A 52-year-old man self-refers to dermatology for evaluation of an irritated lesion on the posterolateral aspect of his neck. It’s been there for years, waxing and waning but always being irritated by his shirt collar or seat belt.

He has shown the lesion to his primary care provider on several occasions. Various topical preparations, including steroid and antifungal creams, have been prescribed—to no avail.

The patient owns a landscaping business. He has worked outdoors since he was in his teens and acknowledges that in his younger years, he was not careful about sun protection. For the past 20 years or so, however, he has worn a wide-brimmed hat and long-sleeved shirt while working.

His health is good in all other respects.

EXAMINATION
The lesion is a pink, scaly, 2-cm ovoid patch on the left side of the patient’s neck. Several areas of scabbing are seen within the bounds of the lesion, the margins of which are very well defined.

There is much evidence of sun damage on his neck and arms, with prominent pilosebaceous units and rhomboidal lining of the neck skin. Elsewhere, on sun-exposed skin, there are numerous actinic keratoses, telangiectasias, and poikilodermatous changes.

The lesion is biopsied by shave technique and the sample submitted to pathology.

What’s the diagnosis?

DISCUSSION
The biopsy results confirmed the impression of superficial squamous cell carcinoma (SSC) with focal areas of invasion.

One thinks of skin cancer as being “a thing,” a papule or nodule, and that’s usually true. But there are several types of skin cancer that manifest as a fixed rash—meaning it stays in the same place year after year, unlike other rashes (eg, psoriasis, eczema, or fungal infection). Common examples, besides superficial SCC (also known as Bowen disease), include superficial basal cell carcinoma (BCC), Paget disease (mammary and extramammary), cutaneous T-cell lymphoma, and even local recurrence of breast cancer.

This patient’s occupation and history of (abundantly evident) sun damage put him at risk for a sun-caused skin cancer. As so often happens, the problem was initially misdiagnosed by a provider who was only looking at the lesion instead of factoring in the context in which it appeared. Who has the lesion is almost as important as the lesion itself.

Without a biopsy, Bowen disease is often indistinguishable from superficial BCC; the latter can take on a variety of appearances, from scar-like (cicatricial) to pigmented (especially in patients with darker skin) to the most common, nodular/noduloulcerative. Another item in the differential is discoid lupus erythematosus, particularly when the lesion manifests in a highly sun-exposed area.

Treatment of this patient’s lesion entailed full excision with 3-mm margins. This option was chosen based on the focal areas of invasion and theoretical potential for metastasis.

TAKE-HOME LEARNING POINTS

• Intraepidermal squamous cell carcinoma (Bowen disease) presents as a red, scaly rash with a rounded, well-demarcated border, almost always on skin directly overexposed to the sun.
• These cancers grow slowly, are fixed in location, never heal, and—given enough time—often become focally invasive.
• They will often be misdiagnosed as fungal infection, psoriasis, or eczema, because of the misperception that skin cancers are always papular or nodular.
• A history of sun exposure and resulting markers of dermatoheliosis serve to corroborate the putative diagnosis.

A 52-year-old man self-refers to dermatology for evaluation of an irritated lesion on the posterolateral aspect of his neck. It’s been there for years, waxing and waning but always being irritated by his shirt collar or seat belt.

He has shown the lesion to his primary care provider on several occasions. Various topical preparations, including steroid and antifungal creams, have been prescribed—to no avail.

The patient owns a landscaping business. He has worked outdoors since he was in his teens and acknowledges that in his younger years, he was not careful about sun protection. For the past 20 years or so, however, he has worn a wide-brimmed hat and long-sleeved shirt while working.

His health is good in all other respects.

EXAMINATION
The lesion is a pink, scaly, 2-cm ovoid patch on the left side of the patient’s neck. Several areas of scabbing are seen within the bounds of the lesion, the margins of which are very well defined.

There is much evidence of sun damage on his neck and arms, with prominent pilosebaceous units and rhomboidal lining of the neck skin. Elsewhere, on sun-exposed skin, there are numerous actinic keratoses, telangiectasias, and poikilodermatous changes.

The lesion is biopsied by shave technique and the sample submitted to pathology.

What’s the diagnosis?

DISCUSSION
The biopsy results confirmed the impression of superficial squamous cell carcinoma (SSC) with focal areas of invasion.

One thinks of skin cancer as being “a thing,” a papule or nodule, and that’s usually true. But there are several types of skin cancer that manifest as a fixed rash—meaning it stays in the same place year after year, unlike other rashes (eg, psoriasis, eczema, or fungal infection). Common examples, besides superficial SCC (also known as Bowen disease), include superficial basal cell carcinoma (BCC), Paget disease (mammary and extramammary), cutaneous T-cell lymphoma, and even local recurrence of breast cancer.

This patient’s occupation and history of (abundantly evident) sun damage put him at risk for a sun-caused skin cancer. As so often happens, the problem was initially misdiagnosed by a provider who was only looking at the lesion instead of factoring in the context in which it appeared. Who has the lesion is almost as important as the lesion itself.

Without a biopsy, Bowen disease is often indistinguishable from superficial BCC; the latter can take on a variety of appearances, from scar-like (cicatricial) to pigmented (especially in patients with darker skin) to the most common, nodular/noduloulcerative. Another item in the differential is discoid lupus erythematosus, particularly when the lesion manifests in a highly sun-exposed area.

Treatment of this patient’s lesion entailed full excision with 3-mm margins. This option was chosen based on the focal areas of invasion and theoretical potential for metastasis.

TAKE-HOME LEARNING POINTS

• Intraepidermal squamous cell carcinoma (Bowen disease) presents as a red, scaly rash with a rounded, well-demarcated border, almost always on skin directly overexposed to the sun.
• These cancers grow slowly, are fixed in location, never heal, and—given enough time—often become focally invasive.
• They will often be misdiagnosed as fungal infection, psoriasis, or eczema, because of the misperception that skin cancers are always papular or nodular.
• A history of sun exposure and resulting markers of dermatoheliosis serve to corroborate the putative diagnosis.

A 52-year-old man self-refers to dermatology for evaluation of an irritated lesion on the posterolateral aspect of his neck. It’s been there for years, waxing and waning but always being irritated by his shirt collar or seat belt.

He has shown the lesion to his primary care provider on several occasions. Various topical preparations, including steroid and antifungal creams, have been prescribed—to no avail.

The patient owns a landscaping business. He has worked outdoors since he was in his teens and acknowledges that in his younger years, he was not careful about sun protection. For the past 20 years or so, however, he has worn a wide-brimmed hat and long-sleeved shirt while working.

His health is good in all other respects.

EXAMINATION
The lesion is a pink, scaly, 2-cm ovoid patch on the left side of the patient’s neck. Several areas of scabbing are seen within the bounds of the lesion, the margins of which are very well defined.

There is much evidence of sun damage on his neck and arms, with prominent pilosebaceous units and rhomboidal lining of the neck skin. Elsewhere, on sun-exposed skin, there are numerous actinic keratoses, telangiectasias, and poikilodermatous changes.

The lesion is biopsied by shave technique and the sample submitted to pathology.

What’s the diagnosis?

