William Perlman

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In a commentary about the use of DTC teledermatology in the pediatric arena, the Dermatology Foundation outlined a framework of features needed for such services “to appropriately treat pediatric patients.”

The commentary, by Kavita Sarin, MD, of the department of dermatology, Joyce Teng, MD, of the departments of pediatrics and dermatology, and Alexander L. Fogel, MBA, a medical student at Stanford (Calif.) University, was written on behalf of the Dermatology Foundation in response to the lack of uniform standards and policies governing the use of DTC teledermatology services for pediatric patients.

The writers reported the results of their assessment of the pediatric policies of DTC teledermatology websites and smartphone-based services, which included whether a patient’s age and identity were verified, whether the validity of parental consent was confirmed, and whether any coordination with a patient’s primary care physician or with other physicians occurred.

None of the sites performed all of the features they considered necessary for online pediatric care. “Most services have very minor checks on pediatric access, such as a limit on self-reported age, or a click-box to indicate that parental consent for the visit has been given, and few services allow for medical record capture or coordination with other physicians,” they wrote (J Am Acad Dermatol. 2016 Sep 7. doi: 10.1016/j.jaad.2016.08.002).

Describing the situation as “problematic,” they proposed the framework with features needed for DTC pediatric teledermatology services, which could be “implemented through legislation, regulation, or a third-party certification process,” the researchers wrote.

“We recommend an approach that allows for ample data cross-referencing between patient and parent, and with publicly available records,” to verify identification and parental consent, they noted.

Other elements include the use of standard templates for inputting patient’s medical histories, and sending care plans to the physicians indicated by the parents and patients.

DTC teledermatology “has the potential to offer patients substantial benefits,” but “we must insist on high-quality DTC TD[teledermatology]-services that are coordinated, transparent, focused on quality rather than prescription-writing, and consistent with standards of in-person care,” they wrote.

None of the authors declared any conflicts of interest. Dr. Sarin is supported by a Dermatology Foundation Medical Dermatology Career Development Award.

In a commentary about the use of DTC teledermatology in the pediatric arena, the Dermatology Foundation outlined a framework of features needed for such services “to appropriately treat pediatric patients.”

The commentary, by Kavita Sarin, MD, of the department of dermatology, Joyce Teng, MD, of the departments of pediatrics and dermatology, and Alexander L. Fogel, MBA, a medical student at Stanford (Calif.) University, was written on behalf of the Dermatology Foundation in response to the lack of uniform standards and policies governing the use of DTC teledermatology services for pediatric patients.

The writers reported the results of their assessment of the pediatric policies of DTC teledermatology websites and smartphone-based services, which included whether a patient’s age and identity were verified, whether the validity of parental consent was confirmed, and whether any coordination with a patient’s primary care physician or with other physicians occurred.

None of the sites performed all of the features they considered necessary for online pediatric care. “Most services have very minor checks on pediatric access, such as a limit on self-reported age, or a click-box to indicate that parental consent for the visit has been given, and few services allow for medical record capture or coordination with other physicians,” they wrote (J Am Acad Dermatol. 2016 Sep 7. doi: 10.1016/j.jaad.2016.08.002).

Describing the situation as “problematic,” they proposed the framework with features needed for DTC pediatric teledermatology services, which could be “implemented through legislation, regulation, or a third-party certification process,” the researchers wrote.

“We recommend an approach that allows for ample data cross-referencing between patient and parent, and with publicly available records,” to verify identification and parental consent, they noted.

Other elements include the use of standard templates for inputting patient’s medical histories, and sending care plans to the physicians indicated by the parents and patients.

DTC teledermatology “has the potential to offer patients substantial benefits,” but “we must insist on high-quality DTC TD[teledermatology]-services that are coordinated, transparent, focused on quality rather than prescription-writing, and consistent with standards of in-person care,” they wrote.

None of the authors declared any conflicts of interest. Dr. Sarin is supported by a Dermatology Foundation Medical Dermatology Career Development Award.

In a commentary about the use of DTC teledermatology in the pediatric arena, the Dermatology Foundation outlined a framework of features needed for such services “to appropriately treat pediatric patients.”

The commentary, by Kavita Sarin, MD, of the department of dermatology, Joyce Teng, MD, of the departments of pediatrics and dermatology, and Alexander L. Fogel, MBA, a medical student at Stanford (Calif.) University, was written on behalf of the Dermatology Foundation in response to the lack of uniform standards and policies governing the use of DTC teledermatology services for pediatric patients.

The writers reported the results of their assessment of the pediatric policies of DTC teledermatology websites and smartphone-based services, which included whether a patient’s age and identity were verified, whether the validity of parental consent was confirmed, and whether any coordination with a patient’s primary care physician or with other physicians occurred.

None of the sites performed all of the features they considered necessary for online pediatric care. “Most services have very minor checks on pediatric access, such as a limit on self-reported age, or a click-box to indicate that parental consent for the visit has been given, and few services allow for medical record capture or coordination with other physicians,” they wrote (J Am Acad Dermatol. 2016 Sep 7. doi: 10.1016/j.jaad.2016.08.002).

Describing the situation as “problematic,” they proposed the framework with features needed for DTC pediatric teledermatology services, which could be “implemented through legislation, regulation, or a third-party certification process,” the researchers wrote.

“We recommend an approach that allows for ample data cross-referencing between patient and parent, and with publicly available records,” to verify identification and parental consent, they noted.

Other elements include the use of standard templates for inputting patient’s medical histories, and sending care plans to the physicians indicated by the parents and patients.

DTC teledermatology “has the potential to offer patients substantial benefits,” but “we must insist on high-quality DTC TD[teledermatology]-services that are coordinated, transparent, focused on quality rather than prescription-writing, and consistent with standards of in-person care,” they wrote.

None of the authors declared any conflicts of interest. Dr. Sarin is supported by a Dermatology Foundation Medical Dermatology Career Development Award.

Despite its widespread use as a guideline-recommended, first-line agent for the treatment of hypertension, hydrochlorothiazide (HCTZ) may contribute to an increased risk of skin cancer, according to Armand B. Cognetta Jr., MD, and his associates in the division of dermatology, Mohs Micrographic Surgery Unit, Florida State University, Tallahassee.

The common, long-term use of HCTZ for treatment of hypertension, combined with its known photosensitizing effects, makes it a potential candidate for increasing the risk of squamous cell carcinoma (SCC) and other skin cancers.

To further elucidate the association between longterm HCTZ exposure and skin cancer risk, Dr. Cognetta and his associates screened medication lists of 75 patients seen in their Mohs practice over a period of 5 days for lifetime SCCs and HCTZ exposure. For this study, patients with more than 20 lifetime SCCs were considered high risk. They also conducted a literature review of previous studies exploring this relationship, from 1966 to 2015.

Of the 75 patients screened, 4 met the criteria for inclusion in the high risk category. These four patients had a combined lifetime total of 288 SCC and 98 basal cell carcinomas (BCCs), including 10 that were lip SCC. All four patients were non-Hispanic white males and had been taking HCTZ alone or in combination for 3-15 years (Dermatol Surg. 2016 Sep;42[9]:1107-9).

The literature search produced three relevant studies, all of which had large patient populations, published between 2008 and 2012, “demonstrating an increased risk of SCC or lip cancer” associated with HCTZ use, with the highest risk associated with over 5 years of use, the researchers wrote.

“As cutaneous oncologists, it is our duty to look for ‘correctable’ causes of skin cancer,” they noted. “Hydrochlorothiazide, a known photosensitizer, when taken by white non-Hispanic patients with a history of multiple SCC, skin cancers may represent a ‘correctable’ cause.”

