Azithromycin maintenance therapy may be best reserved for patients with mild to moderate chronic obstructive pulmonary disease (COPD) and few symptoms, according to an analysis from the COLUMBUS randomized controlled trial. The study, reported on in Family Practice News, also revealed that patients with a high serum eosinophil level… http://www.familypracticenews.com/specialty-focus/pulmonary-sleep-medicine/single-article-page/copd-patient-characteristics-predict-response-to-maintenance-drug/f29efaba9a4874ed9b754fb87b77b663.html.

Azithromycin maintenance therapy may be best reserved for patients with mild to moderate chronic obstructive pulmonary disease (COPD) and few symptoms, according to an analysis from the COLUMBUS randomized controlled trial. The study, reported on in Family Practice News, also revealed that patients with a high serum eosinophil level… http://www.familypracticenews.com/specialty-focus/pulmonary-sleep-medicine/single-article-page/copd-patient-characteristics-predict-response-to-maintenance-drug/f29efaba9a4874ed9b754fb87b77b663.html.

Azithromycin maintenance therapy may be best reserved for patients with mild to moderate chronic obstructive pulmonary disease (COPD) and few symptoms, according to an analysis from the COLUMBUS randomized controlled trial. The study, reported on in Family Practice News, also revealed that patients with a high serum eosinophil level… http://www.familypracticenews.com/specialty-focus/pulmonary-sleep-medicine/single-article-page/copd-patient-characteristics-predict-response-to-maintenance-drug/f29efaba9a4874ed9b754fb87b77b663.html.

During the first year on anticoagulant treatment, patients who received a new oral anticoagulant (NOAC) had an ischemic stroke rate similar to that of patients who received the traditional oral anticoagulant, warfarin. But they also had a significantly reduced rate of intracranial hemorrhage, according to Laila Stærk, MD, who reported on the findings at the annual congress of the European Society of Cardiology. The study included 43,299 Danish patients, of which 42% received warfarin, 29% received dabigatran, 16% received apixaban, and 13% received rivaroxaban. More on the results of this study are available in this article and video from Cardiology News: http://www.ecardiologynews.com/specialty-focus/arrhythmias-electrophysiology/single-article-page/video-noacs-cut-intracranial-bleeds-in-real-world-atrial-fib-patients/2c213686c34e2f2e9fb58000ff2cad80.html.

During the first year on anticoagulant treatment, patients who received a new oral anticoagulant (NOAC) had an ischemic stroke rate similar to that of patients who received the traditional oral anticoagulant, warfarin. But they also had a significantly reduced rate of intracranial hemorrhage, according to Laila Stærk, MD, who reported on the findings at the annual congress of the European Society of Cardiology. The study included 43,299 Danish patients, of which 42% received warfarin, 29% received dabigatran, 16% received apixaban, and 13% received rivaroxaban. More on the results of this study are available in this article and video from Cardiology News: http://www.ecardiologynews.com/specialty-focus/arrhythmias-electrophysiology/single-article-page/video-noacs-cut-intracranial-bleeds-in-real-world-atrial-fib-patients/2c213686c34e2f2e9fb58000ff2cad80.html.

During the first year on anticoagulant treatment, patients who received a new oral anticoagulant (NOAC) had an ischemic stroke rate similar to that of patients who received the traditional oral anticoagulant, warfarin. But they also had a significantly reduced rate of intracranial hemorrhage, according to Laila Stærk, MD, who reported on the findings at the annual congress of the European Society of Cardiology. The study included 43,299 Danish patients, of which 42% received warfarin, 29% received dabigatran, 16% received apixaban, and 13% received rivaroxaban. More on the results of this study are available in this article and video from Cardiology News: http://www.ecardiologynews.com/specialty-focus/arrhythmias-electrophysiology/single-article-page/video-noacs-cut-intracranial-bleeds-in-real-world-atrial-fib-patients/2c213686c34e2f2e9fb58000ff2cad80.html.

Aneurysmal bone cysts (ABC) are expansile, hemorrhagic, non-neoplastic lesions that can be locally destructive¹ and that can arise either de novo or secondary to another benign or malignant lesion.² Although primary and secondary ABCs typically are benign, there are cases of malignant degeneration of primary ABCs, though the transformation arises almost exclusively in the context of prior radiation exposure.^3-5 Malignant change without history of irradiation is rare; only 6 such cases have been reported.^5-10 In 4 of these cases, the transformation was to osteosarcoma.^5,8-10

Here we report on an ABC that degenerated into a fibroblastic osteosarcoma—the fifth such case in the medical literature. In addition to reviewing the earlier cases, we describe the radiologic and histologic underpinnings of this diagnosis and the insight that they provide into the pathogenesis of this rare process. Although the prevailing view is that ABCs are benign, it is important to know these lesions have the potential to undergo malignant transformation, even in the absence of prior radiation exposure. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A healthy and previously asymptomatic 37-year-old man presented with thigh pain after a minor fall onto a couch. Radiographs showed a diaphyseal femoral pathologic fracture adjacent to a small but benign-appearing cystic lesion (Figures 1A, 1B).

Two years later, the patient had a bicycle accident and, after 2 weeks of significantly increased thigh swelling, presented to the emergency department at the referring institution. Radiographs showed a lytic lesion in the femoral diaphysis that was highly suspicious for malignancy (Figures 3A, 3B).

Discussion

Aneurysmal bone cysts are expansile, hemorrhagic, locally destructive lesions that generally develop within the first 3 decades of life. Ever since they were first described by Jaffe and Lichtenstein¹¹ in 1942, the most widely accepted theory of their pathogenesis has been that they begin as a benign reactive vascular process.¹² However, more recent molecular studies by Oliveira and colleagues¹³ and Panoutsakopoulos and colleagues¹⁴ have demonstrated a clonal neoplastic basis for primary ABCs related to cytogenetic upregulation of oncogenes USP6 and CDH11 after translocation of 17p13 and 16q22.

Given the clonal nature of these lesions, it is surprising that malignant transformation is so rare. Until now, there have been only 4 reports of an ABC undergoing malignant degeneration to osteosarcoma without prior radiation exposure.

Aneurysmal bone cysts (ABC) are expansile, hemorrhagic, non-neoplastic lesions that can be locally destructive¹ and that can arise either de novo or secondary to another benign or malignant lesion.² Although primary and secondary ABCs typically are benign, there are cases of malignant degeneration of primary ABCs, though the transformation arises almost exclusively in the context of prior radiation exposure.^3-5 Malignant change without history of irradiation is rare; only 6 such cases have been reported.^5-10 In 4 of these cases, the transformation was to osteosarcoma.^5,8-10

Here we report on an ABC that degenerated into a fibroblastic osteosarcoma—the fifth such case in the medical literature. In addition to reviewing the earlier cases, we describe the radiologic and histologic underpinnings of this diagnosis and the insight that they provide into the pathogenesis of this rare process. Although the prevailing view is that ABCs are benign, it is important to know these lesions have the potential to undergo malignant transformation, even in the absence of prior radiation exposure. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A healthy and previously asymptomatic 37-year-old man presented with thigh pain after a minor fall onto a couch. Radiographs showed a diaphyseal femoral pathologic fracture adjacent to a small but benign-appearing cystic lesion (Figures 1A, 1B).

Two years later, the patient had a bicycle accident and, after 2 weeks of significantly increased thigh swelling, presented to the emergency department at the referring institution. Radiographs showed a lytic lesion in the femoral diaphysis that was highly suspicious for malignancy (Figures 3A, 3B).

Discussion

Aneurysmal bone cysts are expansile, hemorrhagic, locally destructive lesions that generally develop within the first 3 decades of life. Ever since they were first described by Jaffe and Lichtenstein¹¹ in 1942, the most widely accepted theory of their pathogenesis has been that they begin as a benign reactive vascular process.¹² However, more recent molecular studies by Oliveira and colleagues¹³ and Panoutsakopoulos and colleagues¹⁴ have demonstrated a clonal neoplastic basis for primary ABCs related to cytogenetic upregulation of oncogenes USP6 and CDH11 after translocation of 17p13 and 16q22.

Given the clonal nature of these lesions, it is surprising that malignant transformation is so rare. Until now, there have been only 4 reports of an ABC undergoing malignant degeneration to osteosarcoma without prior radiation exposure.

Aneurysmal bone cysts (ABC) are expansile, hemorrhagic, non-neoplastic lesions that can be locally destructive¹ and that can arise either de novo or secondary to another benign or malignant lesion.² Although primary and secondary ABCs typically are benign, there are cases of malignant degeneration of primary ABCs, though the transformation arises almost exclusively in the context of prior radiation exposure.^3-5 Malignant change without history of irradiation is rare; only 6 such cases have been reported.^5-10 In 4 of these cases, the transformation was to osteosarcoma.^5,8-10

Here we report on an ABC that degenerated into a fibroblastic osteosarcoma—the fifth such case in the medical literature. In addition to reviewing the earlier cases, we describe the radiologic and histologic underpinnings of this diagnosis and the insight that they provide into the pathogenesis of this rare process. Although the prevailing view is that ABCs are benign, it is important to know these lesions have the potential to undergo malignant transformation, even in the absence of prior radiation exposure. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A healthy and previously asymptomatic 37-year-old man presented with thigh pain after a minor fall onto a couch. Radiographs showed a diaphyseal femoral pathologic fracture adjacent to a small but benign-appearing cystic lesion (Figures 1A, 1B).

