Ron Greeno, MD, FCCP, MHM, says he plans to bring his passion for improving the U.S. healthcare system to his new role representing the interests of hospitalists as a member of the Society of Hospital Medicine's Board of Directors.

As a founding member of SHM, Dr. Greeno has played a major role in the society's advocacy efforts to Congress on issues of import to hospital medicine. "We’ve gone [to Capitol Hill] offering our expertise … trying to provide [lawmakers with] guidance in their endeavors to create the new healthcare system," Dr. Greeno says. In 2011, his work with the society was rewarded when he became one of a select few to receive SHM's Master of Hospital Medicine (MHM) recognition.

"SHM is a nontraditional professional society in that we do believe in advocacy for members, but we also believe we're advocating for patients and the integrity of the American healthcare system," he says.

On his to-do list as an SHM board member, Dr. Greeno plans to focus on overhauling the observation status admissions system, developing solutions to fix the flawed Medicare Sustainable Growth Rate formula, and improving how the quality of patient care provided by hospitalists is measured.

As executive vice president for strategy and innovation at Brentwood, Tenn.–based Cogent Healthcare, Dr. Greeno says his enthusiasm for system improvement has only increased over the years. In his concurrent role as Chairman of SHM's Public Policy Committee, Dr. Greeno and committee members will continue to provide input on hospital management practices to such federal agencies as the Centers for Medicare & Medicaid Services and offer feedback on improving the Affordable Care Act.

SHM Board Member Brian Harte, MD, SFHM, who is treasurer of SHM's Public Policy Committee, says Dr. Greeno's passion for policy is infectious.

"Ron brings an enthusiasm to the issues that really energize the committee," Dr. Harte says. "He does a really good job facilitating an equitable discussion and reaching consensus on a position to recommend to the SHM board."

Ron Greeno, MD, FCCP, MHM, says he plans to bring his passion for improving the U.S. healthcare system to his new role representing the interests of hospitalists as a member of the Society of Hospital Medicine's Board of Directors.

As a founding member of SHM, Dr. Greeno has played a major role in the society's advocacy efforts to Congress on issues of import to hospital medicine. "We’ve gone [to Capitol Hill] offering our expertise … trying to provide [lawmakers with] guidance in their endeavors to create the new healthcare system," Dr. Greeno says. In 2011, his work with the society was rewarded when he became one of a select few to receive SHM's Master of Hospital Medicine (MHM) recognition.

"SHM is a nontraditional professional society in that we do believe in advocacy for members, but we also believe we're advocating for patients and the integrity of the American healthcare system," he says.

On his to-do list as an SHM board member, Dr. Greeno plans to focus on overhauling the observation status admissions system, developing solutions to fix the flawed Medicare Sustainable Growth Rate formula, and improving how the quality of patient care provided by hospitalists is measured.

As executive vice president for strategy and innovation at Brentwood, Tenn.–based Cogent Healthcare, Dr. Greeno says his enthusiasm for system improvement has only increased over the years. In his concurrent role as Chairman of SHM's Public Policy Committee, Dr. Greeno and committee members will continue to provide input on hospital management practices to such federal agencies as the Centers for Medicare & Medicaid Services and offer feedback on improving the Affordable Care Act.

SHM Board Member Brian Harte, MD, SFHM, who is treasurer of SHM's Public Policy Committee, says Dr. Greeno's passion for policy is infectious.

"Ron brings an enthusiasm to the issues that really energize the committee," Dr. Harte says. "He does a really good job facilitating an equitable discussion and reaching consensus on a position to recommend to the SHM board."

Ron Greeno, MD, FCCP, MHM, says he plans to bring his passion for improving the U.S. healthcare system to his new role representing the interests of hospitalists as a member of the Society of Hospital Medicine's Board of Directors.

As a founding member of SHM, Dr. Greeno has played a major role in the society's advocacy efforts to Congress on issues of import to hospital medicine. "We’ve gone [to Capitol Hill] offering our expertise … trying to provide [lawmakers with] guidance in their endeavors to create the new healthcare system," Dr. Greeno says. In 2011, his work with the society was rewarded when he became one of a select few to receive SHM's Master of Hospital Medicine (MHM) recognition.

"SHM is a nontraditional professional society in that we do believe in advocacy for members, but we also believe we're advocating for patients and the integrity of the American healthcare system," he says.

On his to-do list as an SHM board member, Dr. Greeno plans to focus on overhauling the observation status admissions system, developing solutions to fix the flawed Medicare Sustainable Growth Rate formula, and improving how the quality of patient care provided by hospitalists is measured.

As executive vice president for strategy and innovation at Brentwood, Tenn.–based Cogent Healthcare, Dr. Greeno says his enthusiasm for system improvement has only increased over the years. In his concurrent role as Chairman of SHM's Public Policy Committee, Dr. Greeno and committee members will continue to provide input on hospital management practices to such federal agencies as the Centers for Medicare & Medicaid Services and offer feedback on improving the Affordable Care Act.

SHM Board Member Brian Harte, MD, SFHM, who is treasurer of SHM's Public Policy Committee, says Dr. Greeno's passion for policy is infectious.

"Ron brings an enthusiasm to the issues that really energize the committee," Dr. Harte says. "He does a really good job facilitating an equitable discussion and reaching consensus on a position to recommend to the SHM board."

In 2013, the Food and Drug Administration approved 27 new molecular entities (i.e., drugs) for human use. Because of their indications, it is unlikely that four will be used in pregnancy or lactation, so they are not discussed here. The four agents are ospemifene (Osphena), an estrogen agonist/antagonist used for severe dyspareunia; [²²³Ra]radium dichloride (Xofigo), for late-stage metastatic prostate cancer; conjugated estrogens/bazedoxifene (Duavee) for hot flashes associated with menopause and to prevent osteoporosis; and flutemetamol F-18 injection (Vizamyl), a radioactive diagnostic agent to aid in the evaluation of Alzheimer’s disease and dementia.

There are two other drugs that are unlikely to be used in pregnancy: macitentan (Opsumit) and riociguat (Adempas). These drugs are oral vasodilators indicated for the treatment of pulmonary hypertension. Both are teratogenic in rats and rabbits, but there are no reports of their use in human pregnancy. For female patients of reproductive potential, they are only available through restricted programs. Pregnancy must be excluded before starting therapy, monthly during treatment, and for 1 month after treatment is stopped.

The remaining 21 agents can be classified into the following categories: anticonvulsant (1), antidepressant (1), antidiabetics (2), antineoplastics (7), antihyperlipidemic (1), anti-infectives (4), diagnostics (2), immunologic (1), and respiratory (2). It is important to note that, except for two drugs (fluticasone in a combination product and dimethyl fumarate), there is no reported human pregnancy experience for these agents. Moreover, all probably cross the placenta to the embryo and/or the fetus, at least in some part of pregnancy.

Eslicarbazepine (Aptiom) is indicated as adjunctive treatment of partial-onset seizures. Developmental toxicity was observed in three animals: teratogenicity (mice), embryolethality (rats), and fetal growth restriction (rabbits). The no-effect dose was not found in two species, and was less than the human dose based on body surface area in the third. If a pregnant woman is taking this drug, she should be encouraged to enroll in the North American Antiepileptic Drug Pregnancy Registry by calling 888-233-2334.

Vortioxetine (Brintellix) is indicated for the treatment of major depressive disorder. The drug was not teratogenic in animals but did cause developmental delays in one species. Although the antidepressant mechanism is not fully understood, it appears to be related to the inhibition of the reuptake of serotonin (5-hydroxytryptamine). If so, vortioxetine would be closely related to the drugs in the selective serotonin reuptake inhibitor (SSRI) class: citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft), and vilazodone (Viibryd). The relationship could be important because the use of SSRIs or serotonin norepinephrine reuptake inhibitors (SNRIs) close to birth is related to significant toxicity in the newborn.

There are two new antidiabetic agents for the treatment of type 2 diabetes. Alogliptin (Nesina), a dipeptidyl peptidase–4 inhibitor, is in the same pharmacologic class as linagliptin (Tradjenta), saxagliptin (Onglyza), and sitagliptin (Januvia). Canagliflozin (Invokana) is a sodium-glucose cotransporter 2 inhibitor, the first drug in this class to be approved. The animal data for alogliptin suggest low risk, whereas canagliflozin caused renal toxicity in rats at exposures corresponding to the late second and third trimester in humans. Insulin remains the treatment of choice for pregnant diabetics because tight control of glucose levels is beneficial for the mother, embryo-fetus, and newborn.

The seven new antineoplastic agents are ado-trastuzumab emtansine (Kadcyla) for HER2-positive breast cancer; afatinib (Gilotrif) for non–small cell lung cancer; dabrafenib (Tafinlar) for unresectable or metastatic melanoma; ibrutinib (Imbruvica) for mantle cell lymphoma or chronic lymphocytic leukemia; obinutuzumab (Gazyva) for chronic lymphocytic leukemia; pomalidomide (Pomalyst) for multiple myeloma; and trametinib (Mekinist) for unresectable or metastatic melanoma. Only pomalidomide is contraindicated in pregnancy. Although obinutuzumab did not cause teratogenicity in monkeys, its use in the latter portion of pregnancy resulted in newborn depletion of B cells that took up to 6 months after birth to restore. Moreover, it is used in combination with chlorambucil, a known teratogen. The animal data suggest risk in the other five agents. Nevertheless, the maternal condition should determine whether any of these antineoplastics are used in a pregnant woman.

Mipomersen sodium (Kynamro) is given subcutaneously once a week as an adjunct to lipid-lowering medications. The drug caused embryo toxicity in one of three animal species.

Among the four anti-infectives are two oral agents for the treatment of chronic hepatitis C virus infection: simeprevir (Olysio) and sofosbuvir (Sovaldi). Because both agents are recommended to be combined with peginterferon alfa and ribavirin, they are classified as contraindicated in pregnancy. However, when used alone, the animal data suggest that sofosbuvir was low risk, whereas simeprevir might have higher risk.

 

Luliconazole (Luzu), an azole antifungal, is a cream used for the treatment of tinea pedis, tinea cruris, and tinea corporis. Systemic absorption is minimal. The animal data suggest low risk, but there are no human pregnancy reports. Nevertheless, topical use is probably compatible in pregnancy, as are the other topical azole antifungals in this pharmacologic class: clotrimazole (Lotrimin), econazole (Spectazole), ketoconazole (Kuric), miconazole (Micatin), oxiconazole (Oxistat), sertaconazole (Ertaczo), and sulconazole (Exelderm).

Dolutegravir (Tivicay) is an HIV-1 integrase strand transfer inhibitor given in combination with other antiretroviral drugs. The animal data suggest low risk. If indicated, the drug should not be withheld because of pregnancy.

Gadoterate meglumine (Dotarem), a gadolinium-based contrast agent, is indicated to detect and visualize areas with disruption of the blood brain barrier and/or abnormal vascularity. No developmental toxicity was observed in pregnant animals. Closely related diagnostic agents are gadobenate dimeglumine (MultiHance), gadodiamide (Omniscan), gadofosveset (Ablavar), gadopentetate dimeglumine (Magnevist), gadoteridol (Prohance), and gadoversetamide (OptiMARK). Although the animal data for these agents show risk, no harm has been reported in human pregnancies. However, the available human data are very limited, and the risk magnitude for embryo-fetal harm remains unknown.