In their practice, they screen their high-risk SCC non-Hispanic patients for HCTZ use, “and send a standard letter explaining the association to the primary care provider with a request to change to a different antihypertensive if possible,” they wrote. “Many primary care providers are unaware of the association between HCTZ use and skin cancer,” they observed.

The authors had no disclosures.

Despite its widespread use as a guideline-recommended, first-line agent for the treatment of hypertension, hydrochlorothiazide (HCTZ) may contribute to an increased risk of skin cancer, according to Armand B. Cognetta Jr., MD, and his associates in the division of dermatology, Mohs Micrographic Surgery Unit, Florida State University, Tallahassee.

The common, long-term use of HCTZ for treatment of hypertension, combined with its known photosensitizing effects, makes it a potential candidate for increasing the risk of squamous cell carcinoma (SCC) and other skin cancers.

To further elucidate the association between longterm HCTZ exposure and skin cancer risk, Dr. Cognetta and his associates screened medication lists of 75 patients seen in their Mohs practice over a period of 5 days for lifetime SCCs and HCTZ exposure. For this study, patients with more than 20 lifetime SCCs were considered high risk. They also conducted a literature review of previous studies exploring this relationship, from 1966 to 2015.

Of the 75 patients screened, 4 met the criteria for inclusion in the high risk category. These four patients had a combined lifetime total of 288 SCC and 98 basal cell carcinomas (BCCs), including 10 that were lip SCC. All four patients were non-Hispanic white males and had been taking HCTZ alone or in combination for 3-15 years (Dermatol Surg. 2016 Sep;42[9]:1107-9).

The literature search produced three relevant studies, all of which had large patient populations, published between 2008 and 2012, “demonstrating an increased risk of SCC or lip cancer” associated with HCTZ use, with the highest risk associated with over 5 years of use, the researchers wrote.

“As cutaneous oncologists, it is our duty to look for ‘correctable’ causes of skin cancer,” they noted. “Hydrochlorothiazide, a known photosensitizer, when taken by white non-Hispanic patients with a history of multiple SCC, skin cancers may represent a ‘correctable’ cause.”

In their practice, they screen their high-risk SCC non-Hispanic patients for HCTZ use, “and send a standard letter explaining the association to the primary care provider with a request to change to a different antihypertensive if possible,” they wrote. “Many primary care providers are unaware of the association between HCTZ use and skin cancer,” they observed.

The authors had no disclosures.

Despite its widespread use as a guideline-recommended, first-line agent for the treatment of hypertension, hydrochlorothiazide (HCTZ) may contribute to an increased risk of skin cancer, according to Armand B. Cognetta Jr., MD, and his associates in the division of dermatology, Mohs Micrographic Surgery Unit, Florida State University, Tallahassee.

The common, long-term use of HCTZ for treatment of hypertension, combined with its known photosensitizing effects, makes it a potential candidate for increasing the risk of squamous cell carcinoma (SCC) and other skin cancers.

To further elucidate the association between longterm HCTZ exposure and skin cancer risk, Dr. Cognetta and his associates screened medication lists of 75 patients seen in their Mohs practice over a period of 5 days for lifetime SCCs and HCTZ exposure. For this study, patients with more than 20 lifetime SCCs were considered high risk. They also conducted a literature review of previous studies exploring this relationship, from 1966 to 2015.

Of the 75 patients screened, 4 met the criteria for inclusion in the high risk category. These four patients had a combined lifetime total of 288 SCC and 98 basal cell carcinomas (BCCs), including 10 that were lip SCC. All four patients were non-Hispanic white males and had been taking HCTZ alone or in combination for 3-15 years (Dermatol Surg. 2016 Sep;42[9]:1107-9).

The literature search produced three relevant studies, all of which had large patient populations, published between 2008 and 2012, “demonstrating an increased risk of SCC or lip cancer” associated with HCTZ use, with the highest risk associated with over 5 years of use, the researchers wrote.

“As cutaneous oncologists, it is our duty to look for ‘correctable’ causes of skin cancer,” they noted. “Hydrochlorothiazide, a known photosensitizer, when taken by white non-Hispanic patients with a history of multiple SCC, skin cancers may represent a ‘correctable’ cause.”

In their practice, they screen their high-risk SCC non-Hispanic patients for HCTZ use, “and send a standard letter explaining the association to the primary care provider with a request to change to a different antihypertensive if possible,” they wrote. “Many primary care providers are unaware of the association between HCTZ use and skin cancer,” they observed.

The authors had no disclosures.

Primary care practitioners’ use of a seven-item checklist may reduce the number of pediatric patients with respiratory tract infections who are prescribed unnecessary antibiotics, a prognostic cohort study suggests.

The study revealed short illness (a duration of illness of 3 days or less), temperature (a body temperature of 37.8°C or greater at presentation), age (being under 2 years), intercostal or subcostal recession, wheeze on auscultation, asthma, and vomiting (moderate or severe in the previous 24 hours) were each independently associated with hospital admission (P less than .01 for all associations).

©Devonyu/thinkstockphotos.com

The checklist includes these seven characteristics or risk variables (short illness, temperature, age, recession, wheeze, asthma, and vomiting [mnemonic STARWAVe]). To use the checklist, a primary care practitioner would assign one point for the presence of each item in a patient then add up all of the points to determine that patient’s risk level for future hospital admission for respiratory tract infection. A score of 1 point or less, observed in 5,593 (67%) cases would be considered indicative of a very low rate of risk for hospitalization (0.3%, 0.2%-0.4%). A score of 2 or 3 points, found for 2,520 (30%) children, would be considered as a normal level of risk (1.5%, 1.0%-1.9%), and a score of 4 or more points, seen in 204 (3%) children, would signify a high risk level (11.8%, 7.3%-16.2%).

Of the 8,394 children assessed, 78 (0.9%; 95% confidence interval, 0.7%-1.2%) were admitted to a hospital. Most were admitted on days 2-7 (33, 42%) and on days 8-30 (30, 39%) following recruitment. Only 15 (19%) were admitted on the day of recruitment (day 1).

“Many clinicians report that they prescribe antibiotics just in case, to mitigate perceived risk of future hospital admission and complications, and that failing to provide a prescription for a child who subsequently becomes seriously unwell is professionally unacceptable. If primary care clinicians could identify children at low (or very low) risk of such future complications, the reduced clinical uncertainty could lead to a reduced use of antibiotics in these groups of patients,” wrote first author Alastair Hay, MD, from the Centre for Academic Primary Care in the School of Social and Community Medicine at the University of Bristol (England), and his colleagues.

These researchers conducted the study based on a structured, blinded review of the medical records from children aged between 3 months and 16 years presenting with acute cough (less than or equal to 28 days) and respiratory tract infection treated by 519 general practitioners in 247 practices in England between July 2011 and June 2013. The primary study outcome was hospital admission for respiratory tract infection within 30 days.

Additionally, a multivariable model was employed to detect factors associated with increased risk of hospital admission. As measured by receiver operating characteristic curve analysis, the accuracy of the STARWAVe score checklist in predicting risk groups and associated risk of hospitalization was found to be high (0.81; 95% CI, 0.77-0.86). The suggested probability of hospital admission for children who did not have any of the seven characteristics included in the checklist was found to be exceptionally low (0.14%).

Significantly associated parent-reported variables included both moderate or severe vomiting and severe fever, each in the previous 24 hours. Significant clinician-reported variables included intercostal or subcostal recession and wheeze on auscultation.

“The main value of our results is to reduce clinical uncertainty and antibiotic use in children least likely to benefit from them, namely those at very low risk of future hospital admission,” Dr. Hay and his associates noted in The Lancet Respiratory Medicine (Lancet Respir Med. 2016 Sep 1. doi: 10.1016/S2213-2600(16)30223-5).

