SAN DIEGO—Among patients with migraine, eye-related symptoms such as dry eyes and photophobia are common and treatable, said Kathleen B. Digre, MD, Professor of Neurology and Ophthalmology at the University of Utah in Salt Lake City. Neurologists should treat eye-related conditions “in hopes that we can improve our patients’ migraine,” Dr. Digre said at the 58th Annual Scientific Meeting of the American Headache Society.

Dry Eyes

About 20% to 30% of people over age 45 have dry eyes. Dry eyes are more common in women than in men. Reading, computer use, and watching television may worsen dry eye symptoms due to reduced blinking during those activities. Dry climate, hormones, and certain medications used for migraine, such as amitriptyline and antihistamines, can cause or worsen dry eye symptoms. About 45% of people with Sjögren’s syndrome, a condition that causes dry eyes, have migraine. Furthermore, dry eyes are associated with photophobia, Dr. Digre said.

Koktekir et al in 2012 examined tear film function in patients with episodic migraine versus controls and found that migraineurs had significantly more tear film dysfunction, as measured by Schirmer’s test, tear film breakup time, lissamine green stain, and the Ocular Surface Disease Index.

In a case–control study published in Headache in 2015, Krista I. Kinard, MD, Adjunct Assistant Professor of Ophthalmology at the University of Utah, Dr. Digre, and colleagues examined 19 patients with chronic migraine and 30 controls. Tear film breakup time, basal tear cell secretion, and corneal sensitivity did not differ between the groups. Using corneal microscopy, however, the researchers found that controls had denser nerve fibers than patients with chronic migraine. On the Dry Eye Questionnaire, all patients with chronic migraine scored above 6, a result consistent with dry eye syndrome, whereas controls scored less than 3, as expected. Future research should evaluate whether dry eye symptoms result from the migraine process or whether dry eye symptoms may lead to chronic migraine by continuous stimulation, Dr. Digre said.

Therapeutic Options

Over-the-counter artificial tears, gels, and ointments may be safe and effective treatments for dry eyes. A review published in 2016 found that in two trials, polyacrylic acid-based artificial tears more effectively treated dry eye symptoms than polyvinyl alcohol-based artificial tears. Dr. Digre avoids preservatives in artificial tears because some people are sensitive to them. Oral flaxseed oil or fish oil also may help patients. If symptoms do not improve, an ophthalmologist may consider more aggressive dry eye therapy, such as punctal plugs, she said.

Photophobia

Photophobia is one of the major diagnostic criteria of migraine, and migraine is the most common cause of photophobia, Dr. Digre said. Ninety percent of people with migraine have photophobia during a migraine attack. Ocular inflammation, including dry eye, retinal disease, and cone dystrophy, is associated with photophobia. Certain brain disorders, including meningitis, pituitary tumors, and progressive supranuclear palsy, can cause photophobia. In addition, some psychiatric conditions, such as depression, and certain medications, including stimulants, have been associated with photophobia.

Photophobia has an anatomic basis, and patients without vision may still be light sensitive, Dr. Digre said. The discovery of the melanopsin pathway, a pathway of intrinsically photoactive retinal ganglion cells that function when exposed to light and inform circadian rhythm, was a breakthrough in understanding photophobia, she said.

Delwig et al in 2012 reported that when newborn mice with melanopsin-expressing intrinsically photoactive retinal ganglion cells were exposed to light, the mice vocalized in a way that is similar to when mice are distressed by having to leave the litter. Mice without melanopsin do not exhibit this same aversive behavior, Dr. Digre said. Jones et al in 2013 described a melanopsin antagonist that reverses light aversion in mice.

Light sensitivity may be associated with depression and anxiety. To assess the prevalence of anxiety and depression symptoms in migraineurs with and without interictal photophobia, Llop et al studied 16 patients with episodic migraine who had interictal photophobia, 16 patients with episodic migraine who had photophobia only during migraine attacks, and 16 controls. Migraineurs with interictal photophobia had higher scores on the Beck Depression Inventory and Beck Anxiety Inventory, compared with subjects without interictal photophobia.

Treating Light Sensitivity

Tinted lenses may help patients with migraine and photophobia. Good et al in 1991 published a study that included 20 children with migraine. Patients wore glasses with FL-41–tinted lenses (ie, a rose-colored tint) or blue-tinted lenses. Patients with FL-41–tinted lenses had reduced headache frequency at four months, whereas patients with blue-tinted lenses did not experience a sustained reduction in headache frequency.

Patients with photophobia should not keep themselves in the dark. “Every single person who comes in with three layers of sunglasses, you have to tell them that the more you stay in the dark, the worse this is going to get,” Dr. Digre said. “We have to … slowly peel off the sunglasses, lift up the shades, and start getting used to more light.”

Botulinum toxin, sympathetic nerve blocks, gabapentin, and melatonin have been used in people with photophobia. Importantly, physicians should treat any underlying psychiatric or neurologic condition, including migraine, that may be driving patients’ light sensitivity, Dr. Digre said.

—Jake Remaly

Suggested Reading

Delwig A, Logan AM, Copenhagen DR, Ahn AH. Light evokes melanopsin-dependent vocalization and neural activation associated with aversive experience in neonatal mice. PLoS One. 2012;7(9):e43787.

Good PA, Taylor RH, Mortimer MJ. The use of tinted glasses in childhood migraine. Headache. 1991;31(8):533-536.

Jones KA, Hatori M, Mure LS, et al. Small-molecule antagonists of melanopsin-mediated phototransduction. Nat Chem Biol. 2013;9(10):630-635.

Kinard KI, Smith AG, Singleton JR, et al. Chronic migraine is associated with reduced corneal nerve fiber density and symptoms of dry eye. Headache. 2015;55(4):543-549.

Koktekir BE, Celik G, Karalezli A, Kal A. Dry eyes and migraines: is there really a correlation? Cornea. 2012;31(12):1414-1416.

Llop SM, Frandsen JE, Digre KB, et al. Increased prevalence of depression and anxiety in patients with migraine and interictal photophobia. J Headache Pain. 2016;17:34.

Noseda R, Kainz V, Jakubowski M, et al. A neural mechanism for exacerbation of headache by light. Nat Neurosci. 2010;13(2):239-245.

Pucker AD, Ng SM, Nichols JJ. Over the counter (OTC) artificial tear drops for dry eye syndrome. Cochrane Database Syst Rev. 2016 Feb 23;2:CD009729.

SAN DIEGO—Among patients with migraine, eye-related symptoms such as dry eyes and photophobia are common and treatable, said Kathleen B. Digre, MD, Professor of Neurology and Ophthalmology at the University of Utah in Salt Lake City. Neurologists should treat eye-related conditions “in hopes that we can improve our patients’ migraine,” Dr. Digre said at the 58th Annual Scientific Meeting of the American Headache Society.

Dry Eyes

About 20% to 30% of people over age 45 have dry eyes. Dry eyes are more common in women than in men. Reading, computer use, and watching television may worsen dry eye symptoms due to reduced blinking during those activities. Dry climate, hormones, and certain medications used for migraine, such as amitriptyline and antihistamines, can cause or worsen dry eye symptoms. About 45% of people with Sjögren’s syndrome, a condition that causes dry eyes, have migraine. Furthermore, dry eyes are associated with photophobia, Dr. Digre said.

Koktekir et al in 2012 examined tear film function in patients with episodic migraine versus controls and found that migraineurs had significantly more tear film dysfunction, as measured by Schirmer’s test, tear film breakup time, lissamine green stain, and the Ocular Surface Disease Index.

In a case–control study published in Headache in 2015, Krista I. Kinard, MD, Adjunct Assistant Professor of Ophthalmology at the University of Utah, Dr. Digre, and colleagues examined 19 patients with chronic migraine and 30 controls. Tear film breakup time, basal tear cell secretion, and corneal sensitivity did not differ between the groups. Using corneal microscopy, however, the researchers found that controls had denser nerve fibers than patients with chronic migraine. On the Dry Eye Questionnaire, all patients with chronic migraine scored above 6, a result consistent with dry eye syndrome, whereas controls scored less than 3, as expected. Future research should evaluate whether dry eye symptoms result from the migraine process or whether dry eye symptoms may lead to chronic migraine by continuous stimulation, Dr. Digre said.

Therapeutic Options

Over-the-counter artificial tears, gels, and ointments may be safe and effective treatments for dry eyes. A review published in 2016 found that in two trials, polyacrylic acid-based artificial tears more effectively treated dry eye symptoms than polyvinyl alcohol-based artificial tears. Dr. Digre avoids preservatives in artificial tears because some people are sensitive to them. Oral flaxseed oil or fish oil also may help patients. If symptoms do not improve, an ophthalmologist may consider more aggressive dry eye therapy, such as punctal plugs, she said.

Photophobia

Photophobia is one of the major diagnostic criteria of migraine, and migraine is the most common cause of photophobia, Dr. Digre said. Ninety percent of people with migraine have photophobia during a migraine attack. Ocular inflammation, including dry eye, retinal disease, and cone dystrophy, is associated with photophobia. Certain brain disorders, including meningitis, pituitary tumors, and progressive supranuclear palsy, can cause photophobia. In addition, some psychiatric conditions, such as depression, and certain medications, including stimulants, have been associated with photophobia.

