIV virus to bind with its co-receptors and ultimately gain entry into the target T cell. “Importantly the drug is away from the binding site for MHC class II molecules, and therefore not thought to cause T-cell depletion or be immunosuppressive,” Dr. Lalezari said.

In terms of the bigger picture, unlike most HIV drugs taken daily, ibalizumab is the first of the long-acting antiretrovirals, he noted. “I do think a paradigm shift is looming for at least some patients for whom long-acting therapy might be advantageous. There is also a movement toward IM and hopefully subcutaneous therapy as well, which would be very advantageous for patient self-administration.”

Although Dr. Lalezari and Dr. Kuritzkes presented the 14-day findings, the study is ongoing and participants continue to receive 800 mg ibalizumab intravenously every two weeks.

TaiMed Biologics, the sponsor of the study, has an expanded access program. Dr. Lalezari said, “So if you [have] a patient who is in trouble, in need of rescue therapy, there is an option for you now to consider.”

Dr. Lalezari receives research funding from TaiMed Biologics. Dr. Kuritzkes had no relevant financial disclosures.

Laparoscopic sleeve gastrectomy is safe and effective overall, but staple line reinforcement appears to increase the rate of postsurgical leaks – which were associated with readmissions and, in some cases, reoperations.

A large review of quality improvement data found that staple line reinforcement – an extremely common technique – was associated with a 60% increased risk of leak, compared with closures without staple line reinforcement, Elizabeth R. Berger, MD, and her colleagues reported in the October issue of the Annals of Surgery (2016;264:464-73).

“This study also demonstrates that leaks were significantly more morbid than bleeding with higher readmission and reoperation rates in patients with a leak vs. a bleed,” wrote Dr. Berger of Loyola University, Chicago, and her coauthors. “Therefore, a surgeon should consider the benefits, risks, and costs of each surgical technique in performing a laparoscopic sleeve gastrectomy and selectively utilize those that, in their hands, minimize morbidity while maximizing clinical effectiveness.”

The team examined outcomes in 189,477 laparoscopic sleeve gastrectomies performed by 1,634 surgeons at 720 centers from 2012 to 2014. All of the data were extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, created in 2012 by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery.

They examined the impact of staple line reinforcement, oversewing the staple line, bougie size, and distance of the staple line from the pylorus on 30-day outcomes, and their effect on weight loss and weight-related comorbidities at 1 year. Outcomes included morbidity, leak rates, and bleeding, which were examined at both the patient and surgeon levels.

Most patients (126,904; 67%) patients had some type of staple line reinforcement (SLR); the rest had only oversewn staple lines (OSL) or no reinforcement. Leaks occurred in 1,703 patients and bleeds in 1,436 patients. Leaks were more serious than bleeds: Patients with a leak were almost 28% more likely to readmitted and 11% more likely to need a reoperation than were patients who had only a bleed.

At the patient level, those with SLR with or without OSL were 20%-46% more likely to experience a leak than were those who had neither. Bleeding rates were about 70% lower in the SLR groups.

Most surgeons in the analysis (80%) used some type of SLR; almost 20% routinely used only OSL, and 30% routinely used only SLR. At the surgeon level, SLR was associated with a 60% increased risk of a postoperative leak, compared with no reinforcement. There was no association between SLR and bleeding risk, however.

Oversewing had an effect on 1-year weight loss. Patients with oversewn staple lines lost an additional 1.3 points on the body mass index (BMI) scale, compared with patients with no type of reinforcement.

“The reason for increased leaks from SLR is relatively unclear,” the authors wrote. “The two layers of material that are placed within the staple line could increase ischemia or decrease the relative staple heights. At the notches, where one staple firing ends and the next one begins, there is sandwiching of the two layers of staples and a combined four layers of SLR. This bulk may predispose to leaks.”

Larger bougie sizes (BS) seemed more beneficial than did smaller ones, in both the surgeon- and patient-level analyses. A BS of at least 38 French was associated with a 28% decreased risk of a leak (odds ratio 0.72) at the patient level and a 10% decreased risk at the surgeon level (OR 0.90). There were no associations with bleeding.

“Our findings support literature that describes narrower BSs leads to increased ischemia secondary to increased intraluminal pressure, causing more leaks,” the authors wrote.

