HHS Secretary Sylvia M. Burwell

The United States Department of Health and Human Services (HHS) has declared a public health emergency for Puerto Rico due to the Zika virus outbreak.

The declaration allows the federal government to provide support to the government of Puerto Rico to address the outbreak.

“This administration is committed to meeting the Zika outbreak in Puerto Rico with the necessary urgency,” said HHS Secretary Sylvia M. Burwell.

“This emergency declaration allows us to provide additional support to the Puerto Rican government and reminds us of the importance of pregnant women, women of child-bearing age, and their partners taking additional steps to protect themselves and their families from Zika.”

Through the public health emergency declaration, the government of Puerto Rico can:

• Apply for funding to hire and train unemployed workers to assist in vector control and outreach and education efforts through the US Department of Labor’s National Dislocated Worker Grant program
• Request the temporary reassignment of local public health department or agency personnel who are funded through Public Health Service Act programs in Puerto Rico to assist in the Zika response.

“The declaration made by HHS, which grants access to certain funds, is another example of collaboration between the federal government and the government of Puerto Rico,” said Alejandro García Padilla, governor of the Commonwealth of Puerto Rico.

In April, the HHS awarded $5 million to Puerto Rico health centers to fight the spread of the Zika virus. In March, the HHS shipped blood products to the island in response to the Zika outbreak.

Earlier this month, the US Centers for Disease Control and Prevention (CDC) awarded $16 million to US states and territories, including Puerto Rico, to fight the Zika virus. In July, the CDC awarded $25 million to US states, cities, and territories for the same purpose.

According to the Puerto Rico Department of Health, as of August 12, there have been 10,690 laboratory-confirmed cases of Zika in Puerto Rico, which includes 1035 pregnant women.

The actual number of people infected with Zika may be higher because most people with Zika infections have no symptoms and might not seek testing.

HHS Secretary Sylvia M. Burwell

The United States Department of Health and Human Services (HHS) has declared a public health emergency for Puerto Rico due to the Zika virus outbreak.

The declaration allows the federal government to provide support to the government of Puerto Rico to address the outbreak.

“This administration is committed to meeting the Zika outbreak in Puerto Rico with the necessary urgency,” said HHS Secretary Sylvia M. Burwell.

“This emergency declaration allows us to provide additional support to the Puerto Rican government and reminds us of the importance of pregnant women, women of child-bearing age, and their partners taking additional steps to protect themselves and their families from Zika.”

Through the public health emergency declaration, the government of Puerto Rico can:

• Apply for funding to hire and train unemployed workers to assist in vector control and outreach and education efforts through the US Department of Labor’s National Dislocated Worker Grant program
• Request the temporary reassignment of local public health department or agency personnel who are funded through Public Health Service Act programs in Puerto Rico to assist in the Zika response.

“The declaration made by HHS, which grants access to certain funds, is another example of collaboration between the federal government and the government of Puerto Rico,” said Alejandro García Padilla, governor of the Commonwealth of Puerto Rico.

In April, the HHS awarded $5 million to Puerto Rico health centers to fight the spread of the Zika virus. In March, the HHS shipped blood products to the island in response to the Zika outbreak.

Earlier this month, the US Centers for Disease Control and Prevention (CDC) awarded $16 million to US states and territories, including Puerto Rico, to fight the Zika virus. In July, the CDC awarded $25 million to US states, cities, and territories for the same purpose.

According to the Puerto Rico Department of Health, as of August 12, there have been 10,690 laboratory-confirmed cases of Zika in Puerto Rico, which includes 1035 pregnant women.

The actual number of people infected with Zika may be higher because most people with Zika infections have no symptoms and might not seek testing.

HHS Secretary Sylvia M. Burwell

The United States Department of Health and Human Services (HHS) has declared a public health emergency for Puerto Rico due to the Zika virus outbreak.

The declaration allows the federal government to provide support to the government of Puerto Rico to address the outbreak.

“This administration is committed to meeting the Zika outbreak in Puerto Rico with the necessary urgency,” said HHS Secretary Sylvia M. Burwell.

“This emergency declaration allows us to provide additional support to the Puerto Rican government and reminds us of the importance of pregnant women, women of child-bearing age, and their partners taking additional steps to protect themselves and their families from Zika.”

Through the public health emergency declaration, the government of Puerto Rico can:

• Apply for funding to hire and train unemployed workers to assist in vector control and outreach and education efforts through the US Department of Labor’s National Dislocated Worker Grant program
• Request the temporary reassignment of local public health department or agency personnel who are funded through Public Health Service Act programs in Puerto Rico to assist in the Zika response.

“The declaration made by HHS, which grants access to certain funds, is another example of collaboration between the federal government and the government of Puerto Rico,” said Alejandro García Padilla, governor of the Commonwealth of Puerto Rico.

In April, the HHS awarded $5 million to Puerto Rico health centers to fight the spread of the Zika virus. In March, the HHS shipped blood products to the island in response to the Zika outbreak.

Earlier this month, the US Centers for Disease Control and Prevention (CDC) awarded $16 million to US states and territories, including Puerto Rico, to fight the Zika virus. In July, the CDC awarded $25 million to US states, cities, and territories for the same purpose.

According to the Puerto Rico Department of Health, as of August 12, there have been 10,690 laboratory-confirmed cases of Zika in Puerto Rico, which includes 1035 pregnant women.

The actual number of people infected with Zika may be higher because most people with Zika infections have no symptoms and might not seek testing.

Micrograph showing CLL

New research explains how an inherited genetic variant associated with an increased risk of chronic lymphocytic leukemia (CLL) helps cancer cells survive.

Previous research showed that DNA variations at 15q15.1 are linked with an increased risk of CLL.

With the current study, researchers believe they have identified the causal variant at 15q15.1 and determined the mechanism by which it influences tumorigenesis.

Richard Houlston, MD, PhD, of The Institute of Cancer Research in London, UK, and his colleagues conducted this research and detailed the results in Cell Reports.

The researchers said the single nucleotide polymorphism rs539846 underlies the 15q15.1 CLL risk locus.

And the rs539846-A risk allele interferes with BCL-2 modifying factor (BMF), which normally works to produce pro-apoptotic signals.

This interference makes it harder for the protein RELA to “flip on” the activity of BMF and reduces levels of the pro-apoptotic signals, allowing CLL cells to sidestep self-destruction.

“Although many significant risk variants for this type of leukemia have been identified, the biological mechanisms through which these variants affect leukemia development have been less well studied,” Dr Houlston said.

“This study highlights the importance of cell-death-inducing proteins such as BMF in controlling CLL development and could help in the design of new drugs to treat this disease.”

In addition, Dr Houlston and his colleagues said their findings complement work from phase 1 and phase 2 trials of venetoclax (formerly ABT-199) in CLL.

The trials suggested that venetoclax mimics pro-apoptotic proteins by targeting the pro-survival BCL-2 pathway. In this way, the drug can produce anticancer effects in CLL patients.

Dr Houlston and his colleagues believe their discovery could provide important insight into how venetoclax and similar drugs work, which could optimize the drugs’ use.

Micrograph showing CLL

New research explains how an inherited genetic variant associated with an increased risk of chronic lymphocytic leukemia (CLL) helps cancer cells survive.

Previous research showed that DNA variations at 15q15.1 are linked with an increased risk of CLL.

With the current study, researchers believe they have identified the causal variant at 15q15.1 and determined the mechanism by which it influences tumorigenesis.

Richard Houlston, MD, PhD, of The Institute of Cancer Research in London, UK, and his colleagues conducted this research and detailed the results in Cell Reports.

The researchers said the single nucleotide polymorphism rs539846 underlies the 15q15.1 CLL risk locus.

And the rs539846-A risk allele interferes with BCL-2 modifying factor (BMF), which normally works to produce pro-apoptotic signals.

This interference makes it harder for the protein RELA to “flip on” the activity of BMF and reduces levels of the pro-apoptotic signals, allowing CLL cells to sidestep self-destruction.

“Although many significant risk variants for this type of leukemia have been identified, the biological mechanisms through which these variants affect leukemia development have been less well studied,” Dr Houlston said.

“This study highlights the importance of cell-death-inducing proteins such as BMF in controlling CLL development and could help in the design of new drugs to treat this disease.”

In addition, Dr Houlston and his colleagues said their findings complement work from phase 1 and phase 2 trials of venetoclax (formerly ABT-199) in CLL.

The trials suggested that venetoclax mimics pro-apoptotic proteins by targeting the pro-survival BCL-2 pathway. In this way, the drug can produce anticancer effects in CLL patients.

Dr Houlston and his colleagues believe their discovery could provide important insight into how venetoclax and similar drugs work, which could optimize the drugs’ use.

Micrograph showing CLL

New research explains how an inherited genetic variant associated with an increased risk of chronic lymphocytic leukemia (CLL) helps cancer cells survive.

Previous research showed that DNA variations at 15q15.1 are linked with an increased risk of CLL.

With the current study, researchers believe they have identified the causal variant at 15q15.1 and determined the mechanism by which it influences tumorigenesis.

Richard Houlston, MD, PhD, of The Institute of Cancer Research in London, UK, and his colleagues conducted this research and detailed the results in Cell Reports.

The researchers said the single nucleotide polymorphism rs539846 underlies the 15q15.1 CLL risk locus.

And the rs539846-A risk allele interferes with BCL-2 modifying factor (BMF), which normally works to produce pro-apoptotic signals.

This interference makes it harder for the protein RELA to “flip on” the activity of BMF and reduces levels of the pro-apoptotic signals, allowing CLL cells to sidestep self-destruction.

“Although many significant risk variants for this type of leukemia have been identified, the biological mechanisms through which these variants affect leukemia development have been less well studied,” Dr Houlston said.

“This study highlights the importance of cell-death-inducing proteins such as BMF in controlling CLL development and could help in the design of new drugs to treat this disease.”

In addition, Dr Houlston and his colleagues said their findings complement work from phase 1 and phase 2 trials of venetoclax (formerly ABT-199) in CLL.

The trials suggested that venetoclax mimics pro-apoptotic proteins by targeting the pro-survival BCL-2 pathway. In this way, the drug can produce anticancer effects in CLL patients.

Dr Houlston and his colleagues believe their discovery could provide important insight into how venetoclax and similar drugs work, which could optimize the drugs’ use.

Topical timolol maleate acts as an effective alternate to oral propranolol for treatment of certain infantile hemangiomas (IHs), based on data from a retrospective study of 731 children. The findings were published online August 15 in Pediatrics.

“Superficial, relatively thin IHs, regardless of pretreatment surface or body site, are likely to respond reasonably well to several months of treatment with modest, but definite improvements in color and size,” wrote Katherine Püttgen, MD, of Johns Hopkins University in Baltimore, Md., and colleagues in the Hemangioma Investigator Group (Pediatrics 2016;138:e20160355 [doi: 10.1052/peds.2016-0355]).

Courtesy CDC/Richard S. Hibbets

Although topical timolol maleate (TTM) has been used off label to treat infantile hemangiomas since 2010, “there is very limited information regarding off-label safety and pharmacokinetic data when used on hemangioma-affected skin,” the researchers noted.