Photophobia has an anatomic basis, and patients without vision may still be light sensitive, Dr. Digre said. The discovery of the melanopsin pathway, a pathway of intrinsically photoactive retinal ganglion cells that function when exposed to light and inform circadian rhythm, was a breakthrough in understanding photophobia, she said.

Delwig et al in 2012 reported that when newborn mice with melanopsin-expressing intrinsically photoactive retinal ganglion cells were exposed to light, the mice vocalized in a way that is similar to when mice are distressed by having to leave the litter. Mice without melanopsin do not exhibit this same aversive behavior, Dr. Digre said. Jones et al in 2013 described a melanopsin antagonist that reverses light aversion in mice.

Light sensitivity may be associated with depression and anxiety. To assess the prevalence of anxiety and depression symptoms in migraineurs with and without interictal photophobia, Llop et al studied 16 patients with episodic migraine who had interictal photophobia, 16 patients with episodic migraine who had photophobia only during migraine attacks, and 16 controls. Migraineurs with interictal photophobia had higher scores on the Beck Depression Inventory and Beck Anxiety Inventory, compared with subjects without interictal photophobia.

Treating Light Sensitivity

Tinted lenses may help patients with migraine and photophobia. Good et al in 1991 published a study that included 20 children with migraine. Patients wore glasses with FL-41–tinted lenses (ie, a rose-colored tint) or blue-tinted lenses. Patients with FL-41–tinted lenses had reduced headache frequency at four months, whereas patients with blue-tinted lenses did not experience a sustained reduction in headache frequency.

Patients with photophobia should not keep themselves in the dark. “Every single person who comes in with three layers of sunglasses, you have to tell them that the more you stay in the dark, the worse this is going to get,” Dr. Digre said. “We have to … slowly peel off the sunglasses, lift up the shades, and start getting used to more light.”

Botulinum toxin, sympathetic nerve blocks, gabapentin, and melatonin have been used in people with photophobia. Importantly, physicians should treat any underlying psychiatric or neurologic condition, including migraine, that may be driving patients’ light sensitivity, Dr. Digre said.

—Jake Remaly

Suggested Reading

Delwig A, Logan AM, Copenhagen DR, Ahn AH. Light evokes melanopsin-dependent vocalization and neural activation associated with aversive experience in neonatal mice. PLoS One. 2012;7(9):e43787.

Good PA, Taylor RH, Mortimer MJ. The use of tinted glasses in childhood migraine. Headache. 1991;31(8):533-536.

Jones KA, Hatori M, Mure LS, et al. Small-molecule antagonists of melanopsin-mediated phototransduction. Nat Chem Biol. 2013;9(10):630-635.

Kinard KI, Smith AG, Singleton JR, et al. Chronic migraine is associated with reduced corneal nerve fiber density and symptoms of dry eye. Headache. 2015;55(4):543-549.

Koktekir BE, Celik G, Karalezli A, Kal A. Dry eyes and migraines: is there really a correlation? Cornea. 2012;31(12):1414-1416.

Llop SM, Frandsen JE, Digre KB, et al. Increased prevalence of depression and anxiety in patients with migraine and interictal photophobia. J Headache Pain. 2016;17:34.

Noseda R, Kainz V, Jakubowski M, et al. A neural mechanism for exacerbation of headache by light. Nat Neurosci. 2010;13(2):239-245.

Pucker AD, Ng SM, Nichols JJ. Over the counter (OTC) artificial tear drops for dry eye syndrome. Cochrane Database Syst Rev. 2016 Feb 23;2:CD009729.

SAN DIEGO—Among patients with migraine, eye-related symptoms such as dry eyes and photophobia are common and treatable, said Kathleen B. Digre, MD, Professor of Neurology and Ophthalmology at the University of Utah in Salt Lake City. Neurologists should treat eye-related conditions “in hopes that we can improve our patients’ migraine,” Dr. Digre said at the 58th Annual Scientific Meeting of the American Headache Society.

Dry Eyes

About 20% to 30% of people over age 45 have dry eyes. Dry eyes are more common in women than in men. Reading, computer use, and watching television may worsen dry eye symptoms due to reduced blinking during those activities. Dry climate, hormones, and certain medications used for migraine, such as amitriptyline and antihistamines, can cause or worsen dry eye symptoms. About 45% of people with Sjögren’s syndrome, a condition that causes dry eyes, have migraine. Furthermore, dry eyes are associated with photophobia, Dr. Digre said.

Koktekir et al in 2012 examined tear film function in patients with episodic migraine versus controls and found that migraineurs had significantly more tear film dysfunction, as measured by Schirmer’s test, tear film breakup time, lissamine green stain, and the Ocular Surface Disease Index.

In a case–control study published in Headache in 2015, Krista I. Kinard, MD, Adjunct Assistant Professor of Ophthalmology at the University of Utah, Dr. Digre, and colleagues examined 19 patients with chronic migraine and 30 controls. Tear film breakup time, basal tear cell secretion, and corneal sensitivity did not differ between the groups. Using corneal microscopy, however, the researchers found that controls had denser nerve fibers than patients with chronic migraine. On the Dry Eye Questionnaire, all patients with chronic migraine scored above 6, a result consistent with dry eye syndrome, whereas controls scored less than 3, as expected. Future research should evaluate whether dry eye symptoms result from the migraine process or whether dry eye symptoms may lead to chronic migraine by continuous stimulation, Dr. Digre said.

Therapeutic Options

Over-the-counter artificial tears, gels, and ointments may be safe and effective treatments for dry eyes. A review published in 2016 found that in two trials, polyacrylic acid-based artificial tears more effectively treated dry eye symptoms than polyvinyl alcohol-based artificial tears. Dr. Digre avoids preservatives in artificial tears because some people are sensitive to them. Oral flaxseed oil or fish oil also may help patients. If symptoms do not improve, an ophthalmologist may consider more aggressive dry eye therapy, such as punctal plugs, she said.

Photophobia

Photophobia is one of the major diagnostic criteria of migraine, and migraine is the most common cause of photophobia, Dr. Digre said. Ninety percent of people with migraine have photophobia during a migraine attack. Ocular inflammation, including dry eye, retinal disease, and cone dystrophy, is associated with photophobia. Certain brain disorders, including meningitis, pituitary tumors, and progressive supranuclear palsy, can cause photophobia. In addition, some psychiatric conditions, such as depression, and certain medications, including stimulants, have been associated with photophobia.

Photophobia has an anatomic basis, and patients without vision may still be light sensitive, Dr. Digre said. The discovery of the melanopsin pathway, a pathway of intrinsically photoactive retinal ganglion cells that function when exposed to light and inform circadian rhythm, was a breakthrough in understanding photophobia, she said.

Delwig et al in 2012 reported that when newborn mice with melanopsin-expressing intrinsically photoactive retinal ganglion cells were exposed to light, the mice vocalized in a way that is similar to when mice are distressed by having to leave the litter. Mice without melanopsin do not exhibit this same aversive behavior, Dr. Digre said. Jones et al in 2013 described a melanopsin antagonist that reverses light aversion in mice.

Light sensitivity may be associated with depression and anxiety. To assess the prevalence of anxiety and depression symptoms in migraineurs with and without interictal photophobia, Llop et al studied 16 patients with episodic migraine who had interictal photophobia, 16 patients with episodic migraine who had photophobia only during migraine attacks, and 16 controls. Migraineurs with interictal photophobia had higher scores on the Beck Depression Inventory and Beck Anxiety Inventory, compared with subjects without interictal photophobia.

Treating Light Sensitivity

Tinted lenses may help patients with migraine and photophobia. Good et al in 1991 published a study that included 20 children with migraine. Patients wore glasses with FL-41–tinted lenses (ie, a rose-colored tint) or blue-tinted lenses. Patients with FL-41–tinted lenses had reduced headache frequency at four months, whereas patients with blue-tinted lenses did not experience a sustained reduction in headache frequency.

Patients with photophobia should not keep themselves in the dark. “Every single person who comes in with three layers of sunglasses, you have to tell them that the more you stay in the dark, the worse this is going to get,” Dr. Digre said. “We have to … slowly peel off the sunglasses, lift up the shades, and start getting used to more light.”

Botulinum toxin, sympathetic nerve blocks, gabapentin, and melatonin have been used in people with photophobia. Importantly, physicians should treat any underlying psychiatric or neurologic condition, including migraine, that may be driving patients’ light sensitivity, Dr. Digre said.

—Jake Remaly

Suggested Reading

Delwig A, Logan AM, Copenhagen DR, Ahn AH. Light evokes melanopsin-dependent vocalization and neural activation associated with aversive experience in neonatal mice. PLoS One. 2012;7(9):e43787.

Good PA, Taylor RH, Mortimer MJ. The use of tinted glasses in childhood migraine. Headache. 1991;31(8):533-536.

Jones KA, Hatori M, Mure LS, et al. Small-molecule antagonists of melanopsin-mediated phototransduction. Nat Chem Biol. 2013;9(10):630-635.