Two years later, the patient had a bicycle accident and, after 2 weeks of significantly increased thigh swelling, presented to the emergency department at the referring institution. Radiographs showed a lytic lesion in the femoral diaphysis that was highly suspicious for malignancy (Figures 3A, 3B).

Discussion

Aneurysmal bone cysts are expansile, hemorrhagic, locally destructive lesions that generally develop within the first 3 decades of life. Ever since they were first described by Jaffe and Lichtenstein¹¹ in 1942, the most widely accepted theory of their pathogenesis has been that they begin as a benign reactive vascular process.¹² However, more recent molecular studies by Oliveira and colleagues¹³ and Panoutsakopoulos and colleagues¹⁴ have demonstrated a clonal neoplastic basis for primary ABCs related to cytogenetic upregulation of oncogenes USP6 and CDH11 after translocation of 17p13 and 16q22.

Given the clonal nature of these lesions, it is surprising that malignant transformation is so rare. Until now, there have been only 4 reports of an ABC undergoing malignant degeneration to osteosarcoma without prior radiation exposure.

In patients undergoing transcatheter aortic valve implantation, use of a cerebral protection device to entrap and remove embolic debris reduced both the number and the size of ischemic brain lesions, according to a report published in JAMA.

The frequency and severity of postprocedure stroke symptoms were similar with and without the filter; however, the researchers noted that the study included only 100 patients and was not powered to assess differences in stroke rates.

Various cerebral protection devices were invented in response to the finding of a threefold increase in periprocedural stroke mortality following TAVI. Yet “clear evidence of the efficacy of any embolic protection device in TAVI is still missing,” said Stephan Haussig, MD, of the University of Leipzig (Germany) Heart Center, and his associates.

They performed a prospective randomized clinical trial at their center to assess the efficacy of the only cerebral protection device that was available when their study was designed. For the study, 100 patients with severe, symptomatic aortic stenosis were randomly assigned to undergo TAVI either with (50 patients) or without (50 patients) the use of a protective filter to capture embolic debris. The filter device was estimated to fully protect 74% of the brain and partially protect 24%, leaving only 2% unprotected.

The primary endpoint of the study was the number of ischemic brain lesions detected on diffusion-weighted MRI in the filter group, compared with the control group. This imaging was performed at baseline, 2 days after the procedure, and 7 days after the procedure.

In protected brain regions, the median number of new ischemic brain lesions was markedly lower in the filter group than in the control group (4 vs. 10) at 2 days, as well as at 7 days (3 vs. 7, respectively). In addition, the volume of new lesions in protected brain regions also was markedly lower in the filter group at 2 days (242 mm vs. 527 mm) and at 7 days (101 mm vs. 292 mm).

Similar protective effects were evident when the entire brain was evaluated. The median number of new lesions was markedly lower in the filter group than in the control group (8 vs. 16) at 2 days and at 7 days (5 vs. 10, respectively). The median lesion volume also was markedly lower in the filter group at 2 days (466 mm vs. 800 mm) and at 7 days (205 mm vs. 720 mm).

However, this protective effect didn’t translate into a substantive difference in neurologic outcomes between the two study groups, as assessed by the National Institutes of Health Stroke Scale and the modified Rankin scale. Five patients in each group developed symptoms of stroke, and all symptoms were deemed minor and nondisabling, the investigators said (JAMA 2016;316[6]:592-601).

It is important to note that this study wasn’t powered to assess differences in stroke rates. Larger studies will be needed to assess the impact of protective devices on neurological and functional outcomes, Dr. Haussig and his associates wrote.

The two study groups also did not differ with regard to complications. Thirty-day mortality was 0% in the filter group and 2% in the control group, a nonsignificant difference.

The investigators pointed out that protective filter devices can protect the brain only while they are in place during TAVI, “which usually takes less than 1 hour and represents only 2% of the first 48 hours after which the first MRI was performed in this study. Based on the analyzed material captured and removed by the filters – e.g., old and fresh thrombus, endothelium, atheromatous plaque, valve tissue, and calcium – it becomes evident that causes of cerebral injury are multifactorial and that the embolic risk does not resolve immediately at the end of the TAVI procedure,” they said.

Perhaps the study’s most surprising finding was that nearly every patient had new cerebral lesions consistent with infarcts, but most of these were very small and not associated with any neurocognitive or functional impairments.

This study was limited in that it involved a single cardiac team assessing only one brand of filter device at a single hospital, so the results are not necessarily generalizable to a broader patient population or to the many other devices that have since been developed, Dr. Haussig and his associates added.

This study was funded by a grant from Claret Medical and Medtronic. Dr. Haussig reported having no relevant financial disclosures; his associates reported ties to numerous industry sources.

In patients undergoing transcatheter aortic valve implantation, use of a cerebral protection device to entrap and remove embolic debris reduced both the number and the size of ischemic brain lesions, according to a report published in JAMA.

The frequency and severity of postprocedure stroke symptoms were similar with and without the filter; however, the researchers noted that the study included only 100 patients and was not powered to assess differences in stroke rates.

Various cerebral protection devices were invented in response to the finding of a threefold increase in periprocedural stroke mortality following TAVI. Yet “clear evidence of the efficacy of any embolic protection device in TAVI is still missing,” said Stephan Haussig, MD, of the University of Leipzig (Germany) Heart Center, and his associates.

They performed a prospective randomized clinical trial at their center to assess the efficacy of the only cerebral protection device that was available when their study was designed. For the study, 100 patients with severe, symptomatic aortic stenosis were randomly assigned to undergo TAVI either with (50 patients) or without (50 patients) the use of a protective filter to capture embolic debris. The filter device was estimated to fully protect 74% of the brain and partially protect 24%, leaving only 2% unprotected.

The primary endpoint of the study was the number of ischemic brain lesions detected on diffusion-weighted MRI in the filter group, compared with the control group. This imaging was performed at baseline, 2 days after the procedure, and 7 days after the procedure.

In protected brain regions, the median number of new ischemic brain lesions was markedly lower in the filter group than in the control group (4 vs. 10) at 2 days, as well as at 7 days (3 vs. 7, respectively). In addition, the volume of new lesions in protected brain regions also was markedly lower in the filter group at 2 days (242 mm vs. 527 mm) and at 7 days (101 mm vs. 292 mm).

Similar protective effects were evident when the entire brain was evaluated. The median number of new lesions was markedly lower in the filter group than in the control group (8 vs. 16) at 2 days and at 7 days (5 vs. 10, respectively). The median lesion volume also was markedly lower in the filter group at 2 days (466 mm vs. 800 mm) and at 7 days (205 mm vs. 720 mm).

However, this protective effect didn’t translate into a substantive difference in neurologic outcomes between the two study groups, as assessed by the National Institutes of Health Stroke Scale and the modified Rankin scale. Five patients in each group developed symptoms of stroke, and all symptoms were deemed minor and nondisabling, the investigators said (JAMA 2016;316[6]:592-601).

It is important to note that this study wasn’t powered to assess differences in stroke rates. Larger studies will be needed to assess the impact of protective devices on neurological and functional outcomes, Dr. Haussig and his associates wrote.

The two study groups also did not differ with regard to complications. Thirty-day mortality was 0% in the filter group and 2% in the control group, a nonsignificant difference.

The investigators pointed out that protective filter devices can protect the brain only while they are in place during TAVI, “which usually takes less than 1 hour and represents only 2% of the first 48 hours after which the first MRI was performed in this study. Based on the analyzed material captured and removed by the filters – e.g., old and fresh thrombus, endothelium, atheromatous plaque, valve tissue, and calcium – it becomes evident that causes of cerebral injury are multifactorial and that the embolic risk does not resolve immediately at the end of the TAVI procedure,” they said.

Perhaps the study’s most surprising finding was that nearly every patient had new cerebral lesions consistent with infarcts, but most of these were very small and not associated with any neurocognitive or functional impairments.

This study was limited in that it involved a single cardiac team assessing only one brand of filter device at a single hospital, so the results are not necessarily generalizable to a broader patient population or to the many other devices that have since been developed, Dr. Haussig and his associates added.

This study was funded by a grant from Claret Medical and Medtronic. Dr. Haussig reported having no relevant financial disclosures; his associates reported ties to numerous industry sources.

In patients undergoing transcatheter aortic valve implantation, use of a cerebral protection device to entrap and remove embolic debris reduced both the number and the size of ischemic brain lesions, according to a report published in JAMA.

The frequency and severity of postprocedure stroke symptoms were similar with and without the filter; however, the researchers noted that the study included only 100 patients and was not powered to assess differences in stroke rates.

Various cerebral protection devices were invented in response to the finding of a threefold increase in periprocedural stroke mortality following TAVI. Yet “clear evidence of the efficacy of any embolic protection device in TAVI is still missing,” said Stephan Haussig, MD, of the University of Leipzig (Germany) Heart Center, and his associates.

They performed a prospective randomized clinical trial at their center to assess the efficacy of the only cerebral protection device that was available when their study was designed. For the study, 100 patients with severe, symptomatic aortic stenosis were randomly assigned to undergo TAVI either with (50 patients) or without (50 patients) the use of a protective filter to capture embolic debris. The filter device was estimated to fully protect 74% of the brain and partially protect 24%, leaving only 2% unprotected.