DISCUSSION
The biopsy results confirmed the impression of superficial squamous cell carcinoma (SSC) with focal areas of invasion.

One thinks of skin cancer as being “a thing,” a papule or nodule, and that’s usually true. But there are several types of skin cancer that manifest as a fixed rash—meaning it stays in the same place year after year, unlike other rashes (eg, psoriasis, eczema, or fungal infection). Common examples, besides superficial SCC (also known as Bowen disease), include superficial basal cell carcinoma (BCC), Paget disease (mammary and extramammary), cutaneous T-cell lymphoma, and even local recurrence of breast cancer.

This patient’s occupation and history of (abundantly evident) sun damage put him at risk for a sun-caused skin cancer. As so often happens, the problem was initially misdiagnosed by a provider who was only looking at the lesion instead of factoring in the context in which it appeared. Who has the lesion is almost as important as the lesion itself.

Without a biopsy, Bowen disease is often indistinguishable from superficial BCC; the latter can take on a variety of appearances, from scar-like (cicatricial) to pigmented (especially in patients with darker skin) to the most common, nodular/noduloulcerative. Another item in the differential is discoid lupus erythematosus, particularly when the lesion manifests in a highly sun-exposed area.

Treatment of this patient’s lesion entailed full excision with 3-mm margins. This option was chosen based on the focal areas of invasion and theoretical potential for metastasis.

TAKE-HOME LEARNING POINTS

• Intraepidermal squamous cell carcinoma (Bowen disease) presents as a red, scaly rash with a rounded, well-demarcated border, almost always on skin directly overexposed to the sun.
• These cancers grow slowly, are fixed in location, never heal, and—given enough time—often become focally invasive.
• They will often be misdiagnosed as fungal infection, psoriasis, or eczema, because of the misperception that skin cancers are always papular or nodular.
• A history of sun exposure and resulting markers of dermatoheliosis serve to corroborate the putative diagnosis.

The FP thought this looked like granuloma annulare (GA) but had never seen so many lesions on a patient. Some lesions were not round (more oval or elongated), while others were not completely enclosed geometric shapes (with breaks in the multiple ring patterns). However, all of the lesions were slightly raised with erythema and no scale. (The FP also considered tinea corporis, but ruled it out because there was no scale.)

He consulted some Internet resources and was convinced that this was disseminated GA. The greatest risk factor for this somewhat mysterious disease of unknown origin is female gender. It is also often associated with diabetes, but diabetes is not the cause.

Although intralesional steroids work when treating disseminated GA, this approach is not realistic for widespread disease. A number of options have been studied and reported in small series or case reports. The FP presented various options to the patient, and together they decided to try pentoxifylline 400 mg 3 times daily for systemic treatment. Pentoxifylline is approved for claudication and has few adverse effects or risks. While this treatment is off-label for GA, there are no FDA approved treatments.

During a follow-up visit 1 month later, the number of lesions had been reduced by half. The FP continued treating the patient with pentoxifylline with the hope of achieving full resolution.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mauskar M, Usatine R. Granuloma annulare. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1141-1146.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The FP thought this looked like granuloma annulare (GA) but had never seen so many lesions on a patient. Some lesions were not round (more oval or elongated), while others were not completely enclosed geometric shapes (with breaks in the multiple ring patterns). However, all of the lesions were slightly raised with erythema and no scale. (The FP also considered tinea corporis, but ruled it out because there was no scale.)

He consulted some Internet resources and was convinced that this was disseminated GA. The greatest risk factor for this somewhat mysterious disease of unknown origin is female gender. It is also often associated with diabetes, but diabetes is not the cause.

Although intralesional steroids work when treating disseminated GA, this approach is not realistic for widespread disease. A number of options have been studied and reported in small series or case reports. The FP presented various options to the patient, and together they decided to try pentoxifylline 400 mg 3 times daily for systemic treatment. Pentoxifylline is approved for claudication and has few adverse effects or risks. While this treatment is off-label for GA, there are no FDA approved treatments.

During a follow-up visit 1 month later, the number of lesions had been reduced by half. The FP continued treating the patient with pentoxifylline with the hope of achieving full resolution.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mauskar M, Usatine R. Granuloma annulare. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1141-1146.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The FP thought this looked like granuloma annulare (GA) but had never seen so many lesions on a patient. Some lesions were not round (more oval or elongated), while others were not completely enclosed geometric shapes (with breaks in the multiple ring patterns). However, all of the lesions were slightly raised with erythema and no scale. (The FP also considered tinea corporis, but ruled it out because there was no scale.)

He consulted some Internet resources and was convinced that this was disseminated GA. The greatest risk factor for this somewhat mysterious disease of unknown origin is female gender. It is also often associated with diabetes, but diabetes is not the cause.

Although intralesional steroids work when treating disseminated GA, this approach is not realistic for widespread disease. A number of options have been studied and reported in small series or case reports. The FP presented various options to the patient, and together they decided to try pentoxifylline 400 mg 3 times daily for systemic treatment. Pentoxifylline is approved for claudication and has few adverse effects or risks. While this treatment is off-label for GA, there are no FDA approved treatments.

During a follow-up visit 1 month later, the number of lesions had been reduced by half. The FP continued treating the patient with pentoxifylline with the hope of achieving full resolution.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mauskar M, Usatine R. Granuloma annulare. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1141-1146.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

As the Vascular Annual Meeting approaches, we hope you are gearing up for a great few days of vascular programming, networking, receptions and fun! We invite you to share meeting details with your peers and colleagues on social media to generate excitement and increase attendance. To help you do this, we've put together a social media kit with directions, example posts and images you may use to spread the word about VAM. Start posting with directions listed here.

As the Vascular Annual Meeting approaches, we hope you are gearing up for a great few days of vascular programming, networking, receptions and fun! We invite you to share meeting details with your peers and colleagues on social media to generate excitement and increase attendance. To help you do this, we've put together a social media kit with directions, example posts and images you may use to spread the word about VAM. Start posting with directions listed here.

As the Vascular Annual Meeting approaches, we hope you are gearing up for a great few days of vascular programming, networking, receptions and fun! We invite you to share meeting details with your peers and colleagues on social media to generate excitement and increase attendance. To help you do this, we've put together a social media kit with directions, example posts and images you may use to spread the word about VAM. Start posting with directions listed here.

A community has opened specifically for our PA Section members on SVSConnect. This community is meant to provide a private space for vascular PAs to engage and collaborate with one another. Members will be able to have in depth discussions surrounding important issues including case complications and surgical procedures, research projects, wellness topics and much more. If you haven’t logged into SVSConnect yet, what are you waiting for? All you need are your SVS log in credentials to get started. Email communications@vascularsociety.org or call 312-334-2300 with questions. Sign in here.

A community has opened specifically for our PA Section members on SVSConnect. This community is meant to provide a private space for vascular PAs to engage and collaborate with one another. Members will be able to have in depth discussions surrounding important issues including case complications and surgical procedures, research projects, wellness topics and much more. If you haven’t logged into SVSConnect yet, what are you waiting for? All you need are your SVS log in credentials to get started. Email communications@vascularsociety.org or call 312-334-2300 with questions. Sign in here.