Kinard KI, Smith AG, Singleton JR, et al. Chronic migraine is associated with reduced corneal nerve fiber density and symptoms of dry eye. Headache. 2015;55(4):543-549.

Koktekir BE, Celik G, Karalezli A, Kal A. Dry eyes and migraines: is there really a correlation? Cornea. 2012;31(12):1414-1416.

Llop SM, Frandsen JE, Digre KB, et al. Increased prevalence of depression and anxiety in patients with migraine and interictal photophobia. J Headache Pain. 2016;17:34.

Noseda R, Kainz V, Jakubowski M, et al. A neural mechanism for exacerbation of headache by light. Nat Neurosci. 2010;13(2):239-245.

Pucker AD, Ng SM, Nichols JJ. Over the counter (OTC) artificial tear drops for dry eye syndrome. Cochrane Database Syst Rev. 2016 Feb 23;2:CD009729.

Patients with HIV facial lipoatrophy (FLA) had improved quality of life scores after treatment with hyaluronic acid (HA) filler, report Derek Ho of the Sacramento VA Medical Center, and coauthors.

A prospective, open-label, phase I and II study assessed 20 patients with an HIV FLA Carruthers Lipoatrophy Severity Scale (CLSS) grade of 2 or higher, who had not received treatment for HIV FLA in the past year. Volumizing of the cheeks and temples was performed using a 20 mg/mL HA filler, with an optional touch-up at 2 weeks follow-up. Patients were given a vision exam before treatment, immediately after treatment, and 15 minutes after treatment.

Quality of life was assessed before treatment and at 12 months follow-up using the Dermatology Life Quality Index (DLQI). Satisfaction was evaluated using a subject satisfaction questionnaire at 12 months follow-up, Mr. Ho and his colleagues reported.

DLQI scores were 1.6±3.0 (range = 0-11) and 0.5±1.2 (range = 0-5) at baseline and follow-up, respectively, the authors said. Additionally, 100% of patients reported high satisfaction as indicated by answers on the subject satisfaction questionnaire, they added.

The investigators warned, however, that they would not recommend the DLQI in the future as a measure of quality of life, as this scale focuses on disability, and fails to account for mental health issues.

Still, the findings highlight “the importance of educating and offering aesthetic and corrective treatment to all patients with HIV FLA,” the authors concluded.

Read the full article in the Journal of Drugs in Dermatology.

Patients with HIV facial lipoatrophy (FLA) had improved quality of life scores after treatment with hyaluronic acid (HA) filler, report Derek Ho of the Sacramento VA Medical Center, and coauthors.

A prospective, open-label, phase I and II study assessed 20 patients with an HIV FLA Carruthers Lipoatrophy Severity Scale (CLSS) grade of 2 or higher, who had not received treatment for HIV FLA in the past year. Volumizing of the cheeks and temples was performed using a 20 mg/mL HA filler, with an optional touch-up at 2 weeks follow-up. Patients were given a vision exam before treatment, immediately after treatment, and 15 minutes after treatment.

Quality of life was assessed before treatment and at 12 months follow-up using the Dermatology Life Quality Index (DLQI). Satisfaction was evaluated using a subject satisfaction questionnaire at 12 months follow-up, Mr. Ho and his colleagues reported.

DLQI scores were 1.6±3.0 (range = 0-11) and 0.5±1.2 (range = 0-5) at baseline and follow-up, respectively, the authors said. Additionally, 100% of patients reported high satisfaction as indicated by answers on the subject satisfaction questionnaire, they added.

The investigators warned, however, that they would not recommend the DLQI in the future as a measure of quality of life, as this scale focuses on disability, and fails to account for mental health issues.

Still, the findings highlight “the importance of educating and offering aesthetic and corrective treatment to all patients with HIV FLA,” the authors concluded.

Read the full article in the Journal of Drugs in Dermatology.

Patients with HIV facial lipoatrophy (FLA) had improved quality of life scores after treatment with hyaluronic acid (HA) filler, report Derek Ho of the Sacramento VA Medical Center, and coauthors.

A prospective, open-label, phase I and II study assessed 20 patients with an HIV FLA Carruthers Lipoatrophy Severity Scale (CLSS) grade of 2 or higher, who had not received treatment for HIV FLA in the past year. Volumizing of the cheeks and temples was performed using a 20 mg/mL HA filler, with an optional touch-up at 2 weeks follow-up. Patients were given a vision exam before treatment, immediately after treatment, and 15 minutes after treatment.

Quality of life was assessed before treatment and at 12 months follow-up using the Dermatology Life Quality Index (DLQI). Satisfaction was evaluated using a subject satisfaction questionnaire at 12 months follow-up, Mr. Ho and his colleagues reported.

DLQI scores were 1.6±3.0 (range = 0-11) and 0.5±1.2 (range = 0-5) at baseline and follow-up, respectively, the authors said. Additionally, 100% of patients reported high satisfaction as indicated by answers on the subject satisfaction questionnaire, they added.

The investigators warned, however, that they would not recommend the DLQI in the future as a measure of quality of life, as this scale focuses on disability, and fails to account for mental health issues.

Still, the findings highlight “the importance of educating and offering aesthetic and corrective treatment to all patients with HIV FLA,” the authors concluded.

Read the full article in the Journal of Drugs in Dermatology.

Long-acting bronchodilators, including tiotropium, do not appear to increase the risk of cardiovascular events in the first year of use, according to a study in patients with chronic obstructive pulmonary disease.

Long-acting bronchodilators are recommended as first-line maintenance therapy for chronic obstructive pulmonary disease (COPD), but they can cause cardiac complications, wrote Samy Suissa, PhD, and his colleagues at the Centre for Clinical Epidemiology, Lady Davis Institute, Montreal.

“Indeed, long-acting anticholinergics are believed to suppress parasympathetic control, while LABAs [long-acting beta2-agonists] stimulate sympathetic tone, possibly leading to tachyarrhythmia and coronary insufficiency,” the authors wrote (Chest. 2016 Aug 20. doi: 10.1016/j.chest.2016.08.001). “Furthermore, these pharmacologic effects would be expected to occur immediately at initiation of therapy.”

However, the observational studies and randomized trials comparing the safety of LABAs and the long-acting anticholinergic tiotropium have shown inconclusive results, possibly because of insufficient numbers, short follow-ups or “treatment-experienced” patients.

Dr. Suissa and his colleagues analyzed data from 26,442 new tiotropium users and 26,442 LABA initiators from a U.K. primary care database. Participants in each arm were matched on high-dimensional propensity scores and prior inhaled corticosteroid use, and followed for 1 year for occurrence of acute myocardial infarction, stroke, heart failure, arrhythmia, and pneumonia.

The researchers saw no significant difference between tiotropium and LABA users in the risk of acute myocardial infarction (hazard ratio, 1.10; 95% CI, 0.88-1.38), stroke (HR, 1.02; 95% CI, 0.78-1.34), arrhythmia (HR, 0.81; 95% CI, 0.60-1.09), or heart failure (HR, 0.90; 95% CI, 0.79-1.02). This was the case even when the current exposure time window was varied from 60-day periods to 30- or 90-day periods.

There was a significantly lower incidence of pneumonia in individuals treated with tiotropium (HR, 0.81; 95% CI, 0.72-0.92), which the authors suggested was likely due to the presence of inhaled corticosteroids in many LABAs.

“In our study, 78% of the LABA users were receiving a combined inhaler that included an inhaled corticosteroid, two-thirds of which were for fluticasone, which has been associated with an up to twofold increase in the risk of pneumonia,” they reported.

The authors acknowledged that the presence of an inhaled corticosteroid in combination with many of the LABAs could attract criticism that the study was therefore not a strict comparison between tiotropium and a LABA. However, they noted that the study aimed to represent the real-world experience of clinical practice.

“In this real-world–setting study of the treatment of COPD, the initiation of maintenance treatment with tiotropium compared with a LABA does not increase cardiovascular risk, but reduces significantly the risk of pneumonia, albeit a likely adverse effect of the inhaled corticosteroid component present in many LABA inhalers,” the authors wrote.

“This differential risk that appears to confer a safety advantage to tiotropium as the initial long-acting bronchodilator in COPD should be considered against the comparative effectiveness of these two treatments at initiation,” they noted.

The Canadian Institutes of Health Research, the Canadian Foundation for Innovation, and Boehringer Ingelheim supported the study. One author disclosed ties with Boehringer Ingelheim, AstraZeneca, Novartis, and Pfizer. No other conflicts of interest were declared.

Long-acting bronchodilators, including tiotropium, do not appear to increase the risk of cardiovascular events in the first year of use, according to a study in patients with chronic obstructive pulmonary disease.

Long-acting bronchodilators are recommended as first-line maintenance therapy for chronic obstructive pulmonary disease (COPD), but they can cause cardiac complications, wrote Samy Suissa, PhD, and his colleagues at the Centre for Clinical Epidemiology, Lady Davis Institute, Montreal.