Technetium (^99mTc) tilmanocept (Lymphoseek) is a radioactive diagnostic agent used in patients with breast cancer or melanoma. The active ingredient is technetium (^99mTc). Animal reproduction studies have not been conducted. ^99mTc is probably compatible in pregnancy (see Drugs in Pregnancy and Lactation, 10th ed.; Philadelphia: Lippincott, Williams and Wilkins, 2014:1317-8; to be released in August), but the risk of the tilmanocept moiety is unknown.

The immunologic agent dimethyl fumarate (Tecfidera) is indicated for the treatment of patients with relapsing forms of multiple sclerosis. The drug caused developmental toxicity (embryolethality, impaired growth, and birth defects) in animals during all portions of pregnancy. In clinical trials, there were 38 exposed pregnancies with the following outcomes: 22 live births, 3 spontaneous abortions, 9 elective abortions, 3 ongoing pregnancies, and 1 lost to follow-up (CNS Drugs 2014;28:89-94). A pregnancy registry has been established, and patients should be encouraged to enroll by calling 800-456-2255.

Two new respiratory combination products were approved in 2013, both for chronic obstructive pulmonary disease: fluticasone/vilanterol (Breo Ellipta) and umeclidinium/vilanterol (Anoro Ellipta). Inhaled fluticasone, a corticosteroid, is compatible in pregnancy (see Drugs in Pregnancy and Lactation, 9th ed.; Philadelphia: Lippincott, Williams and Wilkins; 2011:599-601). Vilanterol is a long-acting beta₂-adrenergic agonist that is probably compatible in pregnancy. The absolute bioavailability of inhaled fluticasone and vilanterol in nonpregnant adults was about 15% and 27%, respectively. The animal data for the combination or when given individually suggest low risk in pregnancy. Umeclidinium is a long-acting anticholinergic. It also is absorbed from the lung, but the amount was not specified by the manufacturer. The animal data for umeclidinium suggest low risk.

There are no reports of the above drugs being used during breastfeeding, but excretion into breast milk should be expected. The effect of these exposures on a nursing infant is unknown. However, if a mother is taking one of these drugs and breastfeeding, her infant should be monitored for adverse effects, especially those that are the most common (typically listed on the first page of the package insert) in patients taking the drug. Close monitoring is particularly important during the first 2 postpartum months. A 2003 study found that most adverse reactions in nursing infants occurred within that time period (Clin. Pediatr. 2003;42:325-40).

Mr. Briggs is a pharmacist clinical specialist at the outpatient clinics of Memorial Care Center for Women at Miller Children’s Hospital in Long Beach, Calif.; clinical professor of pharmacy at the University of California, San Francisco; and adjunct professor of pharmacy at the University of Southern California, Los Angeles, and Washington State University, Spokane. He also is coauthor of "Drugs in Pregnancy and Lactation," and coeditor of "Diseases, Complications, and Drug Therapy in Obstetrics." He had no other relevant financial disclosures. Contact him at [email protected].

In 2013, the Food and Drug Administration approved 27 new molecular entities (i.e., drugs) for human use. Because of their indications, it is unlikely that four will be used in pregnancy or lactation, so they are not discussed here. The four agents are ospemifene (Osphena), an estrogen agonist/antagonist used for severe dyspareunia; [²²³Ra]radium dichloride (Xofigo), for late-stage metastatic prostate cancer; conjugated estrogens/bazedoxifene (Duavee) for hot flashes associated with menopause and to prevent osteoporosis; and flutemetamol F-18 injection (Vizamyl), a radioactive diagnostic agent to aid in the evaluation of Alzheimer’s disease and dementia.

There are two other drugs that are unlikely to be used in pregnancy: macitentan (Opsumit) and riociguat (Adempas). These drugs are oral vasodilators indicated for the treatment of pulmonary hypertension. Both are teratogenic in rats and rabbits, but there are no reports of their use in human pregnancy. For female patients of reproductive potential, they are only available through restricted programs. Pregnancy must be excluded before starting therapy, monthly during treatment, and for 1 month after treatment is stopped.

The remaining 21 agents can be classified into the following categories: anticonvulsant (1), antidepressant (1), antidiabetics (2), antineoplastics (7), antihyperlipidemic (1), anti-infectives (4), diagnostics (2), immunologic (1), and respiratory (2). It is important to note that, except for two drugs (fluticasone in a combination product and dimethyl fumarate), there is no reported human pregnancy experience for these agents. Moreover, all probably cross the placenta to the embryo and/or the fetus, at least in some part of pregnancy.

Eslicarbazepine (Aptiom) is indicated as adjunctive treatment of partial-onset seizures. Developmental toxicity was observed in three animals: teratogenicity (mice), embryolethality (rats), and fetal growth restriction (rabbits). The no-effect dose was not found in two species, and was less than the human dose based on body surface area in the third. If a pregnant woman is taking this drug, she should be encouraged to enroll in the North American Antiepileptic Drug Pregnancy Registry by calling 888-233-2334.

Vortioxetine (Brintellix) is indicated for the treatment of major depressive disorder. The drug was not teratogenic in animals but did cause developmental delays in one species. Although the antidepressant mechanism is not fully understood, it appears to be related to the inhibition of the reuptake of serotonin (5-hydroxytryptamine). If so, vortioxetine would be closely related to the drugs in the selective serotonin reuptake inhibitor (SSRI) class: citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft), and vilazodone (Viibryd). The relationship could be important because the use of SSRIs or serotonin norepinephrine reuptake inhibitors (SNRIs) close to birth is related to significant toxicity in the newborn.

There are two new antidiabetic agents for the treatment of type 2 diabetes. Alogliptin (Nesina), a dipeptidyl peptidase–4 inhibitor, is in the same pharmacologic class as linagliptin (Tradjenta), saxagliptin (Onglyza), and sitagliptin (Januvia). Canagliflozin (Invokana) is a sodium-glucose cotransporter 2 inhibitor, the first drug in this class to be approved. The animal data for alogliptin suggest low risk, whereas canagliflozin caused renal toxicity in rats at exposures corresponding to the late second and third trimester in humans. Insulin remains the treatment of choice for pregnant diabetics because tight control of glucose levels is beneficial for the mother, embryo-fetus, and newborn.

The seven new antineoplastic agents are ado-trastuzumab emtansine (Kadcyla) for HER2-positive breast cancer; afatinib (Gilotrif) for non–small cell lung cancer; dabrafenib (Tafinlar) for unresectable or metastatic melanoma; ibrutinib (Imbruvica) for mantle cell lymphoma or chronic lymphocytic leukemia; obinutuzumab (Gazyva) for chronic lymphocytic leukemia; pomalidomide (Pomalyst) for multiple myeloma; and trametinib (Mekinist) for unresectable or metastatic melanoma. Only pomalidomide is contraindicated in pregnancy. Although obinutuzumab did not cause teratogenicity in monkeys, its use in the latter portion of pregnancy resulted in newborn depletion of B cells that took up to 6 months after birth to restore. Moreover, it is used in combination with chlorambucil, a known teratogen. The animal data suggest risk in the other five agents. Nevertheless, the maternal condition should determine whether any of these antineoplastics are used in a pregnant woman.

Mipomersen sodium (Kynamro) is given subcutaneously once a week as an adjunct to lipid-lowering medications. The drug caused embryo toxicity in one of three animal species.

Among the four anti-infectives are two oral agents for the treatment of chronic hepatitis C virus infection: simeprevir (Olysio) and sofosbuvir (Sovaldi). Because both agents are recommended to be combined with peginterferon alfa and ribavirin, they are classified as contraindicated in pregnancy. However, when used alone, the animal data suggest that sofosbuvir was low risk, whereas simeprevir might have higher risk.

 

Luliconazole (Luzu), an azole antifungal, is a cream used for the treatment of tinea pedis, tinea cruris, and tinea corporis. Systemic absorption is minimal. The animal data suggest low risk, but there are no human pregnancy reports. Nevertheless, topical use is probably compatible in pregnancy, as are the other topical azole antifungals in this pharmacologic class: clotrimazole (Lotrimin), econazole (Spectazole), ketoconazole (Kuric), miconazole (Micatin), oxiconazole (Oxistat), sertaconazole (Ertaczo), and sulconazole (Exelderm).

Dolutegravir (Tivicay) is an HIV-1 integrase strand transfer inhibitor given in combination with other antiretroviral drugs. The animal data suggest low risk. If indicated, the drug should not be withheld because of pregnancy.

Gadoterate meglumine (Dotarem), a gadolinium-based contrast agent, is indicated to detect and visualize areas with disruption of the blood brain barrier and/or abnormal vascularity. No developmental toxicity was observed in pregnant animals. Closely related diagnostic agents are gadobenate dimeglumine (MultiHance), gadodiamide (Omniscan), gadofosveset (Ablavar), gadopentetate dimeglumine (Magnevist), gadoteridol (Prohance), and gadoversetamide (OptiMARK). Although the animal data for these agents show risk, no harm has been reported in human pregnancies. However, the available human data are very limited, and the risk magnitude for embryo-fetal harm remains unknown.

Technetium (^99mTc) tilmanocept (Lymphoseek) is a radioactive diagnostic agent used in patients with breast cancer or melanoma. The active ingredient is technetium (^99mTc). Animal reproduction studies have not been conducted. ^99mTc is probably compatible in pregnancy (see Drugs in Pregnancy and Lactation, 10th ed.; Philadelphia: Lippincott, Williams and Wilkins, 2014:1317-8; to be released in August), but the risk of the tilmanocept moiety is unknown.

The immunologic agent dimethyl fumarate (Tecfidera) is indicated for the treatment of patients with relapsing forms of multiple sclerosis. The drug caused developmental toxicity (embryolethality, impaired growth, and birth defects) in animals during all portions of pregnancy. In clinical trials, there were 38 exposed pregnancies with the following outcomes: 22 live births, 3 spontaneous abortions, 9 elective abortions, 3 ongoing pregnancies, and 1 lost to follow-up (CNS Drugs 2014;28:89-94). A pregnancy registry has been established, and patients should be encouraged to enroll by calling 800-456-2255.

Two new respiratory combination products were approved in 2013, both for chronic obstructive pulmonary disease: fluticasone/vilanterol (Breo Ellipta) and umeclidinium/vilanterol (Anoro Ellipta). Inhaled fluticasone, a corticosteroid, is compatible in pregnancy (see Drugs in Pregnancy and Lactation, 9th ed.; Philadelphia: Lippincott, Williams and Wilkins; 2011:599-601). Vilanterol is a long-acting beta₂-adrenergic agonist that is probably compatible in pregnancy. The absolute bioavailability of inhaled fluticasone and vilanterol in nonpregnant adults was about 15% and 27%, respectively. The animal data for the combination or when given individually suggest low risk in pregnancy. Umeclidinium is a long-acting anticholinergic. It also is absorbed from the lung, but the amount was not specified by the manufacturer. The animal data for umeclidinium suggest low risk.

There are no reports of the above drugs being used during breastfeeding, but excretion into breast milk should be expected. The effect of these exposures on a nursing infant is unknown. However, if a mother is taking one of these drugs and breastfeeding, her infant should be monitored for adverse effects, especially those that are the most common (typically listed on the first page of the package insert) in patients taking the drug. Close monitoring is particularly important during the first 2 postpartum months. A 2003 study found that most adverse reactions in nursing infants occurred within that time period (Clin. Pediatr. 2003;42:325-40).

Mr. Briggs is a pharmacist clinical specialist at the outpatient clinics of Memorial Care Center for Women at Miller Children’s Hospital in Long Beach, Calif.; clinical professor of pharmacy at the University of California, San Francisco; and adjunct professor of pharmacy at the University of Southern California, Los Angeles, and Washington State University, Spokane. He also is coauthor of "Drugs in Pregnancy and Lactation," and coeditor of "Diseases, Complications, and Drug Therapy in Obstetrics." He had no other relevant financial disclosures. Contact him at [email protected].