A BS of at least 40 French had a significant impact on weight loss. At 1 year, patients with the larger BS had lost 2.45 points more on the BMI scale than did those with smaller sizes.

This finding is in accord with other studies, including one that found the best weight-loss outcomes associated with a BS of more than 60 French. “Perhaps the sleeve works because of more rapid emptying, which is favored by a relatively larger BS, rather than because of restriction,” they said.

The distance to the pylorus (DP) from the staple line initiation point was divided into four sections: less than 4 cm; 4-5 cm; 5-6 cm; and 6 cm or more.

On a patient level, there was no association between DP and leak rates. There was, however, an association with bleeding. A DP of 4-4.99 cm had the highest rate, 90%, while a DP of 5-5.99 cm had the lowest (71%). DP was also associated with weight loss on this level, with a distance of more than 6 cm being associated with the biggest BMI decrease (3.7 points).

“Our data show significantly increased excess weight loss in a stepwise fashion as the DP increases,” the authors said. “Our data suggest that as DP increased, there was an increased excess weight loss, possibly explained by preserving the ‘antral mill.’ Stapling further from the pylorus perhaps keeps the antrum’s functional component intact and allows food to enter the distal gut more quickly, leading to earlier satiety and increased weight loss.”

Only 114 surgeons (8%) used a DP of less than 4 cm. There were no significant associations with any 30-day outcomes and DP after adjustment.

The authors had no financial disclosures.

Laparoscopic sleeve gastrectomy is safe and effective overall, but staple line reinforcement appears to increase the rate of postsurgical leaks – which were associated with readmissions and, in some cases, reoperations.

A large review of quality improvement data found that staple line reinforcement – an extremely common technique – was associated with a 60% increased risk of leak, compared with closures without staple line reinforcement, Elizabeth R. Berger, MD, and her colleagues reported in the October issue of the Annals of Surgery (2016;264:464-73).

“This study also demonstrates that leaks were significantly more morbid than bleeding with higher readmission and reoperation rates in patients with a leak vs. a bleed,” wrote Dr. Berger of Loyola University, Chicago, and her coauthors. “Therefore, a surgeon should consider the benefits, risks, and costs of each surgical technique in performing a laparoscopic sleeve gastrectomy and selectively utilize those that, in their hands, minimize morbidity while maximizing clinical effectiveness.”

The team examined outcomes in 189,477 laparoscopic sleeve gastrectomies performed by 1,634 surgeons at 720 centers from 2012 to 2014. All of the data were extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, created in 2012 by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery.

They examined the impact of staple line reinforcement, oversewing the staple line, bougie size, and distance of the staple line from the pylorus on 30-day outcomes, and their effect on weight loss and weight-related comorbidities at 1 year. Outcomes included morbidity, leak rates, and bleeding, which were examined at both the patient and surgeon levels.

Most patients (126,904; 67%) patients had some type of staple line reinforcement (SLR); the rest had only oversewn staple lines (OSL) or no reinforcement. Leaks occurred in 1,703 patients and bleeds in 1,436 patients. Leaks were more serious than bleeds: Patients with a leak were almost 28% more likely to readmitted and 11% more likely to need a reoperation than were patients who had only a bleed.

At the patient level, those with SLR with or without OSL were 20%-46% more likely to experience a leak than were those who had neither. Bleeding rates were about 70% lower in the SLR groups.

Most surgeons in the analysis (80%) used some type of SLR; almost 20% routinely used only OSL, and 30% routinely used only SLR. At the surgeon level, SLR was associated with a 60% increased risk of a postoperative leak, compared with no reinforcement. There was no association between SLR and bleeding risk, however.

Oversewing had an effect on 1-year weight loss. Patients with oversewn staple lines lost an additional 1.3 points on the body mass index (BMI) scale, compared with patients with no type of reinforcement.

“The reason for increased leaks from SLR is relatively unclear,” the authors wrote. “The two layers of material that are placed within the staple line could increase ischemia or decrease the relative staple heights. At the notches, where one staple firing ends and the next one begins, there is sandwiching of the two layers of staples and a combined four layers of SLR. This bulk may predispose to leaks.”