Funding for this study was provided by the National Institute for Health Research and sponsored by the University of Bristol. Only one of the study’s authors, Dr. Peter Muir, reported ties to industry sources.

Primary care practitioners’ use of a seven-item checklist may reduce the number of pediatric patients with respiratory tract infections who are prescribed unnecessary antibiotics, a prognostic cohort study suggests.

The study revealed short illness (a duration of illness of 3 days or less), temperature (a body temperature of 37.8°C or greater at presentation), age (being under 2 years), intercostal or subcostal recession, wheeze on auscultation, asthma, and vomiting (moderate or severe in the previous 24 hours) were each independently associated with hospital admission (P less than .01 for all associations).

©Devonyu/thinkstockphotos.com

The checklist includes these seven characteristics or risk variables (short illness, temperature, age, recession, wheeze, asthma, and vomiting [mnemonic STARWAVe]). To use the checklist, a primary care practitioner would assign one point for the presence of each item in a patient then add up all of the points to determine that patient’s risk level for future hospital admission for respiratory tract infection. A score of 1 point or less, observed in 5,593 (67%) cases would be considered indicative of a very low rate of risk for hospitalization (0.3%, 0.2%-0.4%). A score of 2 or 3 points, found for 2,520 (30%) children, would be considered as a normal level of risk (1.5%, 1.0%-1.9%), and a score of 4 or more points, seen in 204 (3%) children, would signify a high risk level (11.8%, 7.3%-16.2%).

Of the 8,394 children assessed, 78 (0.9%; 95% confidence interval, 0.7%-1.2%) were admitted to a hospital. Most were admitted on days 2-7 (33, 42%) and on days 8-30 (30, 39%) following recruitment. Only 15 (19%) were admitted on the day of recruitment (day 1).

“Many clinicians report that they prescribe antibiotics just in case, to mitigate perceived risk of future hospital admission and complications, and that failing to provide a prescription for a child who subsequently becomes seriously unwell is professionally unacceptable. If primary care clinicians could identify children at low (or very low) risk of such future complications, the reduced clinical uncertainty could lead to a reduced use of antibiotics in these groups of patients,” wrote first author Alastair Hay, MD, from the Centre for Academic Primary Care in the School of Social and Community Medicine at the University of Bristol (England), and his colleagues.

These researchers conducted the study based on a structured, blinded review of the medical records from children aged between 3 months and 16 years presenting with acute cough (less than or equal to 28 days) and respiratory tract infection treated by 519 general practitioners in 247 practices in England between July 2011 and June 2013. The primary study outcome was hospital admission for respiratory tract infection within 30 days.

Additionally, a multivariable model was employed to detect factors associated with increased risk of hospital admission. As measured by receiver operating characteristic curve analysis, the accuracy of the STARWAVe score checklist in predicting risk groups and associated risk of hospitalization was found to be high (0.81; 95% CI, 0.77-0.86). The suggested probability of hospital admission for children who did not have any of the seven characteristics included in the checklist was found to be exceptionally low (0.14%).

Significantly associated parent-reported variables included both moderate or severe vomiting and severe fever, each in the previous 24 hours. Significant clinician-reported variables included intercostal or subcostal recession and wheeze on auscultation.

“The main value of our results is to reduce clinical uncertainty and antibiotic use in children least likely to benefit from them, namely those at very low risk of future hospital admission,” Dr. Hay and his associates noted in The Lancet Respiratory Medicine (Lancet Respir Med. 2016 Sep 1. doi: 10.1016/S2213-2600(16)30223-5).

Funding for this study was provided by the National Institute for Health Research and sponsored by the University of Bristol. Only one of the study’s authors, Dr. Peter Muir, reported ties to industry sources.

Primary care practitioners’ use of a seven-item checklist may reduce the number of pediatric patients with respiratory tract infections who are prescribed unnecessary antibiotics, a prognostic cohort study suggests.

The study revealed short illness (a duration of illness of 3 days or less), temperature (a body temperature of 37.8°C or greater at presentation), age (being under 2 years), intercostal or subcostal recession, wheeze on auscultation, asthma, and vomiting (moderate or severe in the previous 24 hours) were each independently associated with hospital admission (P less than .01 for all associations).

©Devonyu/thinkstockphotos.com

The checklist includes these seven characteristics or risk variables (short illness, temperature, age, recession, wheeze, asthma, and vomiting [mnemonic STARWAVe]). To use the checklist, a primary care practitioner would assign one point for the presence of each item in a patient then add up all of the points to determine that patient’s risk level for future hospital admission for respiratory tract infection. A score of 1 point or less, observed in 5,593 (67%) cases would be considered indicative of a very low rate of risk for hospitalization (0.3%, 0.2%-0.4%). A score of 2 or 3 points, found for 2,520 (30%) children, would be considered as a normal level of risk (1.5%, 1.0%-1.9%), and a score of 4 or more points, seen in 204 (3%) children, would signify a high risk level (11.8%, 7.3%-16.2%).

Of the 8,394 children assessed, 78 (0.9%; 95% confidence interval, 0.7%-1.2%) were admitted to a hospital. Most were admitted on days 2-7 (33, 42%) and on days 8-30 (30, 39%) following recruitment. Only 15 (19%) were admitted on the day of recruitment (day 1).

“Many clinicians report that they prescribe antibiotics just in case, to mitigate perceived risk of future hospital admission and complications, and that failing to provide a prescription for a child who subsequently becomes seriously unwell is professionally unacceptable. If primary care clinicians could identify children at low (or very low) risk of such future complications, the reduced clinical uncertainty could lead to a reduced use of antibiotics in these groups of patients,” wrote first author Alastair Hay, MD, from the Centre for Academic Primary Care in the School of Social and Community Medicine at the University of Bristol (England), and his colleagues.

These researchers conducted the study based on a structured, blinded review of the medical records from children aged between 3 months and 16 years presenting with acute cough (less than or equal to 28 days) and respiratory tract infection treated by 519 general practitioners in 247 practices in England between July 2011 and June 2013. The primary study outcome was hospital admission for respiratory tract infection within 30 days.

Additionally, a multivariable model was employed to detect factors associated with increased risk of hospital admission. As measured by receiver operating characteristic curve analysis, the accuracy of the STARWAVe score checklist in predicting risk groups and associated risk of hospitalization was found to be high (0.81; 95% CI, 0.77-0.86). The suggested probability of hospital admission for children who did not have any of the seven characteristics included in the checklist was found to be exceptionally low (0.14%).

Significantly associated parent-reported variables included both moderate or severe vomiting and severe fever, each in the previous 24 hours. Significant clinician-reported variables included intercostal or subcostal recession and wheeze on auscultation.

“The main value of our results is to reduce clinical uncertainty and antibiotic use in children least likely to benefit from them, namely those at very low risk of future hospital admission,” Dr. Hay and his associates noted in The Lancet Respiratory Medicine (Lancet Respir Med. 2016 Sep 1. doi: 10.1016/S2213-2600(16)30223-5).

Funding for this study was provided by the National Institute for Health Research and sponsored by the University of Bristol. Only one of the study’s authors, Dr. Peter Muir, reported ties to industry sources.

Although related by their European origins in neighboring countries and similar cultural lifestyles, the immune profiles and prevalences of asthma and allergic sensitization differ between Amish and Hutterite school children, according to the results of a study published in the New England Journal of Medicine.