In 2013, the Food and Drug Administration approved 27 new molecular entities (i.e., drugs) for human use. Because of their indications, it is unlikely that four will be used in pregnancy or lactation, so they are not discussed here. The four agents are ospemifene (Osphena), an estrogen agonist/antagonist used for severe dyspareunia; [²²³Ra]radium dichloride (Xofigo), for late-stage metastatic prostate cancer; conjugated estrogens/bazedoxifene (Duavee) for hot flashes associated with menopause and to prevent osteoporosis; and flutemetamol F-18 injection (Vizamyl), a radioactive diagnostic agent to aid in the evaluation of Alzheimer’s disease and dementia.

There are two other drugs that are unlikely to be used in pregnancy: macitentan (Opsumit) and riociguat (Adempas). These drugs are oral vasodilators indicated for the treatment of pulmonary hypertension. Both are teratogenic in rats and rabbits, but there are no reports of their use in human pregnancy. For female patients of reproductive potential, they are only available through restricted programs. Pregnancy must be excluded before starting therapy, monthly during treatment, and for 1 month after treatment is stopped.

The remaining 21 agents can be classified into the following categories: anticonvulsant (1), antidepressant (1), antidiabetics (2), antineoplastics (7), antihyperlipidemic (1), anti-infectives (4), diagnostics (2), immunologic (1), and respiratory (2). It is important to note that, except for two drugs (fluticasone in a combination product and dimethyl fumarate), there is no reported human pregnancy experience for these agents. Moreover, all probably cross the placenta to the embryo and/or the fetus, at least in some part of pregnancy.

Eslicarbazepine (Aptiom) is indicated as adjunctive treatment of partial-onset seizures. Developmental toxicity was observed in three animals: teratogenicity (mice), embryolethality (rats), and fetal growth restriction (rabbits). The no-effect dose was not found in two species, and was less than the human dose based on body surface area in the third. If a pregnant woman is taking this drug, she should be encouraged to enroll in the North American Antiepileptic Drug Pregnancy Registry by calling 888-233-2334.

Vortioxetine (Brintellix) is indicated for the treatment of major depressive disorder. The drug was not teratogenic in animals but did cause developmental delays in one species. Although the antidepressant mechanism is not fully understood, it appears to be related to the inhibition of the reuptake of serotonin (5-hydroxytryptamine). If so, vortioxetine would be closely related to the drugs in the selective serotonin reuptake inhibitor (SSRI) class: citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft), and vilazodone (Viibryd). The relationship could be important because the use of SSRIs or serotonin norepinephrine reuptake inhibitors (SNRIs) close to birth is related to significant toxicity in the newborn.

There are two new antidiabetic agents for the treatment of type 2 diabetes. Alogliptin (Nesina), a dipeptidyl peptidase–4 inhibitor, is in the same pharmacologic class as linagliptin (Tradjenta), saxagliptin (Onglyza), and sitagliptin (Januvia). Canagliflozin (Invokana) is a sodium-glucose cotransporter 2 inhibitor, the first drug in this class to be approved. The animal data for alogliptin suggest low risk, whereas canagliflozin caused renal toxicity in rats at exposures corresponding to the late second and third trimester in humans. Insulin remains the treatment of choice for pregnant diabetics because tight control of glucose levels is beneficial for the mother, embryo-fetus, and newborn.

The seven new antineoplastic agents are ado-trastuzumab emtansine (Kadcyla) for HER2-positive breast cancer; afatinib (Gilotrif) for non–small cell lung cancer; dabrafenib (Tafinlar) for unresectable or metastatic melanoma; ibrutinib (Imbruvica) for mantle cell lymphoma or chronic lymphocytic leukemia; obinutuzumab (Gazyva) for chronic lymphocytic leukemia; pomalidomide (Pomalyst) for multiple myeloma; and trametinib (Mekinist) for unresectable or metastatic melanoma. Only pomalidomide is contraindicated in pregnancy. Although obinutuzumab did not cause teratogenicity in monkeys, its use in the latter portion of pregnancy resulted in newborn depletion of B cells that took up to 6 months after birth to restore. Moreover, it is used in combination with chlorambucil, a known teratogen. The animal data suggest risk in the other five agents. Nevertheless, the maternal condition should determine whether any of these antineoplastics are used in a pregnant woman.

Mipomersen sodium (Kynamro) is given subcutaneously once a week as an adjunct to lipid-lowering medications. The drug caused embryo toxicity in one of three animal species.

Among the four anti-infectives are two oral agents for the treatment of chronic hepatitis C virus infection: simeprevir (Olysio) and sofosbuvir (Sovaldi). Because both agents are recommended to be combined with peginterferon alfa and ribavirin, they are classified as contraindicated in pregnancy. However, when used alone, the animal data suggest that sofosbuvir was low risk, whereas simeprevir might have higher risk.

 

Luliconazole (Luzu), an azole antifungal, is a cream used for the treatment of tinea pedis, tinea cruris, and tinea corporis. Systemic absorption is minimal. The animal data suggest low risk, but there are no human pregnancy reports. Nevertheless, topical use is probably compatible in pregnancy, as are the other topical azole antifungals in this pharmacologic class: clotrimazole (Lotrimin), econazole (Spectazole), ketoconazole (Kuric), miconazole (Micatin), oxiconazole (Oxistat), sertaconazole (Ertaczo), and sulconazole (Exelderm).

Dolutegravir (Tivicay) is an HIV-1 integrase strand transfer inhibitor given in combination with other antiretroviral drugs. The animal data suggest low risk. If indicated, the drug should not be withheld because of pregnancy.

Gadoterate meglumine (Dotarem), a gadolinium-based contrast agent, is indicated to detect and visualize areas with disruption of the blood brain barrier and/or abnormal vascularity. No developmental toxicity was observed in pregnant animals. Closely related diagnostic agents are gadobenate dimeglumine (MultiHance), gadodiamide (Omniscan), gadofosveset (Ablavar), gadopentetate dimeglumine (Magnevist), gadoteridol (Prohance), and gadoversetamide (OptiMARK). Although the animal data for these agents show risk, no harm has been reported in human pregnancies. However, the available human data are very limited, and the risk magnitude for embryo-fetal harm remains unknown.

Technetium (^99mTc) tilmanocept (Lymphoseek) is a radioactive diagnostic agent used in patients with breast cancer or melanoma. The active ingredient is technetium (^99mTc). Animal reproduction studies have not been conducted. ^99mTc is probably compatible in pregnancy (see Drugs in Pregnancy and Lactation, 10th ed.; Philadelphia: Lippincott, Williams and Wilkins, 2014:1317-8; to be released in August), but the risk of the tilmanocept moiety is unknown.

The immunologic agent dimethyl fumarate (Tecfidera) is indicated for the treatment of patients with relapsing forms of multiple sclerosis. The drug caused developmental toxicity (embryolethality, impaired growth, and birth defects) in animals during all portions of pregnancy. In clinical trials, there were 38 exposed pregnancies with the following outcomes: 22 live births, 3 spontaneous abortions, 9 elective abortions, 3 ongoing pregnancies, and 1 lost to follow-up (CNS Drugs 2014;28:89-94). A pregnancy registry has been established, and patients should be encouraged to enroll by calling 800-456-2255.

Two new respiratory combination products were approved in 2013, both for chronic obstructive pulmonary disease: fluticasone/vilanterol (Breo Ellipta) and umeclidinium/vilanterol (Anoro Ellipta). Inhaled fluticasone, a corticosteroid, is compatible in pregnancy (see Drugs in Pregnancy and Lactation, 9th ed.; Philadelphia: Lippincott, Williams and Wilkins; 2011:599-601). Vilanterol is a long-acting beta₂-adrenergic agonist that is probably compatible in pregnancy. The absolute bioavailability of inhaled fluticasone and vilanterol in nonpregnant adults was about 15% and 27%, respectively. The animal data for the combination or when given individually suggest low risk in pregnancy. Umeclidinium is a long-acting anticholinergic. It also is absorbed from the lung, but the amount was not specified by the manufacturer. The animal data for umeclidinium suggest low risk.

There are no reports of the above drugs being used during breastfeeding, but excretion into breast milk should be expected. The effect of these exposures on a nursing infant is unknown. However, if a mother is taking one of these drugs and breastfeeding, her infant should be monitored for adverse effects, especially those that are the most common (typically listed on the first page of the package insert) in patients taking the drug. Close monitoring is particularly important during the first 2 postpartum months. A 2003 study found that most adverse reactions in nursing infants occurred within that time period (Clin. Pediatr. 2003;42:325-40).

Mr. Briggs is a pharmacist clinical specialist at the outpatient clinics of Memorial Care Center for Women at Miller Children’s Hospital in Long Beach, Calif.; clinical professor of pharmacy at the University of California, San Francisco; and adjunct professor of pharmacy at the University of Southern California, Los Angeles, and Washington State University, Spokane. He also is coauthor of "Drugs in Pregnancy and Lactation," and coeditor of "Diseases, Complications, and Drug Therapy in Obstetrics." He had no other relevant financial disclosures. Contact him at [email protected].

Through a series of preclinical experiments, scientists discovered they could reduce the sickling of red blood cells (RBCs) and slow the progression of sickle cell disease (SCD).

In a mouse model of SCD and blood samples from SCD patients, the researchers reduced sickling by manipulating sphingosine-1-phosphate (S1P) and sphingosine kinase 1 (SPHK1).

Yang Xia, MD, PhD, of The University of Texas Health Science Center at Houston, and colleagues described this work in The Journal of Clinical Investigation.

The scientists first discovered that S1P, a lipid enriched and stored in RBCs, is elevated in mice with SCD. Further investigation revealed that elevated SPHK1 activity underlies the increased levels of S1P and contributes to RBC sickling.

To confirm SPHK1’s role in SCD, the researchers tested 2 SPHK1 inhibitors, SK1-I and PF-543, in cells from mice with SCD. Both agents successfully inhibited SPHK1 activity and reduced S1P levels in a dose-dependent manner, but PF-543 demonstrated greater potency.

In subsequent experiments, PF-543 decreased intravascular hemolysis and reduced inflammation in mice with SCD. The treatment also decreased tissue injury and splenomegaly and increased survival in the mice.

When the scientists knocked down SPHK1 in hematopoietic stem cells (HSCs), they observed decreased sickling and reticulocytes in SCD chimeras, resulting from a reduction in S1P levels.

Knocking down SPHK1 in HSCs also decreased intravascular hemolysis, prolonged RBC life span, reduced inflammation, decreased splenomegaly and tissue injury, and increased survival in the mice.

Experiments in cells from patients with SCD showed that SPHK1 activity and S1P levels were elevated and directly contributed to sickling. So the researchers decided to evaluate how PF-543 would affect these cells.

Treating cells with PF-543 significantly inhibited hypoxia-induced SPHK1 activity and prevented the elevation of  S1P in a dose-dependent manner. The treatment also significantly reduced the percentage of sickled cells in a dose-dependent manner.

Finally, the scientists found that S1P-induced sickling was independent of S1P receptor activation. S1P receptor antagonists did not inhibit hypoxia-induced sickling in cells from SCD patients. And treatment with S1P did not enhance sickling under hypoxic conditions.

“This work could lead to novel treatments for sickle cell disease,” said study author Harinder Juneja, MD, of The University of Texas Health Science Center. “The study provides a better understanding of the pathogenesis of the disease and reveals a new therapeutic target.”