Larger bougie sizes (BS) seemed more beneficial than did smaller ones, in both the surgeon- and patient-level analyses. A BS of at least 38 French was associated with a 28% decreased risk of a leak (odds ratio 0.72) at the patient level and a 10% decreased risk at the surgeon level (OR 0.90). There were no associations with bleeding.

“Our findings support literature that describes narrower BSs leads to increased ischemia secondary to increased intraluminal pressure, causing more leaks,” the authors wrote.

A BS of at least 40 French had a significant impact on weight loss. At 1 year, patients with the larger BS had lost 2.45 points more on the BMI scale than did those with smaller sizes.

This finding is in accord with other studies, including one that found the best weight-loss outcomes associated with a BS of more than 60 French. “Perhaps the sleeve works because of more rapid emptying, which is favored by a relatively larger BS, rather than because of restriction,” they said.

The distance to the pylorus (DP) from the staple line initiation point was divided into four sections: less than 4 cm; 4-5 cm; 5-6 cm; and 6 cm or more.

On a patient level, there was no association between DP and leak rates. There was, however, an association with bleeding. A DP of 4-4.99 cm had the highest rate, 90%, while a DP of 5-5.99 cm had the lowest (71%). DP was also associated with weight loss on this level, with a distance of more than 6 cm being associated with the biggest BMI decrease (3.7 points).

“Our data show significantly increased excess weight loss in a stepwise fashion as the DP increases,” the authors said. “Our data suggest that as DP increased, there was an increased excess weight loss, possibly explained by preserving the ‘antral mill.’ Stapling further from the pylorus perhaps keeps the antrum’s functional component intact and allows food to enter the distal gut more quickly, leading to earlier satiety and increased weight loss.”

Only 114 surgeons (8%) used a DP of less than 4 cm. There were no significant associations with any 30-day outcomes and DP after adjustment.

The authors had no financial disclosures.

Laparoscopic sleeve gastrectomy is safe and effective overall, but staple line reinforcement appears to increase the rate of postsurgical leaks – which were associated with readmissions and, in some cases, reoperations.

A large review of quality improvement data found that staple line reinforcement – an extremely common technique – was associated with a 60% increased risk of leak, compared with closures without staple line reinforcement, Elizabeth R. Berger, MD, and her colleagues reported in the October issue of the Annals of Surgery (2016;264:464-73).

“This study also demonstrates that leaks were significantly more morbid than bleeding with higher readmission and reoperation rates in patients with a leak vs. a bleed,” wrote Dr. Berger of Loyola University, Chicago, and her coauthors. “Therefore, a surgeon should consider the benefits, risks, and costs of each surgical technique in performing a laparoscopic sleeve gastrectomy and selectively utilize those that, in their hands, minimize morbidity while maximizing clinical effectiveness.”

The team examined outcomes in 189,477 laparoscopic sleeve gastrectomies performed by 1,634 surgeons at 720 centers from 2012 to 2014. All of the data were extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, created in 2012 by the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery.

They examined the impact of staple line reinforcement, oversewing the staple line, bougie size, and distance of the staple line from the pylorus on 30-day outcomes, and their effect on weight loss and weight-related comorbidities at 1 year. Outcomes included morbidity, leak rates, and bleeding, which were examined at both the patient and surgeon levels.

Most patients (126,904; 67%) patients had some type of staple line reinforcement (SLR); the rest had only oversewn staple lines (OSL) or no reinforcement. Leaks occurred in 1,703 patients and bleeds in 1,436 patients. Leaks were more serious than bleeds: Patients with a leak were almost 28% more likely to readmitted and 11% more likely to need a reoperation than were patients who had only a bleed.

At the patient level, those with SLR with or without OSL were 20%-46% more likely to experience a leak than were those who had neither. Bleeding rates were about 70% lower in the SLR groups.

Most surgeons in the analysis (80%) used some type of SLR; almost 20% routinely used only OSL, and 30% routinely used only SLR. At the surgeon level, SLR was associated with a 60% increased risk of a postoperative leak, compared with no reinforcement. There was no association between SLR and bleeding risk, however.