The primary endpoint of the study was the number of ischemic brain lesions detected on diffusion-weighted MRI in the filter group, compared with the control group. This imaging was performed at baseline, 2 days after the procedure, and 7 days after the procedure.

In protected brain regions, the median number of new ischemic brain lesions was markedly lower in the filter group than in the control group (4 vs. 10) at 2 days, as well as at 7 days (3 vs. 7, respectively). In addition, the volume of new lesions in protected brain regions also was markedly lower in the filter group at 2 days (242 mm vs. 527 mm) and at 7 days (101 mm vs. 292 mm).

Similar protective effects were evident when the entire brain was evaluated. The median number of new lesions was markedly lower in the filter group than in the control group (8 vs. 16) at 2 days and at 7 days (5 vs. 10, respectively). The median lesion volume also was markedly lower in the filter group at 2 days (466 mm vs. 800 mm) and at 7 days (205 mm vs. 720 mm).

However, this protective effect didn’t translate into a substantive difference in neurologic outcomes between the two study groups, as assessed by the National Institutes of Health Stroke Scale and the modified Rankin scale. Five patients in each group developed symptoms of stroke, and all symptoms were deemed minor and nondisabling, the investigators said (JAMA 2016;316[6]:592-601).

It is important to note that this study wasn’t powered to assess differences in stroke rates. Larger studies will be needed to assess the impact of protective devices on neurological and functional outcomes, Dr. Haussig and his associates wrote.

The two study groups also did not differ with regard to complications. Thirty-day mortality was 0% in the filter group and 2% in the control group, a nonsignificant difference.

The investigators pointed out that protective filter devices can protect the brain only while they are in place during TAVI, “which usually takes less than 1 hour and represents only 2% of the first 48 hours after which the first MRI was performed in this study. Based on the analyzed material captured and removed by the filters – e.g., old and fresh thrombus, endothelium, atheromatous plaque, valve tissue, and calcium – it becomes evident that causes of cerebral injury are multifactorial and that the embolic risk does not resolve immediately at the end of the TAVI procedure,” they said.

Perhaps the study’s most surprising finding was that nearly every patient had new cerebral lesions consistent with infarcts, but most of these were very small and not associated with any neurocognitive or functional impairments.

This study was limited in that it involved a single cardiac team assessing only one brand of filter device at a single hospital, so the results are not necessarily generalizable to a broader patient population or to the many other devices that have since been developed, Dr. Haussig and his associates added.

This study was funded by a grant from Claret Medical and Medtronic. Dr. Haussig reported having no relevant financial disclosures; his associates reported ties to numerous industry sources.

Myth: UVB phototherapy causes skin cancer

Phototherapy is a common treatment modality for psoriasis patients that can be used in the physician’s office or psoriasis clinic or at home. Options include UVB phototherapy (broadband and narrowband), which slows the growth of affected skin cells; psoralen plus UVA (PUVA), which slows excessive skin cell growth; and excimer laser therapy, which targets select areas of the skin affected by mild to moderate psoriasis and is particularly useful for scalp psoriasis. Each of these therapies may be combined with other topical and/or systemic psoriasis treatments. The effects of UV light on the skin and the connection to skin cancer is widely known. Therefore, patient education on the risk for skin cancer with phototherapy is essential.

Evidence suggests that UVB phototherapy remains a safe treatment modality. In a 2005 analysis of prospective and retrospective studies on skin cancer risk from UVB phototherapy, 11 studies (10 concerning psoriasis patients) were reviewed and the researchers concluded that all studies eventually showed no increased skin cancer risk with UVB phototherapy. One of the PUVA cohort studies examined genital skin cancers and found an increased rate of genital tumors associated with UVB phototherapy.

Another analysis to define the long-term carcinogenic risk for narrowband UVB treatment found that there was no association between narrowband UVB exposure alone (without PUVA) and any skin cancer. For patients treated with narrowband UVB and PUVA, there was a small increase in basal cell carcinomas.

Dermatologists should monitor psoriasis patients for self-administered treatment with tanning beds. Based on a questionnaire sent to approximately 14,000 subscribers of National Psoriasis Foundation emails, 62% of 617 tanners started tanning to treat psoriasis; they were more likely to have received medical phototherapy and had more severe psoriasis. Approximately 30% of these patients indicated that they used tanning as a self-treatment for psoriasis because of the inconvenience and cost of UV light treatment in a physician’s office as well as treatment failure of other therapies prescribed by the physician. “Our results imply that tanning bed usage among psoriasis sufferers is widespread and linked with tanning addiction,” reported Felton et al. “Practitioners should be particularly vigilant to the possibility of tanning bed usage in at-risk patients.” These patients may be at increased risk for skin cancer. Problematic tanning behaviors may be seen in younger female patients diagnosed with psoriasis at an early age as well as patients with severe psoriasis who were previously prescribed phototherapy treatment.

Expert Commentary on next page

Expert Commentary

UVB phototherapy is an effective therapy that does not increase the risk of nonmelanoma skin cancers (NMSCs), according to the 2 analyses mentioned above. When I discuss the risks and benefits of UVB phototherapy with psoriasis patients, I do say that there is a theoretical increased risk for NMSC but that the 2005 study mentioned above does not indicate an increased risk. However, UVB phototherapy and cyclosporine should not be combined, as this combination does increase the risk for NMSC.

Psoralen plus UVA definitely will increase the risk for NMSC, particularly squamous cell carcinoma. However, in this age of the biologics, PUVA use has fallen out of favor, partly due to the increased risk for NMSC, and many patients will not encounter dermatology practices that still use PUVA.
—Jashin J. Wu, MD (Los Angeles, California)

Myth: UVB phototherapy causes skin cancer

Phototherapy is a common treatment modality for psoriasis patients that can be used in the physician’s office or psoriasis clinic or at home. Options include UVB phototherapy (broadband and narrowband), which slows the growth of affected skin cells; psoralen plus UVA (PUVA), which slows excessive skin cell growth; and excimer laser therapy, which targets select areas of the skin affected by mild to moderate psoriasis and is particularly useful for scalp psoriasis. Each of these therapies may be combined with other topical and/or systemic psoriasis treatments. The effects of UV light on the skin and the connection to skin cancer is widely known. Therefore, patient education on the risk for skin cancer with phototherapy is essential.

Evidence suggests that UVB phototherapy remains a safe treatment modality. In a 2005 analysis of prospective and retrospective studies on skin cancer risk from UVB phototherapy, 11 studies (10 concerning psoriasis patients) were reviewed and the researchers concluded that all studies eventually showed no increased skin cancer risk with UVB phototherapy. One of the PUVA cohort studies examined genital skin cancers and found an increased rate of genital tumors associated with UVB phototherapy.

Another analysis to define the long-term carcinogenic risk for narrowband UVB treatment found that there was no association between narrowband UVB exposure alone (without PUVA) and any skin cancer. For patients treated with narrowband UVB and PUVA, there was a small increase in basal cell carcinomas.

Dermatologists should monitor psoriasis patients for self-administered treatment with tanning beds. Based on a questionnaire sent to approximately 14,000 subscribers of National Psoriasis Foundation emails, 62% of 617 tanners started tanning to treat psoriasis; they were more likely to have received medical phototherapy and had more severe psoriasis. Approximately 30% of these patients indicated that they used tanning as a self-treatment for psoriasis because of the inconvenience and cost of UV light treatment in a physician’s office as well as treatment failure of other therapies prescribed by the physician. “Our results imply that tanning bed usage among psoriasis sufferers is widespread and linked with tanning addiction,” reported Felton et al. “Practitioners should be particularly vigilant to the possibility of tanning bed usage in at-risk patients.” These patients may be at increased risk for skin cancer. Problematic tanning behaviors may be seen in younger female patients diagnosed with psoriasis at an early age as well as patients with severe psoriasis who were previously prescribed phototherapy treatment.

Expert Commentary on next page

Expert Commentary

UVB phototherapy is an effective therapy that does not increase the risk of nonmelanoma skin cancers (NMSCs), according to the 2 analyses mentioned above. When I discuss the risks and benefits of UVB phototherapy with psoriasis patients, I do say that there is a theoretical increased risk for NMSC but that the 2005 study mentioned above does not indicate an increased risk. However, UVB phototherapy and cyclosporine should not be combined, as this combination does increase the risk for NMSC.

Psoralen plus UVA definitely will increase the risk for NMSC, particularly squamous cell carcinoma. However, in this age of the biologics, PUVA use has fallen out of favor, partly due to the increased risk for NMSC, and many patients will not encounter dermatology practices that still use PUVA.
—Jashin J. Wu, MD (Los Angeles, California)

Myth: UVB phototherapy causes skin cancer

Phototherapy is a common treatment modality for psoriasis patients that can be used in the physician’s office or psoriasis clinic or at home. Options include UVB phototherapy (broadband and narrowband), which slows the growth of affected skin cells; psoralen plus UVA (PUVA), which slows excessive skin cell growth; and excimer laser therapy, which targets select areas of the skin affected by mild to moderate psoriasis and is particularly useful for scalp psoriasis. Each of these therapies may be combined with other topical and/or systemic psoriasis treatments. The effects of UV light on the skin and the connection to skin cancer is widely known. Therefore, patient education on the risk for skin cancer with phototherapy is essential.