“Indeed, long-acting anticholinergics are believed to suppress parasympathetic control, while LABAs [long-acting beta2-agonists] stimulate sympathetic tone, possibly leading to tachyarrhythmia and coronary insufficiency,” the authors wrote (Chest. 2016 Aug 20. doi: 10.1016/j.chest.2016.08.001). “Furthermore, these pharmacologic effects would be expected to occur immediately at initiation of therapy.”

However, the observational studies and randomized trials comparing the safety of LABAs and the long-acting anticholinergic tiotropium have shown inconclusive results, possibly because of insufficient numbers, short follow-ups or “treatment-experienced” patients.

Dr. Suissa and his colleagues analyzed data from 26,442 new tiotropium users and 26,442 LABA initiators from a U.K. primary care database. Participants in each arm were matched on high-dimensional propensity scores and prior inhaled corticosteroid use, and followed for 1 year for occurrence of acute myocardial infarction, stroke, heart failure, arrhythmia, and pneumonia.

The researchers saw no significant difference between tiotropium and LABA users in the risk of acute myocardial infarction (hazard ratio, 1.10; 95% CI, 0.88-1.38), stroke (HR, 1.02; 95% CI, 0.78-1.34), arrhythmia (HR, 0.81; 95% CI, 0.60-1.09), or heart failure (HR, 0.90; 95% CI, 0.79-1.02). This was the case even when the current exposure time window was varied from 60-day periods to 30- or 90-day periods.

There was a significantly lower incidence of pneumonia in individuals treated with tiotropium (HR, 0.81; 95% CI, 0.72-0.92), which the authors suggested was likely due to the presence of inhaled corticosteroids in many LABAs.

“In our study, 78% of the LABA users were receiving a combined inhaler that included an inhaled corticosteroid, two-thirds of which were for fluticasone, which has been associated with an up to twofold increase in the risk of pneumonia,” they reported.

The authors acknowledged that the presence of an inhaled corticosteroid in combination with many of the LABAs could attract criticism that the study was therefore not a strict comparison between tiotropium and a LABA. However, they noted that the study aimed to represent the real-world experience of clinical practice.

“In this real-world–setting study of the treatment of COPD, the initiation of maintenance treatment with tiotropium compared with a LABA does not increase cardiovascular risk, but reduces significantly the risk of pneumonia, albeit a likely adverse effect of the inhaled corticosteroid component present in many LABA inhalers,” the authors wrote.

“This differential risk that appears to confer a safety advantage to tiotropium as the initial long-acting bronchodilator in COPD should be considered against the comparative effectiveness of these two treatments at initiation,” they noted.

The Canadian Institutes of Health Research, the Canadian Foundation for Innovation, and Boehringer Ingelheim supported the study. One author disclosed ties with Boehringer Ingelheim, AstraZeneca, Novartis, and Pfizer. No other conflicts of interest were declared.

Long-acting bronchodilators, including tiotropium, do not appear to increase the risk of cardiovascular events in the first year of use, according to a study in patients with chronic obstructive pulmonary disease.

Long-acting bronchodilators are recommended as first-line maintenance therapy for chronic obstructive pulmonary disease (COPD), but they can cause cardiac complications, wrote Samy Suissa, PhD, and his colleagues at the Centre for Clinical Epidemiology, Lady Davis Institute, Montreal.

“Indeed, long-acting anticholinergics are believed to suppress parasympathetic control, while LABAs [long-acting beta2-agonists] stimulate sympathetic tone, possibly leading to tachyarrhythmia and coronary insufficiency,” the authors wrote (Chest. 2016 Aug 20. doi: 10.1016/j.chest.2016.08.001). “Furthermore, these pharmacologic effects would be expected to occur immediately at initiation of therapy.”

However, the observational studies and randomized trials comparing the safety of LABAs and the long-acting anticholinergic tiotropium have shown inconclusive results, possibly because of insufficient numbers, short follow-ups or “treatment-experienced” patients.

Dr. Suissa and his colleagues analyzed data from 26,442 new tiotropium users and 26,442 LABA initiators from a U.K. primary care database. Participants in each arm were matched on high-dimensional propensity scores and prior inhaled corticosteroid use, and followed for 1 year for occurrence of acute myocardial infarction, stroke, heart failure, arrhythmia, and pneumonia.

The researchers saw no significant difference between tiotropium and LABA users in the risk of acute myocardial infarction (hazard ratio, 1.10; 95% CI, 0.88-1.38), stroke (HR, 1.02; 95% CI, 0.78-1.34), arrhythmia (HR, 0.81; 95% CI, 0.60-1.09), or heart failure (HR, 0.90; 95% CI, 0.79-1.02). This was the case even when the current exposure time window was varied from 60-day periods to 30- or 90-day periods.

There was a significantly lower incidence of pneumonia in individuals treated with tiotropium (HR, 0.81; 95% CI, 0.72-0.92), which the authors suggested was likely due to the presence of inhaled corticosteroids in many LABAs.

“In our study, 78% of the LABA users were receiving a combined inhaler that included an inhaled corticosteroid, two-thirds of which were for fluticasone, which has been associated with an up to twofold increase in the risk of pneumonia,” they reported.

The authors acknowledged that the presence of an inhaled corticosteroid in combination with many of the LABAs could attract criticism that the study was therefore not a strict comparison between tiotropium and a LABA. However, they noted that the study aimed to represent the real-world experience of clinical practice.

“In this real-world–setting study of the treatment of COPD, the initiation of maintenance treatment with tiotropium compared with a LABA does not increase cardiovascular risk, but reduces significantly the risk of pneumonia, albeit a likely adverse effect of the inhaled corticosteroid component present in many LABA inhalers,” the authors wrote.

“This differential risk that appears to confer a safety advantage to tiotropium as the initial long-acting bronchodilator in COPD should be considered against the comparative effectiveness of these two treatments at initiation,” they noted.

The Canadian Institutes of Health Research, the Canadian Foundation for Innovation, and Boehringer Ingelheim supported the study. One author disclosed ties with Boehringer Ingelheim, AstraZeneca, Novartis, and Pfizer. No other conflicts of interest were declared.

Naturally occurring variations on or near the NPC1L1 gene, which is linked to lower LDL-cholesterol levels, were associated with a higher risk of type 2 diabetes in a meta-analysis reported online Oct. 4 in JAMA.

©Christian Jasiuk/Thinkstock

Some cholesterol-lowering medications, notably ezetimibe, work by inhibiting the action of the NPC1L1 gene. The findings of this meta-analysis suggest that by doing so, these cholesterol-lowering agents may raise the risk of type 2 diabetes, said Luca A. Lotta, MD, PhD, of the Medical Research Council Epidemiology Unit, University of Cambridge (U.K.), and his associates. The investigators examined gene-association analyses in several studies and databases covering 50,775 adults with type 2 diabetes and 270,269 control subjects in Europe and the United States during 1991-2016. They found that alleles at the NPC1L1 locus that are known to be associated with lower LDL-cholesterol levels also were strongly associated with higher rates of diabetes. For every genetically predicted reduction in LDL-C of 1 mmol/L, the risk for type 2 diabetes increased (odds ratio, 2.42).

The estimated absolute risk difference was 5.3 incident cases/1,000 person-years for every genetically predicted 1-mmol/L reduction in LDL-C, Dr. Lotta and his associates said (JAMA. 2016 Oct. 4. doi: 10.1001/jama.2016.14568).

These findings are consistent with reports that link cholesterol-lowering medications with weight gain and a higher incidence of new-onset type 2 diabetes, as well as with the clinical observation that patients with familial hypercholesterolemia carry a lower risk for diabetes. “These results warrant the continued monitoring of the glycemic effects of ezetimibe in clinical trials and in clinical practice,” the researchers noted.

Naturally occurring variations on or near the NPC1L1 gene, which is linked to lower LDL-cholesterol levels, were associated with a higher risk of type 2 diabetes in a meta-analysis reported online Oct. 4 in JAMA.

©Christian Jasiuk/Thinkstock

Some cholesterol-lowering medications, notably ezetimibe, work by inhibiting the action of the NPC1L1 gene. The findings of this meta-analysis suggest that by doing so, these cholesterol-lowering agents may raise the risk of type 2 diabetes, said Luca A. Lotta, MD, PhD, of the Medical Research Council Epidemiology Unit, University of Cambridge (U.K.), and his associates. The investigators examined gene-association analyses in several studies and databases covering 50,775 adults with type 2 diabetes and 270,269 control subjects in Europe and the United States during 1991-2016. They found that alleles at the NPC1L1 locus that are known to be associated with lower LDL-cholesterol levels also were strongly associated with higher rates of diabetes. For every genetically predicted reduction in LDL-C of 1 mmol/L, the risk for type 2 diabetes increased (odds ratio, 2.42).

The estimated absolute risk difference was 5.3 incident cases/1,000 person-years for every genetically predicted 1-mmol/L reduction in LDL-C, Dr. Lotta and his associates said (JAMA. 2016 Oct. 4. doi: 10.1001/jama.2016.14568).

These findings are consistent with reports that link cholesterol-lowering medications with weight gain and a higher incidence of new-onset type 2 diabetes, as well as with the clinical observation that patients with familial hypercholesterolemia carry a lower risk for diabetes. “These results warrant the continued monitoring of the glycemic effects of ezetimibe in clinical trials and in clinical practice,” the researchers noted.