Oversewing had an effect on 1-year weight loss. Patients with oversewn staple lines lost an additional 1.3 points on the body mass index (BMI) scale, compared with patients with no type of reinforcement.

“The reason for increased leaks from SLR is relatively unclear,” the authors wrote. “The two layers of material that are placed within the staple line could increase ischemia or decrease the relative staple heights. At the notches, where one staple firing ends and the next one begins, there is sandwiching of the two layers of staples and a combined four layers of SLR. This bulk may predispose to leaks.”

Larger bougie sizes (BS) seemed more beneficial than did smaller ones, in both the surgeon- and patient-level analyses. A BS of at least 38 French was associated with a 28% decreased risk of a leak (odds ratio 0.72) at the patient level and a 10% decreased risk at the surgeon level (OR 0.90). There were no associations with bleeding.

“Our findings support literature that describes narrower BSs leads to increased ischemia secondary to increased intraluminal pressure, causing more leaks,” the authors wrote.

A BS of at least 40 French had a significant impact on weight loss. At 1 year, patients with the larger BS had lost 2.45 points more on the BMI scale than did those with smaller sizes.

This finding is in accord with other studies, including one that found the best weight-loss outcomes associated with a BS of more than 60 French. “Perhaps the sleeve works because of more rapid emptying, which is favored by a relatively larger BS, rather than because of restriction,” they said.

The distance to the pylorus (DP) from the staple line initiation point was divided into four sections: less than 4 cm; 4-5 cm; 5-6 cm; and 6 cm or more.

On a patient level, there was no association between DP and leak rates. There was, however, an association with bleeding. A DP of 4-4.99 cm had the highest rate, 90%, while a DP of 5-5.99 cm had the lowest (71%). DP was also associated with weight loss on this level, with a distance of more than 6 cm being associated with the biggest BMI decrease (3.7 points).

“Our data show significantly increased excess weight loss in a stepwise fashion as the DP increases,” the authors said. “Our data suggest that as DP increased, there was an increased excess weight loss, possibly explained by preserving the ‘antral mill.’ Stapling further from the pylorus perhaps keeps the antrum’s functional component intact and allows food to enter the distal gut more quickly, leading to earlier satiety and increased weight loss.”

Only 114 surgeons (8%) used a DP of less than 4 cm. There were no significant associations with any 30-day outcomes and DP after adjustment.

The authors had no financial disclosures.

ORLANDO – The disparity in U.S. heart failure incidence continued undiminished during 2002-2013, with African Americans maintaining a steady 2.3-fold increased rate of heart failure, compared with whites, based on national levels of heart failure hospitalizations, a reasonable surrogate for incidence rates, Boback Ziaeian, MD, reported at the annual scientific meeting of the Heart Failure Society of America.

The same period also showed a substantial relative improvement in the heart failure hospitalization rates among U.S. Hispanics, compared with whites, so that, by 2013, the ethnic disparity seen in 2002 between Hispanics and whites largely disappeared, reported Dr. Ziaeian, a cardiologist at the University of California, Los Angeles. The data he analyzed also showed that Asian Americans had the lowest heart failure hospitalization rates of any racial or ethnic group throughout the 11-year period, and that the incidence of heart failure fell more sharply in women than in men during the period, based on the hospitalization numbers.

[email protected]

On Twitter @mitchelzoler

ORLANDO – The disparity in U.S. heart failure incidence continued undiminished during 2002-2013, with African Americans maintaining a steady 2.3-fold increased rate of heart failure, compared with whites, based on national levels of heart failure hospitalizations, a reasonable surrogate for incidence rates, Boback Ziaeian, MD, reported at the annual scientific meeting of the Heart Failure Society of America.

The same period also showed a substantial relative improvement in the heart failure hospitalization rates among U.S. Hispanics, compared with whites, so that, by 2013, the ethnic disparity seen in 2002 between Hispanics and whites largely disappeared, reported Dr. Ziaeian, a cardiologist at the University of California, Los Angeles. The data he analyzed also showed that Asian Americans had the lowest heart failure hospitalization rates of any racial or ethnic group throughout the 11-year period, and that the incidence of heart failure fell more sharply in women than in men during the period, based on the hospitalization numbers.