The predominant differences between the Amish and Hutterite populations today are region of concentration (Indiana and South Dakota, respectively) and agrarian style (traditional and industrialized farming, respectively). First author Michelle M. Stein of the University of Chicago and her colleagues conducted a study of 30 Amish age- and sex-matched children (aged 7-14 years) living in Indiana and 30 Hutterite children living in South Dakota during the months of November and December, respectively. Immune profile–related variables examined included levels of common allergens and endotoxins detectable in airborne dust, percentages of total peripheral blood leukocytes, cell-surface markers on neutrophils and monocytes, cytokine levels from peripheral-blood leukocytes with or without innate or adaptive stimuli, and gene expression levels from peripheral-blood leukocytes. In additional experiments using a murine model of experimental allergic asthma, house dust from Amish and Hutterite homes was administered intranasally to mice for 4-5 weeks to gauge their immune responses (N Engl J Med. 2016;375:411-21).

©tupungato/Thinkstock.com

A genetic analysis revealed that the two populations shared a closer genetic relationship with each other than with populations from other countries in Europe. The study results also confirmed the known differences between the Amish and Hutterite prevalences of asthma (0% vs. 20%, respectively) and positivity for allergen-specific IgE (17% vs. 30% and 7% vs. 30% using cutoffs of greater than 0.7 and greater than 3.5 kUA/L, respectively). Also, median levels of endotoxins were found to be almost sevenfold greater in Amish homes (4,399 endotoxin units [EU] per square meter vs. 648 EU per square meter, P less than .001).

Compared with results generated using Hutterite peripheral-blood leukocytes, increased proportions of neutrophils, decreased proportions of eosinophils, and similar proportions of monocytes were observed in the Amish. In addition to proportional differences, the phenotypes of the neutrophils from the Amish children also differed by expressing lower levels of the chemokine receptor CXCR4 and the adhesion molecules CD11b and CD11c. The phenotypes of the monocytes differed as well, showing a suppressive phenotype in the Amish children. A specific network of differentially expressed innate immune genes in untreated peripheral-blood leukocytes was found to be associated with the observed differences in the relative amounts of neutrophils, eosinophils, and monocytes, as well as their phenotypes. The median levels of all 23 cytokines detected in peripheral-blood leukocytes following innate stimulation differed between the populations and showed lower levels among the Amish children (P less than .001). Adaptive stimulation, however, did not lead to differences in cytokine levels between the two groups. The results from the murine model indicated that exposure to the Amish conditions was associated with innate immune responses consistent with protective effects against asthma. Collectively, these results strongly suggest that the Amish environment affords protection against asthma via innate immune system signaling.

“A deeper understanding of the relevant stimuli and the innate immune pathways they engage may ultimately pave the way for the development of effective strategies for the prevention of asthma,” wrote Ms. Stein and her colleagues.

Funding for this project was provided by the National Institutes of Health, St. Vincent Foundation, and the American Academy of Allergy, Asthma, and Immunology Foundation. Several study authors disclosed grant support from the NIH; one received support from the European Research Council and the German Research Foundation; and several disclosed ties to industry sources.

Although related by their European origins in neighboring countries and similar cultural lifestyles, the immune profiles and prevalences of asthma and allergic sensitization differ between Amish and Hutterite school children, according to the results of a study published in the New England Journal of Medicine.

The predominant differences between the Amish and Hutterite populations today are region of concentration (Indiana and South Dakota, respectively) and agrarian style (traditional and industrialized farming, respectively). First author Michelle M. Stein of the University of Chicago and her colleagues conducted a study of 30 Amish age- and sex-matched children (aged 7-14 years) living in Indiana and 30 Hutterite children living in South Dakota during the months of November and December, respectively. Immune profile–related variables examined included levels of common allergens and endotoxins detectable in airborne dust, percentages of total peripheral blood leukocytes, cell-surface markers on neutrophils and monocytes, cytokine levels from peripheral-blood leukocytes with or without innate or adaptive stimuli, and gene expression levels from peripheral-blood leukocytes. In additional experiments using a murine model of experimental allergic asthma, house dust from Amish and Hutterite homes was administered intranasally to mice for 4-5 weeks to gauge their immune responses (N Engl J Med. 2016;375:411-21).

©tupungato/Thinkstock.com

A genetic analysis revealed that the two populations shared a closer genetic relationship with each other than with populations from other countries in Europe. The study results also confirmed the known differences between the Amish and Hutterite prevalences of asthma (0% vs. 20%, respectively) and positivity for allergen-specific IgE (17% vs. 30% and 7% vs. 30% using cutoffs of greater than 0.7 and greater than 3.5 kUA/L, respectively). Also, median levels of endotoxins were found to be almost sevenfold greater in Amish homes (4,399 endotoxin units [EU] per square meter vs. 648 EU per square meter, P less than .001).

Compared with results generated using Hutterite peripheral-blood leukocytes, increased proportions of neutrophils, decreased proportions of eosinophils, and similar proportions of monocytes were observed in the Amish. In addition to proportional differences, the phenotypes of the neutrophils from the Amish children also differed by expressing lower levels of the chemokine receptor CXCR4 and the adhesion molecules CD11b and CD11c. The phenotypes of the monocytes differed as well, showing a suppressive phenotype in the Amish children. A specific network of differentially expressed innate immune genes in untreated peripheral-blood leukocytes was found to be associated with the observed differences in the relative amounts of neutrophils, eosinophils, and monocytes, as well as their phenotypes. The median levels of all 23 cytokines detected in peripheral-blood leukocytes following innate stimulation differed between the populations and showed lower levels among the Amish children (P less than .001). Adaptive stimulation, however, did not lead to differences in cytokine levels between the two groups. The results from the murine model indicated that exposure to the Amish conditions was associated with innate immune responses consistent with protective effects against asthma. Collectively, these results strongly suggest that the Amish environment affords protection against asthma via innate immune system signaling.

“A deeper understanding of the relevant stimuli and the innate immune pathways they engage may ultimately pave the way for the development of effective strategies for the prevention of asthma,” wrote Ms. Stein and her colleagues.

Funding for this project was provided by the National Institutes of Health, St. Vincent Foundation, and the American Academy of Allergy, Asthma, and Immunology Foundation. Several study authors disclosed grant support from the NIH; one received support from the European Research Council and the German Research Foundation; and several disclosed ties to industry sources.

Although related by their European origins in neighboring countries and similar cultural lifestyles, the immune profiles and prevalences of asthma and allergic sensitization differ between Amish and Hutterite school children, according to the results of a study published in the New England Journal of Medicine.

The predominant differences between the Amish and Hutterite populations today are region of concentration (Indiana and South Dakota, respectively) and agrarian style (traditional and industrialized farming, respectively). First author Michelle M. Stein of the University of Chicago and her colleagues conducted a study of 30 Amish age- and sex-matched children (aged 7-14 years) living in Indiana and 30 Hutterite children living in South Dakota during the months of November and December, respectively. Immune profile–related variables examined included levels of common allergens and endotoxins detectable in airborne dust, percentages of total peripheral blood leukocytes, cell-surface markers on neutrophils and monocytes, cytokine levels from peripheral-blood leukocytes with or without innate or adaptive stimuli, and gene expression levels from peripheral-blood leukocytes. In additional experiments using a murine model of experimental allergic asthma, house dust from Amish and Hutterite homes was administered intranasally to mice for 4-5 weeks to gauge their immune responses (N Engl J Med. 2016;375:411-21).

©tupungato/Thinkstock.com

A genetic analysis revealed that the two populations shared a closer genetic relationship with each other than with populations from other countries in Europe. The study results also confirmed the known differences between the Amish and Hutterite prevalences of asthma (0% vs. 20%, respectively) and positivity for allergen-specific IgE (17% vs. 30% and 7% vs. 30% using cutoffs of greater than 0.7 and greater than 3.5 kUA/L, respectively). Also, median levels of endotoxins were found to be almost sevenfold greater in Amish homes (4,399 endotoxin units [EU] per square meter vs. 648 EU per square meter, P less than .001).