The researchers reviewed data from 731 children treated at nine pediatric centers in the United States. Patients were treated for at least 30 days; the average treatment duration was 9 months. Most of the children (41%) began treatment between ages 0 and 3 months, and 86% were treatment naïve.

About 85% of the children received TTM 0.5% GFS (gel-forming solution), with parents instructed to apply 1 drop twice daily to the IH; 15% were prescribed 4 drops or more of TTM daily. Treatment response was assessed based on visual analog scales for color (VAS-C) and for size, extent, and volume (VAS-SEV).

Overall, 70% of children showed improvement of at least 10% from baseline on the VAS-C after 1-3 months of treatment, and 92% showed meaningful improvement from baseline after 6-9 months of treatment. VAS-SEV scores improved at least 10% from baseline in 39% of children after 1-3 months and meaningful improvement in 76% after 6-9 months.

Independent predictors of treatment success included longer treatment time and thinner, superficial IH at baseline.

Adverse events were observed in 3% of the patients, approximately half of which were reports of scaly skin. No patients discontinued the study because of adverse events, and no cardiovascular adverse events were reported.

The results were limited by several factors including the lack of controls and the retrospective nature of the study, the researchers noted. In addition, they cautioned against the use of However, the findings suggest that “TTM can be recommended as an initial, and often sole, treatment modality for many relatively superficial His without aggressive growth or threat of functional impairment,” they said. However, the researchers cautioned against TTM in cases of ulcerated IHs because of the potential for increased drug absorption.

Dr. Püttgen and several coauthors disclosed serving as consultants to Pierre Fabre.

Topical timolol maleate acts as an effective alternate to oral propranolol for treatment of certain infantile hemangiomas (IHs), based on data from a retrospective study of 731 children. The findings were published online August 15 in Pediatrics.

“Superficial, relatively thin IHs, regardless of pretreatment surface or body site, are likely to respond reasonably well to several months of treatment with modest, but definite improvements in color and size,” wrote Katherine Püttgen, MD, of Johns Hopkins University in Baltimore, Md., and colleagues in the Hemangioma Investigator Group (Pediatrics 2016;138:e20160355 [doi: 10.1052/peds.2016-0355]).

Courtesy CDC/Richard S. Hibbets

Although topical timolol maleate (TTM) has been used off label to treat infantile hemangiomas since 2010, “there is very limited information regarding off-label safety and pharmacokinetic data when used on hemangioma-affected skin,” the researchers noted.

The researchers reviewed data from 731 children treated at nine pediatric centers in the United States. Patients were treated for at least 30 days; the average treatment duration was 9 months. Most of the children (41%) began treatment between ages 0 and 3 months, and 86% were treatment naïve.

About 85% of the children received TTM 0.5% GFS (gel-forming solution), with parents instructed to apply 1 drop twice daily to the IH; 15% were prescribed 4 drops or more of TTM daily. Treatment response was assessed based on visual analog scales for color (VAS-C) and for size, extent, and volume (VAS-SEV).

Overall, 70% of children showed improvement of at least 10% from baseline on the VAS-C after 1-3 months of treatment, and 92% showed meaningful improvement from baseline after 6-9 months of treatment. VAS-SEV scores improved at least 10% from baseline in 39% of children after 1-3 months and meaningful improvement in 76% after 6-9 months.

Independent predictors of treatment success included longer treatment time and thinner, superficial IH at baseline.

Adverse events were observed in 3% of the patients, approximately half of which were reports of scaly skin. No patients discontinued the study because of adverse events, and no cardiovascular adverse events were reported.

The results were limited by several factors including the lack of controls and the retrospective nature of the study, the researchers noted. In addition, they cautioned against the use of However, the findings suggest that “TTM can be recommended as an initial, and often sole, treatment modality for many relatively superficial His without aggressive growth or threat of functional impairment,” they said. However, the researchers cautioned against TTM in cases of ulcerated IHs because of the potential for increased drug absorption.

Dr. Püttgen and several coauthors disclosed serving as consultants to Pierre Fabre.

Topical timolol maleate acts as an effective alternate to oral propranolol for treatment of certain infantile hemangiomas (IHs), based on data from a retrospective study of 731 children. The findings were published online August 15 in Pediatrics.

“Superficial, relatively thin IHs, regardless of pretreatment surface or body site, are likely to respond reasonably well to several months of treatment with modest, but definite improvements in color and size,” wrote Katherine Püttgen, MD, of Johns Hopkins University in Baltimore, Md., and colleagues in the Hemangioma Investigator Group (Pediatrics 2016;138:e20160355 [doi: 10.1052/peds.2016-0355]).

Courtesy CDC/Richard S. Hibbets

Although topical timolol maleate (TTM) has been used off label to treat infantile hemangiomas since 2010, “there is very limited information regarding off-label safety and pharmacokinetic data when used on hemangioma-affected skin,” the researchers noted.

The researchers reviewed data from 731 children treated at nine pediatric centers in the United States. Patients were treated for at least 30 days; the average treatment duration was 9 months. Most of the children (41%) began treatment between ages 0 and 3 months, and 86% were treatment naïve.

About 85% of the children received TTM 0.5% GFS (gel-forming solution), with parents instructed to apply 1 drop twice daily to the IH; 15% were prescribed 4 drops or more of TTM daily. Treatment response was assessed based on visual analog scales for color (VAS-C) and for size, extent, and volume (VAS-SEV).

Overall, 70% of children showed improvement of at least 10% from baseline on the VAS-C after 1-3 months of treatment, and 92% showed meaningful improvement from baseline after 6-9 months of treatment. VAS-SEV scores improved at least 10% from baseline in 39% of children after 1-3 months and meaningful improvement in 76% after 6-9 months.

Independent predictors of treatment success included longer treatment time and thinner, superficial IH at baseline.

Adverse events were observed in 3% of the patients, approximately half of which were reports of scaly skin. No patients discontinued the study because of adverse events, and no cardiovascular adverse events were reported.

The results were limited by several factors including the lack of controls and the retrospective nature of the study, the researchers noted. In addition, they cautioned against the use of However, the findings suggest that “TTM can be recommended as an initial, and often sole, treatment modality for many relatively superficial His without aggressive growth or threat of functional impairment,” they said. However, the researchers cautioned against TTM in cases of ulcerated IHs because of the potential for increased drug absorption.

Dr. Püttgen and several coauthors disclosed serving as consultants to Pierre Fabre.

NATIONAL HARBOR, MD – “Specialties are like species,” said Frank J. Veith, MD, “they must evolve or go extinct.”

Dr. Veith of the New York University Langone Medical Center made this comparison in his 2016 Homans Lecture on the topic of “The future of vascular surgery,” at this year’s annual meeting hosted by the Society for Vascular Surgery.

©Martin Allred

Dr. Veith reviewed the history of vascular surgery, touched on its present status, and speculated on its potentially bright future. The vascular specialty has evolved dramatically over the past decades, especially in the area of embracing the endovascular revolution, said Dr. Veith, with that revolution putting vascular surgery at the forefront of research to develop new techniques.

His witnessing such innovations as those developed by Dr. Juan Parodi, and being a part of the early history of endovascular surgery, convinced Dr. Veith of its long-term importance to the development and survival of the specialty.

In his 1996 SVS Presidential Address, he predicted that 40%-70% of the open operations being done then would be replaced by endovascular procedures. “Accordingly, to survive, I recommended that vascular surgeons become endocompetent, learn how to do these procedures, and embrace them.” Dr. Veith added that, although his recommendation was not greeted with open arms by everyone, endovascular techniques moved forward.

In fact, “vascular surgeons often lead in developing many evolving endovascular procedures that are currently the standard of care,” he said.

Dr. Veith pointed out that a wide variety of conditions are now amenable to endovascular treatment, although some, including carotid disease, remain controversial. He listed examples of those conditions that he felt were still best treated with open surgery: thoracic outlet and entrapment syndromes, some ascending aorta and arch lesions, a few rare aneurysms not suited for endovascular treatment, some Takayasu’s lesions, some congenital and genetic aortic and renal artery lesions, some infected arteries and arterial grafts, a rare recurrent or complex lower-extremity lesion, some carotid lesions, and some failed endovascular treatments.

“Our specialty has embraced the endovascular revolution and become endocompetent,” he said. “It is why vascular surgery is doing as well as it is today.” He added. “Vascular surgery is presently an exciting, vibrant specialty in the United States.”

Dr. Veith noted, “Well-trained vascular surgeons are the only ones who can provide the most appropriate, full spectrum of care for patients with vascular disease, outside the head and the heart – whether that treatment be medical, endovascular, or open. There are abundant numbers of patients who require our skills. In addition, we use fascinating technology and have good industry relationships. And finally, many patients regard their vascular surgeon as a key doctor who they see regularly. As a result of these advantages, many bright medical students and general surgery residents are choosing to train as vascular surgeons. Vascular surgery should be flourishing.”

However, despite the fact vascular surgery is an exciting and vibrant specialty, and the best for treating vascular disease outside of the heart and the brain, the vascular specialty has significant problems competing with other specialties, he said.

He blamed in part the size and structure of the specialty, in particular with regard to its competition.

“Vascular surgery competes, as it always has, with general and cardiac surgeons. However, general surgeons have become less competitive, but cardiac surgeons have become more in need of work, and thus more active beyond the heart and thoracic aorta – as their open operations are replaced by coronary stents and transcatheter valves. More importantly, as vascular treatments become increasingly endovascular, vascular surgery will be competing with interventional radiology and, importantly, interventional cardiology.”

He outlined a number of major challenges these other disciplines create, in part, because of the DRG/RVU/dollar orientation of institutions, and the fact that most institutions still consider vascular surgery a subspecialty of general or cardiac surgery, or a subordinate part of a Heart & Vascular Center, with administrative control of these centers rarely in the hands of vascular surgeons. Moreover, when institutional resources – like angiography suites or hybrid operating rooms are distributed, the interests of vascular surgery are often represented by a general or cardiac surgeon – or worse a cardiologist,” he added.

He stated that these conditions limit vascular surgery’s ability to get its fair share of institutional resources.

“The competitive playing field is not level, and vascular surgeons are disadvantaged in the Darwinian struggle to survive,” he stated.

“To survive, vascular surgery needs to unify, recognize this inequity, and fix it. This can only be done if all vascular surgeons engage vigorously in this issue. We need equal administrative status with cardiac and general surgery in our institutions,” Dr. Veith advised.

In discussing the technological future, Dr. Veith said that by 2026, 75%-95% of all vascular cases requiring more than medical therapy will be treated endovascularly, with perhaps 5% in a hybrid fashion (open plus endovascular), and between 5% and 15% being treated fully by open surgery. This shift away from open surgery is and will continue to cause challenges in training and patient access to open treatment.

He asked the question: How should vascular surgery deal with the decreasing numbers of complex open procedures and who should do them?

“One solution is to have centers to which these patients are sent and in which vascular surgeons seeking this skill can get adequate open training,” he answered.