A community has opened specifically for our PA Section members on SVSConnect. This community is meant to provide a private space for vascular PAs to engage and collaborate with one another. Members will be able to have in depth discussions surrounding important issues including case complications and surgical procedures, research projects, wellness topics and much more. If you haven’t logged into SVSConnect yet, what are you waiting for? All you need are your SVS log in credentials to get started. Email communications@vascularsociety.org or call 312-334-2300 with questions. Sign in here.

Requirements for starting a vascular surgery training program have been lightened – you no longer need to have a general surgery residency at your institution and faculty requirements are in review. Because of this, SVS members are available to encourage and assist with the formation of new vascular surgery training programs. From 9:30 a.m. to 10:30 a.m. on Friday, June 14, at the Vascular Annual Meeting, an information session will be held for those interested in establishing a vascular training program. If you’re heading to the meeting in June, stop by National Harbor 4 Room at the Gaylord National to hear more about this. Register for VAM today.

Requirements for starting a vascular surgery training program have been lightened – you no longer need to have a general surgery residency at your institution and faculty requirements are in review. Because of this, SVS members are available to encourage and assist with the formation of new vascular surgery training programs. From 9:30 a.m. to 10:30 a.m. on Friday, June 14, at the Vascular Annual Meeting, an information session will be held for those interested in establishing a vascular training program. If you’re heading to the meeting in June, stop by National Harbor 4 Room at the Gaylord National to hear more about this. Register for VAM today.

Requirements for starting a vascular surgery training program have been lightened – you no longer need to have a general surgery residency at your institution and faculty requirements are in review. Because of this, SVS members are available to encourage and assist with the formation of new vascular surgery training programs. From 9:30 a.m. to 10:30 a.m. on Friday, June 14, at the Vascular Annual Meeting, an information session will be held for those interested in establishing a vascular training program. If you’re heading to the meeting in June, stop by National Harbor 4 Room at the Gaylord National to hear more about this. Register for VAM today.

SAN DIEGO – Ethnicity influences the effect of body mass index on metabolic syndrome and other obesity-associated diseases, results from a large survey of national data showed.

Doug Brunk/MDedge News

“It appears that not all components of metabolic syndrome directly correlate with visceral fat,” lead study author Patrick Chen, DO, said at the annual Digestive Disease Week.

According to Dr. Chen, a gastroenterology fellow at Wright State University, Dayton, Ohio, the prevalence of obesity in the United States increased from 30.5% in 2000 to 39.6% in 2015, a condition that costs the U.S. medical system $150 billion each year and is associated with 19% of all deaths. “We also know that abdominal visceral fat is more associated with mortality and cardiac events than overall adiposity, while visceral fat contributes to nonalcoholic fatty liver disease and metabolic syndrome,” he said.

For Asian populations, the World Health Organization has set body mass indexes of 23 kg/m² for overweight and 27.5 kg/m² for obesity. “This has led to an ongoing debate as to whether we should be adopting regional anthropometric criteria based on race-unique risk factors,” Dr. Chen said. “Despite all of these association studies, the mechanisms are still undergoing research and still unknown to this day.”

For the current analysis, he and his colleagues assessed the prevalence of type 2 diabetes, hypertension, and hyperlipidemia and the impact of increasing BMI among racial groups in the United States. They drew from the National Ambulatory Medical Care Survey from 2011 to 2015 to collect and compare data on patient race, BMI, and the prevalence of type 2 diabetes, hypertension, and dyslipidemia, and used SPSS software for chi-square analysis. They excluded patients under the age of 18, those with type 1 diabetes, those with no listed race, and Native American populations, “since there were too few patients for meaningful analysis,” he said.

The 69,949 patients in the analysis included 57,448 whites, 9,281 African Americans, and 2,142 Asians. The majority (64,091) were listed as non-Hispanic, while 5,858 were listed as Hispanic. The mean age of the study population ranged from 49 to 55 years. African Americans had the highest mean BMI (31 kg/m²), followed by whites (29 kg/m²) and Asians (25 kg/m²). Meanwhile, both Hispanics and non-Hispanics had a mean BMI of 29 kg/m².

Dr. Chen reported that African Americans (19.3%) and Asians (18.5%) had a higher prevalence of type 2 diabetes compared with whites (13.4%; P less than .001), while Hispanics had a higher prevalence of type 2 diabetes compared with non-Hispanics (18.9% vs. 13.9%; P less than .001). At the same time, African Americans had a higher prevalence of hypertension (49.6%) compared with whites (38.2%) and Asians (37.9%; P less than .001 for both associations), while non-Hispanics had a higher prevalence of hypertension compared with Hispanics (40.4% vs. 33.1%; P less than .001). Asians had a higher prevalence of hyperlipidemia (28.4%) compared with whites (25.6%; P = .004); both groups had a higher prevalence compared with African Americans (21.9%, P less than .001). Hispanics had a lower prevalence of hyperlipidemia compared with non-Hispanics (23.6% vs. 25.1%; P = .005).

“Diabetes, hypertension, and hyperlipidemia likely have different mechanisms that lead to different race’s predisposition to these diseases,” Dr. Chen concluded. “This study supports that regional anthropometric criteria should be done based on ethnicity-specific risk factors. Some food for thought is whether we need to change our screening guidelines for conditions like diabetes for Asian patients and hypertension in African American patients. We should also consider ethnicity when we look for NAFLD. Overall, continued research is needed to explain these correlations.”

The researchers reported having no financial disclosures.

dbrunk@mdedge.com

SOURCE: Chen P et al. DDW 2019, Abstract 447.

SAN DIEGO – Ethnicity influences the effect of body mass index on metabolic syndrome and other obesity-associated diseases, results from a large survey of national data showed.

Doug Brunk/MDedge News

“It appears that not all components of metabolic syndrome directly correlate with visceral fat,” lead study author Patrick Chen, DO, said at the annual Digestive Disease Week.

According to Dr. Chen, a gastroenterology fellow at Wright State University, Dayton, Ohio, the prevalence of obesity in the United States increased from 30.5% in 2000 to 39.6% in 2015, a condition that costs the U.S. medical system $150 billion each year and is associated with 19% of all deaths. “We also know that abdominal visceral fat is more associated with mortality and cardiac events than overall adiposity, while visceral fat contributes to nonalcoholic fatty liver disease and metabolic syndrome,” he said.

For Asian populations, the World Health Organization has set body mass indexes of 23 kg/m² for overweight and 27.5 kg/m² for obesity. “This has led to an ongoing debate as to whether we should be adopting regional anthropometric criteria based on race-unique risk factors,” Dr. Chen said. “Despite all of these association studies, the mechanisms are still undergoing research and still unknown to this day.”

For the current analysis, he and his colleagues assessed the prevalence of type 2 diabetes, hypertension, and hyperlipidemia and the impact of increasing BMI among racial groups in the United States. They drew from the National Ambulatory Medical Care Survey from 2011 to 2015 to collect and compare data on patient race, BMI, and the prevalence of type 2 diabetes, hypertension, and dyslipidemia, and used SPSS software for chi-square analysis. They excluded patients under the age of 18, those with type 1 diabetes, those with no listed race, and Native American populations, “since there were too few patients for meaningful analysis,” he said.