Compared with results generated using Hutterite peripheral-blood leukocytes, increased proportions of neutrophils, decreased proportions of eosinophils, and similar proportions of monocytes were observed in the Amish. In addition to proportional differences, the phenotypes of the neutrophils from the Amish children also differed by expressing lower levels of the chemokine receptor CXCR4 and the adhesion molecules CD11b and CD11c. The phenotypes of the monocytes differed as well, showing a suppressive phenotype in the Amish children. A specific network of differentially expressed innate immune genes in untreated peripheral-blood leukocytes was found to be associated with the observed differences in the relative amounts of neutrophils, eosinophils, and monocytes, as well as their phenotypes. The median levels of all 23 cytokines detected in peripheral-blood leukocytes following innate stimulation differed between the populations and showed lower levels among the Amish children (P less than .001). Adaptive stimulation, however, did not lead to differences in cytokine levels between the two groups. The results from the murine model indicated that exposure to the Amish conditions was associated with innate immune responses consistent with protective effects against asthma. Collectively, these results strongly suggest that the Amish environment affords protection against asthma via innate immune system signaling.

“A deeper understanding of the relevant stimuli and the innate immune pathways they engage may ultimately pave the way for the development of effective strategies for the prevention of asthma,” wrote Ms. Stein and her colleagues.

Funding for this project was provided by the National Institutes of Health, St. Vincent Foundation, and the American Academy of Allergy, Asthma, and Immunology Foundation. Several study authors disclosed grant support from the NIH; one received support from the European Research Council and the German Research Foundation; and several disclosed ties to industry sources.

Of the almost 9 million children and adolescents aged 17 years and younger estimated to be measles susceptible in the United States, those 3 years and younger show the highest levels of risk for infection, according to the results of a study published in the American Journal of Epidemiology.

Robert A. Bednarczyk, MD, and his colleagues at Emory University, Atlanta, developed a model based on age-specific measles vaccination data from the National Immunization Survey–Teen collected between 2008 and 2013 (18 cumulative birth cohorts) to estimate the number of U.S. children (birth–age 12 years ) and adolescents (aged 13-17 years) susceptible to measles infection (Am J Epidemiol. 2016 Jul 15;184[2]:148-56).

CDC/Dr. Heinz F. Eichenwald

The model was developed using the survey data in conjunction with assumptions designed to account for several potentially confounding variables. These included the effectiveness of the vaccine used, whether infants were protected by maternally derived, vaccine-induced antibodies, and any loss of immunity attributable to treatment for cancer during childhood. The model also allowed for an examination of susceptibility by different age groupings, as well as by state. Additionally, the study authors were able to estimate the impact of decreased measles-containing vaccine effectiveness on susceptibility to infection in adolescents.

Results from the model indicated that 12.5% of the over 69 million of U.S. children and adolescents in the 18 birth cohorts are susceptible to measles infection. Those with the highest percentage of susceptibility were children 3 years of age and younger (24.7%), compared with 9.0% of children and adolescents aged 4-17 years. Geographic differences in susceptibility also were apparent. In addition to the District of Columbia, 10 states had adolescent susceptibility levels of at least 6%, and 14 states each had over 20,000 susceptible adolescents.

Using the model to simulate a 1% decrease in vaccine effectiveness for both the first (93%-92%) and second (97%-96%) measles-containing vaccine doses, the study authors reported the addition of almost 1 million children and adolescents (13.4%) to the measles-susceptible category. This finding indicates that very small changes in vaccine effectiveness can have a substantial impact on susceptibility through a slow accumulation of additional susceptible children and adolescents each year, culminating in a steady decline in the proportion of children and adolescents immune to measles.

Regarding their overall findings, Dr. Bednarczyk and his colleagues stated, “the overall level of immunity to measles is generally at or higher than the operational threshold of 92%. This is compatible with the experience to date that, despite substantial numbers of importations, endemic measles transmission has not been reestablished.”

As for broader implications, the investigators said that “These estimates underscore the need to help public health professionals plan for future immunization programs and potential measles outbreaks, and to maintain appropriate levels of immunity in the population to prevent widespread transmission of this highly infectious disease.”

Of the almost 9 million children and adolescents aged 17 years and younger estimated to be measles susceptible in the United States, those 3 years and younger show the highest levels of risk for infection, according to the results of a study published in the American Journal of Epidemiology.

Robert A. Bednarczyk, MD, and his colleagues at Emory University, Atlanta, developed a model based on age-specific measles vaccination data from the National Immunization Survey–Teen collected between 2008 and 2013 (18 cumulative birth cohorts) to estimate the number of U.S. children (birth–age 12 years ) and adolescents (aged 13-17 years) susceptible to measles infection (Am J Epidemiol. 2016 Jul 15;184[2]:148-56).

CDC/Dr. Heinz F. Eichenwald

The model was developed using the survey data in conjunction with assumptions designed to account for several potentially confounding variables. These included the effectiveness of the vaccine used, whether infants were protected by maternally derived, vaccine-induced antibodies, and any loss of immunity attributable to treatment for cancer during childhood. The model also allowed for an examination of susceptibility by different age groupings, as well as by state. Additionally, the study authors were able to estimate the impact of decreased measles-containing vaccine effectiveness on susceptibility to infection in adolescents.

Results from the model indicated that 12.5% of the over 69 million of U.S. children and adolescents in the 18 birth cohorts are susceptible to measles infection. Those with the highest percentage of susceptibility were children 3 years of age and younger (24.7%), compared with 9.0% of children and adolescents aged 4-17 years. Geographic differences in susceptibility also were apparent. In addition to the District of Columbia, 10 states had adolescent susceptibility levels of at least 6%, and 14 states each had over 20,000 susceptible adolescents.

Using the model to simulate a 1% decrease in vaccine effectiveness for both the first (93%-92%) and second (97%-96%) measles-containing vaccine doses, the study authors reported the addition of almost 1 million children and adolescents (13.4%) to the measles-susceptible category. This finding indicates that very small changes in vaccine effectiveness can have a substantial impact on susceptibility through a slow accumulation of additional susceptible children and adolescents each year, culminating in a steady decline in the proportion of children and adolescents immune to measles.

Regarding their overall findings, Dr. Bednarczyk and his colleagues stated, “the overall level of immunity to measles is generally at or higher than the operational threshold of 92%. This is compatible with the experience to date that, despite substantial numbers of importations, endemic measles transmission has not been reestablished.”

As for broader implications, the investigators said that “These estimates underscore the need to help public health professionals plan for future immunization programs and potential measles outbreaks, and to maintain appropriate levels of immunity in the population to prevent widespread transmission of this highly infectious disease.”

Of the almost 9 million children and adolescents aged 17 years and younger estimated to be measles susceptible in the United States, those 3 years and younger show the highest levels of risk for infection, according to the results of a study published in the American Journal of Epidemiology.

Robert A. Bednarczyk, MD, and his colleagues at Emory University, Atlanta, developed a model based on age-specific measles vaccination data from the National Immunization Survey–Teen collected between 2008 and 2013 (18 cumulative birth cohorts) to estimate the number of U.S. children (birth–age 12 years ) and adolescents (aged 13-17 years) susceptible to measles infection (Am J Epidemiol. 2016 Jul 15;184[2]:148-56).