Coauthor Rod Kellems, PhD, also of The University of Texas Health Science Center, added, “This research provides insight into how red blood cells work, revealing that SPHK1-mediated elevation of S1P contributes to sickling and promotes disease progression and highlights potential therapeutic opportunities for sickle cell disease.”

Through a series of preclinical experiments, scientists discovered they could reduce the sickling of red blood cells (RBCs) and slow the progression of sickle cell disease (SCD).

In a mouse model of SCD and blood samples from SCD patients, the researchers reduced sickling by manipulating sphingosine-1-phosphate (S1P) and sphingosine kinase 1 (SPHK1).

Yang Xia, MD, PhD, of The University of Texas Health Science Center at Houston, and colleagues described this work in The Journal of Clinical Investigation.

The scientists first discovered that S1P, a lipid enriched and stored in RBCs, is elevated in mice with SCD. Further investigation revealed that elevated SPHK1 activity underlies the increased levels of S1P and contributes to RBC sickling.

To confirm SPHK1’s role in SCD, the researchers tested 2 SPHK1 inhibitors, SK1-I and PF-543, in cells from mice with SCD. Both agents successfully inhibited SPHK1 activity and reduced S1P levels in a dose-dependent manner, but PF-543 demonstrated greater potency.

In subsequent experiments, PF-543 decreased intravascular hemolysis and reduced inflammation in mice with SCD. The treatment also decreased tissue injury and splenomegaly and increased survival in the mice.

When the scientists knocked down SPHK1 in hematopoietic stem cells (HSCs), they observed decreased sickling and reticulocytes in SCD chimeras, resulting from a reduction in S1P levels.

Knocking down SPHK1 in HSCs also decreased intravascular hemolysis, prolonged RBC life span, reduced inflammation, decreased splenomegaly and tissue injury, and increased survival in the mice.

Experiments in cells from patients with SCD showed that SPHK1 activity and S1P levels were elevated and directly contributed to sickling. So the researchers decided to evaluate how PF-543 would affect these cells.

Treating cells with PF-543 significantly inhibited hypoxia-induced SPHK1 activity and prevented the elevation of  S1P in a dose-dependent manner. The treatment also significantly reduced the percentage of sickled cells in a dose-dependent manner.

Finally, the scientists found that S1P-induced sickling was independent of S1P receptor activation. S1P receptor antagonists did not inhibit hypoxia-induced sickling in cells from SCD patients. And treatment with S1P did not enhance sickling under hypoxic conditions.

“This work could lead to novel treatments for sickle cell disease,” said study author Harinder Juneja, MD, of The University of Texas Health Science Center. “The study provides a better understanding of the pathogenesis of the disease and reveals a new therapeutic target.”

Coauthor Rod Kellems, PhD, also of The University of Texas Health Science Center, added, “This research provides insight into how red blood cells work, revealing that SPHK1-mediated elevation of S1P contributes to sickling and promotes disease progression and highlights potential therapeutic opportunities for sickle cell disease.”

Through a series of preclinical experiments, scientists discovered they could reduce the sickling of red blood cells (RBCs) and slow the progression of sickle cell disease (SCD).

In a mouse model of SCD and blood samples from SCD patients, the researchers reduced sickling by manipulating sphingosine-1-phosphate (S1P) and sphingosine kinase 1 (SPHK1).

Yang Xia, MD, PhD, of The University of Texas Health Science Center at Houston, and colleagues described this work in The Journal of Clinical Investigation.

The scientists first discovered that S1P, a lipid enriched and stored in RBCs, is elevated in mice with SCD. Further investigation revealed that elevated SPHK1 activity underlies the increased levels of S1P and contributes to RBC sickling.

To confirm SPHK1’s role in SCD, the researchers tested 2 SPHK1 inhibitors, SK1-I and PF-543, in cells from mice with SCD. Both agents successfully inhibited SPHK1 activity and reduced S1P levels in a dose-dependent manner, but PF-543 demonstrated greater potency.

In subsequent experiments, PF-543 decreased intravascular hemolysis and reduced inflammation in mice with SCD. The treatment also decreased tissue injury and splenomegaly and increased survival in the mice.

When the scientists knocked down SPHK1 in hematopoietic stem cells (HSCs), they observed decreased sickling and reticulocytes in SCD chimeras, resulting from a reduction in S1P levels.

Knocking down SPHK1 in HSCs also decreased intravascular hemolysis, prolonged RBC life span, reduced inflammation, decreased splenomegaly and tissue injury, and increased survival in the mice.

Experiments in cells from patients with SCD showed that SPHK1 activity and S1P levels were elevated and directly contributed to sickling. So the researchers decided to evaluate how PF-543 would affect these cells.

Treating cells with PF-543 significantly inhibited hypoxia-induced SPHK1 activity and prevented the elevation of  S1P in a dose-dependent manner. The treatment also significantly reduced the percentage of sickled cells in a dose-dependent manner.

Finally, the scientists found that S1P-induced sickling was independent of S1P receptor activation. S1P receptor antagonists did not inhibit hypoxia-induced sickling in cells from SCD patients. And treatment with S1P did not enhance sickling under hypoxic conditions.

“This work could lead to novel treatments for sickle cell disease,” said study author Harinder Juneja, MD, of The University of Texas Health Science Center. “The study provides a better understanding of the pathogenesis of the disease and reveals a new therapeutic target.”

Coauthor Rod Kellems, PhD, also of The University of Texas Health Science Center, added, “This research provides insight into how red blood cells work, revealing that SPHK1-mediated elevation of S1P contributes to sickling and promotes disease progression and highlights potential therapeutic opportunities for sickle cell disease.”

The US Food and Drug Administration (FDA) has granted breakthrough therapy designation for the investigational PD-1 immune checkpoint inhibitor nivolumab to treat Hodgkin lymphoma (HL) in patients who have failed autologous stem cell transplant and treatment with brentuximab vedotin.

The FDA’s decision is based on data from a cohort of HL patients in an ongoing phase 1b study of patients with relapsed or refractory hematologic malignancies.

According to the FDA, breakthrough designation is intended to expedite the development and review of drugs for serious or life-threatening conditions.

For a treatment to receive this designation, there must be preliminary clinical evidence that demonstrates the drug may offer substantial improvement over currently available therapy on at least 1 clinically significant endpoint.

Nivolumab is an investigational agent that binds to the checkpoint receptor PD-1 expressed on activated T cells. Researchers are investigating whether, by blocking this pathway, nivolumab would enable the immune system to resume its ability to recognize, attack, and destroy cancer cells.

Nivolumab is under investigation in multiple tumor types as monotherapy or in combination with other therapies. There are 35 trials of the agent underway, in which more than 7000 patients have been enrolled.

The breakthrough designation for nivolumab in HL is based on results of a 2-part phase 1 study, which have not been made public.

The researchers planned to enroll 100 patients with relapsed or refractory hematologic malignancies on this study. For the dose-escalation portion, the team planned to treat successive cohorts of patients using a 6+3 escalation design.

Patients would receive 1 mg/kg or 3 mg/kg of intravenous nivolumab every 2 weeks (although the first dose would be followed by a 3-week evaluation period) for 2 years, with the potential for an additional year of therapy for patients who progress.

Then, the researchers would enroll 5 cohorts of 16 patients representing the following tumor sites: HL/primary mediastinal B-cell lymphoma, multiple myeloma, B-cell lymphoma, T-cell lymphoma, and chronic myelogenous leukemia.

These patients would receive nivolumab at the maximum-tolerated dose identified in the first part of the study.

A poster describing the study plan was presented at the 2013 ASCO Annual Meeting (abstract TPS3113). The study is funded by Bristol-Myers Squibb, the company developing nivolumab.

The US Food and Drug Administration (FDA) has granted breakthrough therapy designation for the investigational PD-1 immune checkpoint inhibitor nivolumab to treat Hodgkin lymphoma (HL) in patients who have failed autologous stem cell transplant and treatment with brentuximab vedotin.

The FDA’s decision is based on data from a cohort of HL patients in an ongoing phase 1b study of patients with relapsed or refractory hematologic malignancies.

According to the FDA, breakthrough designation is intended to expedite the development and review of drugs for serious or life-threatening conditions.

For a treatment to receive this designation, there must be preliminary clinical evidence that demonstrates the drug may offer substantial improvement over currently available therapy on at least 1 clinically significant endpoint.

Nivolumab is an investigational agent that binds to the checkpoint receptor PD-1 expressed on activated T cells. Researchers are investigating whether, by blocking this pathway, nivolumab would enable the immune system to resume its ability to recognize, attack, and destroy cancer cells.

Nivolumab is under investigation in multiple tumor types as monotherapy or in combination with other therapies. There are 35 trials of the agent underway, in which more than 7000 patients have been enrolled.

The breakthrough designation for nivolumab in HL is based on results of a 2-part phase 1 study, which have not been made public.

The researchers planned to enroll 100 patients with relapsed or refractory hematologic malignancies on this study. For the dose-escalation portion, the team planned to treat successive cohorts of patients using a 6+3 escalation design.

Patients would receive 1 mg/kg or 3 mg/kg of intravenous nivolumab every 2 weeks (although the first dose would be followed by a 3-week evaluation period) for 2 years, with the potential for an additional year of therapy for patients who progress.

Then, the researchers would enroll 5 cohorts of 16 patients representing the following tumor sites: HL/primary mediastinal B-cell lymphoma, multiple myeloma, B-cell lymphoma, T-cell lymphoma, and chronic myelogenous leukemia.

These patients would receive nivolumab at the maximum-tolerated dose identified in the first part of the study.

A poster describing the study plan was presented at the 2013 ASCO Annual Meeting (abstract TPS3113). The study is funded by Bristol-Myers Squibb, the company developing nivolumab.

The US Food and Drug Administration (FDA) has granted breakthrough therapy designation for the investigational PD-1 immune checkpoint inhibitor nivolumab to treat Hodgkin lymphoma (HL) in patients who have failed autologous stem cell transplant and treatment with brentuximab vedotin.

The FDA’s decision is based on data from a cohort of HL patients in an ongoing phase 1b study of patients with relapsed or refractory hematologic malignancies.

According to the FDA, breakthrough designation is intended to expedite the development and review of drugs for serious or life-threatening conditions.

For a treatment to receive this designation, there must be preliminary clinical evidence that demonstrates the drug may offer substantial improvement over currently available therapy on at least 1 clinically significant endpoint.

Nivolumab is an investigational agent that binds to the checkpoint receptor PD-1 expressed on activated T cells. Researchers are investigating whether, by blocking this pathway, nivolumab would enable the immune system to resume its ability to recognize, attack, and destroy cancer cells.

Nivolumab is under investigation in multiple tumor types as monotherapy or in combination with other therapies. There are 35 trials of the agent underway, in which more than 7000 patients have been enrolled.

The breakthrough designation for nivolumab in HL is based on results of a 2-part phase 1 study, which have not been made public.

The researchers planned to enroll 100 patients with relapsed or refractory hematologic malignancies on this study. For the dose-escalation portion, the team planned to treat successive cohorts of patients using a 6+3 escalation design.

Patients would receive 1 mg/kg or 3 mg/kg of intravenous nivolumab every 2 weeks (although the first dose would be followed by a 3-week evaluation period) for 2 years, with the potential for an additional year of therapy for patients who progress.

Then, the researchers would enroll 5 cohorts of 16 patients representing the following tumor sites: HL/primary mediastinal B-cell lymphoma, multiple myeloma, B-cell lymphoma, T-cell lymphoma, and chronic myelogenous leukemia.