[email protected]

On Twitter @mitchelzoler

ORLANDO – The disparity in U.S. heart failure incidence continued undiminished during 2002-2013, with African Americans maintaining a steady 2.3-fold increased rate of heart failure, compared with whites, based on national levels of heart failure hospitalizations, a reasonable surrogate for incidence rates, Boback Ziaeian, MD, reported at the annual scientific meeting of the Heart Failure Society of America.

The same period also showed a substantial relative improvement in the heart failure hospitalization rates among U.S. Hispanics, compared with whites, so that, by 2013, the ethnic disparity seen in 2002 between Hispanics and whites largely disappeared, reported Dr. Ziaeian, a cardiologist at the University of California, Los Angeles. The data he analyzed also showed that Asian Americans had the lowest heart failure hospitalization rates of any racial or ethnic group throughout the 11-year period, and that the incidence of heart failure fell more sharply in women than in men during the period, based on the hospitalization numbers.

[email protected]

On Twitter @mitchelzoler

A new study of anxiety disorders among young adults aged 18-24 shows that the illnesses are less prevalent among African American and Hispanic young adults, compared with whites. Furthermore, anxiety disorders are 1.5 times as prevalent among married people in this age group, compared with their unmarried peers.

For their research, presented at the annual meeting of the American Academy of Child and Adolescent Psychiatry, Cristiane S. Duarte, PhD, MPH, of Columbia University, New York, and her colleagues looked at data from the 2012/2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample of U.S. households.

“We were trying to look specifically at young adulthood, which there’s emerging consensus to regard as a key developmental period,” said Dr. Duarte, whose research focuses on anxiety disorders in young adults. “It’s a period where several psychiatric disorders tend to become much more prevalent. Having untreated anxiety disorders at this age can put young adults at risk for worse outcomes down the line. If anxiety disorders can be resolved, a young adult’s trajectory can be quite different; it’s a time in life in which the right intervention can have a really big impact,” she said.

The NESARC III survey data used structured diagnostic interviews and DSM-5 criteria to assess anxiety disorders occurring in the past year. These included specific phobia, generalized anxiety disorder, social anxiety, panic disorder, and agoraphobia. 

For the most part, Dr. Duarte said, her group’s findings on anxiety disorders reflected earlier prevalence studies that had used DSM-IV criteria. Women were more likely than were men to report any past-year anxiety disorder (odds ratio, 2.26; 95% confidence interval, 1.80-2.84), as were people with lower personal and family incomes. Rates of anxiety disorders were highest in groups with the lowest personal and family incomes, and among people neither employed nor in an educational program.

Dr. Duarte said in an interview that the latter findings were generally anticipated. However, the finding that African Americans and Hispanics at this age had lower risk relative to whites (OR, 0.52; 95% CI, 0.40-0.67) and (OR, 0.63; 95% CI, 0.49-0.83) was interesting, because it appeared to mirror the lower relative prevalence seen among adults in those two groups, rather than the higher prevalence seen among children in the same groups. More research will be needed, she said, to verify and, if correct, understand this reversing trend in prevalence seen between childhood and adulthood.

The study’s most unexpected finding, Dr. Duarte said, was that married individuals aged 18-24 had higher prevalence of anxiety (OR, 1.54; 95% CI, 1.05-2.26). “Across the board, marriage is protective for many health and mental health conditions,” Dr. Duarte said, but she acknowledged that many factors could be in play. Marriage might not, in fact, be protective in this age group; the institution might be reflective of cultural factors promoting early marriage; or the findings could reflect a selection into marriage possibly related to existing anxiety disorders.

“To better understand this finding, we will need to consider several complexities which are part of young adulthood as a unique developmental period,” she said.

Dr. Duarte’s and her colleagues’ study was funded by the Youth Anxiety Center at New York–Presbyterian Hospital. Three coauthors reported research support from pharmaceutical manufacturers and royalties from commercial publishers. 

A new study of anxiety disorders among young adults aged 18-24 shows that the illnesses are less prevalent among African American and Hispanic young adults, compared with whites. Furthermore, anxiety disorders are 1.5 times as prevalent among married people in this age group, compared with their unmarried peers.

