NASHVILLE, tenn. – Antibiotic use in the first 2 years of life was associated with a small amount of weight gain by 10 years of age, but the amount is “likely clinically insignificant,” according to new data presented at Obesity Week.

Kari Oakes/MDedge News

At 10 years of age, children without chronic health conditions who received any antibiotics had an odds ratio of 1.02 for being overweight or obese; for children with complex chronic conditions, the OR was 1.07 (95% confidence intervals, 0.97-1.07 and 0.96-1.19, respectively). The findings were based on data from almost 60,000 children studied in a large, multi-institutional national cohort.

“This is good news,” said first author Sheryl Rifas-Shiman, MPH, discussing the findings during a poster session. She noted that the 10-year data from the longitudinal study are consistent with findings at the 5-year mark that had previously been reported.

The study comes against the background of a recent meta-analysis finding that children given any antibiotics before age 24 months had a higher body mass index z-score (BMI-z) in childhood than children who didn’t take antibiotics. Disruptions that antibiotics can cause in the gut microbiome have been hypothesized to promote overweight and obesity in children.

The present study was conducted using electronic medical record data from 2009-2016 drawn from institutions participating in PCORnet, a national research collaboration and clearinghouse.

The analysis dichotomized the cohort into those who, by 24 months of age, had received any antibiotics and those who received none. Ms. Rifas-Shiman and her colleagues also looked at a categorical count of the number of antibiotic prescriptions, from 0 to 4 or more.

Finally, they broke the type of antibiotics into narrow- or broad-spectrum, she said in an interview during the poster session. In order for exposure to be considered narrow-spectrum only, the analysis was limited to participants who had no broad-spectrum antibiotic exposure during the same time frame.

The study’s multivariable analysis also took into account complex chronic conditions the children may have had.

Fifty-seven percent of children received antibiotics before the age of 24 months. Patients were overall just under half (48%) female, and about half (49%) were white. Black children made up 37% of the cohort, and Hispanic children constituted 12%.

By 10 years of age, 36% of participants were overweight or obese, with BMIs at or above the 85th percentile, according to 2000 Centers for Disease Control growth charts.

There was a suggestion of a dose-response relationship for both narrow- and broad-spectrum antibiotics because only at the higher antibiotic exposures did increased BMI-z reach statistical significance. However, broad-spectrum antibiotics were not more likely than narrow-spectrum antibiotics to be associated with increased BMI-z.

Other multivariable adjustment took into account site clustering and adjusted for sex, race, ethnicity, preterm birth, asthma or infectious disease diagnoses, and corticosteroid exposure, as well as health care visits in the first 2 years of life.

Limitations of the study included the fact that it was observational, raising the potential for undetected confounders. Also, since the study looked at prescription, rather than dispensing data, there could be some exposure misclassification by which children who were classified as having taken antibiotics did not actually take them or did not take the full amount prescribed.

“Antibiotics should always be used judiciously; however, the long-term risk of childhood obesity from antibiotics in infancy appears to be small and clinically insignificant,” wrote Ms. Rifas-Shiman, of the department of population medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, both in Boston.

The study was funded by an award from the Patient-Centered Outcomes Research Institute.
 

koakes@fdedge.com

SOURCE: Rifas-Shiman et al. Obesity Week 2018, Poster TP-3155.

NASHVILLE, tenn. – Antibiotic use in the first 2 years of life was associated with a small amount of weight gain by 10 years of age, but the amount is “likely clinically insignificant,” according to new data presented at Obesity Week.

Kari Oakes/MDedge News

At 10 years of age, children without chronic health conditions who received any antibiotics had an odds ratio of 1.02 for being overweight or obese; for children with complex chronic conditions, the OR was 1.07 (95% confidence intervals, 0.97-1.07 and 0.96-1.19, respectively). The findings were based on data from almost 60,000 children studied in a large, multi-institutional national cohort.

“This is good news,” said first author Sheryl Rifas-Shiman, MPH, discussing the findings during a poster session. She noted that the 10-year data from the longitudinal study are consistent with findings at the 5-year mark that had previously been reported.