But the technological future he painted was bright. Not only was the future likely to be filled with new advances in medical therapy, but he also highlighted computer-assisted 3-D–device navigational tools to aid endovascular treatment; advances in robotic guidance to decrease radiation exposure and facilitate device placement; computer-enhanced simulation to improve training and, when patient specific, to allow procedure planning and rehearsal; and even 3-D printed modeling of lesions and blood vessels.

He predicted that the endovascular problems of intimal hyperplasia will be overcome by antiproliferative drugs in all vascular beds – once the best way of getting the best drug to the proper location is found – and that computer-enabled remote monitoring of flows within grafts and stents, perhaps using miniaturized piezoelectric sensors, will allow corrective treatment before occlusion occurs.

Dr. Veith stated that, in his view, to take its proper place, vascular surgery should rise above its subspecialty status in the shadow of general surgery and in its competition with cardiology.

This “will help vascular surgery to flourish and be recognized as the main specialty devoted to patients with noncardiac vascular diseases. Vascular surgery can then fulfill its potential for a brighter future. More importantly, patients and society will be the ultimate beneficiaries,” he concluded.

Dr. Veith reported that he had no conflicts to disclose with regard to his remarks.

[email protected]

On Twitter @VascularTweets

NATIONAL HARBOR, MD – “Specialties are like species,” said Frank J. Veith, MD, “they must evolve or go extinct.”

Dr. Veith of the New York University Langone Medical Center made this comparison in his 2016 Homans Lecture on the topic of “The future of vascular surgery,” at this year’s annual meeting hosted by the Society for Vascular Surgery.

©Martin Allred

Dr. Veith reviewed the history of vascular surgery, touched on its present status, and speculated on its potentially bright future. The vascular specialty has evolved dramatically over the past decades, especially in the area of embracing the endovascular revolution, said Dr. Veith, with that revolution putting vascular surgery at the forefront of research to develop new techniques.

His witnessing such innovations as those developed by Dr. Juan Parodi, and being a part of the early history of endovascular surgery, convinced Dr. Veith of its long-term importance to the development and survival of the specialty.

In his 1996 SVS Presidential Address, he predicted that 40%-70% of the open operations being done then would be replaced by endovascular procedures. “Accordingly, to survive, I recommended that vascular surgeons become endocompetent, learn how to do these procedures, and embrace them.” Dr. Veith added that, although his recommendation was not greeted with open arms by everyone, endovascular techniques moved forward.

In fact, “vascular surgeons often lead in developing many evolving endovascular procedures that are currently the standard of care,” he said.

Dr. Veith pointed out that a wide variety of conditions are now amenable to endovascular treatment, although some, including carotid disease, remain controversial. He listed examples of those conditions that he felt were still best treated with open surgery: thoracic outlet and entrapment syndromes, some ascending aorta and arch lesions, a few rare aneurysms not suited for endovascular treatment, some Takayasu’s lesions, some congenital and genetic aortic and renal artery lesions, some infected arteries and arterial grafts, a rare recurrent or complex lower-extremity lesion, some carotid lesions, and some failed endovascular treatments.

“Our specialty has embraced the endovascular revolution and become endocompetent,” he said. “It is why vascular surgery is doing as well as it is today.” He added. “Vascular surgery is presently an exciting, vibrant specialty in the United States.”

Dr. Veith noted, “Well-trained vascular surgeons are the only ones who can provide the most appropriate, full spectrum of care for patients with vascular disease, outside the head and the heart – whether that treatment be medical, endovascular, or open. There are abundant numbers of patients who require our skills. In addition, we use fascinating technology and have good industry relationships. And finally, many patients regard their vascular surgeon as a key doctor who they see regularly. As a result of these advantages, many bright medical students and general surgery residents are choosing to train as vascular surgeons. Vascular surgery should be flourishing.”

However, despite the fact vascular surgery is an exciting and vibrant specialty, and the best for treating vascular disease outside of the heart and the brain, the vascular specialty has significant problems competing with other specialties, he said.

He blamed in part the size and structure of the specialty, in particular with regard to its competition.

“Vascular surgery competes, as it always has, with general and cardiac surgeons. However, general surgeons have become less competitive, but cardiac surgeons have become more in need of work, and thus more active beyond the heart and thoracic aorta – as their open operations are replaced by coronary stents and transcatheter valves. More importantly, as vascular treatments become increasingly endovascular, vascular surgery will be competing with interventional radiology and, importantly, interventional cardiology.”

He outlined a number of major challenges these other disciplines create, in part, because of the DRG/RVU/dollar orientation of institutions, and the fact that most institutions still consider vascular surgery a subspecialty of general or cardiac surgery, or a subordinate part of a Heart & Vascular Center, with administrative control of these centers rarely in the hands of vascular surgeons. Moreover, when institutional resources – like angiography suites or hybrid operating rooms are distributed, the interests of vascular surgery are often represented by a general or cardiac surgeon – or worse a cardiologist,” he added.

He stated that these conditions limit vascular surgery’s ability to get its fair share of institutional resources.

“The competitive playing field is not level, and vascular surgeons are disadvantaged in the Darwinian struggle to survive,” he stated.

“To survive, vascular surgery needs to unify, recognize this inequity, and fix it. This can only be done if all vascular surgeons engage vigorously in this issue. We need equal administrative status with cardiac and general surgery in our institutions,” Dr. Veith advised.

In discussing the technological future, Dr. Veith said that by 2026, 75%-95% of all vascular cases requiring more than medical therapy will be treated endovascularly, with perhaps 5% in a hybrid fashion (open plus endovascular), and between 5% and 15% being treated fully by open surgery. This shift away from open surgery is and will continue to cause challenges in training and patient access to open treatment.

He asked the question: How should vascular surgery deal with the decreasing numbers of complex open procedures and who should do them?

“One solution is to have centers to which these patients are sent and in which vascular surgeons seeking this skill can get adequate open training,” he answered.

But the technological future he painted was bright. Not only was the future likely to be filled with new advances in medical therapy, but he also highlighted computer-assisted 3-D–device navigational tools to aid endovascular treatment; advances in robotic guidance to decrease radiation exposure and facilitate device placement; computer-enhanced simulation to improve training and, when patient specific, to allow procedure planning and rehearsal; and even 3-D printed modeling of lesions and blood vessels.

He predicted that the endovascular problems of intimal hyperplasia will be overcome by antiproliferative drugs in all vascular beds – once the best way of getting the best drug to the proper location is found – and that computer-enabled remote monitoring of flows within grafts and stents, perhaps using miniaturized piezoelectric sensors, will allow corrective treatment before occlusion occurs.

Dr. Veith stated that, in his view, to take its proper place, vascular surgery should rise above its subspecialty status in the shadow of general surgery and in its competition with cardiology.

This “will help vascular surgery to flourish and be recognized as the main specialty devoted to patients with noncardiac vascular diseases. Vascular surgery can then fulfill its potential for a brighter future. More importantly, patients and society will be the ultimate beneficiaries,” he concluded.

Dr. Veith reported that he had no conflicts to disclose with regard to his remarks.

[email protected]

On Twitter @VascularTweets

NATIONAL HARBOR, MD – “Specialties are like species,” said Frank J. Veith, MD, “they must evolve or go extinct.”

Dr. Veith of the New York University Langone Medical Center made this comparison in his 2016 Homans Lecture on the topic of “The future of vascular surgery,” at this year’s annual meeting hosted by the Society for Vascular Surgery.

©Martin Allred

Dr. Veith reviewed the history of vascular surgery, touched on its present status, and speculated on its potentially bright future. The vascular specialty has evolved dramatically over the past decades, especially in the area of embracing the endovascular revolution, said Dr. Veith, with that revolution putting vascular surgery at the forefront of research to develop new techniques.

His witnessing such innovations as those developed by Dr. Juan Parodi, and being a part of the early history of endovascular surgery, convinced Dr. Veith of its long-term importance to the development and survival of the specialty.

In his 1996 SVS Presidential Address, he predicted that 40%-70% of the open operations being done then would be replaced by endovascular procedures. “Accordingly, to survive, I recommended that vascular surgeons become endocompetent, learn how to do these procedures, and embrace them.” Dr. Veith added that, although his recommendation was not greeted with open arms by everyone, endovascular techniques moved forward.

In fact, “vascular surgeons often lead in developing many evolving endovascular procedures that are currently the standard of care,” he said.

Dr. Veith pointed out that a wide variety of conditions are now amenable to endovascular treatment, although some, including carotid disease, remain controversial. He listed examples of those conditions that he felt were still best treated with open surgery: thoracic outlet and entrapment syndromes, some ascending aorta and arch lesions, a few rare aneurysms not suited for endovascular treatment, some Takayasu’s lesions, some congenital and genetic aortic and renal artery lesions, some infected arteries and arterial grafts, a rare recurrent or complex lower-extremity lesion, some carotid lesions, and some failed endovascular treatments.

“Our specialty has embraced the endovascular revolution and become endocompetent,” he said. “It is why vascular surgery is doing as well as it is today.” He added. “Vascular surgery is presently an exciting, vibrant specialty in the United States.”

Dr. Veith noted, “Well-trained vascular surgeons are the only ones who can provide the most appropriate, full spectrum of care for patients with vascular disease, outside the head and the heart – whether that treatment be medical, endovascular, or open. There are abundant numbers of patients who require our skills. In addition, we use fascinating technology and have good industry relationships. And finally, many patients regard their vascular surgeon as a key doctor who they see regularly. As a result of these advantages, many bright medical students and general surgery residents are choosing to train as vascular surgeons. Vascular surgery should be flourishing.”

However, despite the fact vascular surgery is an exciting and vibrant specialty, and the best for treating vascular disease outside of the heart and the brain, the vascular specialty has significant problems competing with other specialties, he said.

He blamed in part the size and structure of the specialty, in particular with regard to its competition.

“Vascular surgery competes, as it always has, with general and cardiac surgeons. However, general surgeons have become less competitive, but cardiac surgeons have become more in need of work, and thus more active beyond the heart and thoracic aorta – as their open operations are replaced by coronary stents and transcatheter valves. More importantly, as vascular treatments become increasingly endovascular, vascular surgery will be competing with interventional radiology and, importantly, interventional cardiology.”

He outlined a number of major challenges these other disciplines create, in part, because of the DRG/RVU/dollar orientation of institutions, and the fact that most institutions still consider vascular surgery a subspecialty of general or cardiac surgery, or a subordinate part of a Heart & Vascular Center, with administrative control of these centers rarely in the hands of vascular surgeons. Moreover, when institutional resources – like angiography suites or hybrid operating rooms are distributed, the interests of vascular surgery are often represented by a general or cardiac surgeon – or worse a cardiologist,” he added.

He stated that these conditions limit vascular surgery’s ability to get its fair share of institutional resources.

“The competitive playing field is not level, and vascular surgeons are disadvantaged in the Darwinian struggle to survive,” he stated.

“To survive, vascular surgery needs to unify, recognize this inequity, and fix it. This can only be done if all vascular surgeons engage vigorously in this issue. We need equal administrative status with cardiac and general surgery in our institutions,” Dr. Veith advised.

In discussing the technological future, Dr. Veith said that by 2026, 75%-95% of all vascular cases requiring more than medical therapy will be treated endovascularly, with perhaps 5% in a hybrid fashion (open plus endovascular), and between 5% and 15% being treated fully by open surgery. This shift away from open surgery is and will continue to cause challenges in training and patient access to open treatment.