These patients would receive nivolumab at the maximum-tolerated dose identified in the first part of the study.

A poster describing the study plan was presented at the 2013 ASCO Annual Meeting (abstract TPS3113). The study is funded by Bristol-Myers Squibb, the company developing nivolumab.

Researchers say they’ve developed a technique that can predict—with 95% accuracy—which stroke patients will benefit from tissue-type plasminogen activator (tPA) and which will suffer from intracranial hemorrhage if treated.

The team devised a method that uses standard MRI scans to measure damage to the blood-brain barrier.

If further tests confirm the method’s accuracy, the researchers say it could allow for more precise use of intravenous tPA.

“If we are able to replicate our findings in more patients, it will indicate we are able to identify which people are likely to have bad outcomes, improving the drug’s safety and also potentially allowing us to give the drug to patients who currently go untreated,” said study author Richard Leigh, MD, of the Johns Hopkins University School of Medicine in Baltimore, Maryland.

Dr Leigh and his colleagues described their technique in Stroke.

The group’s method is a computer program that lets physicians see how much gadolinium, the contrast material injected into a patient’s vein during an MRI scan, has leaked into the brain tissue from surrounding blood vessels.

By quantifying this damage in 75 stroke patients, the researchers identified a threshold for determining how much leakage was dangerous.

Then, they applied this threshold to those 75 records to determine how well it would predict who had suffered a brain hemorrhage and who had not. The test correctly predicted the outcome with 95% accuracy.

The researchers noted that, until now, physicians haven’t been able to predict with any precision which patients are likely to suffer a drug-related bleed and which are not. In these situations, if physicians knew the extent of the damage to the blood-brain barrier, they would be able to more safely administer treatment.

Typically, physicians do a CT scan of a stroke victim to see if he or she has visible bleeding before administering tPA. Dr Leigh said his computer program, which works with an MRI scan instead, can detect subtle changes to the blood-brain barrier that are otherwise impossible to see.

If his findings hold up, Dr Leigh said, “We should probably be doing MRI scans in every stroke patient before we give tPA.”

He conceded that an MRI scan does take longer to conduct in most institutions than a CT scan. But if the benefits of getting tPA into the right patients outweigh the harms of waiting a little longer to get MRI results, physicians should consider changing their practice, according to Dr Leigh.

“If we could eliminate all intracranial hemorrhages, it would be worth it,” he said.

Dr Leigh is now analyzing data from patients who received other treatments for stroke outside the typical time window, in some cases many hours after the FDA-approved cutoff for tPA. It’s possible, he said, that some patients who come to the hospital many hours after a stroke can still benefit from tPA, the only FDA-approved treatment for ischemic stroke.

Researchers say they’ve developed a technique that can predict—with 95% accuracy—which stroke patients will benefit from tissue-type plasminogen activator (tPA) and which will suffer from intracranial hemorrhage if treated.

The team devised a method that uses standard MRI scans to measure damage to the blood-brain barrier.

If further tests confirm the method’s accuracy, the researchers say it could allow for more precise use of intravenous tPA.

“If we are able to replicate our findings in more patients, it will indicate we are able to identify which people are likely to have bad outcomes, improving the drug’s safety and also potentially allowing us to give the drug to patients who currently go untreated,” said study author Richard Leigh, MD, of the Johns Hopkins University School of Medicine in Baltimore, Maryland.

Dr Leigh and his colleagues described their technique in Stroke.

The group’s method is a computer program that lets physicians see how much gadolinium, the contrast material injected into a patient’s vein during an MRI scan, has leaked into the brain tissue from surrounding blood vessels.

By quantifying this damage in 75 stroke patients, the researchers identified a threshold for determining how much leakage was dangerous.

Then, they applied this threshold to those 75 records to determine how well it would predict who had suffered a brain hemorrhage and who had not. The test correctly predicted the outcome with 95% accuracy.

The researchers noted that, until now, physicians haven’t been able to predict with any precision which patients are likely to suffer a drug-related bleed and which are not. In these situations, if physicians knew the extent of the damage to the blood-brain barrier, they would be able to more safely administer treatment.

Typically, physicians do a CT scan of a stroke victim to see if he or she has visible bleeding before administering tPA. Dr Leigh said his computer program, which works with an MRI scan instead, can detect subtle changes to the blood-brain barrier that are otherwise impossible to see.

If his findings hold up, Dr Leigh said, “We should probably be doing MRI scans in every stroke patient before we give tPA.”

He conceded that an MRI scan does take longer to conduct in most institutions than a CT scan. But if the benefits of getting tPA into the right patients outweigh the harms of waiting a little longer to get MRI results, physicians should consider changing their practice, according to Dr Leigh.

“If we could eliminate all intracranial hemorrhages, it would be worth it,” he said.

Dr Leigh is now analyzing data from patients who received other treatments for stroke outside the typical time window, in some cases many hours after the FDA-approved cutoff for tPA. It’s possible, he said, that some patients who come to the hospital many hours after a stroke can still benefit from tPA, the only FDA-approved treatment for ischemic stroke.

Researchers say they’ve developed a technique that can predict—with 95% accuracy—which stroke patients will benefit from tissue-type plasminogen activator (tPA) and which will suffer from intracranial hemorrhage if treated.

The team devised a method that uses standard MRI scans to measure damage to the blood-brain barrier.

If further tests confirm the method’s accuracy, the researchers say it could allow for more precise use of intravenous tPA.

“If we are able to replicate our findings in more patients, it will indicate we are able to identify which people are likely to have bad outcomes, improving the drug’s safety and also potentially allowing us to give the drug to patients who currently go untreated,” said study author Richard Leigh, MD, of the Johns Hopkins University School of Medicine in Baltimore, Maryland.

Dr Leigh and his colleagues described their technique in Stroke.

The group’s method is a computer program that lets physicians see how much gadolinium, the contrast material injected into a patient’s vein during an MRI scan, has leaked into the brain tissue from surrounding blood vessels.

By quantifying this damage in 75 stroke patients, the researchers identified a threshold for determining how much leakage was dangerous.

Then, they applied this threshold to those 75 records to determine how well it would predict who had suffered a brain hemorrhage and who had not. The test correctly predicted the outcome with 95% accuracy.

The researchers noted that, until now, physicians haven’t been able to predict with any precision which patients are likely to suffer a drug-related bleed and which are not. In these situations, if physicians knew the extent of the damage to the blood-brain barrier, they would be able to more safely administer treatment.

Typically, physicians do a CT scan of a stroke victim to see if he or she has visible bleeding before administering tPA. Dr Leigh said his computer program, which works with an MRI scan instead, can detect subtle changes to the blood-brain barrier that are otherwise impossible to see.

If his findings hold up, Dr Leigh said, “We should probably be doing MRI scans in every stroke patient before we give tPA.”

He conceded that an MRI scan does take longer to conduct in most institutions than a CT scan. But if the benefits of getting tPA into the right patients outweigh the harms of waiting a little longer to get MRI results, physicians should consider changing their practice, according to Dr Leigh.

“If we could eliminate all intracranial hemorrhages, it would be worth it,” he said.

Dr Leigh is now analyzing data from patients who received other treatments for stroke outside the typical time window, in some cases many hours after the FDA-approved cutoff for tPA. It’s possible, he said, that some patients who come to the hospital many hours after a stroke can still benefit from tPA, the only FDA-approved treatment for ischemic stroke.

The US Food and Drug Administration (FDA) has granted selinexor (KPT-330) orphan designation for the treatment of acute myeloid leukemia (AML).

Selinexor is a selective inhibitor of nuclear transport that functions by binding to the nuclear export protein XPO1 (also called CRM1).

This leads to the accumulation of tumor suppressor proteins in the cell nucleus, which is thought to cause apoptosis in cancer cells while largely sparing normal cells.

The FDA grants orphan designation to promote the development of drugs that target conditions affecting 200,000 or fewer US patients annually and are expected to provide significant therapeutic advantage over existing treatments.

Selinexor’s orphan designation qualifies the drug’s developer, Karyopharm Therapeutics, Inc., for benefits that apply across all stages of development, including an accelerated approval process, 7 years of market exclusivity following marketing approval, tax credits on US clinical trials, eligibility for orphan drug grants, and a waiver of certain administrative fees.

Promising early results

Selinexor has shown promising results in a phase 1 trial of older patients with relapsed or refractory AML. The study, which was sponsored by Karyopharm, was published in Blood.

Researchers enrolled 16 patients with relapsed or refractory AML. The median age was 71 years, and the median number of prior therapeutic regimens was 2.

Patients received 8 to 10 doses of selinexor on a 4-week cycle across 2 dose levels, 16.8 mg/m² to 23 mg/m² (with additional cohorts ongoing).

The researchers reported no dose-limiting toxicity, no clinically significant cumulative toxicities, and no major organ dysfunction.

However, 4 patients experienced drug-related grade 3/4 adverse events, including hypotension (n=1), increased AST (n=1), hypokalemia (n=1), nausea (n=1), headache (n=1), and fatigue (n=1).

The most common grade 1/2 toxicities were nausea (9/17; 53%), anorexia (8/17; 47%), vomiting (6/17; 35%), fatigue (5/17; 29%), weight loss (5/17; 29%), and diarrhea (3/17; 18%). But these events were manageable.

Fourteen of the patients were evaluable for response. Two (14%) achieved a complete response with full hematologic recovery, and 2 (14%) achieved a complete response without hematologic recovery. Four patients (29%) had stable disease for more than 30 days, and 6 (43%) experienced progression.

Other trials of selinexor in AML

Karyopharm’s development plans for selinexor in AML include a number of additional studies.

In a phase 2 trial, researchers will evaluate selinexor monotherapy in older patients with AML. The study will enroll patients 60 years of age or older with relapsed or refractory AML who are ineligible for intensive chemotherapy and/or transplant.

In another study, researchers will evaluate selinexor in combination with decitabine for patients with relapsed, refractory, or newly diagnosed AML. The study will enroll up to 42 patients aged 60 or older who are ineligible for intensive chemotherapy.

Lastly, researchers are planning a study of selinexor in pediatric leukemia patients. The goal of this study is to determine the oral dosing, toxicity, and preliminary clinical activity of selinexor in pediatric patients. It will enroll up to 28 children with relapsed or refractory AML or acute lymphoblastic leukemia.

The US Food and Drug Administration (FDA) has granted selinexor (KPT-330) orphan designation for the treatment of acute myeloid leukemia (AML).

Selinexor is a selective inhibitor of nuclear transport that functions by binding to the nuclear export protein XPO1 (also called CRM1).

This leads to the accumulation of tumor suppressor proteins in the cell nucleus, which is thought to cause apoptosis in cancer cells while largely sparing normal cells.

The FDA grants orphan designation to promote the development of drugs that target conditions affecting 200,000 or fewer US patients annually and are expected to provide significant therapeutic advantage over existing treatments.

Selinexor’s orphan designation qualifies the drug’s developer, Karyopharm Therapeutics, Inc., for benefits that apply across all stages of development, including an accelerated approval process, 7 years of market exclusivity following marketing approval, tax credits on US clinical trials, eligibility for orphan drug grants, and a waiver of certain administrative fees.

Promising early results

Selinexor has shown promising results in a phase 1 trial of older patients with relapsed or refractory AML. The study, which was sponsored by Karyopharm, was published in Blood.

Researchers enrolled 16 patients with relapsed or refractory AML. The median age was 71 years, and the median number of prior therapeutic regimens was 2.