The study comes against the background of a recent meta-analysis finding that children given any antibiotics before age 24 months had a higher body mass index z-score (BMI-z) in childhood than children who didn’t take antibiotics. Disruptions that antibiotics can cause in the gut microbiome have been hypothesized to promote overweight and obesity in children.

The present study was conducted using electronic medical record data from 2009-2016 drawn from institutions participating in PCORnet, a national research collaboration and clearinghouse.

The analysis dichotomized the cohort into those who, by 24 months of age, had received any antibiotics and those who received none. Ms. Rifas-Shiman and her colleagues also looked at a categorical count of the number of antibiotic prescriptions, from 0 to 4 or more.

Finally, they broke the type of antibiotics into narrow- or broad-spectrum, she said in an interview during the poster session. In order for exposure to be considered narrow-spectrum only, the analysis was limited to participants who had no broad-spectrum antibiotic exposure during the same time frame.

The study’s multivariable analysis also took into account complex chronic conditions the children may have had.

Fifty-seven percent of children received antibiotics before the age of 24 months. Patients were overall just under half (48%) female, and about half (49%) were white. Black children made up 37% of the cohort, and Hispanic children constituted 12%.

By 10 years of age, 36% of participants were overweight or obese, with BMIs at or above the 85th percentile, according to 2000 Centers for Disease Control growth charts.

There was a suggestion of a dose-response relationship for both narrow- and broad-spectrum antibiotics because only at the higher antibiotic exposures did increased BMI-z reach statistical significance. However, broad-spectrum antibiotics were not more likely than narrow-spectrum antibiotics to be associated with increased BMI-z.

Other multivariable adjustment took into account site clustering and adjusted for sex, race, ethnicity, preterm birth, asthma or infectious disease diagnoses, and corticosteroid exposure, as well as health care visits in the first 2 years of life.

Limitations of the study included the fact that it was observational, raising the potential for undetected confounders. Also, since the study looked at prescription, rather than dispensing data, there could be some exposure misclassification by which children who were classified as having taken antibiotics did not actually take them or did not take the full amount prescribed.

“Antibiotics should always be used judiciously; however, the long-term risk of childhood obesity from antibiotics in infancy appears to be small and clinically insignificant,” wrote Ms. Rifas-Shiman, of the department of population medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, both in Boston.

The study was funded by an award from the Patient-Centered Outcomes Research Institute.
 

koakes@fdedge.com

SOURCE: Rifas-Shiman et al. Obesity Week 2018, Poster TP-3155.

NASHVILLE, tenn. – Antibiotic use in the first 2 years of life was associated with a small amount of weight gain by 10 years of age, but the amount is “likely clinically insignificant,” according to new data presented at Obesity Week.

Kari Oakes/MDedge News

At 10 years of age, children without chronic health conditions who received any antibiotics had an odds ratio of 1.02 for being overweight or obese; for children with complex chronic conditions, the OR was 1.07 (95% confidence intervals, 0.97-1.07 and 0.96-1.19, respectively). The findings were based on data from almost 60,000 children studied in a large, multi-institutional national cohort.

“This is good news,” said first author Sheryl Rifas-Shiman, MPH, discussing the findings during a poster session. She noted that the 10-year data from the longitudinal study are consistent with findings at the 5-year mark that had previously been reported.

The study comes against the background of a recent meta-analysis finding that children given any antibiotics before age 24 months had a higher body mass index z-score (BMI-z) in childhood than children who didn’t take antibiotics. Disruptions that antibiotics can cause in the gut microbiome have been hypothesized to promote overweight and obesity in children.

The present study was conducted using electronic medical record data from 2009-2016 drawn from institutions participating in PCORnet, a national research collaboration and clearinghouse.

The analysis dichotomized the cohort into those who, by 24 months of age, had received any antibiotics and those who received none. Ms. Rifas-Shiman and her colleagues also looked at a categorical count of the number of antibiotic prescriptions, from 0 to 4 or more.