He asked the question: How should vascular surgery deal with the decreasing numbers of complex open procedures and who should do them?

“One solution is to have centers to which these patients are sent and in which vascular surgeons seeking this skill can get adequate open training,” he answered.

But the technological future he painted was bright. Not only was the future likely to be filled with new advances in medical therapy, but he also highlighted computer-assisted 3-D–device navigational tools to aid endovascular treatment; advances in robotic guidance to decrease radiation exposure and facilitate device placement; computer-enhanced simulation to improve training and, when patient specific, to allow procedure planning and rehearsal; and even 3-D printed modeling of lesions and blood vessels.

He predicted that the endovascular problems of intimal hyperplasia will be overcome by antiproliferative drugs in all vascular beds – once the best way of getting the best drug to the proper location is found – and that computer-enabled remote monitoring of flows within grafts and stents, perhaps using miniaturized piezoelectric sensors, will allow corrective treatment before occlusion occurs.

Dr. Veith stated that, in his view, to take its proper place, vascular surgery should rise above its subspecialty status in the shadow of general surgery and in its competition with cardiology.

This “will help vascular surgery to flourish and be recognized as the main specialty devoted to patients with noncardiac vascular diseases. Vascular surgery can then fulfill its potential for a brighter future. More importantly, patients and society will be the ultimate beneficiaries,” he concluded.

Dr. Veith reported that he had no conflicts to disclose with regard to his remarks.

[email protected]

On Twitter @VascularTweets

SAN DIEGO – Weight loss isn’t always a top priority for people with diabetes. Patients can figure out their proper carb intake. And don’t fret over an optimal percentage mix of carbs, fat and proteins.

A nutrition consultant gave this advice to colleagues at the annual meeting of the American Association of Diabetes Educators, startling some of those in the audience. And no wonder: A few years ago, these kinds of tips would have surprised the educator herself, Mary Ann Hodorowicz, RN, MBA, a licensed registered dietitian and certified diabetes educator based in the Chicago area.

For instance, she was taught that specific percentages of our diets must come from carbohydrates, protein, and fat. “If you didn’t do it that way, you committed the most major mortal sin,” she said. “You’ll go to diabetes jail, and you’ll probably be fired from your job, and the patient will die.”

In fact, “there’s no evidence to support those percentages,” she said. “They don’t mean anything in terms of blood glucose control, although we do have percentages of fat to control lipids and percentages of protein for health and well-being.”

So how many carbs should diabetics eat? She acknowledges to patients that she doesn’t know: “I don’t have a clue.” Instead, she urges them to figure it out themselves: “How many can you get away with and reach your 2-hour post-meal target? My job is to teach you what how to measure, whether it’s by handfuls, exchanges, servings, or grams. Here’s a log sheet, go home and write about how many carbs you’re eating, and test your blood sugar 2 hours later. You’ll find out really quickly how many carbs you can eat to reach that post-meal target.”

Ms. Hodorowicz provided other “evidence-based” tips about nutrition for diabetes patients:

• Assess the need for weight loss in overweight and obese patients, and don’t assume that weight loss is always the top priority.

In new patients with type 2 diabetes, weight loss of 7% is optimal and can typically be achieved with an energy deficit of 500-750 calories a day: a limit of 1,200-1,500 calories for women and 1,500-1,800 for men.

However, “studies of sustained weight loss at 1 or more years have shown inconsistent effects on hemoglobin A1c, even though modest weight loss is shown to improve insulin resistance in overweight and obese insulin-resistant persons. This blows out what we’ve been taught in our careers,” she said.

Why? Weight reduction does improve blood glucose in these type 2 patients at first, she said, but they’ll go into insulin deficiency if they live long enough.

After that happens, she said, “weight loss is not that effective in controlling blood glucose. At that point, the gurus are saying that we really want to prevent weight gain and seek blood glucose control.”

• Don’t go overboard on the glycemic index.

Ms. Hodorowicz advises patients to substitute low-glycemic foods for high-glycemic foods. However, “the evidence does not support the glycemic index as the best meal planning strategy for a patient with diabetes. It doesn’t do better than controlling carbs.”

In addition, she said, teaching patients about the confusing glycemic index is a drag: “Good luck!” But, she said, “substituting foods is a good thing.”

• Be aware of the limited evidence supporting supplements for glucose control.

On the supplement front, chromium, cinnamon, herbs and vitamin D haven’t been clearly demonstrated to control glucose, she says.

• Encourage consumption – even via supplementation – of fiber and plant stanols and sterols.

Ms. Hodorowicz encourages patients to consume 1.6-3.0 grams a day in plant stanols and sterols, which can be purchased in over-the-counter capsules and via fortified foods like certain Minute Maid and Benecol products.

“You’re fooling the body into thinking it’s cholesterol,” she said, “but it’s innocuous.”

She also advises patients to boost viscous soluble fiber to 7-13 g/day. Since it’s not feasible to do this through food, she recommends supplements: “You really need to supplement your diet with psyllium fiber that you get in a bottle.”

Ms. Hodorowicz reported having no relevant financial disclosures.

SAN DIEGO – Weight loss isn’t always a top priority for people with diabetes. Patients can figure out their proper carb intake. And don’t fret over an optimal percentage mix of carbs, fat and proteins.

A nutrition consultant gave this advice to colleagues at the annual meeting of the American Association of Diabetes Educators, startling some of those in the audience. And no wonder: A few years ago, these kinds of tips would have surprised the educator herself, Mary Ann Hodorowicz, RN, MBA, a licensed registered dietitian and certified diabetes educator based in the Chicago area.

For instance, she was taught that specific percentages of our diets must come from carbohydrates, protein, and fat. “If you didn’t do it that way, you committed the most major mortal sin,” she said. “You’ll go to diabetes jail, and you’ll probably be fired from your job, and the patient will die.”

In fact, “there’s no evidence to support those percentages,” she said. “They don’t mean anything in terms of blood glucose control, although we do have percentages of fat to control lipids and percentages of protein for health and well-being.”

So how many carbs should diabetics eat? She acknowledges to patients that she doesn’t know: “I don’t have a clue.” Instead, she urges them to figure it out themselves: “How many can you get away with and reach your 2-hour post-meal target? My job is to teach you what how to measure, whether it’s by handfuls, exchanges, servings, or grams. Here’s a log sheet, go home and write about how many carbs you’re eating, and test your blood sugar 2 hours later. You’ll find out really quickly how many carbs you can eat to reach that post-meal target.”

Ms. Hodorowicz provided other “evidence-based” tips about nutrition for diabetes patients:

• Assess the need for weight loss in overweight and obese patients, and don’t assume that weight loss is always the top priority.

In new patients with type 2 diabetes, weight loss of 7% is optimal and can typically be achieved with an energy deficit of 500-750 calories a day: a limit of 1,200-1,500 calories for women and 1,500-1,800 for men.

However, “studies of sustained weight loss at 1 or more years have shown inconsistent effects on hemoglobin A1c, even though modest weight loss is shown to improve insulin resistance in overweight and obese insulin-resistant persons. This blows out what we’ve been taught in our careers,” she said.

Why? Weight reduction does improve blood glucose in these type 2 patients at first, she said, but they’ll go into insulin deficiency if they live long enough.

After that happens, she said, “weight loss is not that effective in controlling blood glucose. At that point, the gurus are saying that we really want to prevent weight gain and seek blood glucose control.”

• Don’t go overboard on the glycemic index.

Ms. Hodorowicz advises patients to substitute low-glycemic foods for high-glycemic foods. However, “the evidence does not support the glycemic index as the best meal planning strategy for a patient with diabetes. It doesn’t do better than controlling carbs.”

In addition, she said, teaching patients about the confusing glycemic index is a drag: “Good luck!” But, she said, “substituting foods is a good thing.”

• Be aware of the limited evidence supporting supplements for glucose control.

On the supplement front, chromium, cinnamon, herbs and vitamin D haven’t been clearly demonstrated to control glucose, she says.

• Encourage consumption – even via supplementation – of fiber and plant stanols and sterols.

Ms. Hodorowicz encourages patients to consume 1.6-3.0 grams a day in plant stanols and sterols, which can be purchased in over-the-counter capsules and via fortified foods like certain Minute Maid and Benecol products.

“You’re fooling the body into thinking it’s cholesterol,” she said, “but it’s innocuous.”

She also advises patients to boost viscous soluble fiber to 7-13 g/day. Since it’s not feasible to do this through food, she recommends supplements: “You really need to supplement your diet with psyllium fiber that you get in a bottle.”

Ms. Hodorowicz reported having no relevant financial disclosures.

SAN DIEGO – Weight loss isn’t always a top priority for people with diabetes. Patients can figure out their proper carb intake. And don’t fret over an optimal percentage mix of carbs, fat and proteins.

A nutrition consultant gave this advice to colleagues at the annual meeting of the American Association of Diabetes Educators, startling some of those in the audience. And no wonder: A few years ago, these kinds of tips would have surprised the educator herself, Mary Ann Hodorowicz, RN, MBA, a licensed registered dietitian and certified diabetes educator based in the Chicago area.

For instance, she was taught that specific percentages of our diets must come from carbohydrates, protein, and fat. “If you didn’t do it that way, you committed the most major mortal sin,” she said. “You’ll go to diabetes jail, and you’ll probably be fired from your job, and the patient will die.”

In fact, “there’s no evidence to support those percentages,” she said. “They don’t mean anything in terms of blood glucose control, although we do have percentages of fat to control lipids and percentages of protein for health and well-being.”

So how many carbs should diabetics eat? She acknowledges to patients that she doesn’t know: “I don’t have a clue.” Instead, she urges them to figure it out themselves: “How many can you get away with and reach your 2-hour post-meal target? My job is to teach you what how to measure, whether it’s by handfuls, exchanges, servings, or grams. Here’s a log sheet, go home and write about how many carbs you’re eating, and test your blood sugar 2 hours later. You’ll find out really quickly how many carbs you can eat to reach that post-meal target.”

Ms. Hodorowicz provided other “evidence-based” tips about nutrition for diabetes patients:

• Assess the need for weight loss in overweight and obese patients, and don’t assume that weight loss is always the top priority.

In new patients with type 2 diabetes, weight loss of 7% is optimal and can typically be achieved with an energy deficit of 500-750 calories a day: a limit of 1,200-1,500 calories for women and 1,500-1,800 for men.

However, “studies of sustained weight loss at 1 or more years have shown inconsistent effects on hemoglobin A1c, even though modest weight loss is shown to improve insulin resistance in overweight and obese insulin-resistant persons. This blows out what we’ve been taught in our careers,” she said.

Why? Weight reduction does improve blood glucose in these type 2 patients at first, she said, but they’ll go into insulin deficiency if they live long enough.

After that happens, she said, “weight loss is not that effective in controlling blood glucose. At that point, the gurus are saying that we really want to prevent weight gain and seek blood glucose control.”

• Don’t go overboard on the glycemic index.