CDC/Dr. Heinz F. Eichenwald

The model was developed using the survey data in conjunction with assumptions designed to account for several potentially confounding variables. These included the effectiveness of the vaccine used, whether infants were protected by maternally derived, vaccine-induced antibodies, and any loss of immunity attributable to treatment for cancer during childhood. The model also allowed for an examination of susceptibility by different age groupings, as well as by state. Additionally, the study authors were able to estimate the impact of decreased measles-containing vaccine effectiveness on susceptibility to infection in adolescents.

Results from the model indicated that 12.5% of the over 69 million of U.S. children and adolescents in the 18 birth cohorts are susceptible to measles infection. Those with the highest percentage of susceptibility were children 3 years of age and younger (24.7%), compared with 9.0% of children and adolescents aged 4-17 years. Geographic differences in susceptibility also were apparent. In addition to the District of Columbia, 10 states had adolescent susceptibility levels of at least 6%, and 14 states each had over 20,000 susceptible adolescents.

Using the model to simulate a 1% decrease in vaccine effectiveness for both the first (93%-92%) and second (97%-96%) measles-containing vaccine doses, the study authors reported the addition of almost 1 million children and adolescents (13.4%) to the measles-susceptible category. This finding indicates that very small changes in vaccine effectiveness can have a substantial impact on susceptibility through a slow accumulation of additional susceptible children and adolescents each year, culminating in a steady decline in the proportion of children and adolescents immune to measles.

Regarding their overall findings, Dr. Bednarczyk and his colleagues stated, “the overall level of immunity to measles is generally at or higher than the operational threshold of 92%. This is compatible with the experience to date that, despite substantial numbers of importations, endemic measles transmission has not been reestablished.”

As for broader implications, the investigators said that “These estimates underscore the need to help public health professionals plan for future immunization programs and potential measles outbreaks, and to maintain appropriate levels of immunity in the population to prevent widespread transmission of this highly infectious disease.”

Substituting a less-expensive hepatitis C core antigen test into the standard two-step process for diagnosing active hepatitis C virus (HCV) infection could streamline and cut the cost of HCV detection.

The standard two-step approach – detection of HCV antibodies followed by nucleic acid testing (NAT) as a marker for HCV viremia – may be improved by replacing NAT with the HCV core antigen (HCVcAg) test, according to the results of a study published in Annals of Internal Medicine.

Dr. J. Morgan Freiman, of the Boston Medical Center, and her colleagues conducted a systematic literature review to identify 44 case-control, cross-sectional, cohort, or randomized trials that compared any of five HCVcAg screening tests with a NAT reference standard.

The investigators performed a meta-analysis to assess the sensitivity (proportion of samples with a positive NAT and HCVcAg) and specificity (proportion of samples with a negative NAT and HCVcAg) associated with the five HCVcAg tests, as well as how they correlated with NAT-derived HCV RNA levels greater than 3,000 IU/mL.

The two best-performing HCVcAg tests of the five assessed were the Abbott ARCHITECT HCV Ag and the Ortho HCV Ag ELISA, based on their sensitivity (93.4%and 93.2%, respectively), specificity (98.8% and 99.2%, respectively), and positive (80.6 and 116.5, respectively) and negative (0.06 and 0.06, respectively) likelihood ratios.

Although limited data were available, the results of three quantitative studies showed that Abbott ARCHITECT HCVcAg was well correlated with HCV RNA levels greater than 3,000 IU/mL.

“This systematic review concludes that a well-performing HCVcAg test can achieve similar diagnostic accuracy to NAT for identification of active HCV infection when the viral load exceeds 3,000 IU/mL,” Dr. Freiman and her colleagues noted.

HCVcAg testing should be researched further as a potentially viable and less-expensive alternative to NAT, the investigators said, with the goal of simplifying detection at the point of care and increasing the rate of patient diagnosis (Ann Intern Med. 2016 Jun 21; doi: 10.7326/M16-0065).

The National Institutes of Health funded the study. Dr. White disclosed grant support from the funding source. Dr. Ongarello and Dr. Denkinger reported relationships with the Foundation for Innovative New Diagnostics. No additional authors reported conflicts of interest.

Substituting a less-expensive hepatitis C core antigen test into the standard two-step process for diagnosing active hepatitis C virus (HCV) infection could streamline and cut the cost of HCV detection.

The standard two-step approach – detection of HCV antibodies followed by nucleic acid testing (NAT) as a marker for HCV viremia – may be improved by replacing NAT with the HCV core antigen (HCVcAg) test, according to the results of a study published in Annals of Internal Medicine.

Dr. J. Morgan Freiman, of the Boston Medical Center, and her colleagues conducted a systematic literature review to identify 44 case-control, cross-sectional, cohort, or randomized trials that compared any of five HCVcAg screening tests with a NAT reference standard.

The investigators performed a meta-analysis to assess the sensitivity (proportion of samples with a positive NAT and HCVcAg) and specificity (proportion of samples with a negative NAT and HCVcAg) associated with the five HCVcAg tests, as well as how they correlated with NAT-derived HCV RNA levels greater than 3,000 IU/mL.

The two best-performing HCVcAg tests of the five assessed were the Abbott ARCHITECT HCV Ag and the Ortho HCV Ag ELISA, based on their sensitivity (93.4%and 93.2%, respectively), specificity (98.8% and 99.2%, respectively), and positive (80.6 and 116.5, respectively) and negative (0.06 and 0.06, respectively) likelihood ratios.

Although limited data were available, the results of three quantitative studies showed that Abbott ARCHITECT HCVcAg was well correlated with HCV RNA levels greater than 3,000 IU/mL.

“This systematic review concludes that a well-performing HCVcAg test can achieve similar diagnostic accuracy to NAT for identification of active HCV infection when the viral load exceeds 3,000 IU/mL,” Dr. Freiman and her colleagues noted.

HCVcAg testing should be researched further as a potentially viable and less-expensive alternative to NAT, the investigators said, with the goal of simplifying detection at the point of care and increasing the rate of patient diagnosis (Ann Intern Med. 2016 Jun 21; doi: 10.7326/M16-0065).

The National Institutes of Health funded the study. Dr. White disclosed grant support from the funding source. Dr. Ongarello and Dr. Denkinger reported relationships with the Foundation for Innovative New Diagnostics. No additional authors reported conflicts of interest.

Substituting a less-expensive hepatitis C core antigen test into the standard two-step process for diagnosing active hepatitis C virus (HCV) infection could streamline and cut the cost of HCV detection.

The standard two-step approach – detection of HCV antibodies followed by nucleic acid testing (NAT) as a marker for HCV viremia – may be improved by replacing NAT with the HCV core antigen (HCVcAg) test, according to the results of a study published in Annals of Internal Medicine.

Dr. J. Morgan Freiman, of the Boston Medical Center, and her colleagues conducted a systematic literature review to identify 44 case-control, cross-sectional, cohort, or randomized trials that compared any of five HCVcAg screening tests with a NAT reference standard.

The investigators performed a meta-analysis to assess the sensitivity (proportion of samples with a positive NAT and HCVcAg) and specificity (proportion of samples with a negative NAT and HCVcAg) associated with the five HCVcAg tests, as well as how they correlated with NAT-derived HCV RNA levels greater than 3,000 IU/mL.

The two best-performing HCVcAg tests of the five assessed were the Abbott ARCHITECT HCV Ag and the Ortho HCV Ag ELISA, based on their sensitivity (93.4%and 93.2%, respectively), specificity (98.8% and 99.2%, respectively), and positive (80.6 and 116.5, respectively) and negative (0.06 and 0.06, respectively) likelihood ratios.

Although limited data were available, the results of three quantitative studies showed that Abbott ARCHITECT HCVcAg was well correlated with HCV RNA levels greater than 3,000 IU/mL.