Naturally occurring variations on or near the NPC1L1 gene, which is linked to lower LDL-cholesterol levels, were associated with a higher risk of type 2 diabetes in a meta-analysis reported online Oct. 4 in JAMA.

©Christian Jasiuk/Thinkstock

Some cholesterol-lowering medications, notably ezetimibe, work by inhibiting the action of the NPC1L1 gene. The findings of this meta-analysis suggest that by doing so, these cholesterol-lowering agents may raise the risk of type 2 diabetes, said Luca A. Lotta, MD, PhD, of the Medical Research Council Epidemiology Unit, University of Cambridge (U.K.), and his associates. The investigators examined gene-association analyses in several studies and databases covering 50,775 adults with type 2 diabetes and 270,269 control subjects in Europe and the United States during 1991-2016. They found that alleles at the NPC1L1 locus that are known to be associated with lower LDL-cholesterol levels also were strongly associated with higher rates of diabetes. For every genetically predicted reduction in LDL-C of 1 mmol/L, the risk for type 2 diabetes increased (odds ratio, 2.42).

The estimated absolute risk difference was 5.3 incident cases/1,000 person-years for every genetically predicted 1-mmol/L reduction in LDL-C, Dr. Lotta and his associates said (JAMA. 2016 Oct. 4. doi: 10.1001/jama.2016.14568).

These findings are consistent with reports that link cholesterol-lowering medications with weight gain and a higher incidence of new-onset type 2 diabetes, as well as with the clinical observation that patients with familial hypercholesterolemia carry a lower risk for diabetes. “These results warrant the continued monitoring of the glycemic effects of ezetimibe in clinical trials and in clinical practice,” the researchers noted.

WAIKOLOA, HAWAII – Trauma training for general surgery residents has significantly declined in recent years, results from an analysis of the Accreditation Council for Graduate Medical Education data registry on surgical education showed.

Aaron Strumwasser, MD, an attending trauma surgeon and surgical intensivist at the Los Angeles County/University of Southern California Medical Center, characterized the decline in trauma training as “sobering.” In an effort to test their hypothesis that trauma training for general surgery residents is on the decline since the inception of the 80-hour workweek, Dr. Strumwasser and his associates set out to compare the operative caseloads before and after the inception of the 80-hour workweek; to note trends in specific operative domains and determine if deficiencies exist and to determine whether subspecialty training (specifically, vascular fellowship and integrated vascular surgery residency) has altered general surgery resident operative volume. They extracted data from the ACGME database on resident trauma volume for trauma cases by category and by resident training year for the years 1999-2015. Only those cases logged as primary surgery were included. The researchers subdivided trauma cases into five domains: head and neck, thoracic, abdomen, solid organ, and extremity. Resident trauma experience (operative caseload) was compared, based on before the inception of the 80-hour workweek (1999-2002) and after (2003-present).

Spotmatik/Thinkstock

[email protected]

WAIKOLOA, HAWAII – Trauma training for general surgery residents has significantly declined in recent years, results from an analysis of the Accreditation Council for Graduate Medical Education data registry on surgical education showed.

Aaron Strumwasser, MD, an attending trauma surgeon and surgical intensivist at the Los Angeles County/University of Southern California Medical Center, characterized the decline in trauma training as “sobering.” In an effort to test their hypothesis that trauma training for general surgery residents is on the decline since the inception of the 80-hour workweek, Dr. Strumwasser and his associates set out to compare the operative caseloads before and after the inception of the 80-hour workweek; to note trends in specific operative domains and determine if deficiencies exist and to determine whether subspecialty training (specifically, vascular fellowship and integrated vascular surgery residency) has altered general surgery resident operative volume. They extracted data from the ACGME database on resident trauma volume for trauma cases by category and by resident training year for the years 1999-2015. Only those cases logged as primary surgery were included. The researchers subdivided trauma cases into five domains: head and neck, thoracic, abdomen, solid organ, and extremity. Resident trauma experience (operative caseload) was compared, based on before the inception of the 80-hour workweek (1999-2002) and after (2003-present).

Spotmatik/Thinkstock

[email protected]

WAIKOLOA, HAWAII – Trauma training for general surgery residents has significantly declined in recent years, results from an analysis of the Accreditation Council for Graduate Medical Education data registry on surgical education showed.

Aaron Strumwasser, MD, an attending trauma surgeon and surgical intensivist at the Los Angeles County/University of Southern California Medical Center, characterized the decline in trauma training as “sobering.” In an effort to test their hypothesis that trauma training for general surgery residents is on the decline since the inception of the 80-hour workweek, Dr. Strumwasser and his associates set out to compare the operative caseloads before and after the inception of the 80-hour workweek; to note trends in specific operative domains and determine if deficiencies exist and to determine whether subspecialty training (specifically, vascular fellowship and integrated vascular surgery residency) has altered general surgery resident operative volume. They extracted data from the ACGME database on resident trauma volume for trauma cases by category and by resident training year for the years 1999-2015. Only those cases logged as primary surgery were included. The researchers subdivided trauma cases into five domains: head and neck, thoracic, abdomen, solid organ, and extremity. Resident trauma experience (operative caseload) was compared, based on before the inception of the 80-hour workweek (1999-2002) and after (2003-present).

Spotmatik/Thinkstock

[email protected]

LAS VEGAS – Patients with rheumatoid arthritis who have pulmonary symptoms and a restrictive pulmonary function test pattern have a high likelihood for a diagnosis of interstitial lung disease, making it necessary to put it high on the differential and to begin working collaboratively with pulmonologists, according to Jon T. Giles, MD.

Overall, 8%-15% of RA patients will develop clinically significant interstitial lung disease (ILD), although radiographic evidence of ILD can be seen in up to half of RA patients, and in one study about one in four patients had evidence of ILD on CT scanning within 2 years of RA diagnosis. The overall risk for RA patients to develop ILD has been shown to be nine times higher than for matched controls (Arthritis Rheum. 2010 Jun;62[6]:1583-91), Dr. Giles said at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

An “alphabet soup” of ILD subtypes

Though there’s an “alphabet soup” of subtypes of ILD in RA, 90% of RA patients with ILD will have one of two conditions: usual interstitial pneumonitis (RA-UIP) or nonspecific interstitial pneumonitis (RA-NSIP). It’s not entirely clear whether one type of RA-ILD has a survival advantage over the other, Dr. Giles said.

Care for RA patients should include screening for ILD, said Dr. Giles. Physicians should ask about dry cough, dyspnea, and decreased exercise tolerance. Signs of ILD can include diminished oxygen saturation, a cardiac exam consistent with right heart disease, and rales. It’s not clear, he said, whether periodic chest radiographs or pulmonary function testing in asymptomatic RA patients is warranted.

Positive findings should prompt pulmonary function testing to include DLCO (diffusing capacity of lung for carbon monoxide), which may or may not be reduced in patients with clinically significant ILD. However, testing will show a restrictive pattern. A high-resolution chest CT should also be obtained.

Further evaluation should be done collaboratively with pulmonologists, and preferably with an ILD center, said Dr. Giles. A bronchoalveolar lavage and/or a lung biopsy may be considered.

Radiographic features of RA-UIP can include reticulation and honeycombing, predominantly seen in a subpleural and basilar distribution. Traction bronchiectasis may or may not be present. If a biopsy is performed, the histologic presentation of RA-UIP includes subpleural patches of dense fibrosis and honeycombing adjacent to healthy lung tissue; fibroblastic foci may be seen in the fibrotic regions.

In differentiating RA-UIP from interstitial pulmonary fibrosis (IPF), Dr. Giles said that lymphoid hyperplasia with germinal centers and peribronchial lesions are both more common in RA-UIP than in IPF. By contrast, fibroblastic foci are less common in RA-UIP than in IPF.

Sorting out the relationship between the use of disease-modifying antirheumatic drugs and ILD in RA is complicated by “complexities of attribution,” said Dr. Giles, since “RA patients with the most severe or refractory disease are more likely to both be exposed to a great number of RA therapies and higher doses and more combinations, and to have more risk factors for ILD.” Additionally, hypersensitivity pneumonitis can share some features with some subtypes of RA-ILD.

Treatment goals

Beyond maximizing smoking-cessation intervention, which should be done for all currently smoking ILD patients, treatment goals for RA-ILD are “a balancing act,” Dr. Giles said. Immunizations should be up to date for all RA-ILD patients, and any concomitant pulmonary conditions, such as asthma or chronic obstructive pulmonary disorder, should also be optimally treated. An early evaluation for lung transplant is warranted for RA-ILD as well, he said.

If patients are symptomatic, then the goal is symptom reduction, with the extent of radiographically or histologically documented involvement and the rate of decline to be factored into treatment decisions.

Immunosuppressive treatments for RA-ILD, Dr. Giles said, “are not supported by any randomized clinical trials.” However, corticosteroids are often effective for RA-NSIP; “UIP is often not steroid responsive,” he said. Other agents can include azathioprine, which can give a “double whammy” effect by addressing joint and lung disease. However, azathioprine should not be used concurrently with corticosteroids, he said.