The 69,949 patients in the analysis included 57,448 whites, 9,281 African Americans, and 2,142 Asians. The majority (64,091) were listed as non-Hispanic, while 5,858 were listed as Hispanic. The mean age of the study population ranged from 49 to 55 years. African Americans had the highest mean BMI (31 kg/m²), followed by whites (29 kg/m²) and Asians (25 kg/m²). Meanwhile, both Hispanics and non-Hispanics had a mean BMI of 29 kg/m².

Dr. Chen reported that African Americans (19.3%) and Asians (18.5%) had a higher prevalence of type 2 diabetes compared with whites (13.4%; P less than .001), while Hispanics had a higher prevalence of type 2 diabetes compared with non-Hispanics (18.9% vs. 13.9%; P less than .001). At the same time, African Americans had a higher prevalence of hypertension (49.6%) compared with whites (38.2%) and Asians (37.9%; P less than .001 for both associations), while non-Hispanics had a higher prevalence of hypertension compared with Hispanics (40.4% vs. 33.1%; P less than .001). Asians had a higher prevalence of hyperlipidemia (28.4%) compared with whites (25.6%; P = .004); both groups had a higher prevalence compared with African Americans (21.9%, P less than .001). Hispanics had a lower prevalence of hyperlipidemia compared with non-Hispanics (23.6% vs. 25.1%; P = .005).

“Diabetes, hypertension, and hyperlipidemia likely have different mechanisms that lead to different race’s predisposition to these diseases,” Dr. Chen concluded. “This study supports that regional anthropometric criteria should be done based on ethnicity-specific risk factors. Some food for thought is whether we need to change our screening guidelines for conditions like diabetes for Asian patients and hypertension in African American patients. We should also consider ethnicity when we look for NAFLD. Overall, continued research is needed to explain these correlations.”

The researchers reported having no financial disclosures.

dbrunk@mdedge.com

SOURCE: Chen P et al. DDW 2019, Abstract 447.

SAN DIEGO – Ethnicity influences the effect of body mass index on metabolic syndrome and other obesity-associated diseases, results from a large survey of national data showed.

Doug Brunk/MDedge News

“It appears that not all components of metabolic syndrome directly correlate with visceral fat,” lead study author Patrick Chen, DO, said at the annual Digestive Disease Week.

According to Dr. Chen, a gastroenterology fellow at Wright State University, Dayton, Ohio, the prevalence of obesity in the United States increased from 30.5% in 2000 to 39.6% in 2015, a condition that costs the U.S. medical system $150 billion each year and is associated with 19% of all deaths. “We also know that abdominal visceral fat is more associated with mortality and cardiac events than overall adiposity, while visceral fat contributes to nonalcoholic fatty liver disease and metabolic syndrome,” he said.

For Asian populations, the World Health Organization has set body mass indexes of 23 kg/m² for overweight and 27.5 kg/m² for obesity. “This has led to an ongoing debate as to whether we should be adopting regional anthropometric criteria based on race-unique risk factors,” Dr. Chen said. “Despite all of these association studies, the mechanisms are still undergoing research and still unknown to this day.”

For the current analysis, he and his colleagues assessed the prevalence of type 2 diabetes, hypertension, and hyperlipidemia and the impact of increasing BMI among racial groups in the United States. They drew from the National Ambulatory Medical Care Survey from 2011 to 2015 to collect and compare data on patient race, BMI, and the prevalence of type 2 diabetes, hypertension, and dyslipidemia, and used SPSS software for chi-square analysis. They excluded patients under the age of 18, those with type 1 diabetes, those with no listed race, and Native American populations, “since there were too few patients for meaningful analysis,” he said.

The 69,949 patients in the analysis included 57,448 whites, 9,281 African Americans, and 2,142 Asians. The majority (64,091) were listed as non-Hispanic, while 5,858 were listed as Hispanic. The mean age of the study population ranged from 49 to 55 years. African Americans had the highest mean BMI (31 kg/m²), followed by whites (29 kg/m²) and Asians (25 kg/m²). Meanwhile, both Hispanics and non-Hispanics had a mean BMI of 29 kg/m².

Dr. Chen reported that African Americans (19.3%) and Asians (18.5%) had a higher prevalence of type 2 diabetes compared with whites (13.4%; P less than .001), while Hispanics had a higher prevalence of type 2 diabetes compared with non-Hispanics (18.9% vs. 13.9%; P less than .001). At the same time, African Americans had a higher prevalence of hypertension (49.6%) compared with whites (38.2%) and Asians (37.9%; P less than .001 for both associations), while non-Hispanics had a higher prevalence of hypertension compared with Hispanics (40.4% vs. 33.1%; P less than .001). Asians had a higher prevalence of hyperlipidemia (28.4%) compared with whites (25.6%; P = .004); both groups had a higher prevalence compared with African Americans (21.9%, P less than .001). Hispanics had a lower prevalence of hyperlipidemia compared with non-Hispanics (23.6% vs. 25.1%; P = .005).

“Diabetes, hypertension, and hyperlipidemia likely have different mechanisms that lead to different race’s predisposition to these diseases,” Dr. Chen concluded. “This study supports that regional anthropometric criteria should be done based on ethnicity-specific risk factors. Some food for thought is whether we need to change our screening guidelines for conditions like diabetes for Asian patients and hypertension in African American patients. We should also consider ethnicity when we look for NAFLD. Overall, continued research is needed to explain these correlations.”

The researchers reported having no financial disclosures.

dbrunk@mdedge.com

SOURCE: Chen P et al. DDW 2019, Abstract 447.

The FVIII/W (factor VIII:C/von Willebrand factor antigen) ratio appears to be a reliable biological marker to predict recovery and/or relapse in patients with acquired hemophilia A, according to a retrospective analysis.

Marc Trossaert, MD, PhD, of the CHU de Nantes, France, and colleagues conducted a retrospective analysis of 64 consecutive patients diagnosed with acquired hemophilia A over a period of 15 years (2000-2015). Data were obtained from institutional databases at the Toulouse and Nantes university hospitals in France.

Data collected included patient demographics, comorbidities, biological factors, and information related to immunosuppressive therapy. The findings of the study were published in Haemophilia.

To ascertain normal parameters and uses of the FVIII/W ratio, the team assessed FVIII:C and VWF:Ag levels of 40 healthy individuals and normal parameters of the ratio were defined using these levels.

Among the 64 patients with acquired hemophilia A who were enrolled in the study, 55 patients achieved complete remission. Of that group, 44 patients did not relapse. Researchers had follow-up data of at least 1 year for 22 of these patients. They found that the FVIII/W ratio remained within normal parameters for all 22 patients.

Researchers had follow-up data on 5 of the 11 patients who relapsed during the study period. For 4 of the patients, a decrease of FVIII/W ratio was the first indicator of relapse. In the fifth patient, an abnormal activated partial thromboplastin time (aPTT) displayed before the changes were observed in the FVIII/W ratio.

Dr. Trossaert and his colleagues acknowledged that a key limitation of the study was the retrospective design.

“We cannot eliminate the fact that in these patients less frequent testing may have influenced the chance of seeing a low FVIII/W ratio,” they wrote.

The biomarker now needs to be studied in larger cohorts, the researchers suggested.