Ms. Hodorowicz advises patients to substitute low-glycemic foods for high-glycemic foods. However, “the evidence does not support the glycemic index as the best meal planning strategy for a patient with diabetes. It doesn’t do better than controlling carbs.”

In addition, she said, teaching patients about the confusing glycemic index is a drag: “Good luck!” But, she said, “substituting foods is a good thing.”

• Be aware of the limited evidence supporting supplements for glucose control.

On the supplement front, chromium, cinnamon, herbs and vitamin D haven’t been clearly demonstrated to control glucose, she says.

• Encourage consumption – even via supplementation – of fiber and plant stanols and sterols.

Ms. Hodorowicz encourages patients to consume 1.6-3.0 grams a day in plant stanols and sterols, which can be purchased in over-the-counter capsules and via fortified foods like certain Minute Maid and Benecol products.

“You’re fooling the body into thinking it’s cholesterol,” she said, “but it’s innocuous.”

She also advises patients to boost viscous soluble fiber to 7-13 g/day. Since it’s not feasible to do this through food, she recommends supplements: “You really need to supplement your diet with psyllium fiber that you get in a bottle.”

Ms. Hodorowicz reported having no relevant financial disclosures.

PARIS – Aortomitral continuity calcification, a common finding on CT in patients undergoing transcatheter aortic valve replacement, predicts new-onset atrial fibrillation and the need for permanent pacemaker insertion, Marco Spaziano, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

“Increased surveillance for arrhythmias in the 30 days post TAVR is warranted in patients with aortomitral continuity calcification,” declared Dr. Spaziano of the Paris South Cardiovascular Institute in Massy, France.

Bruce Jancin/Frontline Medical News

He presented a single-center retrospective study of 524 patients undergoing TAVR with a self-expandable or balloon-expandable device. Aortomitral continuity calcification (AMCC) was found on CT in 15.8% of them. Dr. Spaziano defined AMCC as the presence of calcium in the curtain linking the aortic and mitral valve annuli. The clinical implications of this common finding were unknown prior to this study.

The 83 patients with AMCC did not differ significantly from the 441 without that CT finding in terms of baseline demographics, Society of Thoracic Surgeons risk score, prevalence of peripheral vascular disease, QRS duration, left ventricular ejection fraction, complete left or right bundle branch block, or aortic valve calcification volume. The prevalence of atrial fibrillation at baseline was 25.6% in the AMCC group and closely similar at 26.3% in the group without AMCC. Sixteen percent of subjects in each group had a previous pacemaker.

Similarly, the two groups didn’t differ in terms of procedural characteristics, including device type, size, or depth of implantation, or need for a second valve, or annular rupture.

However, excluding from consideration the patients with prior AF, the incidence of new AF in the 30 days post-TAVR was 22.7% in patients with AMCC compared with just 7.6% in the no-AMCC group. In addition, 33% of patients with AMCC received a new permanent pacemaker, as did 21% of those with no AMCC.

Other key 30-day outcomes didn’t differ between the two populations, including rates of death, stroke, vascular complications, and moderate or severe paravalvular regurgitation.

In a multivariate regression analysis adjusted for age, sex, device type and implantation depth, preexisting right bundle branch block, and surgical risk score, AMCC was associated with a statistically significant 1.8-fold increased likelihood of new pacemaker insertion and a 3.4-fold greater risk of new AF.

Dr. Spaziano said that in brainstorming with electrophysiology and echocardiography colleagues, the group came up with two hypotheses to explain the study findings. One is that AMCC might be a biologic marker for concomitant mitral stenosis, a known strong predictor of AF.

“Oftentimes it’s very difficult to diagnose mitral stenosis when there is aortic stenosis, because of left ventricular compliance issues, so potentially the patients with this calcium ridge may also have mitral stenosis,” he observed.

The other proposed hypothesis is that AMCC reflects increased calcification and fibrosis in the electrical system of both the AV node and atrium, with a resultant increased risk of developing new AF after the TAVR procedure.

Session chair Mohammad Abdelghani, MD, wasn’t buying either hypothesis. If either were correct, the group with AMCC would be expected to have a higher baseline rate of AF preprocedurally, observed Dr. Abdelghani of the Academic Medical Center at Amsterdam.

He suggested an alternative explanation on the basis of a German study that showed patients with significant calcification of the left coronary cusp were at sixfold greater risk for pacemaker implantation post TAVR. He proposed that calcification in the left sector of the valve landing zone causes the device to end up being positioned a bit off-line.

“I think the device protrudes away from the calcium and towards the right coronary artery commisure, compressing the conduction system that we know lies there,” Dr. Abdelghani said.

Dr. Spaziano reported having no financial conflicts of interest regarding his study.

[email protected]

PARIS – Aortomitral continuity calcification, a common finding on CT in patients undergoing transcatheter aortic valve replacement, predicts new-onset atrial fibrillation and the need for permanent pacemaker insertion, Marco Spaziano, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

“Increased surveillance for arrhythmias in the 30 days post TAVR is warranted in patients with aortomitral continuity calcification,” declared Dr. Spaziano of the Paris South Cardiovascular Institute in Massy, France.

Bruce Jancin/Frontline Medical News

He presented a single-center retrospective study of 524 patients undergoing TAVR with a self-expandable or balloon-expandable device. Aortomitral continuity calcification (AMCC) was found on CT in 15.8% of them. Dr. Spaziano defined AMCC as the presence of calcium in the curtain linking the aortic and mitral valve annuli. The clinical implications of this common finding were unknown prior to this study.

The 83 patients with AMCC did not differ significantly from the 441 without that CT finding in terms of baseline demographics, Society of Thoracic Surgeons risk score, prevalence of peripheral vascular disease, QRS duration, left ventricular ejection fraction, complete left or right bundle branch block, or aortic valve calcification volume. The prevalence of atrial fibrillation at baseline was 25.6% in the AMCC group and closely similar at 26.3% in the group without AMCC. Sixteen percent of subjects in each group had a previous pacemaker.

Similarly, the two groups didn’t differ in terms of procedural characteristics, including device type, size, or depth of implantation, or need for a second valve, or annular rupture.

However, excluding from consideration the patients with prior AF, the incidence of new AF in the 30 days post-TAVR was 22.7% in patients with AMCC compared with just 7.6% in the no-AMCC group. In addition, 33% of patients with AMCC received a new permanent pacemaker, as did 21% of those with no AMCC.

Other key 30-day outcomes didn’t differ between the two populations, including rates of death, stroke, vascular complications, and moderate or severe paravalvular regurgitation.

In a multivariate regression analysis adjusted for age, sex, device type and implantation depth, preexisting right bundle branch block, and surgical risk score, AMCC was associated with a statistically significant 1.8-fold increased likelihood of new pacemaker insertion and a 3.4-fold greater risk of new AF.

Dr. Spaziano said that in brainstorming with electrophysiology and echocardiography colleagues, the group came up with two hypotheses to explain the study findings. One is that AMCC might be a biologic marker for concomitant mitral stenosis, a known strong predictor of AF.

“Oftentimes it’s very difficult to diagnose mitral stenosis when there is aortic stenosis, because of left ventricular compliance issues, so potentially the patients with this calcium ridge may also have mitral stenosis,” he observed.

The other proposed hypothesis is that AMCC reflects increased calcification and fibrosis in the electrical system of both the AV node and atrium, with a resultant increased risk of developing new AF after the TAVR procedure.

Session chair Mohammad Abdelghani, MD, wasn’t buying either hypothesis. If either were correct, the group with AMCC would be expected to have a higher baseline rate of AF preprocedurally, observed Dr. Abdelghani of the Academic Medical Center at Amsterdam.

He suggested an alternative explanation on the basis of a German study that showed patients with significant calcification of the left coronary cusp were at sixfold greater risk for pacemaker implantation post TAVR. He proposed that calcification in the left sector of the valve landing zone causes the device to end up being positioned a bit off-line.

“I think the device protrudes away from the calcium and towards the right coronary artery commisure, compressing the conduction system that we know lies there,” Dr. Abdelghani said.

Dr. Spaziano reported having no financial conflicts of interest regarding his study.

[email protected]

PARIS – Aortomitral continuity calcification, a common finding on CT in patients undergoing transcatheter aortic valve replacement, predicts new-onset atrial fibrillation and the need for permanent pacemaker insertion, Marco Spaziano, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

“Increased surveillance for arrhythmias in the 30 days post TAVR is warranted in patients with aortomitral continuity calcification,” declared Dr. Spaziano of the Paris South Cardiovascular Institute in Massy, France.

Bruce Jancin/Frontline Medical News

He presented a single-center retrospective study of 524 patients undergoing TAVR with a self-expandable or balloon-expandable device. Aortomitral continuity calcification (AMCC) was found on CT in 15.8% of them. Dr. Spaziano defined AMCC as the presence of calcium in the curtain linking the aortic and mitral valve annuli. The clinical implications of this common finding were unknown prior to this study.

The 83 patients with AMCC did not differ significantly from the 441 without that CT finding in terms of baseline demographics, Society of Thoracic Surgeons risk score, prevalence of peripheral vascular disease, QRS duration, left ventricular ejection fraction, complete left or right bundle branch block, or aortic valve calcification volume. The prevalence of atrial fibrillation at baseline was 25.6% in the AMCC group and closely similar at 26.3% in the group without AMCC. Sixteen percent of subjects in each group had a previous pacemaker.

Similarly, the two groups didn’t differ in terms of procedural characteristics, including device type, size, or depth of implantation, or need for a second valve, or annular rupture.

However, excluding from consideration the patients with prior AF, the incidence of new AF in the 30 days post-TAVR was 22.7% in patients with AMCC compared with just 7.6% in the no-AMCC group. In addition, 33% of patients with AMCC received a new permanent pacemaker, as did 21% of those with no AMCC.

Other key 30-day outcomes didn’t differ between the two populations, including rates of death, stroke, vascular complications, and moderate or severe paravalvular regurgitation.

In a multivariate regression analysis adjusted for age, sex, device type and implantation depth, preexisting right bundle branch block, and surgical risk score, AMCC was associated with a statistically significant 1.8-fold increased likelihood of new pacemaker insertion and a 3.4-fold greater risk of new AF.

Dr. Spaziano said that in brainstorming with electrophysiology and echocardiography colleagues, the group came up with two hypotheses to explain the study findings. One is that AMCC might be a biologic marker for concomitant mitral stenosis, a known strong predictor of AF.

“Oftentimes it’s very difficult to diagnose mitral stenosis when there is aortic stenosis, because of left ventricular compliance issues, so potentially the patients with this calcium ridge may also have mitral stenosis,” he observed.

The other proposed hypothesis is that AMCC reflects increased calcification and fibrosis in the electrical system of both the AV node and atrium, with a resultant increased risk of developing new AF after the TAVR procedure.

Session chair Mohammad Abdelghani, MD, wasn’t buying either hypothesis. If either were correct, the group with AMCC would be expected to have a higher baseline rate of AF preprocedurally, observed Dr. Abdelghani of the Academic Medical Center at Amsterdam.

He suggested an alternative explanation on the basis of a German study that showed patients with significant calcification of the left coronary cusp were at sixfold greater risk for pacemaker implantation post TAVR. He proposed that calcification in the left sector of the valve landing zone causes the device to end up being positioned a bit off-line.