Evidence suggests that UVB phototherapy remains a safe treatment modality. In a 2005 analysis of prospective and retrospective studies on skin cancer risk from UVB phototherapy, 11 studies (10 concerning psoriasis patients) were reviewed and the researchers concluded that all studies eventually showed no increased skin cancer risk with UVB phototherapy. One of the PUVA cohort studies examined genital skin cancers and found an increased rate of genital tumors associated with UVB phototherapy.

Another analysis to define the long-term carcinogenic risk for narrowband UVB treatment found that there was no association between narrowband UVB exposure alone (without PUVA) and any skin cancer. For patients treated with narrowband UVB and PUVA, there was a small increase in basal cell carcinomas.

Dermatologists should monitor psoriasis patients for self-administered treatment with tanning beds. Based on a questionnaire sent to approximately 14,000 subscribers of National Psoriasis Foundation emails, 62% of 617 tanners started tanning to treat psoriasis; they were more likely to have received medical phototherapy and had more severe psoriasis. Approximately 30% of these patients indicated that they used tanning as a self-treatment for psoriasis because of the inconvenience and cost of UV light treatment in a physician’s office as well as treatment failure of other therapies prescribed by the physician. “Our results imply that tanning bed usage among psoriasis sufferers is widespread and linked with tanning addiction,” reported Felton et al. “Practitioners should be particularly vigilant to the possibility of tanning bed usage in at-risk patients.” These patients may be at increased risk for skin cancer. Problematic tanning behaviors may be seen in younger female patients diagnosed with psoriasis at an early age as well as patients with severe psoriasis who were previously prescribed phototherapy treatment.

Expert Commentary on next page

Expert Commentary

UVB phototherapy is an effective therapy that does not increase the risk of nonmelanoma skin cancers (NMSCs), according to the 2 analyses mentioned above. When I discuss the risks and benefits of UVB phototherapy with psoriasis patients, I do say that there is a theoretical increased risk for NMSC but that the 2005 study mentioned above does not indicate an increased risk. However, UVB phototherapy and cyclosporine should not be combined, as this combination does increase the risk for NMSC.

Psoralen plus UVA definitely will increase the risk for NMSC, particularly squamous cell carcinoma. However, in this age of the biologics, PUVA use has fallen out of favor, partly due to the increased risk for NMSC, and many patients will not encounter dermatology practices that still use PUVA.
—Jashin J. Wu, MD (Los Angeles, California)

LAS VEGAS – A ‘fast-track” stenting method for endovascular abdominal aortic aneurysm repair (EVAR) enabled patients to be treated safely and effectively without general anesthetic or ICU admission, and with next-day discharge, Zvonimir Krajcer, MD, said at the 2016 Vascular Interventional Advances meeting.

Dr. Krajcer discussed the final results of the Prospective LIFE Registry, which followed 250 patients treated with the Ovation Abdominal Stent Graft platform, who had suitable femoral arteries to allow the use of the Perclose ProGlide Suture-Mediated Closure (SMC) System.

For the Fast-Track patients, vascular access, stent graft delivery, and deployment were successful. The Fast-Track EVAR protocol was successfully completed in 216 (87%) of the patients. In comparing the Fast-Track cohort (n = 216) to the non–Fast-Track cohort (n = 34), procedure time was found to be 84 vs. 110 minutes, the use of general anesthesia was 0% vs. 18%, and the need for ICU stay was 0% vs. 32%. Hospital stay for the two groups was 1.2 vs. 1.9 days, respectively.

Quality of life score improvement from baseline to 30 days as assessed via the EQ-5D questionnaire, was significantly greater in the Fast-Track patients, compared with the EVAR controls, said Dr. Krajcer, an interventional cardiologist at Texas Heart Institute and St. Luke’s Hospital, Houston, and a clinical professor of medicine at Baylor College of Medicine.

To determine adverse events, patients were followed through 1 month after treatment. The researchers found no device- or procedure-related major adverse events, abdominal aortic aneurysm (AAA) ruptures, surgical conversions, or AAA-related secondary interventions. One patient in the fast-track group died from acute respiratory failure. Overall, for the Fast-Track and control groups, the freedom from type I/III endoleak was 99% and 100%, respectively.

Dr. Krajcer reported that the 30-day hospital readmission rate in the LIFE study was 1.6%, compared to 8% reported for EVAR from the American College of Surgeons National Surgical Quality Improvement Program.

The economic analysis was performed comparing the Fast-Track patients to a control group, which consisted of a database of 8,306 patients treated with elective infrarenal EVAR at 3,750 U.S. hospitals based on inpatient discharge between 2012 and 2015. The researchers calculated costs related to access, anesthesia, ICU stay, and hospital stay.

The Fast-Track protocol showed $21,000 in perioperative cost savings relative to standard EVAR, largely driven by differences in hospital stay costs, according to Dr. Krajcer.

“Fast-track EVAR using the Ovation Prime stent graft is safe and feasible and lowers perioperative costs,” said Dr. Krajcer. “Our results warrant the establishment of a Fast-Track EVAR protocol in experienced EVAR centers,” he concluded.

Dr. Krajcer had nothing to disclose.

[email protected]

LAS VEGAS – A ‘fast-track” stenting method for endovascular abdominal aortic aneurysm repair (EVAR) enabled patients to be treated safely and effectively without general anesthetic or ICU admission, and with next-day discharge, Zvonimir Krajcer, MD, said at the 2016 Vascular Interventional Advances meeting.

Dr. Krajcer discussed the final results of the Prospective LIFE Registry, which followed 250 patients treated with the Ovation Abdominal Stent Graft platform, who had suitable femoral arteries to allow the use of the Perclose ProGlide Suture-Mediated Closure (SMC) System.

For the Fast-Track patients, vascular access, stent graft delivery, and deployment were successful. The Fast-Track EVAR protocol was successfully completed in 216 (87%) of the patients. In comparing the Fast-Track cohort (n = 216) to the non–Fast-Track cohort (n = 34), procedure time was found to be 84 vs. 110 minutes, the use of general anesthesia was 0% vs. 18%, and the need for ICU stay was 0% vs. 32%. Hospital stay for the two groups was 1.2 vs. 1.9 days, respectively.

Quality of life score improvement from baseline to 30 days as assessed via the EQ-5D questionnaire, was significantly greater in the Fast-Track patients, compared with the EVAR controls, said Dr. Krajcer, an interventional cardiologist at Texas Heart Institute and St. Luke’s Hospital, Houston, and a clinical professor of medicine at Baylor College of Medicine.

To determine adverse events, patients were followed through 1 month after treatment. The researchers found no device- or procedure-related major adverse events, abdominal aortic aneurysm (AAA) ruptures, surgical conversions, or AAA-related secondary interventions. One patient in the fast-track group died from acute respiratory failure. Overall, for the Fast-Track and control groups, the freedom from type I/III endoleak was 99% and 100%, respectively.

Dr. Krajcer reported that the 30-day hospital readmission rate in the LIFE study was 1.6%, compared to 8% reported for EVAR from the American College of Surgeons National Surgical Quality Improvement Program.

The economic analysis was performed comparing the Fast-Track patients to a control group, which consisted of a database of 8,306 patients treated with elective infrarenal EVAR at 3,750 U.S. hospitals based on inpatient discharge between 2012 and 2015. The researchers calculated costs related to access, anesthesia, ICU stay, and hospital stay.

The Fast-Track protocol showed $21,000 in perioperative cost savings relative to standard EVAR, largely driven by differences in hospital stay costs, according to Dr. Krajcer.

“Fast-track EVAR using the Ovation Prime stent graft is safe and feasible and lowers perioperative costs,” said Dr. Krajcer. “Our results warrant the establishment of a Fast-Track EVAR protocol in experienced EVAR centers,” he concluded.

Dr. Krajcer had nothing to disclose.

[email protected]

LAS VEGAS – A ‘fast-track” stenting method for endovascular abdominal aortic aneurysm repair (EVAR) enabled patients to be treated safely and effectively without general anesthetic or ICU admission, and with next-day discharge, Zvonimir Krajcer, MD, said at the 2016 Vascular Interventional Advances meeting.

Dr. Krajcer discussed the final results of the Prospective LIFE Registry, which followed 250 patients treated with the Ovation Abdominal Stent Graft platform, who had suitable femoral arteries to allow the use of the Perclose ProGlide Suture-Mediated Closure (SMC) System.

For the Fast-Track patients, vascular access, stent graft delivery, and deployment were successful. The Fast-Track EVAR protocol was successfully completed in 216 (87%) of the patients. In comparing the Fast-Track cohort (n = 216) to the non–Fast-Track cohort (n = 34), procedure time was found to be 84 vs. 110 minutes, the use of general anesthesia was 0% vs. 18%, and the need for ICU stay was 0% vs. 32%. Hospital stay for the two groups was 1.2 vs. 1.9 days, respectively.

Quality of life score improvement from baseline to 30 days as assessed via the EQ-5D questionnaire, was significantly greater in the Fast-Track patients, compared with the EVAR controls, said Dr. Krajcer, an interventional cardiologist at Texas Heart Institute and St. Luke’s Hospital, Houston, and a clinical professor of medicine at Baylor College of Medicine.