No funding sources were reported. The authors reported having no conflicts of interest.

SOURCE: Trossaert M et al. Haemophilia. 2019 May 2. doi: 10.1111/hae.13752.

The FVIII/W (factor VIII:C/von Willebrand factor antigen) ratio appears to be a reliable biological marker to predict recovery and/or relapse in patients with acquired hemophilia A, according to a retrospective analysis.

Marc Trossaert, MD, PhD, of the CHU de Nantes, France, and colleagues conducted a retrospective analysis of 64 consecutive patients diagnosed with acquired hemophilia A over a period of 15 years (2000-2015). Data were obtained from institutional databases at the Toulouse and Nantes university hospitals in France.

Data collected included patient demographics, comorbidities, biological factors, and information related to immunosuppressive therapy. The findings of the study were published in Haemophilia.

To ascertain normal parameters and uses of the FVIII/W ratio, the team assessed FVIII:C and VWF:Ag levels of 40 healthy individuals and normal parameters of the ratio were defined using these levels.

Among the 64 patients with acquired hemophilia A who were enrolled in the study, 55 patients achieved complete remission. Of that group, 44 patients did not relapse. Researchers had follow-up data of at least 1 year for 22 of these patients. They found that the FVIII/W ratio remained within normal parameters for all 22 patients.

Researchers had follow-up data on 5 of the 11 patients who relapsed during the study period. For 4 of the patients, a decrease of FVIII/W ratio was the first indicator of relapse. In the fifth patient, an abnormal activated partial thromboplastin time (aPTT) displayed before the changes were observed in the FVIII/W ratio.

Dr. Trossaert and his colleagues acknowledged that a key limitation of the study was the retrospective design.

“We cannot eliminate the fact that in these patients less frequent testing may have influenced the chance of seeing a low FVIII/W ratio,” they wrote.

The biomarker now needs to be studied in larger cohorts, the researchers suggested.

No funding sources were reported. The authors reported having no conflicts of interest.

SOURCE: Trossaert M et al. Haemophilia. 2019 May 2. doi: 10.1111/hae.13752.

The FVIII/W (factor VIII:C/von Willebrand factor antigen) ratio appears to be a reliable biological marker to predict recovery and/or relapse in patients with acquired hemophilia A, according to a retrospective analysis.

Marc Trossaert, MD, PhD, of the CHU de Nantes, France, and colleagues conducted a retrospective analysis of 64 consecutive patients diagnosed with acquired hemophilia A over a period of 15 years (2000-2015). Data were obtained from institutional databases at the Toulouse and Nantes university hospitals in France.

Data collected included patient demographics, comorbidities, biological factors, and information related to immunosuppressive therapy. The findings of the study were published in Haemophilia.

To ascertain normal parameters and uses of the FVIII/W ratio, the team assessed FVIII:C and VWF:Ag levels of 40 healthy individuals and normal parameters of the ratio were defined using these levels.

Among the 64 patients with acquired hemophilia A who were enrolled in the study, 55 patients achieved complete remission. Of that group, 44 patients did not relapse. Researchers had follow-up data of at least 1 year for 22 of these patients. They found that the FVIII/W ratio remained within normal parameters for all 22 patients.

Researchers had follow-up data on 5 of the 11 patients who relapsed during the study period. For 4 of the patients, a decrease of FVIII/W ratio was the first indicator of relapse. In the fifth patient, an abnormal activated partial thromboplastin time (aPTT) displayed before the changes were observed in the FVIII/W ratio.

Dr. Trossaert and his colleagues acknowledged that a key limitation of the study was the retrospective design.

“We cannot eliminate the fact that in these patients less frequent testing may have influenced the chance of seeing a low FVIII/W ratio,” they wrote.

The biomarker now needs to be studied in larger cohorts, the researchers suggested.

No funding sources were reported. The authors reported having no conflicts of interest.

SOURCE: Trossaert M et al. Haemophilia. 2019 May 2. doi: 10.1111/hae.13752.

NASHVILLE, TENN. – A targeted next-generation sequencing panel rapidly identifies both germline and somatic Lynch syndrome pathogenic mutations in women with – or at risk for – endometrial cancer, according to findings in a prospective patient cohort.

Sharon Worcester/MDedge News

The findings, which also suggest that the incidence of Lynch syndrome among endometrial cancer patients is higher than previously recognized, have “immediate and major implications for the individual patient with endometrial cancer ... and implications for related family members,” Maria Mercedes M. Padron, MD, reported during an e-poster session at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

Of 71 patients included in the study, 67 were undergoing endometrial cancer treatment and 7 (3 among those undergoing endometrial cancer treatment and 4 who did not have endometrial cancer) were known to have Lynch syndrome.

Of the 67 undergoing treatment, 22 (33%) were identified by the direct sequencing panel as having Lynch syndrome mutations, and of those, 7 (10%) had mutations classified as high confidence inactivating mutations in either MLH1, MSH6, PMS2, or MSH2 genes, said Dr. Padron, a research scholar at Icahn School of Medicine at Mount Sinai, New York. The remaining 15 patients had rare mutations and met previously defined phenotypic criteria for Lynch syndrome pathogenicity, she reported.

The sequencing panel–based results were compared with commercially available gene tests, including immunohistochemistry (IHC) and microsatellite instability testing (MSI); 10 patients were identified by IHC to have loss of nuclear mismatch repair (MMR) protein expression, and 8 of those were Lynch syndrome mutation positive. In addition, two patients were MSI-high, and both of those were Lynch syndrome mutation positive.

Thus, two Lynch syndrome patients were missed by direct sequencing, noted Dr. Padron.

However, an additional 10 patients who were not identified as having Lynch syndrome by IHC and MSI testing were potentially identified as such using the sequencing panel, Dr. Padron said, noting that “the pathogenicity of these additional variants needs to be defined.”

Lynch syndrome is a hereditary cancer syndrome caused by germline mutations in DNA MMR genes; it is the third most common malignancy in women and it confers an increased risk of several types of cancer, including colorectal, ovarian, gastric, and endometrial cancer, among others.

“It is estimated that 3% to 5% of endometrial cancers will arise from Lynch syndrome,” Dr. Padron explained during the poster session.

Because the presence of Lynch syndrome directly affects immediate clinical management and future risk-reducing and surveillance strategies for patients and at-risk family members, screening is recommended in all women with endometrial cancer, she added, noting, however, that “the optimum screening method has yet to be established.”

The sequencing panel evaluated in this study – Swift’s Accel-Amplicon Plus Lynch Syndrome Panel – requires only low input amounts of DNA, and in an earlier test using 10 control samples, it exhibited greater than 90% on-target and coverage uniformity. The work flow allowed for data analysis within 2 days, Dr. Padron noted.

The panel then was tested in the current cohort of patients who were referred to a gynecology oncology clinic for either treatment of endometrial cancer or for evaluation of risk for endometrial cancer.

Germline/tumor DNA was isolated and 10 ng DNA was used for targeted exon-level hotspot coverage of MLH1, MSH2, MSH6, and PMS2.

The findings suggest that the prevalence of Lynch syndrome may be six to seven times greater than previously estimated, Dr. Padron said during the poster presentation.