“This systematic review concludes that a well-performing HCVcAg test can achieve similar diagnostic accuracy to NAT for identification of active HCV infection when the viral load exceeds 3,000 IU/mL,” Dr. Freiman and her colleagues noted.

HCVcAg testing should be researched further as a potentially viable and less-expensive alternative to NAT, the investigators said, with the goal of simplifying detection at the point of care and increasing the rate of patient diagnosis (Ann Intern Med. 2016 Jun 21; doi: 10.7326/M16-0065).

The National Institutes of Health funded the study. Dr. White disclosed grant support from the funding source. Dr. Ongarello and Dr. Denkinger reported relationships with the Foundation for Innovative New Diagnostics. No additional authors reported conflicts of interest.

Recent marijuana use may have an effect similar to recent tobacco use with regard to decreased production of exhaled nitric oxide (eNO), but a very different effect on forced vital capacity (FVC), according to the results of a study published in Chest.

Dr. Stefania I. Papatheodorou from the Cyprus International Institute for Environmental and Public Health, Limassol, Cyprus, in association with the Harvard T. H. Chan School of Public Health, and her colleagues conducted a retrospective analysis of National Health and Nutrition Examination Survey (NHANES) data collected from 10,327 people aged 18-59 years between 2007 to 2012. Respondents completed a questionnaire on illicit drug use and were given a physical examination. Outcomes of interest for this study were eNO levels and pulmonary function measurements including the forced expiratory volume in 1 second (FEV₁), FVC, the FEV1/FVC ratio, and the average forced expiratory flow during the mid (25%-75%) portion of the FVC (FEF_25%-75%) (Chest. 2016 Jan 16. doi: 10.1016/j.chest.2015.12.033).

©KatarzynaBialasiewicz/thinkstockphotos.com

The population available for analysis included 4,797 people who reported never having used marijuana, and 4,084 who reported past use. The recent users were divided into two groups; 555 and 891 respondents who reported using marijuana 5-30 days and 0-4 days before their examinations, respectively. The study results from age-adjusted analyses standardized to the 2000 U.S. Census population indicated that both past and current users had significantly lower eNO levels (in parts per billion) than those that had never used (all P less than .001). The same analysis demonstrated that FEV₁, FVC, and FEV₁/FVC ratios were all higher in current and past users than in never users (all P less than .001).

Using a multivariable model adjusted for age, sex, race/ethnicity, height, education level, income, marital status, asthma, tobacco use in pack-years, smoking category, and body mass index, both the 0-4 day users and the 5-30 day users showed significantly decreased eNO levels, compared with never users (-7%, 95% confidence interval -12% to -2%, P = .03; -13%, CI -18% to -8%, P less than .001, respectively). Additionally, recent users in the 0-4 day group had significantly higher FEV₁ measures than never users (89 mL, CI 29-150, P = 0.005), as well as lower FEV₁/FVC ratios (-.02, CI –.03 to –.01, P = .003).

Regarding the broader implications of their study findings, Dr. Papatheodorou and colleagues stated, “Given that nitric oxide plays a role in inflammatory and immune defense pathways in the respiratory system and is a mediator of vasodilation in the pulmonary and systemic vasculature, it would be useful to further explore the associations between marijuana use and vascular and pulmonary function in randomized trials.”

Dr. Mary B. Rice received funding from the Institute for Environmental Sciences. The other authors reported no conflicts of interest.

Recent marijuana use may have an effect similar to recent tobacco use with regard to decreased production of exhaled nitric oxide (eNO), but a very different effect on forced vital capacity (FVC), according to the results of a study published in Chest.

Dr. Stefania I. Papatheodorou from the Cyprus International Institute for Environmental and Public Health, Limassol, Cyprus, in association with the Harvard T. H. Chan School of Public Health, and her colleagues conducted a retrospective analysis of National Health and Nutrition Examination Survey (NHANES) data collected from 10,327 people aged 18-59 years between 2007 to 2012. Respondents completed a questionnaire on illicit drug use and were given a physical examination. Outcomes of interest for this study were eNO levels and pulmonary function measurements including the forced expiratory volume in 1 second (FEV₁), FVC, the FEV1/FVC ratio, and the average forced expiratory flow during the mid (25%-75%) portion of the FVC (FEF_25%-75%) (Chest. 2016 Jan 16. doi: 10.1016/j.chest.2015.12.033).

©KatarzynaBialasiewicz/thinkstockphotos.com

The population available for analysis included 4,797 people who reported never having used marijuana, and 4,084 who reported past use. The recent users were divided into two groups; 555 and 891 respondents who reported using marijuana 5-30 days and 0-4 days before their examinations, respectively. The study results from age-adjusted analyses standardized to the 2000 U.S. Census population indicated that both past and current users had significantly lower eNO levels (in parts per billion) than those that had never used (all P less than .001). The same analysis demonstrated that FEV₁, FVC, and FEV₁/FVC ratios were all higher in current and past users than in never users (all P less than .001).

Using a multivariable model adjusted for age, sex, race/ethnicity, height, education level, income, marital status, asthma, tobacco use in pack-years, smoking category, and body mass index, both the 0-4 day users and the 5-30 day users showed significantly decreased eNO levels, compared with never users (-7%, 95% confidence interval -12% to -2%, P = .03; -13%, CI -18% to -8%, P less than .001, respectively). Additionally, recent users in the 0-4 day group had significantly higher FEV₁ measures than never users (89 mL, CI 29-150, P = 0.005), as well as lower FEV₁/FVC ratios (-.02, CI –.03 to –.01, P = .003).

Regarding the broader implications of their study findings, Dr. Papatheodorou and colleagues stated, “Given that nitric oxide plays a role in inflammatory and immune defense pathways in the respiratory system and is a mediator of vasodilation in the pulmonary and systemic vasculature, it would be useful to further explore the associations between marijuana use and vascular and pulmonary function in randomized trials.”

Dr. Mary B. Rice received funding from the Institute for Environmental Sciences. The other authors reported no conflicts of interest.

Recent marijuana use may have an effect similar to recent tobacco use with regard to decreased production of exhaled nitric oxide (eNO), but a very different effect on forced vital capacity (FVC), according to the results of a study published in Chest.

Dr. Stefania I. Papatheodorou from the Cyprus International Institute for Environmental and Public Health, Limassol, Cyprus, in association with the Harvard T. H. Chan School of Public Health, and her colleagues conducted a retrospective analysis of National Health and Nutrition Examination Survey (NHANES) data collected from 10,327 people aged 18-59 years between 2007 to 2012. Respondents completed a questionnaire on illicit drug use and were given a physical examination. Outcomes of interest for this study were eNO levels and pulmonary function measurements including the forced expiratory volume in 1 second (FEV₁), FVC, the FEV1/FVC ratio, and the average forced expiratory flow during the mid (25%-75%) portion of the FVC (FEF_25%-75%) (Chest. 2016 Jan 16. doi: 10.1016/j.chest.2015.12.033).

©KatarzynaBialasiewicz/thinkstockphotos.com

The population available for analysis included 4,797 people who reported never having used marijuana, and 4,084 who reported past use. The recent users were divided into two groups; 555 and 891 respondents who reported using marijuana 5-30 days and 0-4 days before their examinations, respectively. The study results from age-adjusted analyses standardized to the 2000 U.S. Census population indicated that both past and current users had significantly lower eNO levels (in parts per billion) than those that had never used (all P less than .001). The same analysis demonstrated that FEV₁, FVC, and FEV₁/FVC ratios were all higher in current and past users than in never users (all P less than .001).