To determine adverse events, patients were followed through 1 month after treatment. The researchers found no device- or procedure-related major adverse events, abdominal aortic aneurysm (AAA) ruptures, surgical conversions, or AAA-related secondary interventions. One patient in the fast-track group died from acute respiratory failure. Overall, for the Fast-Track and control groups, the freedom from type I/III endoleak was 99% and 100%, respectively.

Dr. Krajcer reported that the 30-day hospital readmission rate in the LIFE study was 1.6%, compared to 8% reported for EVAR from the American College of Surgeons National Surgical Quality Improvement Program.

The economic analysis was performed comparing the Fast-Track patients to a control group, which consisted of a database of 8,306 patients treated with elective infrarenal EVAR at 3,750 U.S. hospitals based on inpatient discharge between 2012 and 2015. The researchers calculated costs related to access, anesthesia, ICU stay, and hospital stay.

The Fast-Track protocol showed $21,000 in perioperative cost savings relative to standard EVAR, largely driven by differences in hospital stay costs, according to Dr. Krajcer.

“Fast-track EVAR using the Ovation Prime stent graft is safe and feasible and lowers perioperative costs,” said Dr. Krajcer. “Our results warrant the establishment of a Fast-Track EVAR protocol in experienced EVAR centers,” he concluded.

Dr. Krajcer had nothing to disclose.

[email protected]

WAIKOLOA, HAWAII – Sarcopenia is an independent predictor of 1-year mortality in elderly patients undergoing emergency abdominal surgery, results from a single-center study demonstrated.

“Setting expectations about operative outcomes is an important part of the preoperative counseling process, Erika L. Rangel, MD, FACS, said at the annual meeting of the American Association for the Surgery of Trauma. In a previous study that she and her associates conducted at Brigham and Women’s Hospital, Boston, the risk for mortality was found to continue long after hospital discharge in older patients who undergo emergency surgery: 16% at 30 days, 22% at 3 months, 28% at 6 months, and 32% 1 year after surgery (J Trauma and Acute Care Surg. 2015 Sep;79[3]:349-58).

[email protected]

WAIKOLOA, HAWAII – Sarcopenia is an independent predictor of 1-year mortality in elderly patients undergoing emergency abdominal surgery, results from a single-center study demonstrated.

“Setting expectations about operative outcomes is an important part of the preoperative counseling process, Erika L. Rangel, MD, FACS, said at the annual meeting of the American Association for the Surgery of Trauma. In a previous study that she and her associates conducted at Brigham and Women’s Hospital, Boston, the risk for mortality was found to continue long after hospital discharge in older patients who undergo emergency surgery: 16% at 30 days, 22% at 3 months, 28% at 6 months, and 32% 1 year after surgery (J Trauma and Acute Care Surg. 2015 Sep;79[3]:349-58).

[email protected]

WAIKOLOA, HAWAII – Sarcopenia is an independent predictor of 1-year mortality in elderly patients undergoing emergency abdominal surgery, results from a single-center study demonstrated.

“Setting expectations about operative outcomes is an important part of the preoperative counseling process, Erika L. Rangel, MD, FACS, said at the annual meeting of the American Association for the Surgery of Trauma. In a previous study that she and her associates conducted at Brigham and Women’s Hospital, Boston, the risk for mortality was found to continue long after hospital discharge in older patients who undergo emergency surgery: 16% at 30 days, 22% at 3 months, 28% at 6 months, and 32% 1 year after surgery (J Trauma and Acute Care Surg. 2015 Sep;79[3]:349-58).

[email protected]

Three-dimensional imaging techniques are changing the scope and precision of planning radiotherapy for cervical cancer. Researchers from Jiaotong University in China who compared planning using 3D magnetic resonance imaging and conventional 2D point A–based intracavitary brachytherapy (BT), say 3D imaging exhibits definite advantages “in a complex way.”

Conventional 2D planning (using a fixed reference point) can overestimate tumor dosages and underestimate the dosages for other organs at risk (OARs), such as rectum and bladder, the researchers say. By contrast in this study, they found that, in general, 3D MRI-based planning helped create accurate estimates for increased dose coverage in big tumors, eccentric tumors, and tumors invading adjacent tissues.

Related: Simultaneous Integrated Boost in Lieu of Vaginal Brachytherapy Boost in Endometrial Cancer

In the study, 79 patients with cervical cancer were treated first with CT-based external beam radiation therapy, then with high-dose rate BT (all patients underwent both 2D and 3D planning for HDR-BT). The researchers compared dose-volume histogram (DVH) parameters for gross tumor volume, high-risk clinical target volume, intermediate-risk clinical target volume, and OARs. Cervical cancer was confirmed by histologic examination on biopsy. Twenty patients had big tumors, and 59 had small tumors.

The researchers say their findings indicate that 3D MRI image-guided BT planning generally show advantages in the treatment of cervical cancer with the exception of cervical cancer that feature  small tumors.

For small tumors, DVH parameters did not differ significantly between 2D and 3D BT planning. In big tumors, however, almost all DVH parameters were significantly higher in 3D planning compared with 2D planning. Doses to OARs were also higher.

Related: Early Cancer Detection Helps Underserved Women

The researchers found a “diverse” response of small vs big tumors. In the eccentric cervical tumors, 3D BT planning led to more required dosage and reduced doses to the OARs compared with 2D BT planning. In cervical tumors invading adjacent tissues, 3D planning generally increased the tumor dose coverage but diversely affected the doses to OARs compared with 2D planning.

Only in big tumors, the researchers conclude, does 3D BT planning show obvious advantage.

Source:
Ren J, Yuan W, Wang R, et al. PLoS One. 2016;11(9):e0161932.
doi: 10.1371/journal.pone.0161932.

Three-dimensional imaging techniques are changing the scope and precision of planning radiotherapy for cervical cancer. Researchers from Jiaotong University in China who compared planning using 3D magnetic resonance imaging and conventional 2D point A–based intracavitary brachytherapy (BT), say 3D imaging exhibits definite advantages “in a complex way.”

Conventional 2D planning (using a fixed reference point) can overestimate tumor dosages and underestimate the dosages for other organs at risk (OARs), such as rectum and bladder, the researchers say. By contrast in this study, they found that, in general, 3D MRI-based planning helped create accurate estimates for increased dose coverage in big tumors, eccentric tumors, and tumors invading adjacent tissues.

Related: Simultaneous Integrated Boost in Lieu of Vaginal Brachytherapy Boost in Endometrial Cancer

In the study, 79 patients with cervical cancer were treated first with CT-based external beam radiation therapy, then with high-dose rate BT (all patients underwent both 2D and 3D planning for HDR-BT). The researchers compared dose-volume histogram (DVH) parameters for gross tumor volume, high-risk clinical target volume, intermediate-risk clinical target volume, and OARs. Cervical cancer was confirmed by histologic examination on biopsy. Twenty patients had big tumors, and 59 had small tumors.

The researchers say their findings indicate that 3D MRI image-guided BT planning generally show advantages in the treatment of cervical cancer with the exception of cervical cancer that feature  small tumors.

For small tumors, DVH parameters did not differ significantly between 2D and 3D BT planning. In big tumors, however, almost all DVH parameters were significantly higher in 3D planning compared with 2D planning. Doses to OARs were also higher.

Related: Early Cancer Detection Helps Underserved Women

The researchers found a “diverse” response of small vs big tumors. In the eccentric cervical tumors, 3D BT planning led to more required dosage and reduced doses to the OARs compared with 2D BT planning. In cervical tumors invading adjacent tissues, 3D planning generally increased the tumor dose coverage but diversely affected the doses to OARs compared with 2D planning.

Only in big tumors, the researchers conclude, does 3D BT planning show obvious advantage.

Source:
Ren J, Yuan W, Wang R, et al. PLoS One. 2016;11(9):e0161932.
doi: 10.1371/journal.pone.0161932.

Three-dimensional imaging techniques are changing the scope and precision of planning radiotherapy for cervical cancer. Researchers from Jiaotong University in China who compared planning using 3D magnetic resonance imaging and conventional 2D point A–based intracavitary brachytherapy (BT), say 3D imaging exhibits definite advantages “in a complex way.”

Conventional 2D planning (using a fixed reference point) can overestimate tumor dosages and underestimate the dosages for other organs at risk (OARs), such as rectum and bladder, the researchers say. By contrast in this study, they found that, in general, 3D MRI-based planning helped create accurate estimates for increased dose coverage in big tumors, eccentric tumors, and tumors invading adjacent tissues.

Related: Simultaneous Integrated Boost in Lieu of Vaginal Brachytherapy Boost in Endometrial Cancer

In the study, 79 patients with cervical cancer were treated first with CT-based external beam radiation therapy, then with high-dose rate BT (all patients underwent both 2D and 3D planning for HDR-BT). The researchers compared dose-volume histogram (DVH) parameters for gross tumor volume, high-risk clinical target volume, intermediate-risk clinical target volume, and OARs. Cervical cancer was confirmed by histologic examination on biopsy. Twenty patients had big tumors, and 59 had small tumors.

The researchers say their findings indicate that 3D MRI image-guided BT planning generally show advantages in the treatment of cervical cancer with the exception of cervical cancer that feature  small tumors.