Patients received 8 to 10 doses of selinexor on a 4-week cycle across 2 dose levels, 16.8 mg/m² to 23 mg/m² (with additional cohorts ongoing).

The researchers reported no dose-limiting toxicity, no clinically significant cumulative toxicities, and no major organ dysfunction.

However, 4 patients experienced drug-related grade 3/4 adverse events, including hypotension (n=1), increased AST (n=1), hypokalemia (n=1), nausea (n=1), headache (n=1), and fatigue (n=1).

The most common grade 1/2 toxicities were nausea (9/17; 53%), anorexia (8/17; 47%), vomiting (6/17; 35%), fatigue (5/17; 29%), weight loss (5/17; 29%), and diarrhea (3/17; 18%). But these events were manageable.

Fourteen of the patients were evaluable for response. Two (14%) achieved a complete response with full hematologic recovery, and 2 (14%) achieved a complete response without hematologic recovery. Four patients (29%) had stable disease for more than 30 days, and 6 (43%) experienced progression.

Other trials of selinexor in AML

Karyopharm’s development plans for selinexor in AML include a number of additional studies.

In a phase 2 trial, researchers will evaluate selinexor monotherapy in older patients with AML. The study will enroll patients 60 years of age or older with relapsed or refractory AML who are ineligible for intensive chemotherapy and/or transplant.

In another study, researchers will evaluate selinexor in combination with decitabine for patients with relapsed, refractory, or newly diagnosed AML. The study will enroll up to 42 patients aged 60 or older who are ineligible for intensive chemotherapy.

Lastly, researchers are planning a study of selinexor in pediatric leukemia patients. The goal of this study is to determine the oral dosing, toxicity, and preliminary clinical activity of selinexor in pediatric patients. It will enroll up to 28 children with relapsed or refractory AML or acute lymphoblastic leukemia.

The US Food and Drug Administration (FDA) has granted selinexor (KPT-330) orphan designation for the treatment of acute myeloid leukemia (AML).

Selinexor is a selective inhibitor of nuclear transport that functions by binding to the nuclear export protein XPO1 (also called CRM1).

This leads to the accumulation of tumor suppressor proteins in the cell nucleus, which is thought to cause apoptosis in cancer cells while largely sparing normal cells.

The FDA grants orphan designation to promote the development of drugs that target conditions affecting 200,000 or fewer US patients annually and are expected to provide significant therapeutic advantage over existing treatments.

Selinexor’s orphan designation qualifies the drug’s developer, Karyopharm Therapeutics, Inc., for benefits that apply across all stages of development, including an accelerated approval process, 7 years of market exclusivity following marketing approval, tax credits on US clinical trials, eligibility for orphan drug grants, and a waiver of certain administrative fees.

Promising early results

Selinexor has shown promising results in a phase 1 trial of older patients with relapsed or refractory AML. The study, which was sponsored by Karyopharm, was published in Blood.

Researchers enrolled 16 patients with relapsed or refractory AML. The median age was 71 years, and the median number of prior therapeutic regimens was 2.

Patients received 8 to 10 doses of selinexor on a 4-week cycle across 2 dose levels, 16.8 mg/m² to 23 mg/m² (with additional cohorts ongoing).

The researchers reported no dose-limiting toxicity, no clinically significant cumulative toxicities, and no major organ dysfunction.

However, 4 patients experienced drug-related grade 3/4 adverse events, including hypotension (n=1), increased AST (n=1), hypokalemia (n=1), nausea (n=1), headache (n=1), and fatigue (n=1).

The most common grade 1/2 toxicities were nausea (9/17; 53%), anorexia (8/17; 47%), vomiting (6/17; 35%), fatigue (5/17; 29%), weight loss (5/17; 29%), and diarrhea (3/17; 18%). But these events were manageable.

Fourteen of the patients were evaluable for response. Two (14%) achieved a complete response with full hematologic recovery, and 2 (14%) achieved a complete response without hematologic recovery. Four patients (29%) had stable disease for more than 30 days, and 6 (43%) experienced progression.

Other trials of selinexor in AML

Karyopharm’s development plans for selinexor in AML include a number of additional studies.

In a phase 2 trial, researchers will evaluate selinexor monotherapy in older patients with AML. The study will enroll patients 60 years of age or older with relapsed or refractory AML who are ineligible for intensive chemotherapy and/or transplant.

In another study, researchers will evaluate selinexor in combination with decitabine for patients with relapsed, refractory, or newly diagnosed AML. The study will enroll up to 42 patients aged 60 or older who are ineligible for intensive chemotherapy.

Lastly, researchers are planning a study of selinexor in pediatric leukemia patients. The goal of this study is to determine the oral dosing, toxicity, and preliminary clinical activity of selinexor in pediatric patients. It will enroll up to 28 children with relapsed or refractory AML or acute lymphoblastic leukemia.

Hear from:

Michael Baggish, MD (St. Helena, California)

Rupen Baxi, MD (Royal Oak, Michigan)

Jennifer Hollings, MD (Richmond, Virginia)

Gwinnett Ladson, MD (Nashville, Tennessee)

Rich Persino, MD (McHenry, Illinois)

Teresa Tam, MD (Chicago, Illinois)

Yvonne Wolny, MD (Chicago, Illinois)

Hear from:

Michael Baggish, MD (St. Helena, California)

Rupen Baxi, MD (Royal Oak, Michigan)

Jennifer Hollings, MD (Richmond, Virginia)

Gwinnett Ladson, MD (Nashville, Tennessee)

Rich Persino, MD (McHenry, Illinois)

Teresa Tam, MD (Chicago, Illinois)

Yvonne Wolny, MD (Chicago, Illinois)

Hear from:

Michael Baggish, MD (St. Helena, California)

Rupen Baxi, MD (Royal Oak, Michigan)

Jennifer Hollings, MD (Richmond, Virginia)

Gwinnett Ladson, MD (Nashville, Tennessee)

Rich Persino, MD (McHenry, Illinois)

Teresa Tam, MD (Chicago, Illinois)

Yvonne Wolny, MD (Chicago, Illinois)

The spectrum of idiopathic ultraviolet-induced dermatoses includes the most severe variant, polymorphous light eruption (PMLE), in which erythematous papules, papulovesicles, and plaques form from a delayed type IV hypersensitivity reaction to the sun. Its milder cousins, benign summer light eruption and juvenile springtime eruption, are milder, more transient variants.

Patients may experience sudden-onset, pruritic, sometimes painful papules and papulovesicles or cheilitis within 30 minutes to several hours of exposure to UV light in areas normally covered in the winter months. The rash subsides over 1-7 days (or sooner with effective topical steroid administration and strict sun avoidance) and without scarring. Occasionally, patients experience systemic flulike symptoms after sun exposure. Triggers can be UVA, UVB, or UVC. However, because most cases appear in the spring, describing these variants as benign summer light eruption is something of a misnomer.

These seasonal rashes are often underrecognized in skin of color patients, particularly those with Fitzpatrick skin types III-VI, because many practitioners assume a protective role of melanin (Photochem. Photobiol. Sci. 2013;12:65-77). A study by Kerr and Lim identified 280 patients with photodermatoses; 135 (48%) were African American, 110 (40%) were white, and 35 (12%) were other ethnicities. They noted a significantly higher proportion of African Americans with PMLE, compared with whites (J. Am. Acad. Dermatol. 2007;57:638-43). Also, Native Americans have a hereditary form of PMLE with autosomal dominant inheritance that can involve the face and is most common in patients with Fitzpatrick skin types III-VI.

For sun-sensitive patients, and especially skin of color patients, diagnosis and treatment include ruling out other photosensitive diseases such as systemic lupus, and then counseling about the importance of sun avoidance and the use of sunscreens, which include both UVA and UVB protection. Prophylactic phototherapy or photochemotherapy at the beginning of spring for several weeks may prevent flare-ups throughout the summer. PUVA (psoralen and UVA) therapy, as well as UVB phototherapy, have been successful at preventing flares in several studies. Topical steroids, antihistamines, and oral prednisone are mainstays of treatment for severe flares, alone or in combination with phototherapy. For severe cases, or those recalcitrant to first-line treatment, antimalarials, azathioprine, and thalidomide have been used with variable efficacy.

Particularly at this time of year, I always ask patients with photo-distributed rashes about their ethnicities. One can never assume ethnicity, culture, skin type, background, or even photosensitivity based on skin color alone. I have been surprised by the many patients with dark skin who may have Native American origins who present with photosensitive rashes, or the many patients with hereditary photosensitive rashes with fair skin. Our beautiful, multicultural society makes it harder to define or categorize dermatoses by skin type alone, based on the definitions we have set for skin type in our literature today.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice at McLean (Va.) Dermatology Center. Dr. Wesley practices dermatology in Beverly Hills, Calif.

The spectrum of idiopathic ultraviolet-induced dermatoses includes the most severe variant, polymorphous light eruption (PMLE), in which erythematous papules, papulovesicles, and plaques form from a delayed type IV hypersensitivity reaction to the sun. Its milder cousins, benign summer light eruption and juvenile springtime eruption, are milder, more transient variants.

Patients may experience sudden-onset, pruritic, sometimes painful papules and papulovesicles or cheilitis within 30 minutes to several hours of exposure to UV light in areas normally covered in the winter months. The rash subsides over 1-7 days (or sooner with effective topical steroid administration and strict sun avoidance) and without scarring. Occasionally, patients experience systemic flulike symptoms after sun exposure. Triggers can be UVA, UVB, or UVC. However, because most cases appear in the spring, describing these variants as benign summer light eruption is something of a misnomer.

These seasonal rashes are often underrecognized in skin of color patients, particularly those with Fitzpatrick skin types III-VI, because many practitioners assume a protective role of melanin (Photochem. Photobiol. Sci. 2013;12:65-77). A study by Kerr and Lim identified 280 patients with photodermatoses; 135 (48%) were African American, 110 (40%) were white, and 35 (12%) were other ethnicities. They noted a significantly higher proportion of African Americans with PMLE, compared with whites (J. Am. Acad. Dermatol. 2007;57:638-43). Also, Native Americans have a hereditary form of PMLE with autosomal dominant inheritance that can involve the face and is most common in patients with Fitzpatrick skin types III-VI.

For sun-sensitive patients, and especially skin of color patients, diagnosis and treatment include ruling out other photosensitive diseases such as systemic lupus, and then counseling about the importance of sun avoidance and the use of sunscreens, which include both UVA and UVB protection. Prophylactic phototherapy or photochemotherapy at the beginning of spring for several weeks may prevent flare-ups throughout the summer. PUVA (psoralen and UVA) therapy, as well as UVB phototherapy, have been successful at preventing flares in several studies. Topical steroids, antihistamines, and oral prednisone are mainstays of treatment for severe flares, alone or in combination with phototherapy. For severe cases, or those recalcitrant to first-line treatment, antimalarials, azathioprine, and thalidomide have been used with variable efficacy.

Particularly at this time of year, I always ask patients with photo-distributed rashes about their ethnicities. One can never assume ethnicity, culture, skin type, background, or even photosensitivity based on skin color alone. I have been surprised by the many patients with dark skin who may have Native American origins who present with photosensitive rashes, or the many patients with hereditary photosensitive rashes with fair skin. Our beautiful, multicultural society makes it harder to define or categorize dermatoses by skin type alone, based on the definitions we have set for skin type in our literature today.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice at McLean (Va.) Dermatology Center. Dr. Wesley practices dermatology in Beverly Hills, Calif.