Using a multivariable model adjusted for age, sex, race/ethnicity, height, education level, income, marital status, asthma, tobacco use in pack-years, smoking category, and body mass index, both the 0-4 day users and the 5-30 day users showed significantly decreased eNO levels, compared with never users (-7%, 95% confidence interval -12% to -2%, P = .03; -13%, CI -18% to -8%, P less than .001, respectively). Additionally, recent users in the 0-4 day group had significantly higher FEV₁ measures than never users (89 mL, CI 29-150, P = 0.005), as well as lower FEV₁/FVC ratios (-.02, CI –.03 to –.01, P = .003).

Regarding the broader implications of their study findings, Dr. Papatheodorou and colleagues stated, “Given that nitric oxide plays a role in inflammatory and immune defense pathways in the respiratory system and is a mediator of vasodilation in the pulmonary and systemic vasculature, it would be useful to further explore the associations between marijuana use and vascular and pulmonary function in randomized trials.”

Dr. Mary B. Rice received funding from the Institute for Environmental Sciences. The other authors reported no conflicts of interest.

The hemodynamic characteristics of precapillary pulmonary hypertension differ from those typically thought of as defining the disease, suggests a study published in Chest.

A pulmonary hypertension patient’s diagnostic category is used to select which patients will or won’t receive pulmonary arterial hypertension (PAH)-targeted therapies, such as treprostinil. Currently, patients with a mean pulmonary arterial wedge pressure (mPAWP) less than or equal to 15 mm Hg are classified as having precapillary pulmonary hypertension, which includes PAH; and patients with a mPAWP above 15 mm Hg are classified as having postcapillary pulmonary hypertension. Current recommendations advise against treating patients with postcapillary hypertension with PAH-targeted therapies.

First author Dr. Christian Gerges of the division of cardiology, Vienna General Hospital, Medical University of Vienna and colleagues hypothesized that a precapillary hemodynamic profile is characterized by a mPAWP that is lower than the currently accepted 15 mm Hg, an elevated diastolic pulmonary vascular pressure gradient (DPG), “and a beneficial response to PAH-targeted therapies.”

The study identified an mPAWP less than 12 mm Hg and a DPG greater than or equal to 7 mm Hg as the best hemodynamic discriminators between idiopathic PAH and postcapillary pulmonary hypertension.

This study also found that patients with a mPAWP less than 12 mm Hg combined with a diastolic pulmonary vascular pressure gradient (DPG) greater than 20 mm Hg are likely to have a significant response to PAH-targeted-therapy.

The researchers analyzed hemodynamic data from a retrospective cohort of 4,363 stable patients who underwent a first diagnostic right heart catheterization at the Medical University of Vienna between May 1996 and June 2006. Of these patients, 3,524 (81%) also received a left heart catheterization. Additionally, the researchers analyzed deidentified individual data for 541 patients from four randomized placebo-controlled trials and 437 patients from one open-label trial of treprostinil in PAH. These trials all had similar inclusion criteria and data collection processes (Chest. 2016 Apr;149[4]:1061-73. doi: 10.1378/chest.15-0928).

Funding was provided by educational grants from Bayer and United Therapeutics Corporation. All but two coauthors had no disclosures; the remaining authors disclosed numerous ties to industry sources.*

*Correction, 6/14/16: An earlier version of this article misstated the investigators' conflicts of interest.

The hemodynamic characteristics of precapillary pulmonary hypertension differ from those typically thought of as defining the disease, suggests a study published in Chest.

A pulmonary hypertension patient’s diagnostic category is used to select which patients will or won’t receive pulmonary arterial hypertension (PAH)-targeted therapies, such as treprostinil. Currently, patients with a mean pulmonary arterial wedge pressure (mPAWP) less than or equal to 15 mm Hg are classified as having precapillary pulmonary hypertension, which includes PAH; and patients with a mPAWP above 15 mm Hg are classified as having postcapillary pulmonary hypertension. Current recommendations advise against treating patients with postcapillary hypertension with PAH-targeted therapies.

First author Dr. Christian Gerges of the division of cardiology, Vienna General Hospital, Medical University of Vienna and colleagues hypothesized that a precapillary hemodynamic profile is characterized by a mPAWP that is lower than the currently accepted 15 mm Hg, an elevated diastolic pulmonary vascular pressure gradient (DPG), “and a beneficial response to PAH-targeted therapies.”

The study identified an mPAWP less than 12 mm Hg and a DPG greater than or equal to 7 mm Hg as the best hemodynamic discriminators between idiopathic PAH and postcapillary pulmonary hypertension.

This study also found that patients with a mPAWP less than 12 mm Hg combined with a diastolic pulmonary vascular pressure gradient (DPG) greater than 20 mm Hg are likely to have a significant response to PAH-targeted-therapy.

The researchers analyzed hemodynamic data from a retrospective cohort of 4,363 stable patients who underwent a first diagnostic right heart catheterization at the Medical University of Vienna between May 1996 and June 2006. Of these patients, 3,524 (81%) also received a left heart catheterization. Additionally, the researchers analyzed deidentified individual data for 541 patients from four randomized placebo-controlled trials and 437 patients from one open-label trial of treprostinil in PAH. These trials all had similar inclusion criteria and data collection processes (Chest. 2016 Apr;149[4]:1061-73. doi: 10.1378/chest.15-0928).

Funding was provided by educational grants from Bayer and United Therapeutics Corporation. All but two coauthors had no disclosures; the remaining authors disclosed numerous ties to industry sources.*

*Correction, 6/14/16: An earlier version of this article misstated the investigators' conflicts of interest.

The hemodynamic characteristics of precapillary pulmonary hypertension differ from those typically thought of as defining the disease, suggests a study published in Chest.

A pulmonary hypertension patient’s diagnostic category is used to select which patients will or won’t receive pulmonary arterial hypertension (PAH)-targeted therapies, such as treprostinil. Currently, patients with a mean pulmonary arterial wedge pressure (mPAWP) less than or equal to 15 mm Hg are classified as having precapillary pulmonary hypertension, which includes PAH; and patients with a mPAWP above 15 mm Hg are classified as having postcapillary pulmonary hypertension. Current recommendations advise against treating patients with postcapillary hypertension with PAH-targeted therapies.

First author Dr. Christian Gerges of the division of cardiology, Vienna General Hospital, Medical University of Vienna and colleagues hypothesized that a precapillary hemodynamic profile is characterized by a mPAWP that is lower than the currently accepted 15 mm Hg, an elevated diastolic pulmonary vascular pressure gradient (DPG), “and a beneficial response to PAH-targeted therapies.”

The study identified an mPAWP less than 12 mm Hg and a DPG greater than or equal to 7 mm Hg as the best hemodynamic discriminators between idiopathic PAH and postcapillary pulmonary hypertension.

This study also found that patients with a mPAWP less than 12 mm Hg combined with a diastolic pulmonary vascular pressure gradient (DPG) greater than 20 mm Hg are likely to have a significant response to PAH-targeted-therapy.

The researchers analyzed hemodynamic data from a retrospective cohort of 4,363 stable patients who underwent a first diagnostic right heart catheterization at the Medical University of Vienna between May 1996 and June 2006. Of these patients, 3,524 (81%) also received a left heart catheterization. Additionally, the researchers analyzed deidentified individual data for 541 patients from four randomized placebo-controlled trials and 437 patients from one open-label trial of treprostinil in PAH. These trials all had similar inclusion criteria and data collection processes (Chest. 2016 Apr;149[4]:1061-73. doi: 10.1378/chest.15-0928).

Funding was provided by educational grants from Bayer and United Therapeutics Corporation. All but two coauthors had no disclosures; the remaining authors disclosed numerous ties to industry sources.*

*Correction, 6/14/16: An earlier version of this article misstated the investigators' conflicts of interest.