For small tumors, DVH parameters did not differ significantly between 2D and 3D BT planning. In big tumors, however, almost all DVH parameters were significantly higher in 3D planning compared with 2D planning. Doses to OARs were also higher.

Related: Early Cancer Detection Helps Underserved Women

The researchers found a “diverse” response of small vs big tumors. In the eccentric cervical tumors, 3D BT planning led to more required dosage and reduced doses to the OARs compared with 2D BT planning. In cervical tumors invading adjacent tissues, 3D planning generally increased the tumor dose coverage but diversely affected the doses to OARs compared with 2D planning.

Only in big tumors, the researchers conclude, does 3D BT planning show obvious advantage.

Source:
Ren J, Yuan W, Wang R, et al. PLoS One. 2016;11(9):e0161932.
doi: 10.1371/journal.pone.0161932.

Certain lifestyle, dietary, environmental, serologic, and genetic factors may raise the risk of non-Hodgkin lymphoma (NHL), according to researchers who reviewed 40 years of follow-up data from the Nurses’ Health Study (NHS).

Related: Exercise Lowers Risk of Some Cancers

The researchers, from Brigham and Women’s Hospital, Harvard, and Boston University, all in Massachusetts, aimed to highlight the NHS’s contributions to epidemiologic knowledge of endometrial, ovarian, pancreatic, and hematologic cancers. They focused on findings that identified novel risk factors or markers of early detection or helped clarify discrepant literature.

Because the researchers say severe immune compromise is the “strongest, best-established risk factor” for NHL, they studied factors that might lead to subclinical immune dysregulation, such as diet, body mass index (BMI), and supplement use. They found several risk factors and biomarkers for NHL and more than 35 distinct tumors in that category, including chronic lymphocytic leukemia. Trans fats and red meat, for instance, doubled the risk of NHL. The researchers also found a higher risk for women who reported long-term multivitamin use. However, they found no risk associated with diet or sugar-sweetened soda or aspartame or with dietary intake of vitamin D.

Related: IBD and the Risk of Oral Cancer

Greater adiposity during childhood and adolescence was significantly associated with NHL. The researchers also observed a 19% increased risk of all NHL per 5 kg/m² increase in BMI in young adulthood. Interestingly, taller women also had a higher risk of NHL.

The researchers conducted one of the first prospective studies to evaluate a putative inverse association of NHL risk with exposure to ambient ultraviolet radiation. They found, “contrary to expectation,” a 10% to 20% increased risk of NHL among women with the highest (vs lowest) ultraviolet-B exposure at baseline and birth, 15 years, and 30 years.

In investigating biomarkers, the researchers noted a “suggestive increase” in chronic lymphocytic leukemia risk associated with an Epstein-Barr virus antibody profile indicative of poor host immune control of the virus.

Related: Sexual Orientation and Cancer Risk

The researchers have established several working groups to study cancers, such as NHL and multiple myeloma. They also are collecting archival tissue specimens for NHL, multiple myeloma, and Hodgkin lymphoma, for better evaluation of factors related to the unique molecular subsets of hematologic tumors.

Source:
Birmann BM, Barnard ME, Bertrand KA, et al. Am J Public Health. 2016;106(9):1608-1615.
doi: 10.2105/AJPH.2016.303337.

Certain lifestyle, dietary, environmental, serologic, and genetic factors may raise the risk of non-Hodgkin lymphoma (NHL), according to researchers who reviewed 40 years of follow-up data from the Nurses’ Health Study (NHS).

Related: Exercise Lowers Risk of Some Cancers

The researchers, from Brigham and Women’s Hospital, Harvard, and Boston University, all in Massachusetts, aimed to highlight the NHS’s contributions to epidemiologic knowledge of endometrial, ovarian, pancreatic, and hematologic cancers. They focused on findings that identified novel risk factors or markers of early detection or helped clarify discrepant literature.

Because the researchers say severe immune compromise is the “strongest, best-established risk factor” for NHL, they studied factors that might lead to subclinical immune dysregulation, such as diet, body mass index (BMI), and supplement use. They found several risk factors and biomarkers for NHL and more than 35 distinct tumors in that category, including chronic lymphocytic leukemia. Trans fats and red meat, for instance, doubled the risk of NHL. The researchers also found a higher risk for women who reported long-term multivitamin use. However, they found no risk associated with diet or sugar-sweetened soda or aspartame or with dietary intake of vitamin D.

Related: IBD and the Risk of Oral Cancer

Greater adiposity during childhood and adolescence was significantly associated with NHL. The researchers also observed a 19% increased risk of all NHL per 5 kg/m² increase in BMI in young adulthood. Interestingly, taller women also had a higher risk of NHL.

The researchers conducted one of the first prospective studies to evaluate a putative inverse association of NHL risk with exposure to ambient ultraviolet radiation. They found, “contrary to expectation,” a 10% to 20% increased risk of NHL among women with the highest (vs lowest) ultraviolet-B exposure at baseline and birth, 15 years, and 30 years.

In investigating biomarkers, the researchers noted a “suggestive increase” in chronic lymphocytic leukemia risk associated with an Epstein-Barr virus antibody profile indicative of poor host immune control of the virus.

Related: Sexual Orientation and Cancer Risk

The researchers have established several working groups to study cancers, such as NHL and multiple myeloma. They also are collecting archival tissue specimens for NHL, multiple myeloma, and Hodgkin lymphoma, for better evaluation of factors related to the unique molecular subsets of hematologic tumors.

Source:
Birmann BM, Barnard ME, Bertrand KA, et al. Am J Public Health. 2016;106(9):1608-1615.
doi: 10.2105/AJPH.2016.303337.

Certain lifestyle, dietary, environmental, serologic, and genetic factors may raise the risk of non-Hodgkin lymphoma (NHL), according to researchers who reviewed 40 years of follow-up data from the Nurses’ Health Study (NHS).

Related: Exercise Lowers Risk of Some Cancers

The researchers, from Brigham and Women’s Hospital, Harvard, and Boston University, all in Massachusetts, aimed to highlight the NHS’s contributions to epidemiologic knowledge of endometrial, ovarian, pancreatic, and hematologic cancers. They focused on findings that identified novel risk factors or markers of early detection or helped clarify discrepant literature.

Because the researchers say severe immune compromise is the “strongest, best-established risk factor” for NHL, they studied factors that might lead to subclinical immune dysregulation, such as diet, body mass index (BMI), and supplement use. They found several risk factors and biomarkers for NHL and more than 35 distinct tumors in that category, including chronic lymphocytic leukemia. Trans fats and red meat, for instance, doubled the risk of NHL. The researchers also found a higher risk for women who reported long-term multivitamin use. However, they found no risk associated with diet or sugar-sweetened soda or aspartame or with dietary intake of vitamin D.

Related: IBD and the Risk of Oral Cancer

Greater adiposity during childhood and adolescence was significantly associated with NHL. The researchers also observed a 19% increased risk of all NHL per 5 kg/m² increase in BMI in young adulthood. Interestingly, taller women also had a higher risk of NHL.

The researchers conducted one of the first prospective studies to evaluate a putative inverse association of NHL risk with exposure to ambient ultraviolet radiation. They found, “contrary to expectation,” a 10% to 20% increased risk of NHL among women with the highest (vs lowest) ultraviolet-B exposure at baseline and birth, 15 years, and 30 years.

In investigating biomarkers, the researchers noted a “suggestive increase” in chronic lymphocytic leukemia risk associated with an Epstein-Barr virus antibody profile indicative of poor host immune control of the virus.

Related: Sexual Orientation and Cancer Risk

The researchers have established several working groups to study cancers, such as NHL and multiple myeloma. They also are collecting archival tissue specimens for NHL, multiple myeloma, and Hodgkin lymphoma, for better evaluation of factors related to the unique molecular subsets of hematologic tumors.

Source:
Birmann BM, Barnard ME, Bertrand KA, et al. Am J Public Health. 2016;106(9):1608-1615.
doi: 10.2105/AJPH.2016.303337.

In this presidential election cycle, health care issues are at the forefront of political discussions. In particular, presidential candidate Donald Trump has spotlighted the issue of caring for veterans by offering a 10-point plan.¹ Mr. Trump insists that his plan would ensure that veterans have convenient access to the best quality care and “decrease wait time, improve health care outcomes, and facilitate a seamless transition from service to civilian life.”²

Whether one agrees with Mr. Trump’s policy proposals or not, one thing is clear: We need to provide better care for our veterans.³ Even the Veterans Choice Program, enacted 2 years ago, has shown signs of substantial difficulties.⁴ The improvement of veteran care likely requires a multifaceted approach. There are many factors that can, and do, hinder the optimal delivery of care, but the shortages of nurses, pharmacists, nurse practitioners, physician assistants, and other health care providers is one of the most important.⁵

The shortage of physicians, which is the focus of this editorial, is especially acute.⁵ The Office of Inspector General (OIG) determined that a shortage of medical officers (defined as health care providers with an MD or DO degree) was the top issue affecting veteran care and the nurse shortage was second.⁵ However, the study did not break down the physician shortage by clinical specialty. According to other reports, the VA’s specialty physician shortage seems to vary. While some VA medical centers (VAMCs) had a shortage of primary care physicians (PCPs), others had a greater need for specialists.^6,7

Enhancing communication regarding the importance of veteran care, improving the VA physician recruitment process, and reducing the compensation disparity between VA physicians and non-VA physicians may help reduce the VA physician shortage indicated by OIG. Still the best way to resolve the VA physician shortage is unclear.