“I think the device protrudes away from the calcium and towards the right coronary artery commisure, compressing the conduction system that we know lies there,” Dr. Abdelghani said.

Dr. Spaziano reported having no financial conflicts of interest regarding his study.

[email protected]

DURBAN, SOUTH AFRICA – A large, longitudinal study of alcohol consumption patterns among HIV-infected U.S. military veterans indicates that only the highest level of persistent heavy drinking is associated with more advanced HIV disease severity over time.

In this study of 3,539 veterans receiving care for HIV infection for 15,354 person-years of follow-up at 8 VA centers, only those scoring in the top 8% on a validated measure of unhealthy drinking showed significant worsening of HIV disease over the 8-year study period, Brandon D.L. Marshall, PhD, reported at the 21st International AIDS Conference.

Bruce Jancin/Frontline Medical News

“The relationship between persistent unhealthy alcohol use and greater HIV disease severity is perhaps not as strong as we would have hypothesized. This suggests that, given the relatively small number of people reporting consistent unhealthy alcohol use, targeted risk reduction and treatment strategies are needed only in those consistent unhealthy drinkers,” said Dr. Marshall, an epidemiologist at Brown University in Providence, R.I.

The subjects’ median age was 49 years; 98% were men, and 68% were African American.

Alcohol use patterns were evaluated annually using the Alcohol Use Disorders Identification Test (AUDIT-C), a validated 3-question screening tool measuring self-reported frequency, quantity, and binge alcohol use. Alcohol use trajectories were linear and relatively stable over time. Eight percent of subjects were classified as high-risk drinkers on the basis of an AUDIT-C score of 8-12; 24% were deemed at moderate risk, with a score of 6-7; the 44% with a score of 4-5 were categorized as lower risk; and 24% of participants were abstainers. The abstainers fell into two distinct groups: sick quitters with worsening HIV disease and healthy abstainers.

Of note, this was the first large study to utilize an objective biomarker in order to validate long-term self-reported alcohol use patterns as assessed by the AUDIT-C test. Nearly 1,500 subjects had a blood test for phosphatidylethanol, a reliable indicator of exposure to alcohol within the previous 21 days. The biomarker has high specificity for alcohol abstinence and showed good correlation with AUDIT-C results across the board, according to Dr. Marshall.

Subjects’ HIV disease severity trajectory was determined annually using the Veterans Aging Cohort Study (VACS) Index, a weighted score that estimates an individual’s risk of all-cause mortality based upon age, HIV RNA viral load, CD4 count, and general indicators of organ system injury including hemoglobin, platelets, glomerular filtration rate, and hepatitis C infection. As was the case for AUDIT-C scores, VACS scores remained relatively stable over 8 years of follow-up. The HIV disease trajectory was categorized as low risk in 2% of subjects, moderate in 46%, high risk in 36%, and extreme in 16%.

To plot the joint trajectories of alcohol use and HIV disease severity, the investigators employed a statistical technique called group-based finite mixture modeling and performed a multivariate logistic regression analysis in which the moderate-risk drinkers and moderate VACS subgroups served as reference standards. Only two significant associations emerged: the highest-risk subgroup of drinkers were at 1.83-fold increased risk of extremely poor VACS trajectory, and the abstainers were at 1.9-fold increased risk for both the most favorable VACS trajectory and an extremely-high-mortality VACS trajectory, reflecting the split in prognosis between the healthy abstainer and sick quitter subgroups. No high-risk drinkers were in the low VACS group.

Unhealthy alcohol use is hypothesized to accelerate HIV disease progression through two mechanisms: Heavy drinkers are less likely to adhere to antiretroviral therapy and remain in care, and the heavy drinking itself has direct negative immunologic effects, Dr. Marshall said.

He reported having no financial conflicts of interest regarding his study, funded by the National Institute on Alcohol Abuse and Alcoholism and the National Institute of Allergy and Infectious Diseases.

[email protected]

DURBAN, SOUTH AFRICA – A large, longitudinal study of alcohol consumption patterns among HIV-infected U.S. military veterans indicates that only the highest level of persistent heavy drinking is associated with more advanced HIV disease severity over time.

In this study of 3,539 veterans receiving care for HIV infection for 15,354 person-years of follow-up at 8 VA centers, only those scoring in the top 8% on a validated measure of unhealthy drinking showed significant worsening of HIV disease over the 8-year study period, Brandon D.L. Marshall, PhD, reported at the 21st International AIDS Conference.

Bruce Jancin/Frontline Medical News

“The relationship between persistent unhealthy alcohol use and greater HIV disease severity is perhaps not as strong as we would have hypothesized. This suggests that, given the relatively small number of people reporting consistent unhealthy alcohol use, targeted risk reduction and treatment strategies are needed only in those consistent unhealthy drinkers,” said Dr. Marshall, an epidemiologist at Brown University in Providence, R.I.

The subjects’ median age was 49 years; 98% were men, and 68% were African American.

Alcohol use patterns were evaluated annually using the Alcohol Use Disorders Identification Test (AUDIT-C), a validated 3-question screening tool measuring self-reported frequency, quantity, and binge alcohol use. Alcohol use trajectories were linear and relatively stable over time. Eight percent of subjects were classified as high-risk drinkers on the basis of an AUDIT-C score of 8-12; 24% were deemed at moderate risk, with a score of 6-7; the 44% with a score of 4-5 were categorized as lower risk; and 24% of participants were abstainers. The abstainers fell into two distinct groups: sick quitters with worsening HIV disease and healthy abstainers.

Of note, this was the first large study to utilize an objective biomarker in order to validate long-term self-reported alcohol use patterns as assessed by the AUDIT-C test. Nearly 1,500 subjects had a blood test for phosphatidylethanol, a reliable indicator of exposure to alcohol within the previous 21 days. The biomarker has high specificity for alcohol abstinence and showed good correlation with AUDIT-C results across the board, according to Dr. Marshall.

Subjects’ HIV disease severity trajectory was determined annually using the Veterans Aging Cohort Study (VACS) Index, a weighted score that estimates an individual’s risk of all-cause mortality based upon age, HIV RNA viral load, CD4 count, and general indicators of organ system injury including hemoglobin, platelets, glomerular filtration rate, and hepatitis C infection. As was the case for AUDIT-C scores, VACS scores remained relatively stable over 8 years of follow-up. The HIV disease trajectory was categorized as low risk in 2% of subjects, moderate in 46%, high risk in 36%, and extreme in 16%.

To plot the joint trajectories of alcohol use and HIV disease severity, the investigators employed a statistical technique called group-based finite mixture modeling and performed a multivariate logistic regression analysis in which the moderate-risk drinkers and moderate VACS subgroups served as reference standards. Only two significant associations emerged: the highest-risk subgroup of drinkers were at 1.83-fold increased risk of extremely poor VACS trajectory, and the abstainers were at 1.9-fold increased risk for both the most favorable VACS trajectory and an extremely-high-mortality VACS trajectory, reflecting the split in prognosis between the healthy abstainer and sick quitter subgroups. No high-risk drinkers were in the low VACS group.

Unhealthy alcohol use is hypothesized to accelerate HIV disease progression through two mechanisms: Heavy drinkers are less likely to adhere to antiretroviral therapy and remain in care, and the heavy drinking itself has direct negative immunologic effects, Dr. Marshall said.

He reported having no financial conflicts of interest regarding his study, funded by the National Institute on Alcohol Abuse and Alcoholism and the National Institute of Allergy and Infectious Diseases.

[email protected]

DURBAN, SOUTH AFRICA – A large, longitudinal study of alcohol consumption patterns among HIV-infected U.S. military veterans indicates that only the highest level of persistent heavy drinking is associated with more advanced HIV disease severity over time.

In this study of 3,539 veterans receiving care for HIV infection for 15,354 person-years of follow-up at 8 VA centers, only those scoring in the top 8% on a validated measure of unhealthy drinking showed significant worsening of HIV disease over the 8-year study period, Brandon D.L. Marshall, PhD, reported at the 21st International AIDS Conference.

Bruce Jancin/Frontline Medical News

“The relationship between persistent unhealthy alcohol use and greater HIV disease severity is perhaps not as strong as we would have hypothesized. This suggests that, given the relatively small number of people reporting consistent unhealthy alcohol use, targeted risk reduction and treatment strategies are needed only in those consistent unhealthy drinkers,” said Dr. Marshall, an epidemiologist at Brown University in Providence, R.I.

The subjects’ median age was 49 years; 98% were men, and 68% were African American.

Alcohol use patterns were evaluated annually using the Alcohol Use Disorders Identification Test (AUDIT-C), a validated 3-question screening tool measuring self-reported frequency, quantity, and binge alcohol use. Alcohol use trajectories were linear and relatively stable over time. Eight percent of subjects were classified as high-risk drinkers on the basis of an AUDIT-C score of 8-12; 24% were deemed at moderate risk, with a score of 6-7; the 44% with a score of 4-5 were categorized as lower risk; and 24% of participants were abstainers. The abstainers fell into two distinct groups: sick quitters with worsening HIV disease and healthy abstainers.

Of note, this was the first large study to utilize an objective biomarker in order to validate long-term self-reported alcohol use patterns as assessed by the AUDIT-C test. Nearly 1,500 subjects had a blood test for phosphatidylethanol, a reliable indicator of exposure to alcohol within the previous 21 days. The biomarker has high specificity for alcohol abstinence and showed good correlation with AUDIT-C results across the board, according to Dr. Marshall.

Subjects’ HIV disease severity trajectory was determined annually using the Veterans Aging Cohort Study (VACS) Index, a weighted score that estimates an individual’s risk of all-cause mortality based upon age, HIV RNA viral load, CD4 count, and general indicators of organ system injury including hemoglobin, platelets, glomerular filtration rate, and hepatitis C infection. As was the case for AUDIT-C scores, VACS scores remained relatively stable over 8 years of follow-up. The HIV disease trajectory was categorized as low risk in 2% of subjects, moderate in 46%, high risk in 36%, and extreme in 16%.

To plot the joint trajectories of alcohol use and HIV disease severity, the investigators employed a statistical technique called group-based finite mixture modeling and performed a multivariate logistic regression analysis in which the moderate-risk drinkers and moderate VACS subgroups served as reference standards. Only two significant associations emerged: the highest-risk subgroup of drinkers were at 1.83-fold increased risk of extremely poor VACS trajectory, and the abstainers were at 1.9-fold increased risk for both the most favorable VACS trajectory and an extremely-high-mortality VACS trajectory, reflecting the split in prognosis between the healthy abstainer and sick quitter subgroups. No high-risk drinkers were in the low VACS group.

Unhealthy alcohol use is hypothesized to accelerate HIV disease progression through two mechanisms: Heavy drinkers are less likely to adhere to antiretroviral therapy and remain in care, and the heavy drinking itself has direct negative immunologic effects, Dr. Marshall said.

He reported having no financial conflicts of interest regarding his study, funded by the National Institute on Alcohol Abuse and Alcoholism and the National Institute of Allergy and Infectious Diseases.

[email protected]

The majority of physician practices are uncertain about joining or starting an accountable care organization (ACO), according to a survey.