For their research, presented at the annual meeting of the American Academy of Child and Adolescent Psychiatry, Cristiane S. Duarte, PhD, MPH, of Columbia University, New York, and her colleagues looked at data from the 2012/2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample of U.S. households.

“We were trying to look specifically at young adulthood, which there’s emerging consensus to regard as a key developmental period,” said Dr. Duarte, whose research focuses on anxiety disorders in young adults. “It’s a period where several psychiatric disorders tend to become much more prevalent. Having untreated anxiety disorders at this age can put young adults at risk for worse outcomes down the line. If anxiety disorders can be resolved, a young adult’s trajectory can be quite different; it’s a time in life in which the right intervention can have a really big impact,” she said.

The NESARC III survey data used structured diagnostic interviews and DSM-5 criteria to assess anxiety disorders occurring in the past year. These included specific phobia, generalized anxiety disorder, social anxiety, panic disorder, and agoraphobia. 

For the most part, Dr. Duarte said, her group’s findings on anxiety disorders reflected earlier prevalence studies that had used DSM-IV criteria. Women were more likely than were men to report any past-year anxiety disorder (odds ratio, 2.26; 95% confidence interval, 1.80-2.84), as were people with lower personal and family incomes. Rates of anxiety disorders were highest in groups with the lowest personal and family incomes, and among people neither employed nor in an educational program.

Dr. Duarte said in an interview that the latter findings were generally anticipated. However, the finding that African Americans and Hispanics at this age had lower risk relative to whites (OR, 0.52; 95% CI, 0.40-0.67) and (OR, 0.63; 95% CI, 0.49-0.83) was interesting, because it appeared to mirror the lower relative prevalence seen among adults in those two groups, rather than the higher prevalence seen among children in the same groups. More research will be needed, she said, to verify and, if correct, understand this reversing trend in prevalence seen between childhood and adulthood.

The study’s most unexpected finding, Dr. Duarte said, was that married individuals aged 18-24 had higher prevalence of anxiety (OR, 1.54; 95% CI, 1.05-2.26). “Across the board, marriage is protective for many health and mental health conditions,” Dr. Duarte said, but she acknowledged that many factors could be in play. Marriage might not, in fact, be protective in this age group; the institution might be reflective of cultural factors promoting early marriage; or the findings could reflect a selection into marriage possibly related to existing anxiety disorders.

“To better understand this finding, we will need to consider several complexities which are part of young adulthood as a unique developmental period,” she said.

Dr. Duarte’s and her colleagues’ study was funded by the Youth Anxiety Center at New York–Presbyterian Hospital. Three coauthors reported research support from pharmaceutical manufacturers and royalties from commercial publishers. 

A new study of anxiety disorders among young adults aged 18-24 shows that the illnesses are less prevalent among African American and Hispanic young adults, compared with whites. Furthermore, anxiety disorders are 1.5 times as prevalent among married people in this age group, compared with their unmarried peers.

For their research, presented at the annual meeting of the American Academy of Child and Adolescent Psychiatry, Cristiane S. Duarte, PhD, MPH, of Columbia University, New York, and her colleagues looked at data from the 2012/2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample of U.S. households.

“We were trying to look specifically at young adulthood, which there’s emerging consensus to regard as a key developmental period,” said Dr. Duarte, whose research focuses on anxiety disorders in young adults. “It’s a period where several psychiatric disorders tend to become much more prevalent. Having untreated anxiety disorders at this age can put young adults at risk for worse outcomes down the line. If anxiety disorders can be resolved, a young adult’s trajectory can be quite different; it’s a time in life in which the right intervention can have a really big impact,” she said.

The NESARC III survey data used structured diagnostic interviews and DSM-5 criteria to assess anxiety disorders occurring in the past year. These included specific phobia, generalized anxiety disorder, social anxiety, panic disorder, and agoraphobia. 

For the most part, Dr. Duarte said, her group’s findings on anxiety disorders reflected earlier prevalence studies that had used DSM-IV criteria. Women were more likely than were men to report any past-year anxiety disorder (odds ratio, 2.26; 95% confidence interval, 1.80-2.84), as were people with lower personal and family incomes. Rates of anxiety disorders were highest in groups with the lowest personal and family incomes, and among people neither employed nor in an educational program.