I propose that instituting a service requirement for graduating residents is possibly a more effective way to solve the VA physician shortage. I will delineate my argument in 3 simple points: fairness, feasibility, and altruism.

Fairness

The VAMCs have been the backbone of resident physician training and therefore deserve to be served by the graduating residents they help to train. Historically, VAMCs often have been affiliated with nearby medical schools to provide veterans with state-of-the-art health care. In turn, VAMCs provide some of the best training opportunities for resident physicians and medical students. Drs. Magnuson and DeBakey conceived the idea of a “marriage” between a VAMC and a medical school following World War II.⁸ With few exceptions, the best residency programs have at least 1 VAMC affiliation. According to the 2016 ranking of the best medical schools in the U.S. by U.S. News and World Report, 13 of the top 15 medical schools have a VAMC affiliate.⁹ Currently, the VA has formal affiliation agreements with 135 of 141 medical schools.⁸

Each year, VAMCs provide practical experience to medical students, resident physicians, and other health care trainees. In 2013, more than 20,000 medical students, 41,000 resident physicians, and 300 fellowship physicians received part or all of their training at VAMCs. Overall, about 70% of all U.S. physicians received their training at VA facilities.

Moreover, VAMCs provide not only the training facility and opportunity, but also substantial financial support to train residents: They currently fund more than 10,000 full-time equivalent positions for residents, about one-third of all resident positions in the U.S.⁸ While other federal government funding for residency training programs has flat-lined, the VA is the only federal government agency that has received increased funding recently.⁸ Most of the remaining federal funding for residency programs is provided through Medicare.

Given that the federal government (and the VA in particular) has provided so much support for resident physician training, it is perhaps fair that we ask our graduated residents to help solve the VA physician shortage. In addition, VA could consider tying in this service with a student loan reduction program, which would make this arrangement not only ethically compelling, but also financially practical.

Feasibility

Currently about 30,000 resident physicians graduate from 4,756 programs in the U.S. yearly.¹⁰ It has been estimated there is a shortage of 1,400 VA physicians in the U.S. The VA needs < 5% of graduating resident physicians to serve in VAMCs for 1 year in order to completely and certainly solve the physician shortage problem.

To be sure, the optimum resolution would be for the VA to recruit permanent physicians who build long-term, trusting relationships with patients and continuity of care. However, with the current situation in which permanent positions are left unfilled, a short-term program may be better than the status quo. In addition, having experienced the VA working environment, some of these newly graduated physicians serving short-term at the VA may decide later to make the VA a permanent home.

How do we then carry out this requirement? First, we could ask for volunteers once the VA determines the exact number of physicians needed in a given year. If resident physicians volunteers cannot meet VA’s needs, the remaining slots can be filled using a lottery.

Logistically, a lottery can be achieved in the following way. The process needs to be started 3 years before graduation due to residents’ need for advanced career planning. For the 3-year residency program, the lottery would be held at the beginning of the first year of residency. For the 5-year residency program, the lottery would be held at the beginning of third year of residency. All residency programs would be required to report the names of residents and residents who volunteer for 1 year VA service after residency to a central government depository, which would run a random, computerized process to generate names of the residents for the obligation. Residents would learn the lottery results no later than the end of that training year, so residents would have 2 years to plan for their careers, either for a permanent job or additional fellowship training, according to the lottery outcomes. Obviously, federal legislation would be needed to fund and establish the rightful authority to enforce the arrangement.

Altruism

Whether a person is a Republican, Democrat, or independent, we all sincerely appreciate the sacrifice that veterans provide to protect our nation through the ages. Regardless if one agrees with the objective of a particular war or not, our veterans served at the command of the presidents from both major parties. Veterans simply serve their country with their lives on the line. Since World War I, 116,516 World War I, 405,399 World War II, 54,246 Korean War, 90,220 Vietnam War, and 4,424 Operation Iraq Freedom U.S. soldiers and military personnel have died for our country during active duty.^11,12 In addition, many more veterans experienced permanent injuries and illness while protecting our country and our freedom.^11,12 Is it too much to ask our graduated residents, albeit a tiny percentage, to share some of the burden to care for our national heroes for just 1 year? I certainly do not think so.

One possible way to raise national awareness of the need for veteran health care is to make this issue a national service obligation, much like that of military service. We could promote the concept in a slogan, such as “The soldiers’ obligation: Serve the nation in the front lines; the nation’s obligation: Provides care when soldiers return home.” Volunteerism is the preferred method of military recruitment. However, if voluntary enlistment does not fulfill the military need, drafting may be the next necessity. The same logical argument can be used to promote the solution for the VA physician shortage.

Although I’ve focused on the solution for physicians, the same process can be expanded for the shortage of nurses, nurse practitioners, physician assistants, and other health care providers. That way, the VA patient would receive even better care.

I’ve served as a part-time VA physician for 25 consecutive years, and I have gladly provided care for our veterans and would be delighted to welcome our graduating residents in joining me and other dedicated VA physicians in this noble effort. As one Chicago VAMC banner beautifully depicted, “Honored to serve … those who served” (Figure), this is, indeed, the right thing to do.

In this presidential election cycle, health care issues are at the forefront of political discussions. In particular, presidential candidate Donald Trump has spotlighted the issue of caring for veterans by offering a 10-point plan.¹ Mr. Trump insists that his plan would ensure that veterans have convenient access to the best quality care and “decrease wait time, improve health care outcomes, and facilitate a seamless transition from service to civilian life.”²

Whether one agrees with Mr. Trump’s policy proposals or not, one thing is clear: We need to provide better care for our veterans.³ Even the Veterans Choice Program, enacted 2 years ago, has shown signs of substantial difficulties.⁴ The improvement of veteran care likely requires a multifaceted approach. There are many factors that can, and do, hinder the optimal delivery of care, but the shortages of nurses, pharmacists, nurse practitioners, physician assistants, and other health care providers is one of the most important.⁵

The shortage of physicians, which is the focus of this editorial, is especially acute.⁵ The Office of Inspector General (OIG) determined that a shortage of medical officers (defined as health care providers with an MD or DO degree) was the top issue affecting veteran care and the nurse shortage was second.⁵ However, the study did not break down the physician shortage by clinical specialty. According to other reports, the VA’s specialty physician shortage seems to vary. While some VA medical centers (VAMCs) had a shortage of primary care physicians (PCPs), others had a greater need for specialists.^6,7

Enhancing communication regarding the importance of veteran care, improving the VA physician recruitment process, and reducing the compensation disparity between VA physicians and non-VA physicians may help reduce the VA physician shortage indicated by OIG. Still the best way to resolve the VA physician shortage is unclear.

I propose that instituting a service requirement for graduating residents is possibly a more effective way to solve the VA physician shortage. I will delineate my argument in 3 simple points: fairness, feasibility, and altruism.

Fairness

The VAMCs have been the backbone of resident physician training and therefore deserve to be served by the graduating residents they help to train. Historically, VAMCs often have been affiliated with nearby medical schools to provide veterans with state-of-the-art health care. In turn, VAMCs provide some of the best training opportunities for resident physicians and medical students. Drs. Magnuson and DeBakey conceived the idea of a “marriage” between a VAMC and a medical school following World War II.⁸ With few exceptions, the best residency programs have at least 1 VAMC affiliation. According to the 2016 ranking of the best medical schools in the U.S. by U.S. News and World Report, 13 of the top 15 medical schools have a VAMC affiliate.⁹ Currently, the VA has formal affiliation agreements with 135 of 141 medical schools.⁸

Each year, VAMCs provide practical experience to medical students, resident physicians, and other health care trainees. In 2013, more than 20,000 medical students, 41,000 resident physicians, and 300 fellowship physicians received part or all of their training at VAMCs. Overall, about 70% of all U.S. physicians received their training at VA facilities.

Moreover, VAMCs provide not only the training facility and opportunity, but also substantial financial support to train residents: They currently fund more than 10,000 full-time equivalent positions for residents, about one-third of all resident positions in the U.S.⁸ While other federal government funding for residency training programs has flat-lined, the VA is the only federal government agency that has received increased funding recently.⁸ Most of the remaining federal funding for residency programs is provided through Medicare.

Given that the federal government (and the VA in particular) has provided so much support for resident physician training, it is perhaps fair that we ask our graduated residents to help solve the VA physician shortage. In addition, VA could consider tying in this service with a student loan reduction program, which would make this arrangement not only ethically compelling, but also financially practical.

Feasibility

Currently about 30,000 resident physicians graduate from 4,756 programs in the U.S. yearly.¹⁰ It has been estimated there is a shortage of 1,400 VA physicians in the U.S. The VA needs < 5% of graduating resident physicians to serve in VAMCs for 1 year in order to completely and certainly solve the physician shortage problem.

To be sure, the optimum resolution would be for the VA to recruit permanent physicians who build long-term, trusting relationships with patients and continuity of care. However, with the current situation in which permanent positions are left unfilled, a short-term program may be better than the status quo. In addition, having experienced the VA working environment, some of these newly graduated physicians serving short-term at the VA may decide later to make the VA a permanent home.