“If confirmed, this would have huge implications for our patients and health care system,” she said, adding that the ability to perform and analyze the sequencing within 48 hours of sample collection using a very low DNA input also was of note.

Taken together, “the findings of this study support future larger studies that can be performed concurrently with current standard of care technologies,” she and her colleagues concluded, noting that such studies would better determine more robust estimates of the prevalence of Lynch syndrome in women with endometrial cancer, help define improved standard-of-care guidelines, and provide future guidance for possible universal/targeted screening programs – all with the goal of improving the clinical care of women.

Dr. Padron reported having no relevant financial disclosures.

sworcester@mdedge.com

NASHVILLE, TENN. – A targeted next-generation sequencing panel rapidly identifies both germline and somatic Lynch syndrome pathogenic mutations in women with – or at risk for – endometrial cancer, according to findings in a prospective patient cohort.

Sharon Worcester/MDedge News

The findings, which also suggest that the incidence of Lynch syndrome among endometrial cancer patients is higher than previously recognized, have “immediate and major implications for the individual patient with endometrial cancer ... and implications for related family members,” Maria Mercedes M. Padron, MD, reported during an e-poster session at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

Of 71 patients included in the study, 67 were undergoing endometrial cancer treatment and 7 (3 among those undergoing endometrial cancer treatment and 4 who did not have endometrial cancer) were known to have Lynch syndrome.

Of the 67 undergoing treatment, 22 (33%) were identified by the direct sequencing panel as having Lynch syndrome mutations, and of those, 7 (10%) had mutations classified as high confidence inactivating mutations in either MLH1, MSH6, PMS2, or MSH2 genes, said Dr. Padron, a research scholar at Icahn School of Medicine at Mount Sinai, New York. The remaining 15 patients had rare mutations and met previously defined phenotypic criteria for Lynch syndrome pathogenicity, she reported.

The sequencing panel–based results were compared with commercially available gene tests, including immunohistochemistry (IHC) and microsatellite instability testing (MSI); 10 patients were identified by IHC to have loss of nuclear mismatch repair (MMR) protein expression, and 8 of those were Lynch syndrome mutation positive. In addition, two patients were MSI-high, and both of those were Lynch syndrome mutation positive.

Thus, two Lynch syndrome patients were missed by direct sequencing, noted Dr. Padron.

However, an additional 10 patients who were not identified as having Lynch syndrome by IHC and MSI testing were potentially identified as such using the sequencing panel, Dr. Padron said, noting that “the pathogenicity of these additional variants needs to be defined.”

Lynch syndrome is a hereditary cancer syndrome caused by germline mutations in DNA MMR genes; it is the third most common malignancy in women and it confers an increased risk of several types of cancer, including colorectal, ovarian, gastric, and endometrial cancer, among others.

“It is estimated that 3% to 5% of endometrial cancers will arise from Lynch syndrome,” Dr. Padron explained during the poster session.

Because the presence of Lynch syndrome directly affects immediate clinical management and future risk-reducing and surveillance strategies for patients and at-risk family members, screening is recommended in all women with endometrial cancer, she added, noting, however, that “the optimum screening method has yet to be established.”

The sequencing panel evaluated in this study – Swift’s Accel-Amplicon Plus Lynch Syndrome Panel – requires only low input amounts of DNA, and in an earlier test using 10 control samples, it exhibited greater than 90% on-target and coverage uniformity. The work flow allowed for data analysis within 2 days, Dr. Padron noted.

The panel then was tested in the current cohort of patients who were referred to a gynecology oncology clinic for either treatment of endometrial cancer or for evaluation of risk for endometrial cancer.

Germline/tumor DNA was isolated and 10 ng DNA was used for targeted exon-level hotspot coverage of MLH1, MSH2, MSH6, and PMS2.

The findings suggest that the prevalence of Lynch syndrome may be six to seven times greater than previously estimated, Dr. Padron said during the poster presentation.

“If confirmed, this would have huge implications for our patients and health care system,” she said, adding that the ability to perform and analyze the sequencing within 48 hours of sample collection using a very low DNA input also was of note.

Taken together, “the findings of this study support future larger studies that can be performed concurrently with current standard of care technologies,” she and her colleagues concluded, noting that such studies would better determine more robust estimates of the prevalence of Lynch syndrome in women with endometrial cancer, help define improved standard-of-care guidelines, and provide future guidance for possible universal/targeted screening programs – all with the goal of improving the clinical care of women.

Dr. Padron reported having no relevant financial disclosures.

sworcester@mdedge.com

NASHVILLE, TENN. – A targeted next-generation sequencing panel rapidly identifies both germline and somatic Lynch syndrome pathogenic mutations in women with – or at risk for – endometrial cancer, according to findings in a prospective patient cohort.

Sharon Worcester/MDedge News

The findings, which also suggest that the incidence of Lynch syndrome among endometrial cancer patients is higher than previously recognized, have “immediate and major implications for the individual patient with endometrial cancer ... and implications for related family members,” Maria Mercedes M. Padron, MD, reported during an e-poster session at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

Of 71 patients included in the study, 67 were undergoing endometrial cancer treatment and 7 (3 among those undergoing endometrial cancer treatment and 4 who did not have endometrial cancer) were known to have Lynch syndrome.

Of the 67 undergoing treatment, 22 (33%) were identified by the direct sequencing panel as having Lynch syndrome mutations, and of those, 7 (10%) had mutations classified as high confidence inactivating mutations in either MLH1, MSH6, PMS2, or MSH2 genes, said Dr. Padron, a research scholar at Icahn School of Medicine at Mount Sinai, New York. The remaining 15 patients had rare mutations and met previously defined phenotypic criteria for Lynch syndrome pathogenicity, she reported.

The sequencing panel–based results were compared with commercially available gene tests, including immunohistochemistry (IHC) and microsatellite instability testing (MSI); 10 patients were identified by IHC to have loss of nuclear mismatch repair (MMR) protein expression, and 8 of those were Lynch syndrome mutation positive. In addition, two patients were MSI-high, and both of those were Lynch syndrome mutation positive.

Thus, two Lynch syndrome patients were missed by direct sequencing, noted Dr. Padron.

However, an additional 10 patients who were not identified as having Lynch syndrome by IHC and MSI testing were potentially identified as such using the sequencing panel, Dr. Padron said, noting that “the pathogenicity of these additional variants needs to be defined.”

Lynch syndrome is a hereditary cancer syndrome caused by germline mutations in DNA MMR genes; it is the third most common malignancy in women and it confers an increased risk of several types of cancer, including colorectal, ovarian, gastric, and endometrial cancer, among others.

“It is estimated that 3% to 5% of endometrial cancers will arise from Lynch syndrome,” Dr. Padron explained during the poster session.

Because the presence of Lynch syndrome directly affects immediate clinical management and future risk-reducing and surveillance strategies for patients and at-risk family members, screening is recommended in all women with endometrial cancer, she added, noting, however, that “the optimum screening method has yet to be established.”

The sequencing panel evaluated in this study – Swift’s Accel-Amplicon Plus Lynch Syndrome Panel – requires only low input amounts of DNA, and in an earlier test using 10 control samples, it exhibited greater than 90% on-target and coverage uniformity. The work flow allowed for data analysis within 2 days, Dr. Padron noted.