Finally, they broke the type of antibiotics into narrow- or broad-spectrum, she said in an interview during the poster session. In order for exposure to be considered narrow-spectrum only, the analysis was limited to participants who had no broad-spectrum antibiotic exposure during the same time frame.

The study’s multivariable analysis also took into account complex chronic conditions the children may have had.

Fifty-seven percent of children received antibiotics before the age of 24 months. Patients were overall just under half (48%) female, and about half (49%) were white. Black children made up 37% of the cohort, and Hispanic children constituted 12%.

By 10 years of age, 36% of participants were overweight or obese, with BMIs at or above the 85th percentile, according to 2000 Centers for Disease Control growth charts.

There was a suggestion of a dose-response relationship for both narrow- and broad-spectrum antibiotics because only at the higher antibiotic exposures did increased BMI-z reach statistical significance. However, broad-spectrum antibiotics were not more likely than narrow-spectrum antibiotics to be associated with increased BMI-z.

Other multivariable adjustment took into account site clustering and adjusted for sex, race, ethnicity, preterm birth, asthma or infectious disease diagnoses, and corticosteroid exposure, as well as health care visits in the first 2 years of life.

Limitations of the study included the fact that it was observational, raising the potential for undetected confounders. Also, since the study looked at prescription, rather than dispensing data, there could be some exposure misclassification by which children who were classified as having taken antibiotics did not actually take them or did not take the full amount prescribed.

“Antibiotics should always be used judiciously; however, the long-term risk of childhood obesity from antibiotics in infancy appears to be small and clinically insignificant,” wrote Ms. Rifas-Shiman, of the department of population medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, both in Boston.

The study was funded by an award from the Patient-Centered Outcomes Research Institute.
 

koakes@fdedge.com

SOURCE: Rifas-Shiman et al. Obesity Week 2018, Poster TP-3155.

BERLIN – Demyelinating diseases appear to disrupt white matter development in children, slowing the trajectory of brain growth to almost unmeasurable levels, based on results from a single-center comparison study of 213 individuals.

While children with multiple sclerosis (MS) showed the most severe slowing, even a single demyelinating event slowed white matter growth, Robert A. Brown, PhD, said at the annual congress of the European Committees for Treatment and Research in Multiple Sclerosis.

Dr. Brown of the Montreal Neurological Institute at McGill University, Montreal, employed a signal mass correction of consecutive brain MRIs enhanced with magnetization transfer. Magnetization transfer ratio (MTR) quantifies myelin more effectively than does other imaging enhancement modalities, Dr. Brown said.

“It labels the macromolecules of myelin and correlates almost perfectly with Luxol fast blue stain on histology,” he said. And by measuring myelin instead of whole-brain volume, MTR sidesteps the confounders of inflammation and edema. “When tissue swells, the water dilutes the myelin. MRI is really sensitive to density, so dilution with water lowers that signal.”

But MTR isn’t failsafe either, he said, especially in teens. “A cautionary note: In healthy adolescents, white matter MTR can actually decrease, not increase, not because they are losing myelin but because the axons in brain tissue are growing so fast that they outstrip the production of new myelin. So, we can get another dilution effect here, except that instead of water, axons are diluting the myelin. We have to take that into account when using MTR.”

A volume-corrected MTR calculates both mass and volume to give what Dr. Brown termed signal mass. “We have demonstrated previously that signal mass is about twice as powerful as volume change alone for measuring the differences [in brain volume] between adults with MS and healthy controls.”

The study he presented at ECTRIMS used this technique to examine the trajectory of white matter change in a cohort of children from the Canadian Pediatric Demyelinating Disease Study who were all scanned at the same site in the same center. He compared brain volume at baseline and 1 year in 102 children with a monophasic demyelinating disease, 87 with MS, and 24 healthy, age-matched controls.