How do we then carry out this requirement? First, we could ask for volunteers once the VA determines the exact number of physicians needed in a given year. If resident physicians volunteers cannot meet VA’s needs, the remaining slots can be filled using a lottery.

Logistically, a lottery can be achieved in the following way. The process needs to be started 3 years before graduation due to residents’ need for advanced career planning. For the 3-year residency program, the lottery would be held at the beginning of the first year of residency. For the 5-year residency program, the lottery would be held at the beginning of third year of residency. All residency programs would be required to report the names of residents and residents who volunteer for 1 year VA service after residency to a central government depository, which would run a random, computerized process to generate names of the residents for the obligation. Residents would learn the lottery results no later than the end of that training year, so residents would have 2 years to plan for their careers, either for a permanent job or additional fellowship training, according to the lottery outcomes. Obviously, federal legislation would be needed to fund and establish the rightful authority to enforce the arrangement.

Altruism

Whether a person is a Republican, Democrat, or independent, we all sincerely appreciate the sacrifice that veterans provide to protect our nation through the ages. Regardless if one agrees with the objective of a particular war or not, our veterans served at the command of the presidents from both major parties. Veterans simply serve their country with their lives on the line. Since World War I, 116,516 World War I, 405,399 World War II, 54,246 Korean War, 90,220 Vietnam War, and 4,424 Operation Iraq Freedom U.S. soldiers and military personnel have died for our country during active duty.^11,12 In addition, many more veterans experienced permanent injuries and illness while protecting our country and our freedom.^11,12 Is it too much to ask our graduated residents, albeit a tiny percentage, to share some of the burden to care for our national heroes for just 1 year? I certainly do not think so.

One possible way to raise national awareness of the need for veteran health care is to make this issue a national service obligation, much like that of military service. We could promote the concept in a slogan, such as “The soldiers’ obligation: Serve the nation in the front lines; the nation’s obligation: Provides care when soldiers return home.” Volunteerism is the preferred method of military recruitment. However, if voluntary enlistment does not fulfill the military need, drafting may be the next necessity. The same logical argument can be used to promote the solution for the VA physician shortage.

Although I’ve focused on the solution for physicians, the same process can be expanded for the shortage of nurses, nurse practitioners, physician assistants, and other health care providers. That way, the VA patient would receive even better care.

I’ve served as a part-time VA physician for 25 consecutive years, and I have gladly provided care for our veterans and would be delighted to welcome our graduating residents in joining me and other dedicated VA physicians in this noble effort. As one Chicago VAMC banner beautifully depicted, “Honored to serve … those who served” (Figure), this is, indeed, the right thing to do.

In this presidential election cycle, health care issues are at the forefront of political discussions. In particular, presidential candidate Donald Trump has spotlighted the issue of caring for veterans by offering a 10-point plan.¹ Mr. Trump insists that his plan would ensure that veterans have convenient access to the best quality care and “decrease wait time, improve health care outcomes, and facilitate a seamless transition from service to civilian life.”²

Whether one agrees with Mr. Trump’s policy proposals or not, one thing is clear: We need to provide better care for our veterans.³ Even the Veterans Choice Program, enacted 2 years ago, has shown signs of substantial difficulties.⁴ The improvement of veteran care likely requires a multifaceted approach. There are many factors that can, and do, hinder the optimal delivery of care, but the shortages of nurses, pharmacists, nurse practitioners, physician assistants, and other health care providers is one of the most important.⁵

The shortage of physicians, which is the focus of this editorial, is especially acute.⁵ The Office of Inspector General (OIG) determined that a shortage of medical officers (defined as health care providers with an MD or DO degree) was the top issue affecting veteran care and the nurse shortage was second.⁵ However, the study did not break down the physician shortage by clinical specialty. According to other reports, the VA’s specialty physician shortage seems to vary. While some VA medical centers (VAMCs) had a shortage of primary care physicians (PCPs), others had a greater need for specialists.^6,7

Enhancing communication regarding the importance of veteran care, improving the VA physician recruitment process, and reducing the compensation disparity between VA physicians and non-VA physicians may help reduce the VA physician shortage indicated by OIG. Still the best way to resolve the VA physician shortage is unclear.

I propose that instituting a service requirement for graduating residents is possibly a more effective way to solve the VA physician shortage. I will delineate my argument in 3 simple points: fairness, feasibility, and altruism.

Fairness

The VAMCs have been the backbone of resident physician training and therefore deserve to be served by the graduating residents they help to train. Historically, VAMCs often have been affiliated with nearby medical schools to provide veterans with state-of-the-art health care. In turn, VAMCs provide some of the best training opportunities for resident physicians and medical students. Drs. Magnuson and DeBakey conceived the idea of a “marriage” between a VAMC and a medical school following World War II.⁸ With few exceptions, the best residency programs have at least 1 VAMC affiliation. According to the 2016 ranking of the best medical schools in the U.S. by U.S. News and World Report, 13 of the top 15 medical schools have a VAMC affiliate.⁹ Currently, the VA has formal affiliation agreements with 135 of 141 medical schools.⁸

Each year, VAMCs provide practical experience to medical students, resident physicians, and other health care trainees. In 2013, more than 20,000 medical students, 41,000 resident physicians, and 300 fellowship physicians received part or all of their training at VAMCs. Overall, about 70% of all U.S. physicians received their training at VA facilities.

Moreover, VAMCs provide not only the training facility and opportunity, but also substantial financial support to train residents: They currently fund more than 10,000 full-time equivalent positions for residents, about one-third of all resident positions in the U.S.⁸ While other federal government funding for residency training programs has flat-lined, the VA is the only federal government agency that has received increased funding recently.⁸ Most of the remaining federal funding for residency programs is provided through Medicare.

Given that the federal government (and the VA in particular) has provided so much support for resident physician training, it is perhaps fair that we ask our graduated residents to help solve the VA physician shortage. In addition, VA could consider tying in this service with a student loan reduction program, which would make this arrangement not only ethically compelling, but also financially practical.

Feasibility

Currently about 30,000 resident physicians graduate from 4,756 programs in the U.S. yearly.¹⁰ It has been estimated there is a shortage of 1,400 VA physicians in the U.S. The VA needs < 5% of graduating resident physicians to serve in VAMCs for 1 year in order to completely and certainly solve the physician shortage problem.

To be sure, the optimum resolution would be for the VA to recruit permanent physicians who build long-term, trusting relationships with patients and continuity of care. However, with the current situation in which permanent positions are left unfilled, a short-term program may be better than the status quo. In addition, having experienced the VA working environment, some of these newly graduated physicians serving short-term at the VA may decide later to make the VA a permanent home.

How do we then carry out this requirement? First, we could ask for volunteers once the VA determines the exact number of physicians needed in a given year. If resident physicians volunteers cannot meet VA’s needs, the remaining slots can be filled using a lottery.

Logistically, a lottery can be achieved in the following way. The process needs to be started 3 years before graduation due to residents’ need for advanced career planning. For the 3-year residency program, the lottery would be held at the beginning of the first year of residency. For the 5-year residency program, the lottery would be held at the beginning of third year of residency. All residency programs would be required to report the names of residents and residents who volunteer for 1 year VA service after residency to a central government depository, which would run a random, computerized process to generate names of the residents for the obligation. Residents would learn the lottery results no later than the end of that training year, so residents would have 2 years to plan for their careers, either for a permanent job or additional fellowship training, according to the lottery outcomes. Obviously, federal legislation would be needed to fund and establish the rightful authority to enforce the arrangement.

Altruism

Whether a person is a Republican, Democrat, or independent, we all sincerely appreciate the sacrifice that veterans provide to protect our nation through the ages. Regardless if one agrees with the objective of a particular war or not, our veterans served at the command of the presidents from both major parties. Veterans simply serve their country with their lives on the line. Since World War I, 116,516 World War I, 405,399 World War II, 54,246 Korean War, 90,220 Vietnam War, and 4,424 Operation Iraq Freedom U.S. soldiers and military personnel have died for our country during active duty.^11,12 In addition, many more veterans experienced permanent injuries and illness while protecting our country and our freedom.^11,12 Is it too much to ask our graduated residents, albeit a tiny percentage, to share some of the burden to care for our national heroes for just 1 year? I certainly do not think so.

One possible way to raise national awareness of the need for veteran health care is to make this issue a national service obligation, much like that of military service. We could promote the concept in a slogan, such as “The soldiers’ obligation: Serve the nation in the front lines; the nation’s obligation: Provides care when soldiers return home.” Volunteerism is the preferred method of military recruitment. However, if voluntary enlistment does not fulfill the military need, drafting may be the next necessity. The same logical argument can be used to promote the solution for the VA physician shortage.

Although I’ve focused on the solution for physicians, the same process can be expanded for the shortage of nurses, nurse practitioners, physician assistants, and other health care providers. That way, the VA patient would receive even better care.

I’ve served as a part-time VA physician for 25 consecutive years, and I have gladly provided care for our veterans and would be delighted to welcome our graduating residents in joining me and other dedicated VA physicians in this noble effort. As one Chicago VAMC banner beautifully depicted, “Honored to serve … those who served” (Figure), this is, indeed, the right thing to do.