The panel then was tested in the current cohort of patients who were referred to a gynecology oncology clinic for either treatment of endometrial cancer or for evaluation of risk for endometrial cancer.

Germline/tumor DNA was isolated and 10 ng DNA was used for targeted exon-level hotspot coverage of MLH1, MSH2, MSH6, and PMS2.

The findings suggest that the prevalence of Lynch syndrome may be six to seven times greater than previously estimated, Dr. Padron said during the poster presentation.

“If confirmed, this would have huge implications for our patients and health care system,” she said, adding that the ability to perform and analyze the sequencing within 48 hours of sample collection using a very low DNA input also was of note.

Taken together, “the findings of this study support future larger studies that can be performed concurrently with current standard of care technologies,” she and her colleagues concluded, noting that such studies would better determine more robust estimates of the prevalence of Lynch syndrome in women with endometrial cancer, help define improved standard-of-care guidelines, and provide future guidance for possible universal/targeted screening programs – all with the goal of improving the clinical care of women.

Dr. Padron reported having no relevant financial disclosures.

sworcester@mdedge.com

Adolescents and adults had similar weight loss after bariatric surgery, but diabetes and hypertension reoccurred more often in the older cohort, according to two related studies of 5-year outcomes after Roux-en-Y gastric bypass.

However, despite adolescents’ better outcomes for diabetes and hypertension, their rate of abdominal reoperations was significantly higher during the 5-year follow-up period, and at 2 years post surgery, they were found to have low ferritin levels. The rates of death were similar in the two groups at 5 years.

“We have documented similar and durable weight loss after gastric bypass in adolescents and adults, but important differences between these cohorts were observed in specific health outcomes,” wrote Thomas H. Inge, MD, PhD, of the University of Colorado at Denver, Aurora, and his coauthors. The study was published in the New England Journal of Medicine.

To evaluate and compare outcomes after bariatric surgery, the researchers undertook the Teen–Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study and the LABS study. The two were related but independent observational studies of postsurgery patient cohorts. The Teen-LABS study included 161 adolescents with severe obesity, and the LABS study included 396 adults who reported becoming obese during adolescence.

At 5-year follow-up, there was no significant difference in mean percentage weight change between adolescents (−26%; 95% confidence interval, −29 to −23) and adults (−29%; 95% CI, −31 to −27; P = .08). Adolescents were more likely than were adults to have remission of type 2 diabetes (86% vs. 53%, respectively; risk ratio, 1.27; 95% CI, 1.03 to 1.57; P = .03) as well as hypertension (68% vs. 41%; risk ratio, 1.51; 95% CI, 1.21 to 1.88; P less than .001).

In addition, 20% of adolescents and 16% of adults underwent intra-abdominal procedures within 5 years of surgery, with cholecystectomy being the most common, followed by surgery for bowel obstruction or hernia repair, and gastrostomy. At 2 years, ferritin levels were lower in adolescents than in adults (48% of patients vs. 29%, respectively). Five-year ferritin levels were not assessed.

In all, three adolescents (1.9%) and seven adults (1.8%) died over the 5-year period. Among the adolescents, one patient with type 1 diabetes died 3 years after surgery from complications after a hypoglycemic episode, and the other two deaths, both 4 years after surgery, were consistent with overdose. Among the adults, three of the deaths occurred within 3 weeks of surgery and were related to gastric bypass, two were of indeterminate cause (at 11 months and 5 years after surgery), one was by suicide at 3 years, and one was from colon cancer at 4 years.

The authors acknowledged the limitations of their study, including its observational design, low counts for some of the outcomes, and a lack of nonsurgical controls. They also noted potential unmeasured biases in the adult cohort, including the effects of weight cycling and inaccuracies in recalling adolescent weight issues.

The study and several of its authors were supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases. Several authors reported receiving grants, honoraria, and consulting fees from medical technology and pharmaceutical companies.

SOURCE: Inge TH et al. N Engl J Med. 2019 May 16. doi: 10.1056/NEJMoa1813909.

Adolescents and adults had similar weight loss after bariatric surgery, but diabetes and hypertension reoccurred more often in the older cohort, according to two related studies of 5-year outcomes after Roux-en-Y gastric bypass.

However, despite adolescents’ better outcomes for diabetes and hypertension, their rate of abdominal reoperations was significantly higher during the 5-year follow-up period, and at 2 years post surgery, they were found to have low ferritin levels. The rates of death were similar in the two groups at 5 years.

“We have documented similar and durable weight loss after gastric bypass in adolescents and adults, but important differences between these cohorts were observed in specific health outcomes,” wrote Thomas H. Inge, MD, PhD, of the University of Colorado at Denver, Aurora, and his coauthors. The study was published in the New England Journal of Medicine.

To evaluate and compare outcomes after bariatric surgery, the researchers undertook the Teen–Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study and the LABS study. The two were related but independent observational studies of postsurgery patient cohorts. The Teen-LABS study included 161 adolescents with severe obesity, and the LABS study included 396 adults who reported becoming obese during adolescence.

At 5-year follow-up, there was no significant difference in mean percentage weight change between adolescents (−26%; 95% confidence interval, −29 to −23) and adults (−29%; 95% CI, −31 to −27; P = .08). Adolescents were more likely than were adults to have remission of type 2 diabetes (86% vs. 53%, respectively; risk ratio, 1.27; 95% CI, 1.03 to 1.57; P = .03) as well as hypertension (68% vs. 41%; risk ratio, 1.51; 95% CI, 1.21 to 1.88; P less than .001).

In addition, 20% of adolescents and 16% of adults underwent intra-abdominal procedures within 5 years of surgery, with cholecystectomy being the most common, followed by surgery for bowel obstruction or hernia repair, and gastrostomy. At 2 years, ferritin levels were lower in adolescents than in adults (48% of patients vs. 29%, respectively). Five-year ferritin levels were not assessed.

In all, three adolescents (1.9%) and seven adults (1.8%) died over the 5-year period. Among the adolescents, one patient with type 1 diabetes died 3 years after surgery from complications after a hypoglycemic episode, and the other two deaths, both 4 years after surgery, were consistent with overdose. Among the adults, three of the deaths occurred within 3 weeks of surgery and were related to gastric bypass, two were of indeterminate cause (at 11 months and 5 years after surgery), one was by suicide at 3 years, and one was from colon cancer at 4 years.

The authors acknowledged the limitations of their study, including its observational design, low counts for some of the outcomes, and a lack of nonsurgical controls. They also noted potential unmeasured biases in the adult cohort, including the effects of weight cycling and inaccuracies in recalling adolescent weight issues.

The study and several of its authors were supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases. Several authors reported receiving grants, honoraria, and consulting fees from medical technology and pharmaceutical companies.

SOURCE: Inge TH et al. N Engl J Med. 2019 May 16. doi: 10.1056/NEJMoa1813909.

Adolescents and adults had similar weight loss after bariatric surgery, but diabetes and hypertension reoccurred more often in the older cohort, according to two related studies of 5-year outcomes after Roux-en-Y gastric bypass.