The spectrum of idiopathic ultraviolet-induced dermatoses includes the most severe variant, polymorphous light eruption (PMLE), in which erythematous papules, papulovesicles, and plaques form from a delayed type IV hypersensitivity reaction to the sun. Its milder cousins, benign summer light eruption and juvenile springtime eruption, are milder, more transient variants.

Patients may experience sudden-onset, pruritic, sometimes painful papules and papulovesicles or cheilitis within 30 minutes to several hours of exposure to UV light in areas normally covered in the winter months. The rash subsides over 1-7 days (or sooner with effective topical steroid administration and strict sun avoidance) and without scarring. Occasionally, patients experience systemic flulike symptoms after sun exposure. Triggers can be UVA, UVB, or UVC. However, because most cases appear in the spring, describing these variants as benign summer light eruption is something of a misnomer.

These seasonal rashes are often underrecognized in skin of color patients, particularly those with Fitzpatrick skin types III-VI, because many practitioners assume a protective role of melanin (Photochem. Photobiol. Sci. 2013;12:65-77). A study by Kerr and Lim identified 280 patients with photodermatoses; 135 (48%) were African American, 110 (40%) were white, and 35 (12%) were other ethnicities. They noted a significantly higher proportion of African Americans with PMLE, compared with whites (J. Am. Acad. Dermatol. 2007;57:638-43). Also, Native Americans have a hereditary form of PMLE with autosomal dominant inheritance that can involve the face and is most common in patients with Fitzpatrick skin types III-VI.

For sun-sensitive patients, and especially skin of color patients, diagnosis and treatment include ruling out other photosensitive diseases such as systemic lupus, and then counseling about the importance of sun avoidance and the use of sunscreens, which include both UVA and UVB protection. Prophylactic phototherapy or photochemotherapy at the beginning of spring for several weeks may prevent flare-ups throughout the summer. PUVA (psoralen and UVA) therapy, as well as UVB phototherapy, have been successful at preventing flares in several studies. Topical steroids, antihistamines, and oral prednisone are mainstays of treatment for severe flares, alone or in combination with phototherapy. For severe cases, or those recalcitrant to first-line treatment, antimalarials, azathioprine, and thalidomide have been used with variable efficacy.

Particularly at this time of year, I always ask patients with photo-distributed rashes about their ethnicities. One can never assume ethnicity, culture, skin type, background, or even photosensitivity based on skin color alone. I have been surprised by the many patients with dark skin who may have Native American origins who present with photosensitive rashes, or the many patients with hereditary photosensitive rashes with fair skin. Our beautiful, multicultural society makes it harder to define or categorize dermatoses by skin type alone, based on the definitions we have set for skin type in our literature today.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice at McLean (Va.) Dermatology Center. Dr. Wesley practices dermatology in Beverly Hills, Calif.

NEW YORK – Outcomes of thoracoabdominal aortic aneurysm (TAAA) repair in octogenarians vary considerably with the extent of repair. Those who undergo Extent II TAAA repair have significantly higher risks of morbidity and mortality, while Extent I, III, and IV repairs can be performed with relatively good outcomes, according to Dr. Muhammad Aftab, who presented the findings at the meeting sponsored by the American Association for Thoracic Surgery.

"Extensive TAAA repair should be performed with caution in octogenarians," says Dr. Aftab, a Fellow in cardiothoracic surgery at the Baylor College of Medicine–Texas Heart Institute, Houston. He recommends that a thorough preoperative discussion to assess the risks and benefits with the patient and his family is necessary before proceeding with surgery.

In this retrospective review of patients seen between January 2005 and September 2013, octogenarians with thoracoabdominal aortic aneurysms (TAAAs) (n = 88) were compared with a younger cohort (n = 1,179 patients, aged 70 years). Dr. Aftab found that octogenarians were threefold more likely to present with aneurysm rupture (13.6% vs. 4.6%; P less than .001) but less likely to present with aortic dissections (12.5% vs. 43.9%; P less than .001) than did the younger patients.

During surgery, the use of other types of adjunctive interventions, such as left heart bypass, cerebrospinal fluid drainage, cold renal perfusion, and visceral perfusion differed significantly among the octogenarians based on the extent of repair and clinical condition (all P less than .001). Because the octogenarians had a greater atherosclerotic burden and higher incidence of renal and mesenteric occlusive disease, they were also more likely to require renal/visceral endarterectomy, stenting, or both (57.9% vs. 33.6%; P less than.001).

Overall, octogenarians had higher rates of operative mortality (26.1% vs. 6.9%), in-hospital deaths (25% vs. 6.4%), 30-day deaths (13.6% vs. 4.8%), and adverse outcomes (36.4% vs. 15.7%; P less than .001) than did the younger group, all significant differences. The outcomes included significantly higher rates of permanent renal failure, cardiac complications, and pulmonary complications. The octogenarians had longer recovery times, as suggested by longer postoperative ICU and hospital stays. Spinal cord deficits and paraplegia were higher in the older group, but the difference was not significant.

Poor outcomes differed according to the extent of surgery, and seemed to be exacerbated for those who underwent repair of Extent II aneurysms (according to the Crawford Classification, these involve the subclavian artery and extend to the bifurcation of the aorta in the pelvis). For instance, the Extent II group had the highest risk of operative mortality (61.5%) vs. Extent I (31.6%), III (21.4%), and IV (10.7%), a significant difference. The Extent II group also had much higher rates of in-hospital and 30-day death rates. The most common causes of deaths for the Extent II octogenarians were multisystem organ failure and cardiac problems.

Adverse outcomes were also significantly much higher for the Extent II group (76.9%) than for the other groups (42.1%, 28.6%, and 21.4%). Similar patterns were found for permanent paraplegia, renal failure requiring permanent dialysis, stroke, and days spent in the ICU. Almost 85% of those who required Extent II repair needed renal/visceral endarterectomy, stenting, or both as a part of the surgical procedure.

Extent II TAAA repair was identified as an independent predictor of perioperative mortality by multivariate analysis, conferring an 11-fold increased risk of death. Aneurysm rupture and dissection were also identified as predictors of perioperative mortality while only Extent II TAAA and dissection were independent predictors of adverse outcomes.

While these problems were exacerbated in those with Extent II repairs, Extent I, III, and IV TAAA repairs may be performed with relatively low risk, according to Dr. Aftab. The results suggest that while octogenarians present more challenges than younger individuals, outcomes vary greatly according to the type of aneurysm repair.

Dr. Aftab had no relevant disclosures.

NEW YORK – Outcomes of thoracoabdominal aortic aneurysm (TAAA) repair in octogenarians vary considerably with the extent of repair. Those who undergo Extent II TAAA repair have significantly higher risks of morbidity and mortality, while Extent I, III, and IV repairs can be performed with relatively good outcomes, according to Dr. Muhammad Aftab, who presented the findings at the meeting sponsored by the American Association for Thoracic Surgery.

"Extensive TAAA repair should be performed with caution in octogenarians," says Dr. Aftab, a Fellow in cardiothoracic surgery at the Baylor College of Medicine–Texas Heart Institute, Houston. He recommends that a thorough preoperative discussion to assess the risks and benefits with the patient and his family is necessary before proceeding with surgery.

In this retrospective review of patients seen between January 2005 and September 2013, octogenarians with thoracoabdominal aortic aneurysms (TAAAs) (n = 88) were compared with a younger cohort (n = 1,179 patients, aged 70 years). Dr. Aftab found that octogenarians were threefold more likely to present with aneurysm rupture (13.6% vs. 4.6%; P less than .001) but less likely to present with aortic dissections (12.5% vs. 43.9%; P less than .001) than did the younger patients.

During surgery, the use of other types of adjunctive interventions, such as left heart bypass, cerebrospinal fluid drainage, cold renal perfusion, and visceral perfusion differed significantly among the octogenarians based on the extent of repair and clinical condition (all P less than .001). Because the octogenarians had a greater atherosclerotic burden and higher incidence of renal and mesenteric occlusive disease, they were also more likely to require renal/visceral endarterectomy, stenting, or both (57.9% vs. 33.6%; P less than.001).

Overall, octogenarians had higher rates of operative mortality (26.1% vs. 6.9%), in-hospital deaths (25% vs. 6.4%), 30-day deaths (13.6% vs. 4.8%), and adverse outcomes (36.4% vs. 15.7%; P less than .001) than did the younger group, all significant differences. The outcomes included significantly higher rates of permanent renal failure, cardiac complications, and pulmonary complications. The octogenarians had longer recovery times, as suggested by longer postoperative ICU and hospital stays. Spinal cord deficits and paraplegia were higher in the older group, but the difference was not significant.

Poor outcomes differed according to the extent of surgery, and seemed to be exacerbated for those who underwent repair of Extent II aneurysms (according to the Crawford Classification, these involve the subclavian artery and extend to the bifurcation of the aorta in the pelvis). For instance, the Extent II group had the highest risk of operative mortality (61.5%) vs. Extent I (31.6%), III (21.4%), and IV (10.7%), a significant difference. The Extent II group also had much higher rates of in-hospital and 30-day death rates. The most common causes of deaths for the Extent II octogenarians were multisystem organ failure and cardiac problems.

Adverse outcomes were also significantly much higher for the Extent II group (76.9%) than for the other groups (42.1%, 28.6%, and 21.4%). Similar patterns were found for permanent paraplegia, renal failure requiring permanent dialysis, stroke, and days spent in the ICU. Almost 85% of those who required Extent II repair needed renal/visceral endarterectomy, stenting, or both as a part of the surgical procedure.

Extent II TAAA repair was identified as an independent predictor of perioperative mortality by multivariate analysis, conferring an 11-fold increased risk of death. Aneurysm rupture and dissection were also identified as predictors of perioperative mortality while only Extent II TAAA and dissection were independent predictors of adverse outcomes.

While these problems were exacerbated in those with Extent II repairs, Extent I, III, and IV TAAA repairs may be performed with relatively low risk, according to Dr. Aftab. The results suggest that while octogenarians present more challenges than younger individuals, outcomes vary greatly according to the type of aneurysm repair.

Dr. Aftab had no relevant disclosures.

NEW YORK – Outcomes of thoracoabdominal aortic aneurysm (TAAA) repair in octogenarians vary considerably with the extent of repair. Those who undergo Extent II TAAA repair have significantly higher risks of morbidity and mortality, while Extent I, III, and IV repairs can be performed with relatively good outcomes, according to Dr. Muhammad Aftab, who presented the findings at the meeting sponsored by the American Association for Thoracic Surgery.

"Extensive TAAA repair should be performed with caution in octogenarians," says Dr. Aftab, a Fellow in cardiothoracic surgery at the Baylor College of Medicine–Texas Heart Institute, Houston. He recommends that a thorough preoperative discussion to assess the risks and benefits with the patient and his family is necessary before proceeding with surgery.

In this retrospective review of patients seen between January 2005 and September 2013, octogenarians with thoracoabdominal aortic aneurysms (TAAAs) (n = 88) were compared with a younger cohort (n = 1,179 patients, aged 70 years). Dr. Aftab found that octogenarians were threefold more likely to present with aneurysm rupture (13.6% vs. 4.6%; P less than .001) but less likely to present with aortic dissections (12.5% vs. 43.9%; P less than .001) than did the younger patients.

During surgery, the use of other types of adjunctive interventions, such as left heart bypass, cerebrospinal fluid drainage, cold renal perfusion, and visceral perfusion differed significantly among the octogenarians based on the extent of repair and clinical condition (all P less than .001). Because the octogenarians had a greater atherosclerotic burden and higher incidence of renal and mesenteric occlusive disease, they were also more likely to require renal/visceral endarterectomy, stenting, or both (57.9% vs. 33.6%; P less than.001).