Dr. Duarte said in an interview that the latter findings were generally anticipated. However, the finding that African Americans and Hispanics at this age had lower risk relative to whites (OR, 0.52; 95% CI, 0.40-0.67) and (OR, 0.63; 95% CI, 0.49-0.83) was interesting, because it appeared to mirror the lower relative prevalence seen among adults in those two groups, rather than the higher prevalence seen among children in the same groups. More research will be needed, she said, to verify and, if correct, understand this reversing trend in prevalence seen between childhood and adulthood.

The study’s most unexpected finding, Dr. Duarte said, was that married individuals aged 18-24 had higher prevalence of anxiety (OR, 1.54; 95% CI, 1.05-2.26). “Across the board, marriage is protective for many health and mental health conditions,” Dr. Duarte said, but she acknowledged that many factors could be in play. Marriage might not, in fact, be protective in this age group; the institution might be reflective of cultural factors promoting early marriage; or the findings could reflect a selection into marriage possibly related to existing anxiety disorders.

“To better understand this finding, we will need to consider several complexities which are part of young adulthood as a unique developmental period,” she said.

Dr. Duarte’s and her colleagues’ study was funded by the Youth Anxiety Center at New York–Presbyterian Hospital. Three coauthors reported research support from pharmaceutical manufacturers and royalties from commercial publishers. 

COLUMBUS, OHIO – A study of vascular procedures at 35 Michigan hospitals has identified three risk factors for surgical site infection after lower-extremity bypass that hospitals and vascular surgery teams may be able to modify.

“Patients who had iodine-only skin antiseptic preparation, a high-peak intraoperative glucose, or long operative times were more likely to have substantially increased risk for surgical site infection (SSI),” Frank Davis, MD, of the University of Michigan said in reporting the study results at the annual meeting of the Midwestern Vascular Surgical Society. Those risk factors are modifiable, Dr. Davis said.

COLUMBUS, OHIO – A study of vascular procedures at 35 Michigan hospitals has identified three risk factors for surgical site infection after lower-extremity bypass that hospitals and vascular surgery teams may be able to modify.

“Patients who had iodine-only skin antiseptic preparation, a high-peak intraoperative glucose, or long operative times were more likely to have substantially increased risk for surgical site infection (SSI),” Frank Davis, MD, of the University of Michigan said in reporting the study results at the annual meeting of the Midwestern Vascular Surgical Society. Those risk factors are modifiable, Dr. Davis said.

COLUMBUS, OHIO – A study of vascular procedures at 35 Michigan hospitals has identified three risk factors for surgical site infection after lower-extremity bypass that hospitals and vascular surgery teams may be able to modify.

“Patients who had iodine-only skin antiseptic preparation, a high-peak intraoperative glucose, or long operative times were more likely to have substantially increased risk for surgical site infection (SSI),” Frank Davis, MD, of the University of Michigan said in reporting the study results at the annual meeting of the Midwestern Vascular Surgical Society. Those risk factors are modifiable, Dr. Davis said.

ATLANTA – Physicians are falling short on syphilis testing in both the prenatal period and at the time of delivery, suggest the findings of a study examining insurance claims from nearly 10,000 women who experienced stillbirths.

Overall, less than 10% of women in the study were tested for syphilis following a stillbirth delivery, while less than two-thirds of women who experienced a stillbirth had received prenatal syphilis testing.

jarun011/Thinkstock

[email protected]

ATLANTA – Physicians are falling short on syphilis testing in both the prenatal period and at the time of delivery, suggest the findings of a study examining insurance claims from nearly 10,000 women who experienced stillbirths.

Overall, less than 10% of women in the study were tested for syphilis following a stillbirth delivery, while less than two-thirds of women who experienced a stillbirth had received prenatal syphilis testing.

jarun011/Thinkstock

[email protected]

ATLANTA – Physicians are falling short on syphilis testing in both the prenatal period and at the time of delivery, suggest the findings of a study examining insurance claims from nearly 10,000 women who experienced stillbirths.

Overall, less than 10% of women in the study were tested for syphilis following a stillbirth delivery, while less than two-thirds of women who experienced a stillbirth had received prenatal syphilis testing.

jarun011/Thinkstock

[email protected]