However, despite adolescents’ better outcomes for diabetes and hypertension, their rate of abdominal reoperations was significantly higher during the 5-year follow-up period, and at 2 years post surgery, they were found to have low ferritin levels. The rates of death were similar in the two groups at 5 years.

“We have documented similar and durable weight loss after gastric bypass in adolescents and adults, but important differences between these cohorts were observed in specific health outcomes,” wrote Thomas H. Inge, MD, PhD, of the University of Colorado at Denver, Aurora, and his coauthors. The study was published in the New England Journal of Medicine.

To evaluate and compare outcomes after bariatric surgery, the researchers undertook the Teen–Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study and the LABS study. The two were related but independent observational studies of postsurgery patient cohorts. The Teen-LABS study included 161 adolescents with severe obesity, and the LABS study included 396 adults who reported becoming obese during adolescence.

At 5-year follow-up, there was no significant difference in mean percentage weight change between adolescents (−26%; 95% confidence interval, −29 to −23) and adults (−29%; 95% CI, −31 to −27; P = .08). Adolescents were more likely than were adults to have remission of type 2 diabetes (86% vs. 53%, respectively; risk ratio, 1.27; 95% CI, 1.03 to 1.57; P = .03) as well as hypertension (68% vs. 41%; risk ratio, 1.51; 95% CI, 1.21 to 1.88; P less than .001).

In addition, 20% of adolescents and 16% of adults underwent intra-abdominal procedures within 5 years of surgery, with cholecystectomy being the most common, followed by surgery for bowel obstruction or hernia repair, and gastrostomy. At 2 years, ferritin levels were lower in adolescents than in adults (48% of patients vs. 29%, respectively). Five-year ferritin levels were not assessed.

In all, three adolescents (1.9%) and seven adults (1.8%) died over the 5-year period. Among the adolescents, one patient with type 1 diabetes died 3 years after surgery from complications after a hypoglycemic episode, and the other two deaths, both 4 years after surgery, were consistent with overdose. Among the adults, three of the deaths occurred within 3 weeks of surgery and were related to gastric bypass, two were of indeterminate cause (at 11 months and 5 years after surgery), one was by suicide at 3 years, and one was from colon cancer at 4 years.

The authors acknowledged the limitations of their study, including its observational design, low counts for some of the outcomes, and a lack of nonsurgical controls. They also noted potential unmeasured biases in the adult cohort, including the effects of weight cycling and inaccuracies in recalling adolescent weight issues.

The study and several of its authors were supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases. Several authors reported receiving grants, honoraria, and consulting fees from medical technology and pharmaceutical companies.

SOURCE: Inge TH et al. N Engl J Med. 2019 May 16. doi: 10.1056/NEJMoa1813909.

SAN FRANCISCO – Some physicians are uncomfortable providing mental health care to patients with intellectual disability (ID) because many of the patients’ communications skills are limited. But many resources are available that can help.

In this video, Nita V. Bhatt, MD, MPH, interviews Julie P. Gentile, MD, about some of those resources and discusses how to approach psychiatric treatment interventions for patients with ID.

In addition to the DSM-5, Dr. Gentile said the National Association for the Dually Diagnosed has published the Diagnostic Manual – Intellectual Disability. Another resource is a practical reference manual originally proposed by one of Dr. Gentile’s residents.

“He came into my office for supervision one day and said, ‘You know, there’s all these nuances for psychiatric treatment in this patient population. So we should write a practice, quick reference manual to help clinicians who aren’t able to spend as much time concentrate on this patient population.’ ”

As a result, several residents and faculty members formed a team to produce an 18-chapter book published this year by Springer called the Guide to Intellectual Disabilities: A Clinical Handbook.

Dr. Bhatt is a staff psychiatrist at Twin Valley Behavioral Healthcare, the state psychiatric hospital in Columbus, Ohio. Dr. Gentile is professor and chair of the department of psychiatry at Wright State in Dayton. She is also serves as project director of Ohio’s Telepsychiatry Project for Intellectual Disability and has been awarded more than $7 million in grant funding to support her projects in the field of ID.

Dr. Gentile’s work has been funded by the Ohio Department of Developmental Disabilities and the Ohio Department of Mental Health and Addiction Services.
 

ghenderson@mdedge.com

SAN FRANCISCO – Some physicians are uncomfortable providing mental health care to patients with intellectual disability (ID) because many of the patients’ communications skills are limited. But many resources are available that can help.

In this video, Nita V. Bhatt, MD, MPH, interviews Julie P. Gentile, MD, about some of those resources and discusses how to approach psychiatric treatment interventions for patients with ID.

In addition to the DSM-5, Dr. Gentile said the National Association for the Dually Diagnosed has published the Diagnostic Manual – Intellectual Disability. Another resource is a practical reference manual originally proposed by one of Dr. Gentile’s residents.

“He came into my office for supervision one day and said, ‘You know, there’s all these nuances for psychiatric treatment in this patient population. So we should write a practice, quick reference manual to help clinicians who aren’t able to spend as much time concentrate on this patient population.’ ”

As a result, several residents and faculty members formed a team to produce an 18-chapter book published this year by Springer called the Guide to Intellectual Disabilities: A Clinical Handbook.

Dr. Bhatt is a staff psychiatrist at Twin Valley Behavioral Healthcare, the state psychiatric hospital in Columbus, Ohio. Dr. Gentile is professor and chair of the department of psychiatry at Wright State in Dayton. She is also serves as project director of Ohio’s Telepsychiatry Project for Intellectual Disability and has been awarded more than $7 million in grant funding to support her projects in the field of ID.

Dr. Gentile’s work has been funded by the Ohio Department of Developmental Disabilities and the Ohio Department of Mental Health and Addiction Services.
 

ghenderson@mdedge.com

SAN FRANCISCO – Some physicians are uncomfortable providing mental health care to patients with intellectual disability (ID) because many of the patients’ communications skills are limited. But many resources are available that can help.

In this video, Nita V. Bhatt, MD, MPH, interviews Julie P. Gentile, MD, about some of those resources and discusses how to approach psychiatric treatment interventions for patients with ID.

In addition to the DSM-5, Dr. Gentile said the National Association for the Dually Diagnosed has published the Diagnostic Manual – Intellectual Disability. Another resource is a practical reference manual originally proposed by one of Dr. Gentile’s residents.

“He came into my office for supervision one day and said, ‘You know, there’s all these nuances for psychiatric treatment in this patient population. So we should write a practice, quick reference manual to help clinicians who aren’t able to spend as much time concentrate on this patient population.’ ”

As a result, several residents and faculty members formed a team to produce an 18-chapter book published this year by Springer called the Guide to Intellectual Disabilities: A Clinical Handbook.

Dr. Bhatt is a staff psychiatrist at Twin Valley Behavioral Healthcare, the state psychiatric hospital in Columbus, Ohio. Dr. Gentile is professor and chair of the department of psychiatry at Wright State in Dayton. She is also serves as project director of Ohio’s Telepsychiatry Project for Intellectual Disability and has been awarded more than $7 million in grant funding to support her projects in the field of ID.

Dr. Gentile’s work has been funded by the Ohio Department of Developmental Disabilities and the Ohio Department of Mental Health and Addiction Services.
 

ghenderson@mdedge.com