Of nearly 400 hospital-owned and freestanding outpatient practices, 65% were unsure how to approach accountable care, a survey by Healthcare Information and Management Systems Society (HIMSS) Analytics found. About 13% of health providers said they expected to join an established ACO, while 14% planned to form an ACO, and 8% planned to create an ACO with a neighboring provider.

HIMSS Analytics director of research Brendan FitzGeraldand his team surveyed 436 health providers during June 23–July 12, 2016, regarding electronic health record (EHR) adoption, accountable care, and health information exchanges, among other subjects. The respondents included physicians, practice managers/administrators, physician assistants, nurse practitioners, and practice IT directors. Investigators also analyzed the HIMSS Analytics LOGIC database, which includes 47,084 hospital-owned practices and 57,909 freestanding practices.

Respondents also reported a high level of uncertainty around plans to join a health information exchange (HIE): 48% of health providers were unsure about whether to join an HIE, compared with 46% who were uncertain in 2015. Of respondents who plan to join an HIE, 10% plan to enter a hospital or health system HIE, 7% plan to enter a regional HIE, and 17% plan to join a state health information exchange.

As far as EHR adoption, nearly 78% of respondents representing a free standing outpatient facility (228 practices) reported having an EHR, a 30% increase since 2010. Data from the LOGIC database found 92% of hospital-owned outpatient facilities had a live and operational EHR. Of all survey respondents, 66% did not have plans to replace or upgrade their current outpatient solution, or purchase a new solution. Of health providers that planned to purchase a new EHR, 18% said they would be upgrading, 9% would be purchasing a new solution, and 7% would be replacing a their current EHR.

The survey shows that most doctors appear to be content with the EHR solutions they have adopted with no plans to change systems, said Mr. FitzGerald.

“The level of universal adoption is great, and it seems that physicians for the most part, are satisfied with the work they’ve done to implement and utilize these solutions the first time around,” he said in an interview. “While there may be some getting used to the process of using these particular solutions or even some functionality shortcomings, it seems likes physicians are moving forward with the solutions they have on hand.”

[email protected]

On Twitter @legal_med

The majority of physician practices are uncertain about joining or starting an accountable care organization (ACO), according to a survey.

Of nearly 400 hospital-owned and freestanding outpatient practices, 65% were unsure how to approach accountable care, a survey by Healthcare Information and Management Systems Society (HIMSS) Analytics found. About 13% of health providers said they expected to join an established ACO, while 14% planned to form an ACO, and 8% planned to create an ACO with a neighboring provider.

HIMSS Analytics director of research Brendan FitzGeraldand his team surveyed 436 health providers during June 23–July 12, 2016, regarding electronic health record (EHR) adoption, accountable care, and health information exchanges, among other subjects. The respondents included physicians, practice managers/administrators, physician assistants, nurse practitioners, and practice IT directors. Investigators also analyzed the HIMSS Analytics LOGIC database, which includes 47,084 hospital-owned practices and 57,909 freestanding practices.

Respondents also reported a high level of uncertainty around plans to join a health information exchange (HIE): 48% of health providers were unsure about whether to join an HIE, compared with 46% who were uncertain in 2015. Of respondents who plan to join an HIE, 10% plan to enter a hospital or health system HIE, 7% plan to enter a regional HIE, and 17% plan to join a state health information exchange.

As far as EHR adoption, nearly 78% of respondents representing a free standing outpatient facility (228 practices) reported having an EHR, a 30% increase since 2010. Data from the LOGIC database found 92% of hospital-owned outpatient facilities had a live and operational EHR. Of all survey respondents, 66% did not have plans to replace or upgrade their current outpatient solution, or purchase a new solution. Of health providers that planned to purchase a new EHR, 18% said they would be upgrading, 9% would be purchasing a new solution, and 7% would be replacing a their current EHR.

The survey shows that most doctors appear to be content with the EHR solutions they have adopted with no plans to change systems, said Mr. FitzGerald.

“The level of universal adoption is great, and it seems that physicians for the most part, are satisfied with the work they’ve done to implement and utilize these solutions the first time around,” he said in an interview. “While there may be some getting used to the process of using these particular solutions or even some functionality shortcomings, it seems likes physicians are moving forward with the solutions they have on hand.”

[email protected]

On Twitter @legal_med

The majority of physician practices are uncertain about joining or starting an accountable care organization (ACO), according to a survey.

Of nearly 400 hospital-owned and freestanding outpatient practices, 65% were unsure how to approach accountable care, a survey by Healthcare Information and Management Systems Society (HIMSS) Analytics found. About 13% of health providers said they expected to join an established ACO, while 14% planned to form an ACO, and 8% planned to create an ACO with a neighboring provider.

HIMSS Analytics director of research Brendan FitzGeraldand his team surveyed 436 health providers during June 23–July 12, 2016, regarding electronic health record (EHR) adoption, accountable care, and health information exchanges, among other subjects. The respondents included physicians, practice managers/administrators, physician assistants, nurse practitioners, and practice IT directors. Investigators also analyzed the HIMSS Analytics LOGIC database, which includes 47,084 hospital-owned practices and 57,909 freestanding practices.

Respondents also reported a high level of uncertainty around plans to join a health information exchange (HIE): 48% of health providers were unsure about whether to join an HIE, compared with 46% who were uncertain in 2015. Of respondents who plan to join an HIE, 10% plan to enter a hospital or health system HIE, 7% plan to enter a regional HIE, and 17% plan to join a state health information exchange.

As far as EHR adoption, nearly 78% of respondents representing a free standing outpatient facility (228 practices) reported having an EHR, a 30% increase since 2010. Data from the LOGIC database found 92% of hospital-owned outpatient facilities had a live and operational EHR. Of all survey respondents, 66% did not have plans to replace or upgrade their current outpatient solution, or purchase a new solution. Of health providers that planned to purchase a new EHR, 18% said they would be upgrading, 9% would be purchasing a new solution, and 7% would be replacing a their current EHR.

The survey shows that most doctors appear to be content with the EHR solutions they have adopted with no plans to change systems, said Mr. FitzGerald.

“The level of universal adoption is great, and it seems that physicians for the most part, are satisfied with the work they’ve done to implement and utilize these solutions the first time around,” he said in an interview. “While there may be some getting used to the process of using these particular solutions or even some functionality shortcomings, it seems likes physicians are moving forward with the solutions they have on hand.”

[email protected]

On Twitter @legal_med

DENVER – MRI of the sacroiliac joint now serves as the primary imaging driver for a diagnosis of spondyloarthritis, especially early spondyloarthritis, and has largely supplanted radiographic assessment, Walter P. Maksymowych, MD, said at an educational symposium organized by the Spondyloarthritis Research and Treatment Network.

“MRI is reliable for early diagnosis; radiographic assessment of early spondyloarthritis is problematic,” said Dr. Maksymowych, a rheumatologist and professor of medicine at the University of Alberta in Edmonton. “The EULAR recommendations now say that early diagnosis of spondyloarthritis needs to focus on MRI.”

Mitchel L. Zoler/Frontline Medical News

While the recommendations from the European League Against Rheumatism (EULAR) that came out last year on using imaging for diagnosing and managing spondyloarthritis (SpA) cite radiography of the patient’s sacroiliac joint as the recommended first imaging method to use to diagnose sacroiliitis as part of a diagnosis of axial SpA, the EULAR recommendations place MRI very close behind.

The recommendations list MRI as an “alternative” first-line approach for diagnostic imaging. For patients who appear negative for axial SpA on radiographic imaging but who remain suspected of having SpA the EULAR panel “recommended” MRI of the sacroiliac joints as a backup method for imaging assessment and to definitively rule out SpA. No other imaging method received EULAR’s endorsement for SpA diagnosis aside from these two approaches.

The recommendations direct the MRI examination to include assessment of inflammation based on bone marrow edema, and also structural abnormalities including bone erosion, new bone formation, sclerosis and fat infiltration. The 2015 EULAR recommendations also cite roles for MRI in diagnosing peripheral SpA, monitoring disease activity in axial and peripheral SpA, monioring structural changes in axial and peripheral SpA, predicting outcome and treatment effect in axial SpA, assessing spinal fracture in patients with axial SpA and to assess osteoporosis in selected axial SpA patients.

The MRI imaging sequences particularly useful for SpA diagnosis are “short tau inversion recovery” (STIR), a “water sensitive” sequence that involves suppression of the fat MRI signal, and a T1 weighted sequence that is a “fat sensitive” scan, explained Dr. Maksymowych at the symposium, also organized by the Group for the Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA). He strongly encouraged clinicians to apply a standardized approach to imaging in every patient suspected of having axial SpA.

The definition of an MRI imaging result that is positive for SpA remains a consensus of expert opinion without a firm evidence base. The currently accepted MRI marker of SpA involves identifying several areas of bone marrow edema in a single T1 and STIR MRI image-slice through the sacroiliac joint, or focal bone marrow edema visible in at least two consecutive sacroiliac joint T1 and STIR image slices.

The confluence of a structural lesion at the same site as bone marrow edema provides further confirmatory information, he said. “A structural lesions at the site of bone marrow edema enhances your confidence in the diagnosis,” he said.

“The specificity of MRI for SpA is quite high,” Dr. Maksymowych noted, with specificity rates often in the range of 85%-95%. Sensitivity rates are lower, often 50%-70%. Sensitivity further improves by factoring in the presence of bone erosions. Diagnostic confidence also increases as the number of lesions visualized increases.

MRI has become so integral to the assessment of SpA that “to understand SpA you need to understand the language of MRI,” Dr. Maksymowych concluded.

Dr. Maksymowych has received honoraria from eight drug companies and research grant support from Abbvie and Pfizer.

[email protected]

On Twitter @mitchelzoler

DENVER – MRI of the sacroiliac joint now serves as the primary imaging driver for a diagnosis of spondyloarthritis, especially early spondyloarthritis, and has largely supplanted radiographic assessment, Walter P. Maksymowych, MD, said at an educational symposium organized by the Spondyloarthritis Research and Treatment Network.

“MRI is reliable for early diagnosis; radiographic assessment of early spondyloarthritis is problematic,” said Dr. Maksymowych, a rheumatologist and professor of medicine at the University of Alberta in Edmonton. “The EULAR recommendations now say that early diagnosis of spondyloarthritis needs to focus on MRI.”

Mitchel L. Zoler/Frontline Medical News

While the recommendations from the European League Against Rheumatism (EULAR) that came out last year on using imaging for diagnosing and managing spondyloarthritis (SpA) cite radiography of the patient’s sacroiliac joint as the recommended first imaging method to use to diagnose sacroiliitis as part of a diagnosis of axial SpA, the EULAR recommendations place MRI very close behind.

The recommendations list MRI as an “alternative” first-line approach for diagnostic imaging. For patients who appear negative for axial SpA on radiographic imaging but who remain suspected of having SpA the EULAR panel “recommended” MRI of the sacroiliac joints as a backup method for imaging assessment and to definitively rule out SpA. No other imaging method received EULAR’s endorsement for SpA diagnosis aside from these two approaches.