Mycophenolate mofetil (CellCept) has known antifibrotic effects, and there have been case reports of improvement in RA-ILD. Cyclophosphamide is also occasionally used. A host of other treatments have been attempted, including the antifibrotics pirfenidone (Esbriet) and nintedanib (Ofev), although these have been studied only in interstitial pulmonary fibrosis, said Dr. Giles. “Treating symptomatic RA-ILD is always a challenge,” he said.

Dr. Giles has been a consultant to Roche/Genentech and Proximagen and has received grant funding from Pfizer.

Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

On Twitter @karioakes

LAS VEGAS – Patients with rheumatoid arthritis who have pulmonary symptoms and a restrictive pulmonary function test pattern have a high likelihood for a diagnosis of interstitial lung disease, making it necessary to put it high on the differential and to begin working collaboratively with pulmonologists, according to Jon T. Giles, MD.

Overall, 8%-15% of RA patients will develop clinically significant interstitial lung disease (ILD), although radiographic evidence of ILD can be seen in up to half of RA patients, and in one study about one in four patients had evidence of ILD on CT scanning within 2 years of RA diagnosis. The overall risk for RA patients to develop ILD has been shown to be nine times higher than for matched controls (Arthritis Rheum. 2010 Jun;62[6]:1583-91), Dr. Giles said at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

An “alphabet soup” of ILD subtypes

Though there’s an “alphabet soup” of subtypes of ILD in RA, 90% of RA patients with ILD will have one of two conditions: usual interstitial pneumonitis (RA-UIP) or nonspecific interstitial pneumonitis (RA-NSIP). It’s not entirely clear whether one type of RA-ILD has a survival advantage over the other, Dr. Giles said.

Care for RA patients should include screening for ILD, said Dr. Giles. Physicians should ask about dry cough, dyspnea, and decreased exercise tolerance. Signs of ILD can include diminished oxygen saturation, a cardiac exam consistent with right heart disease, and rales. It’s not clear, he said, whether periodic chest radiographs or pulmonary function testing in asymptomatic RA patients is warranted.

Positive findings should prompt pulmonary function testing to include DLCO (diffusing capacity of lung for carbon monoxide), which may or may not be reduced in patients with clinically significant ILD. However, testing will show a restrictive pattern. A high-resolution chest CT should also be obtained.

Further evaluation should be done collaboratively with pulmonologists, and preferably with an ILD center, said Dr. Giles. A bronchoalveolar lavage and/or a lung biopsy may be considered.

Radiographic features of RA-UIP can include reticulation and honeycombing, predominantly seen in a subpleural and basilar distribution. Traction bronchiectasis may or may not be present. If a biopsy is performed, the histologic presentation of RA-UIP includes subpleural patches of dense fibrosis and honeycombing adjacent to healthy lung tissue; fibroblastic foci may be seen in the fibrotic regions.

In differentiating RA-UIP from interstitial pulmonary fibrosis (IPF), Dr. Giles said that lymphoid hyperplasia with germinal centers and peribronchial lesions are both more common in RA-UIP than in IPF. By contrast, fibroblastic foci are less common in RA-UIP than in IPF.

Sorting out the relationship between the use of disease-modifying antirheumatic drugs and ILD in RA is complicated by “complexities of attribution,” said Dr. Giles, since “RA patients with the most severe or refractory disease are more likely to both be exposed to a great number of RA therapies and higher doses and more combinations, and to have more risk factors for ILD.” Additionally, hypersensitivity pneumonitis can share some features with some subtypes of RA-ILD.

Treatment goals

Beyond maximizing smoking-cessation intervention, which should be done for all currently smoking ILD patients, treatment goals for RA-ILD are “a balancing act,” Dr. Giles said. Immunizations should be up to date for all RA-ILD patients, and any concomitant pulmonary conditions, such as asthma or chronic obstructive pulmonary disorder, should also be optimally treated. An early evaluation for lung transplant is warranted for RA-ILD as well, he said.

If patients are symptomatic, then the goal is symptom reduction, with the extent of radiographically or histologically documented involvement and the rate of decline to be factored into treatment decisions.

Immunosuppressive treatments for RA-ILD, Dr. Giles said, “are not supported by any randomized clinical trials.” However, corticosteroids are often effective for RA-NSIP; “UIP is often not steroid responsive,” he said. Other agents can include azathioprine, which can give a “double whammy” effect by addressing joint and lung disease. However, azathioprine should not be used concurrently with corticosteroids, he said.

Mycophenolate mofetil (CellCept) has known antifibrotic effects, and there have been case reports of improvement in RA-ILD. Cyclophosphamide is also occasionally used. A host of other treatments have been attempted, including the antifibrotics pirfenidone (Esbriet) and nintedanib (Ofev), although these have been studied only in interstitial pulmonary fibrosis, said Dr. Giles. “Treating symptomatic RA-ILD is always a challenge,” he said.

Dr. Giles has been a consultant to Roche/Genentech and Proximagen and has received grant funding from Pfizer.

Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

On Twitter @karioakes

LAS VEGAS – Patients with rheumatoid arthritis who have pulmonary symptoms and a restrictive pulmonary function test pattern have a high likelihood for a diagnosis of interstitial lung disease, making it necessary to put it high on the differential and to begin working collaboratively with pulmonologists, according to Jon T. Giles, MD.

Overall, 8%-15% of RA patients will develop clinically significant interstitial lung disease (ILD), although radiographic evidence of ILD can be seen in up to half of RA patients, and in one study about one in four patients had evidence of ILD on CT scanning within 2 years of RA diagnosis. The overall risk for RA patients to develop ILD has been shown to be nine times higher than for matched controls (Arthritis Rheum. 2010 Jun;62[6]:1583-91), Dr. Giles said at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

An “alphabet soup” of ILD subtypes

Though there’s an “alphabet soup” of subtypes of ILD in RA, 90% of RA patients with ILD will have one of two conditions: usual interstitial pneumonitis (RA-UIP) or nonspecific interstitial pneumonitis (RA-NSIP). It’s not entirely clear whether one type of RA-ILD has a survival advantage over the other, Dr. Giles said.

Care for RA patients should include screening for ILD, said Dr. Giles. Physicians should ask about dry cough, dyspnea, and decreased exercise tolerance. Signs of ILD can include diminished oxygen saturation, a cardiac exam consistent with right heart disease, and rales. It’s not clear, he said, whether periodic chest radiographs or pulmonary function testing in asymptomatic RA patients is warranted.

Positive findings should prompt pulmonary function testing to include DLCO (diffusing capacity of lung for carbon monoxide), which may or may not be reduced in patients with clinically significant ILD. However, testing will show a restrictive pattern. A high-resolution chest CT should also be obtained.

Further evaluation should be done collaboratively with pulmonologists, and preferably with an ILD center, said Dr. Giles. A bronchoalveolar lavage and/or a lung biopsy may be considered.

Radiographic features of RA-UIP can include reticulation and honeycombing, predominantly seen in a subpleural and basilar distribution. Traction bronchiectasis may or may not be present. If a biopsy is performed, the histologic presentation of RA-UIP includes subpleural patches of dense fibrosis and honeycombing adjacent to healthy lung tissue; fibroblastic foci may be seen in the fibrotic regions.

In differentiating RA-UIP from interstitial pulmonary fibrosis (IPF), Dr. Giles said that lymphoid hyperplasia with germinal centers and peribronchial lesions are both more common in RA-UIP than in IPF. By contrast, fibroblastic foci are less common in RA-UIP than in IPF.

Sorting out the relationship between the use of disease-modifying antirheumatic drugs and ILD in RA is complicated by “complexities of attribution,” said Dr. Giles, since “RA patients with the most severe or refractory disease are more likely to both be exposed to a great number of RA therapies and higher doses and more combinations, and to have more risk factors for ILD.” Additionally, hypersensitivity pneumonitis can share some features with some subtypes of RA-ILD.

Treatment goals

Beyond maximizing smoking-cessation intervention, which should be done for all currently smoking ILD patients, treatment goals for RA-ILD are “a balancing act,” Dr. Giles said. Immunizations should be up to date for all RA-ILD patients, and any concomitant pulmonary conditions, such as asthma or chronic obstructive pulmonary disorder, should also be optimally treated. An early evaluation for lung transplant is warranted for RA-ILD as well, he said.

If patients are symptomatic, then the goal is symptom reduction, with the extent of radiographically or histologically documented involvement and the rate of decline to be factored into treatment decisions.

Immunosuppressive treatments for RA-ILD, Dr. Giles said, “are not supported by any randomized clinical trials.” However, corticosteroids are often effective for RA-NSIP; “UIP is often not steroid responsive,” he said. Other agents can include azathioprine, which can give a “double whammy” effect by addressing joint and lung disease. However, azathioprine should not be used concurrently with corticosteroids, he said.