Overall, octogenarians had higher rates of operative mortality (26.1% vs. 6.9%), in-hospital deaths (25% vs. 6.4%), 30-day deaths (13.6% vs. 4.8%), and adverse outcomes (36.4% vs. 15.7%; P less than .001) than did the younger group, all significant differences. The outcomes included significantly higher rates of permanent renal failure, cardiac complications, and pulmonary complications. The octogenarians had longer recovery times, as suggested by longer postoperative ICU and hospital stays. Spinal cord deficits and paraplegia were higher in the older group, but the difference was not significant.

Poor outcomes differed according to the extent of surgery, and seemed to be exacerbated for those who underwent repair of Extent II aneurysms (according to the Crawford Classification, these involve the subclavian artery and extend to the bifurcation of the aorta in the pelvis). For instance, the Extent II group had the highest risk of operative mortality (61.5%) vs. Extent I (31.6%), III (21.4%), and IV (10.7%), a significant difference. The Extent II group also had much higher rates of in-hospital and 30-day death rates. The most common causes of deaths for the Extent II octogenarians were multisystem organ failure and cardiac problems.

Adverse outcomes were also significantly much higher for the Extent II group (76.9%) than for the other groups (42.1%, 28.6%, and 21.4%). Similar patterns were found for permanent paraplegia, renal failure requiring permanent dialysis, stroke, and days spent in the ICU. Almost 85% of those who required Extent II repair needed renal/visceral endarterectomy, stenting, or both as a part of the surgical procedure.

Extent II TAAA repair was identified as an independent predictor of perioperative mortality by multivariate analysis, conferring an 11-fold increased risk of death. Aneurysm rupture and dissection were also identified as predictors of perioperative mortality while only Extent II TAAA and dissection were independent predictors of adverse outcomes.

While these problems were exacerbated in those with Extent II repairs, Extent I, III, and IV TAAA repairs may be performed with relatively low risk, according to Dr. Aftab. The results suggest that while octogenarians present more challenges than younger individuals, outcomes vary greatly according to the type of aneurysm repair.

Dr. Aftab had no relevant disclosures.

BOSTON—Results of a phase 2 study suggest an investigational vaccine may be able to prevent Clostridium difficile infection (CDI).

The vaccine generated an immune response against C difficile toxins A and B. And adverse reactions were generally mild and of short duration.

Researchers presented these results at the 114th General Meeting of the American Society for Microbiology. The study was sponsored by Sanofi, the company developing the vaccine.

“C diff infection threatens the many people who frequently use antibiotics, as well as older hospitalized patients and residents in long-term healthcare facilities,” said study investigator Jamshid Saleh, MD of the Northern California Clinical Research Center in Redding, California.

“It would be great if we could offer patients a way to help prevent this contagious and debilitating disease versus just treating it after it happens.”

To find out if Sanofi’s vaccine would do the job, Dr Saleh and his colleagues conducted a randomized, multicenter trial split into 2 stages.

The first stage, conducted with 455 volunteers, was placebo-controlled, double-blind, and designed for dose and formulation selection. The second stage, which included 206 additional volunteers, was designed to compare the dose and formulation chosen in the first stage against 2 alternate dosing schedules.

Volunteers ranged in age from 40 to 75 years and were at risk of CDI due to impending hospitalization or residence in a long-term healthcare facility.

In stage 1, volunteers were randomized into 1 of 5 study groups: high-dose or low-dose vaccine, either with or without adjuvant, or placebo. Each formulation was administered on days 0, 7, and 30.

Researchers measured immune responses using both enzyme linked immunosorbent assay (ELISA), which assesses antitoxin A and B immunoglobulin G (IgG) concentrations, and toxin neutralization activity (TNA), which measures antitoxin A and B neutralizing activity.

Composite ELISA ranking analysis determined that the high-dose plus adjuvant vaccine formulation (group 3) generated the greatest immune response over a 60-day period. ELISA results also showed a 4-fold increase in the development of detectable antibodies for both toxins A and B.

So the researchers selected the high-dose plus adjuvant vaccine formulation for further study in stage 2 of the trial. They compared its use across 3 schedules: days 0, 7, and 30 (group 3, n=101); days 0, 7, and 180 (group 6, n=103); and days 0, 30, and 180 (group 7, n=103). The team analyzed subjects on days 0, 7, 14, 30, 60, 180, and 210.

There were increased immune responses in all vaccine groups and with each dose, according to ELISA and TNA. Overall, group 3 demonstrated the most favorable immune profile over the 30-, 60- and 180-day periods, particularly in volunteers aged 65-75 years.

The safety profile of all vaccine doses was deemed acceptable throughout the study. Reactions were monitored until day 210 and were generally grade 1, of short duration, did not lead to study discontinuation, and were not considered clinically significant.

“Sanofi Pasteur’s investigational vaccine stimulates a person’s immune system to fight C diff toxins upon exposure and, ultimately, may help prevent a future CDI from occurring,” Dr Saleh said.

“Like other toxoid vaccines—such as tetanus, diphtheria, and whooping cough—this investigational vaccine targets the symptom-causing toxins generated by C diff bacteria and could be an important public health measure to help protect individuals from CDI.”

Based on the phase 2 results, researchers started a phase 3 trial in August 2013.

BOSTON—Results of a phase 2 study suggest an investigational vaccine may be able to prevent Clostridium difficile infection (CDI).

The vaccine generated an immune response against C difficile toxins A and B. And adverse reactions were generally mild and of short duration.

Researchers presented these results at the 114th General Meeting of the American Society for Microbiology. The study was sponsored by Sanofi, the company developing the vaccine.

“C diff infection threatens the many people who frequently use antibiotics, as well as older hospitalized patients and residents in long-term healthcare facilities,” said study investigator Jamshid Saleh, MD of the Northern California Clinical Research Center in Redding, California.

“It would be great if we could offer patients a way to help prevent this contagious and debilitating disease versus just treating it after it happens.”

To find out if Sanofi’s vaccine would do the job, Dr Saleh and his colleagues conducted a randomized, multicenter trial split into 2 stages.

The first stage, conducted with 455 volunteers, was placebo-controlled, double-blind, and designed for dose and formulation selection. The second stage, which included 206 additional volunteers, was designed to compare the dose and formulation chosen in the first stage against 2 alternate dosing schedules.

Volunteers ranged in age from 40 to 75 years and were at risk of CDI due to impending hospitalization or residence in a long-term healthcare facility.

In stage 1, volunteers were randomized into 1 of 5 study groups: high-dose or low-dose vaccine, either with or without adjuvant, or placebo. Each formulation was administered on days 0, 7, and 30.

Researchers measured immune responses using both enzyme linked immunosorbent assay (ELISA), which assesses antitoxin A and B immunoglobulin G (IgG) concentrations, and toxin neutralization activity (TNA), which measures antitoxin A and B neutralizing activity.

Composite ELISA ranking analysis determined that the high-dose plus adjuvant vaccine formulation (group 3) generated the greatest immune response over a 60-day period. ELISA results also showed a 4-fold increase in the development of detectable antibodies for both toxins A and B.

So the researchers selected the high-dose plus adjuvant vaccine formulation for further study in stage 2 of the trial. They compared its use across 3 schedules: days 0, 7, and 30 (group 3, n=101); days 0, 7, and 180 (group 6, n=103); and days 0, 30, and 180 (group 7, n=103). The team analyzed subjects on days 0, 7, 14, 30, 60, 180, and 210.

There were increased immune responses in all vaccine groups and with each dose, according to ELISA and TNA. Overall, group 3 demonstrated the most favorable immune profile over the 30-, 60- and 180-day periods, particularly in volunteers aged 65-75 years.

The safety profile of all vaccine doses was deemed acceptable throughout the study. Reactions were monitored until day 210 and were generally grade 1, of short duration, did not lead to study discontinuation, and were not considered clinically significant.

“Sanofi Pasteur’s investigational vaccine stimulates a person’s immune system to fight C diff toxins upon exposure and, ultimately, may help prevent a future CDI from occurring,” Dr Saleh said.

“Like other toxoid vaccines—such as tetanus, diphtheria, and whooping cough—this investigational vaccine targets the symptom-causing toxins generated by C diff bacteria and could be an important public health measure to help protect individuals from CDI.”

Based on the phase 2 results, researchers started a phase 3 trial in August 2013.

BOSTON—Results of a phase 2 study suggest an investigational vaccine may be able to prevent Clostridium difficile infection (CDI).

The vaccine generated an immune response against C difficile toxins A and B. And adverse reactions were generally mild and of short duration.

Researchers presented these results at the 114th General Meeting of the American Society for Microbiology. The study was sponsored by Sanofi, the company developing the vaccine.

“C diff infection threatens the many people who frequently use antibiotics, as well as older hospitalized patients and residents in long-term healthcare facilities,” said study investigator Jamshid Saleh, MD of the Northern California Clinical Research Center in Redding, California.

“It would be great if we could offer patients a way to help prevent this contagious and debilitating disease versus just treating it after it happens.”

To find out if Sanofi’s vaccine would do the job, Dr Saleh and his colleagues conducted a randomized, multicenter trial split into 2 stages.

The first stage, conducted with 455 volunteers, was placebo-controlled, double-blind, and designed for dose and formulation selection. The second stage, which included 206 additional volunteers, was designed to compare the dose and formulation chosen in the first stage against 2 alternate dosing schedules.

Volunteers ranged in age from 40 to 75 years and were at risk of CDI due to impending hospitalization or residence in a long-term healthcare facility.

In stage 1, volunteers were randomized into 1 of 5 study groups: high-dose or low-dose vaccine, either with or without adjuvant, or placebo. Each formulation was administered on days 0, 7, and 30.

Researchers measured immune responses using both enzyme linked immunosorbent assay (ELISA), which assesses antitoxin A and B immunoglobulin G (IgG) concentrations, and toxin neutralization activity (TNA), which measures antitoxin A and B neutralizing activity.

Composite ELISA ranking analysis determined that the high-dose plus adjuvant vaccine formulation (group 3) generated the greatest immune response over a 60-day period. ELISA results also showed a 4-fold increase in the development of detectable antibodies for both toxins A and B.

So the researchers selected the high-dose plus adjuvant vaccine formulation for further study in stage 2 of the trial. They compared its use across 3 schedules: days 0, 7, and 30 (group 3, n=101); days 0, 7, and 180 (group 6, n=103); and days 0, 30, and 180 (group 7, n=103). The team analyzed subjects on days 0, 7, 14, 30, 60, 180, and 210.

There were increased immune responses in all vaccine groups and with each dose, according to ELISA and TNA. Overall, group 3 demonstrated the most favorable immune profile over the 30-, 60- and 180-day periods, particularly in volunteers aged 65-75 years.

The safety profile of all vaccine doses was deemed acceptable throughout the study. Reactions were monitored until day 210 and were generally grade 1, of short duration, did not lead to study discontinuation, and were not considered clinically significant.

“Sanofi Pasteur’s investigational vaccine stimulates a person’s immune system to fight C diff toxins upon exposure and, ultimately, may help prevent a future CDI from occurring,” Dr Saleh said.

“Like other toxoid vaccines—such as tetanus, diphtheria, and whooping cough—this investigational vaccine targets the symptom-causing toxins generated by C diff bacteria and could be an important public health measure to help protect individuals from CDI.”

Based on the phase 2 results, researchers started a phase 3 trial in August 2013.