The recommendations direct the MRI examination to include assessment of inflammation based on bone marrow edema, and also structural abnormalities including bone erosion, new bone formation, sclerosis and fat infiltration. The 2015 EULAR recommendations also cite roles for MRI in diagnosing peripheral SpA, monitoring disease activity in axial and peripheral SpA, monioring structural changes in axial and peripheral SpA, predicting outcome and treatment effect in axial SpA, assessing spinal fracture in patients with axial SpA and to assess osteoporosis in selected axial SpA patients.

The MRI imaging sequences particularly useful for SpA diagnosis are “short tau inversion recovery” (STIR), a “water sensitive” sequence that involves suppression of the fat MRI signal, and a T1 weighted sequence that is a “fat sensitive” scan, explained Dr. Maksymowych at the symposium, also organized by the Group for the Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA). He strongly encouraged clinicians to apply a standardized approach to imaging in every patient suspected of having axial SpA.

The definition of an MRI imaging result that is positive for SpA remains a consensus of expert opinion without a firm evidence base. The currently accepted MRI marker of SpA involves identifying several areas of bone marrow edema in a single T1 and STIR MRI image-slice through the sacroiliac joint, or focal bone marrow edema visible in at least two consecutive sacroiliac joint T1 and STIR image slices.

The confluence of a structural lesion at the same site as bone marrow edema provides further confirmatory information, he said. “A structural lesions at the site of bone marrow edema enhances your confidence in the diagnosis,” he said.

“The specificity of MRI for SpA is quite high,” Dr. Maksymowych noted, with specificity rates often in the range of 85%-95%. Sensitivity rates are lower, often 50%-70%. Sensitivity further improves by factoring in the presence of bone erosions. Diagnostic confidence also increases as the number of lesions visualized increases.

MRI has become so integral to the assessment of SpA that “to understand SpA you need to understand the language of MRI,” Dr. Maksymowych concluded.

Dr. Maksymowych has received honoraria from eight drug companies and research grant support from Abbvie and Pfizer.

[email protected]

On Twitter @mitchelzoler

DENVER – MRI of the sacroiliac joint now serves as the primary imaging driver for a diagnosis of spondyloarthritis, especially early spondyloarthritis, and has largely supplanted radiographic assessment, Walter P. Maksymowych, MD, said at an educational symposium organized by the Spondyloarthritis Research and Treatment Network.

“MRI is reliable for early diagnosis; radiographic assessment of early spondyloarthritis is problematic,” said Dr. Maksymowych, a rheumatologist and professor of medicine at the University of Alberta in Edmonton. “The EULAR recommendations now say that early diagnosis of spondyloarthritis needs to focus on MRI.”

Mitchel L. Zoler/Frontline Medical News

While the recommendations from the European League Against Rheumatism (EULAR) that came out last year on using imaging for diagnosing and managing spondyloarthritis (SpA) cite radiography of the patient’s sacroiliac joint as the recommended first imaging method to use to diagnose sacroiliitis as part of a diagnosis of axial SpA, the EULAR recommendations place MRI very close behind.

The recommendations list MRI as an “alternative” first-line approach for diagnostic imaging. For patients who appear negative for axial SpA on radiographic imaging but who remain suspected of having SpA the EULAR panel “recommended” MRI of the sacroiliac joints as a backup method for imaging assessment and to definitively rule out SpA. No other imaging method received EULAR’s endorsement for SpA diagnosis aside from these two approaches.

The recommendations direct the MRI examination to include assessment of inflammation based on bone marrow edema, and also structural abnormalities including bone erosion, new bone formation, sclerosis and fat infiltration. The 2015 EULAR recommendations also cite roles for MRI in diagnosing peripheral SpA, monitoring disease activity in axial and peripheral SpA, monioring structural changes in axial and peripheral SpA, predicting outcome and treatment effect in axial SpA, assessing spinal fracture in patients with axial SpA and to assess osteoporosis in selected axial SpA patients.

The MRI imaging sequences particularly useful for SpA diagnosis are “short tau inversion recovery” (STIR), a “water sensitive” sequence that involves suppression of the fat MRI signal, and a T1 weighted sequence that is a “fat sensitive” scan, explained Dr. Maksymowych at the symposium, also organized by the Group for the Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA). He strongly encouraged clinicians to apply a standardized approach to imaging in every patient suspected of having axial SpA.

The definition of an MRI imaging result that is positive for SpA remains a consensus of expert opinion without a firm evidence base. The currently accepted MRI marker of SpA involves identifying several areas of bone marrow edema in a single T1 and STIR MRI image-slice through the sacroiliac joint, or focal bone marrow edema visible in at least two consecutive sacroiliac joint T1 and STIR image slices.

The confluence of a structural lesion at the same site as bone marrow edema provides further confirmatory information, he said. “A structural lesions at the site of bone marrow edema enhances your confidence in the diagnosis,” he said.

“The specificity of MRI for SpA is quite high,” Dr. Maksymowych noted, with specificity rates often in the range of 85%-95%. Sensitivity rates are lower, often 50%-70%. Sensitivity further improves by factoring in the presence of bone erosions. Diagnostic confidence also increases as the number of lesions visualized increases.

MRI has become so integral to the assessment of SpA that “to understand SpA you need to understand the language of MRI,” Dr. Maksymowych concluded.

Dr. Maksymowych has received honoraria from eight drug companies and research grant support from Abbvie and Pfizer.

[email protected]

On Twitter @mitchelzoler

Ticagrelor tablets

Photo from AstraZeneca

The National Institute for Health and Care Excellence (NICE) has published a draft guidance recommending the antiplatelet agent ticagrelor (Brilique, AstraZeneca) be made available on the National Health Service (NHS) at a lower dose that can be used for a longer duration.

NICE previously decided ticagrelor should be available on the NHS as a treatment option for certain patients with acute coronary syndromes.

For these patients, the drug could be given at a dose of 90 mg, in combination with low-dose aspirin, for up to a year to prevent atherothrombotic events.

Now, NICE is recommending an additional option.

The agency’s new draft guidance recommends ticagrelor at 60 mg, to be given twice a day in combination with aspirin at 75 mg to 150 mg daily, as a continuation therapy for the prevention of atherothrombotic events in certain patients with a history of myocardial infarction and a high risk of developing atherothrombotic events.

Patients must have had a myocardial infarction at least a year ago and have already taken ticagrelor at 90 mg (or another adenosine diphosphate receptor inhibitor therapy), in combination with aspirin, for 1 year.

Ticagrelor at 60 mg, plus aspirin, must be continued without interruption. And the treatment must be stopped when clinically indicated or after a maximum of 3 years.

“The evidence shows that ticagrelor, in combination with aspirin, is effective at reducing the risk of further heart attacks and strokes in people who have already had a heart attack,” said Carole Longson, director of the Centre for Health Technology Evaluation at NICE.

“In provisionally recommending ticagrelor, we are pleased to be able to increase the treatment options available to the many thousands of people who stand to benefit from it.”

NICE’s new draft guidance is not intended to affect the position of patients whose treatment with ticagrelor at 60 mg, in combination with aspirin, as a continuation therapy was started within the NHS before this guidance was published.

Treatment of those patients may continue without change to whatever funding arrangements were in place for them before this guidance was published until they and their NHS clinician consider it appropriate to stop.

NICE’s draft guidance is open for comments until 5 pm (GMT) on September 5, 2016.

Ticagrelor tablets

Photo from AstraZeneca

The National Institute for Health and Care Excellence (NICE) has published a draft guidance recommending the antiplatelet agent ticagrelor (Brilique, AstraZeneca) be made available on the National Health Service (NHS) at a lower dose that can be used for a longer duration.

NICE previously decided ticagrelor should be available on the NHS as a treatment option for certain patients with acute coronary syndromes.

For these patients, the drug could be given at a dose of 90 mg, in combination with low-dose aspirin, for up to a year to prevent atherothrombotic events.

Now, NICE is recommending an additional option.

The agency’s new draft guidance recommends ticagrelor at 60 mg, to be given twice a day in combination with aspirin at 75 mg to 150 mg daily, as a continuation therapy for the prevention of atherothrombotic events in certain patients with a history of myocardial infarction and a high risk of developing atherothrombotic events.

Patients must have had a myocardial infarction at least a year ago and have already taken ticagrelor at 90 mg (or another adenosine diphosphate receptor inhibitor therapy), in combination with aspirin, for 1 year.

Ticagrelor at 60 mg, plus aspirin, must be continued without interruption. And the treatment must be stopped when clinically indicated or after a maximum of 3 years.

“The evidence shows that ticagrelor, in combination with aspirin, is effective at reducing the risk of further heart attacks and strokes in people who have already had a heart attack,” said Carole Longson, director of the Centre for Health Technology Evaluation at NICE.

“In provisionally recommending ticagrelor, we are pleased to be able to increase the treatment options available to the many thousands of people who stand to benefit from it.”

NICE’s new draft guidance is not intended to affect the position of patients whose treatment with ticagrelor at 60 mg, in combination with aspirin, as a continuation therapy was started within the NHS before this guidance was published.

Treatment of those patients may continue without change to whatever funding arrangements were in place for them before this guidance was published until they and their NHS clinician consider it appropriate to stop.

NICE’s draft guidance is open for comments until 5 pm (GMT) on September 5, 2016.

Ticagrelor tablets

Photo from AstraZeneca

The National Institute for Health and Care Excellence (NICE) has published a draft guidance recommending the antiplatelet agent ticagrelor (Brilique, AstraZeneca) be made available on the National Health Service (NHS) at a lower dose that can be used for a longer duration.

NICE previously decided ticagrelor should be available on the NHS as a treatment option for certain patients with acute coronary syndromes.

For these patients, the drug could be given at a dose of 90 mg, in combination with low-dose aspirin, for up to a year to prevent atherothrombotic events.

Now, NICE is recommending an additional option.

The agency’s new draft guidance recommends ticagrelor at 60 mg, to be given twice a day in combination with aspirin at 75 mg to 150 mg daily, as a continuation therapy for the prevention of atherothrombotic events in certain patients with a history of myocardial infarction and a high risk of developing atherothrombotic events.

Patients must have had a myocardial infarction at least a year ago and have already taken ticagrelor at 90 mg (or another adenosine diphosphate receptor inhibitor therapy), in combination with aspirin, for 1 year.

Ticagrelor at 60 mg, plus aspirin, must be continued without interruption. And the treatment must be stopped when clinically indicated or after a maximum of 3 years.

“The evidence shows that ticagrelor, in combination with aspirin, is effective at reducing the risk of further heart attacks and strokes in people who have already had a heart attack,” said Carole Longson, director of the Centre for Health Technology Evaluation at NICE.

“In provisionally recommending ticagrelor, we are pleased to be able to increase the treatment options available to the many thousands of people who stand to benefit from it.”

NICE’s new draft guidance is not intended to affect the position of patients whose treatment with ticagrelor at 60 mg, in combination with aspirin, as a continuation therapy was started within the NHS before this guidance was published.

Treatment of those patients may continue without change to whatever funding arrangements were in place for them before this guidance was published until they and their NHS clinician consider it appropriate to stop.

NICE’s draft guidance is open for comments until 5 pm (GMT) on September 5, 2016.