Mycophenolate mofetil (CellCept) has known antifibrotic effects, and there have been case reports of improvement in RA-ILD. Cyclophosphamide is also occasionally used. A host of other treatments have been attempted, including the antifibrotics pirfenidone (Esbriet) and nintedanib (Ofev), although these have been studied only in interstitial pulmonary fibrosis, said Dr. Giles. “Treating symptomatic RA-ILD is always a challenge,” he said.

Dr. Giles has been a consultant to Roche/Genentech and Proximagen and has received grant funding from Pfizer.

Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

On Twitter @karioakes

BOSTON – Patients with stage II or III non–small-cell lung cancer with comorbidities that make them poor candidates for surgery or chemotherapy may still benefit from accelerated hypofractionated radiation, an interim analysis of a randomized trial suggests.

Among 48 patients followed for a median of 24 months, there were no statistical differences in either overall survival (OS) or progression-free survival between patients with stage II or III NSCLC and poor performance status treated with either conventional radiation delivered over 6 weeks, or image-guided radiation therapy (IGRT) delivered over 3 weeks, reported Puneeth Iyengar, MD, PhD, of the University of Texas Southwestern in Dallas.

BOSTON – Patients with stage II or III non–small-cell lung cancer with comorbidities that make them poor candidates for surgery or chemotherapy may still benefit from accelerated hypofractionated radiation, an interim analysis of a randomized trial suggests.

Among 48 patients followed for a median of 24 months, there were no statistical differences in either overall survival (OS) or progression-free survival between patients with stage II or III NSCLC and poor performance status treated with either conventional radiation delivered over 6 weeks, or image-guided radiation therapy (IGRT) delivered over 3 weeks, reported Puneeth Iyengar, MD, PhD, of the University of Texas Southwestern in Dallas.

BOSTON – Patients with stage II or III non–small-cell lung cancer with comorbidities that make them poor candidates for surgery or chemotherapy may still benefit from accelerated hypofractionated radiation, an interim analysis of a randomized trial suggests.

Among 48 patients followed for a median of 24 months, there were no statistical differences in either overall survival (OS) or progression-free survival between patients with stage II or III NSCLC and poor performance status treated with either conventional radiation delivered over 6 weeks, or image-guided radiation therapy (IGRT) delivered over 3 weeks, reported Puneeth Iyengar, MD, PhD, of the University of Texas Southwestern in Dallas.

In a large retrospective study of patients with hidradenitis suppurativa (HS) managed with surgical procedures, excision and unroofing methods were associated with low rates of complications, moderate levels of postoperative recurrences, and low rates of reoperations for those experiencing recurrences.

“Data from this surgical series of patients with HS demonstrate that surgical management is a safe and effective treatment for advanced intractable HS disease,” concluded John J. Kohorst, MD, a resident in dermatology at the Mayo Clinic, Rochester, Minn., and his associates (Dermatol Surg. 2016;42:1030-40).

Although a variety of surgical procedures have been described as treatments for advanced, intractable HS, the efficacy and safety of specific operative methodologies have remained unclear because of the relatively small number of patients examined in previous studies, they noted.

To further elucidate the efficacy and safety of currently available surgical treatment options for patient with advanced HS, they conducted a retrospective medical chart review of 590 consecutive patients with HS who underwent excision, unroofing, or drainage operative procedures between Jan. 1, 1976, and Dec. 31, 2012. This cohort included almost three times as many patients as the largest of the previously published studies on the subject. Their mean age at the time of surgery was 41 years, and most (80.7%) had Hurley stage III disease.

The majority of patients had undergone excision (68.6%) and unroofing (28.5%) procedures.

Most of the procedures were safe and effective, according to the investigators. Only 15 of the 590 patients (2.5%) experienced postoperative complications within the first 30 days of surgery (including 9 cases of cellulitis and 2 skin graft losses). Although 144 patients (24.4%) experienced recurrence at the surgical site, only 69 of the 590 patients (11.7%) required reoperation over an average of about 25 months.

The results of the multivariate Cox proportional hazards regression analysis, used to determine factors associated with risk of recurrence, indicated that surgery at multiple sites (hazard ratio, 1.6; 95% confidence interval, 1.1-2.5), and incision and drainage procedures (HR, 3.5; 95% CI, 1.2-10.7) were all significantly associated with higher rates of recurrence. In addition, “for each decade younger at the time of surgery, patients had a significantly increased recurrence risk,” they wrote.

In an interview, Dr. Kohorst said that there was a “significant effect of age on postoperative recurrence,” with patients under age 30 having approximately a 50% chance of recurrence, compared with a 25% chance of recurrence in patients older than 50 years of age.

Conversely, other variables they assessed including the specific surgical site(s) examined, disease severity based on the patient’s Hurley stage, gender, and the extent of the operation were not associated with an increase in recurrence rates. No difference was detected between the risk of recurrence for those undergoing excision or unroofing (HR, 1.0; 95% CI, 0.6-1.4).

Based on their overall findings, the authors concluded that “with well-planned, individualized surgical care, the likelihood of postoperative recurrence rests largely on patient age at surgical treatment and the number of surgical sites.”

They disclosed no conflicts of interest. A funding source of the study was not provided.

In a large retrospective study of patients with hidradenitis suppurativa (HS) managed with surgical procedures, excision and unroofing methods were associated with low rates of complications, moderate levels of postoperative recurrences, and low rates of reoperations for those experiencing recurrences.

“Data from this surgical series of patients with HS demonstrate that surgical management is a safe and effective treatment for advanced intractable HS disease,” concluded John J. Kohorst, MD, a resident in dermatology at the Mayo Clinic, Rochester, Minn., and his associates (Dermatol Surg. 2016;42:1030-40).

Although a variety of surgical procedures have been described as treatments for advanced, intractable HS, the efficacy and safety of specific operative methodologies have remained unclear because of the relatively small number of patients examined in previous studies, they noted.

To further elucidate the efficacy and safety of currently available surgical treatment options for patient with advanced HS, they conducted a retrospective medical chart review of 590 consecutive patients with HS who underwent excision, unroofing, or drainage operative procedures between Jan. 1, 1976, and Dec. 31, 2012. This cohort included almost three times as many patients as the largest of the previously published studies on the subject. Their mean age at the time of surgery was 41 years, and most (80.7%) had Hurley stage III disease.

The majority of patients had undergone excision (68.6%) and unroofing (28.5%) procedures.

Most of the procedures were safe and effective, according to the investigators. Only 15 of the 590 patients (2.5%) experienced postoperative complications within the first 30 days of surgery (including 9 cases of cellulitis and 2 skin graft losses). Although 144 patients (24.4%) experienced recurrence at the surgical site, only 69 of the 590 patients (11.7%) required reoperation over an average of about 25 months.

The results of the multivariate Cox proportional hazards regression analysis, used to determine factors associated with risk of recurrence, indicated that surgery at multiple sites (hazard ratio, 1.6; 95% confidence interval, 1.1-2.5), and incision and drainage procedures (HR, 3.5; 95% CI, 1.2-10.7) were all significantly associated with higher rates of recurrence. In addition, “for each decade younger at the time of surgery, patients had a significantly increased recurrence risk,” they wrote.

In an interview, Dr. Kohorst said that there was a “significant effect of age on postoperative recurrence,” with patients under age 30 having approximately a 50% chance of recurrence, compared with a 25% chance of recurrence in patients older than 50 years of age.

Conversely, other variables they assessed including the specific surgical site(s) examined, disease severity based on the patient’s Hurley stage, gender, and the extent of the operation were not associated with an increase in recurrence rates. No difference was detected between the risk of recurrence for those undergoing excision or unroofing (HR, 1.0; 95% CI, 0.6-1.4).

Based on their overall findings, the authors concluded that “with well-planned, individualized surgical care, the likelihood of postoperative recurrence rests largely on patient age at surgical treatment and the number of surgical sites.”

They disclosed no conflicts of interest. A funding source of the study was not provided.

In a large retrospective study of patients with hidradenitis suppurativa (HS) managed with surgical procedures, excision and unroofing methods were associated with low rates of complications, moderate levels of postoperative recurrences, and low rates of reoperations for those experiencing recurrences.

“Data from this surgical series of patients with HS demonstrate that surgical management is a safe and effective treatment for advanced intractable HS disease,” concluded John J. Kohorst, MD, a resident in dermatology at the Mayo Clinic, Rochester, Minn., and his associates (Dermatol Surg. 2016;42:1030-40).

Although a variety of surgical procedures have been described as treatments for advanced, intractable HS, the efficacy and safety of specific operative methodologies have remained unclear because of the relatively small number of patients examined in previous studies, they noted.

To further elucidate the efficacy and safety of currently available surgical treatment options for patient with advanced HS, they conducted a retrospective medical chart review of 590 consecutive patients with HS who underwent excision, unroofing, or drainage operative procedures between Jan. 1, 1976, and Dec. 31, 2012. This cohort included almost three times as many patients as the largest of the previously published studies on the subject. Their mean age at the time of surgery was 41 years, and most (80.7%) had Hurley stage III disease.

The majority of patients had undergone excision (68.6%) and unroofing (28.5%) procedures.

Most of the procedures were safe and effective, according to the investigators. Only 15 of the 590 patients (2.5%) experienced postoperative complications within the first 30 days of surgery (including 9 cases of cellulitis and 2 skin graft losses). Although 144 patients (24.4%) experienced recurrence at the surgical site, only 69 of the 590 patients (11.7%) required reoperation over an average of about 25 months.

The results of the multivariate Cox proportional hazards regression analysis, used to determine factors associated with risk of recurrence, indicated that surgery at multiple sites (hazard ratio, 1.6; 95% confidence interval, 1.1-2.5), and incision and drainage procedures (HR, 3.5; 95% CI, 1.2-10.7) were all significantly associated with higher rates of recurrence. In addition, “for each decade younger at the time of surgery, patients had a significantly increased recurrence risk,” they wrote.

In an interview, Dr. Kohorst said that there was a “significant effect of age on postoperative recurrence,” with patients under age 30 having approximately a 50% chance of recurrence, compared with a 25% chance of recurrence in patients older than 50 years of age.

Conversely, other variables they assessed including the specific surgical site(s) examined, disease severity based on the patient’s Hurley stage, gender, and the extent of the operation were not associated with an increase in recurrence rates. No difference was detected between the risk of recurrence for those undergoing excision or unroofing (HR, 1.0; 95% CI, 0.6-1.4).

Based on their overall findings, the authors concluded that “with well-planned, individualized surgical care, the likelihood of postoperative recurrence rests largely on patient age at surgical treatment and the number of surgical sites.”

They disclosed no conflicts of interest. A funding source of the study was not provided.

Several simple, inexpensive operational interventions substantially improve care for viral hepatitis, according to a report published in the Lancet.

Recent advances in treatment for chronic hepatitis B and chronic hepatitis C have the potential to halt or even reverse the progression of associated liver disease and to reduce related mortality, reported Kali Zhou, MD, of the division of gastroenterology, University of California, San Francisco, and her associates. But they can do so only if affected individuals are engaged and retained in the relatively long continuum of care, from diagnosis through viral suppression or cure.

To assess the usefulness of interventions that promote such patient engagement and retention, Dr. Zhou and her colleagues reviewed the scientific literature and performed a meta-analysis of 56 studies. They examined 15 studies on HBV care, 38 on HCV care, and 3 on both types of hepatitis (Lancet Infect Dis. 2016 Sep 5. doi: 10.1016/S1473-3099[16]30208-0).

Among their findings:

• Educating a single lay health worker to improve knowledge about the disease in his or her community and to promote diagnostic testing nearly tripled the testing rate (relative risk, 2.68), compared with no such intervention.

• Clinician reminders during regular office visits to consider hepatitis testing – such as prompts in the patients’ electronic medical records or stickers on their charts – nearly quadrupled the testing rate (RR, 3.70), compared with no clinician reminders.

• Providing guided referral to a hepatitis specialist for people at risk for the disorder markedly improved the rate of visits to such specialists (RR, 1.57), compared with no such referrals.

• Providing psychological counseling and motivational therapy for mental health and/or substance misuse problems along with medical care for hepatitis dramatically increased the number of patients treated (OR, 3.42) and raised the rate of treatment completion (RR, 1.14).

• Combining mental health, substance misuse, and hepatitis treatment services at one location increased the rate of treatment initiation (RR, 1.36), treatment adherence (RR, 1.22), and cure as measured by sustained virologic response rate (RR, 1.21), compared with usual care.These interventions might be useful in augmenting hepatitis treatment programs worldwide, Dr. Zhou and her associates said.

The World Health Organization and the U.S. Fulbright Program supported the study. Dr. Zhou and her associates reported having no relevant financial disclosures.

 

Several simple, inexpensive operational interventions substantially improve care for viral hepatitis, according to a report published in the Lancet.

Recent advances in treatment for chronic hepatitis B and chronic hepatitis C have the potential to halt or even reverse the progression of associated liver disease and to reduce related mortality, reported Kali Zhou, MD, of the division of gastroenterology, University of California, San Francisco, and her associates. But they can do so only if affected individuals are engaged and retained in the relatively long continuum of care, from diagnosis through viral suppression or cure.

To assess the usefulness of interventions that promote such patient engagement and retention, Dr. Zhou and her colleagues reviewed the scientific literature and performed a meta-analysis of 56 studies. They examined 15 studies on HBV care, 38 on HCV care, and 3 on both types of hepatitis (Lancet Infect Dis. 2016 Sep 5. doi: 10.1016/S1473-3099[16]30208-0).

Among their findings:

• Educating a single lay health worker to improve knowledge about the disease in his or her community and to promote diagnostic testing nearly tripled the testing rate (relative risk, 2.68), compared with no such intervention.

• Clinician reminders during regular office visits to consider hepatitis testing – such as prompts in the patients’ electronic medical records or stickers on their charts – nearly quadrupled the testing rate (RR, 3.70), compared with no clinician reminders.

• Providing guided referral to a hepatitis specialist for people at risk for the disorder markedly improved the rate of visits to such specialists (RR, 1.57), compared with no such referrals.

• Providing psychological counseling and motivational therapy for mental health and/or substance misuse problems along with medical care for hepatitis dramatically increased the number of patients treated (OR, 3.42) and raised the rate of treatment completion (RR, 1.14).

• Combining mental health, substance misuse, and hepatitis treatment services at one location increased the rate of treatment initiation (RR, 1.36), treatment adherence (RR, 1.22), and cure as measured by sustained virologic response rate (RR, 1.21), compared with usual care.These interventions might be useful in augmenting hepatitis treatment programs worldwide, Dr. Zhou and her associates said.

The World Health Organization and the U.S. Fulbright Program supported the study. Dr. Zhou and her associates reported having no relevant financial disclosures.

 

Several simple, inexpensive operational interventions substantially improve care for viral hepatitis, according to a report published in the Lancet.

Recent advances in treatment for chronic hepatitis B and chronic hepatitis C have the potential to halt or even reverse the progression of associated liver disease and to reduce related mortality, reported Kali Zhou, MD, of the division of gastroenterology, University of California, San Francisco, and her associates. But they can do so only if affected individuals are engaged and retained in the relatively long continuum of care, from diagnosis through viral suppression or cure.

To assess the usefulness of interventions that promote such patient engagement and retention, Dr. Zhou and her colleagues reviewed the scientific literature and performed a meta-analysis of 56 studies. They examined 15 studies on HBV care, 38 on HCV care, and 3 on both types of hepatitis (Lancet Infect Dis. 2016 Sep 5. doi: 10.1016/S1473-3099[16]30208-0).

Among their findings:

• Educating a single lay health worker to improve knowledge about the disease in his or her community and to promote diagnostic testing nearly tripled the testing rate (relative risk, 2.68), compared with no such intervention.

• Clinician reminders during regular office visits to consider hepatitis testing – such as prompts in the patients’ electronic medical records or stickers on their charts – nearly quadrupled the testing rate (RR, 3.70), compared with no clinician reminders.

• Providing guided referral to a hepatitis specialist for people at risk for the disorder markedly improved the rate of visits to such specialists (RR, 1.57), compared with no such referrals.

• Providing psychological counseling and motivational therapy for mental health and/or substance misuse problems along with medical care for hepatitis dramatically increased the number of patients treated (OR, 3.42) and raised the rate of treatment completion (RR, 1.14).

• Combining mental health, substance misuse, and hepatitis treatment services at one location increased the rate of treatment initiation (RR, 1.36), treatment adherence (RR, 1.22), and cure as measured by sustained virologic response rate (RR, 1.21), compared with usual care.These interventions might be useful in augmenting hepatitis treatment programs worldwide, Dr. Zhou and her associates said.

The World Health Organization and the U.S. Fulbright Program supported the study. Dr. Zhou and her associates reported having no relevant financial disclosures.

 

Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than two weeks, 10% to 15% will have prolonged symptoms (greater than one month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.

I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient's being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.

I am not surprised by the results of the study. A large proportion of the adolescents I treat for concussions are referred by their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including CBT, patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills, and the bonus is that these skills are incredibly useful across one's lifetime, not just for concussion recovery.

Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10 to 20 years down the road.

—Cynthia LaBella, MD
Director of the Concussion Program
Ann & Robert H. Lurie Children's Hospital of Chicago

Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than two weeks, 10% to 15% will have prolonged symptoms (greater than one month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.

I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient's being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.

I am not surprised by the results of the study. A large proportion of the adolescents I treat for concussions are referred by their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including CBT, patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills, and the bonus is that these skills are incredibly useful across one's lifetime, not just for concussion recovery.

Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10 to 20 years down the road.

—Cynthia LaBella, MD
Director of the Concussion Program
Ann & Robert H. Lurie Children's Hospital of Chicago

Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than two weeks, 10% to 15% will have prolonged symptoms (greater than one month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.

I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient's being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.

I am not surprised by the results of the study. A large proportion of the adolescents I treat for concussions are referred by their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including CBT, patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills, and the bonus is that these skills are incredibly useful across one's lifetime, not just for concussion recovery.

Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10 to 20 years down the road.

—Cynthia LaBella, MD
Director of the Concussion Program
Ann & Robert H. Lurie Children's Hospital of Chicago