The children with MS were a median of about 17 years old at baseline, while those with a monophasic event and healthy controls were a median of about 12 years old. Median follow-up was 1 year in the healthy controls, 2 years in the MS cohort, and 4 years in the monophasic group. The investigators adjusted their comparisons for sex, since both bioavailable testosterone and androgen-receptor activity correlate with decreased MTR in young men. This doesn’t mean, though, that testosterone decreases myelination. Rather, it’s postulated that testosterone increases axonal caliber, which would decrease the number of neurons in each imaging voxel and, thus, the MTR signal (J Neurosci. 2008 Sep 17;28[38]:9519-24).

In the volume-only assessment, white matter in healthy controls increased at a rate of about 0.5% per year. White matter growth was about 0.2% per year in children with monophasic demyelination, which was significantly lower than in healthy controls.

“The MS children had no white matter growth that we could measure,” with an annual change of about 0.01%, Dr. Brown said. “It looks like a failure of normal development and was significantly lower than what we saw in the children with a demyelination event.”

MTR showed the expected age-associated decreases, which were highest among those with MS: –0.8% per year in healthy controls, –0.6% per year in those with a monophasic event, and –0.9% per year in those with MS.

The signal mass change showed the whole picture, Dr. Brown said. Signal mass declined 0.3% per year in healthy controls, 0.5% per year in the monophasic group, and 0.9% per year in the MS group – a significantly worse trajectory than either the control subjects or those with a monophasic event.

“Signal mass puts it all together and gives us the total picture of tissue loss, with quite severe loss in children with MS. It seems as though both monophasic insult and pediatric-onset MS disrupt brain development.”

Dr. Brown has been a consultant for NeuroRx Research and Biogen.

msullivan@mdedge.com

SOURCE: Brown RA et al. Mult Scler. 2018;24(S2):27-8, Abstract 63.

BERLIN – Demyelinating diseases appear to disrupt white matter development in children, slowing the trajectory of brain growth to almost unmeasurable levels, based on results from a single-center comparison study of 213 individuals.

While children with multiple sclerosis (MS) showed the most severe slowing, even a single demyelinating event slowed white matter growth, Robert A. Brown, PhD, said at the annual congress of the European Committees for Treatment and Research in Multiple Sclerosis.

Dr. Brown of the Montreal Neurological Institute at McGill University, Montreal, employed a signal mass correction of consecutive brain MRIs enhanced with magnetization transfer. Magnetization transfer ratio (MTR) quantifies myelin more effectively than does other imaging enhancement modalities, Dr. Brown said.

“It labels the macromolecules of myelin and correlates almost perfectly with Luxol fast blue stain on histology,” he said. And by measuring myelin instead of whole-brain volume, MTR sidesteps the confounders of inflammation and edema. “When tissue swells, the water dilutes the myelin. MRI is really sensitive to density, so dilution with water lowers that signal.”

But MTR isn’t failsafe either, he said, especially in teens. “A cautionary note: In healthy adolescents, white matter MTR can actually decrease, not increase, not because they are losing myelin but because the axons in brain tissue are growing so fast that they outstrip the production of new myelin. So, we can get another dilution effect here, except that instead of water, axons are diluting the myelin. We have to take that into account when using MTR.”

A volume-corrected MTR calculates both mass and volume to give what Dr. Brown termed signal mass. “We have demonstrated previously that signal mass is about twice as powerful as volume change alone for measuring the differences [in brain volume] between adults with MS and healthy controls.”

The study he presented at ECTRIMS used this technique to examine the trajectory of white matter change in a cohort of children from the Canadian Pediatric Demyelinating Disease Study who were all scanned at the same site in the same center. He compared brain volume at baseline and 1 year in 102 children with a monophasic demyelinating disease, 87 with MS, and 24 healthy, age-matched controls.

The children with MS were a median of about 17 years old at baseline, while those with a monophasic event and healthy controls were a median of about 12 years old. Median follow-up was 1 year in the healthy controls, 2 years in the MS cohort, and 4 years in the monophasic group. The investigators adjusted their comparisons for sex, since both bioavailable testosterone and androgen-receptor activity correlate with decreased MTR in young men. This doesn’t mean, though, that testosterone decreases myelination. Rather, it’s postulated that testosterone increases axonal caliber, which would decrease the number of neurons in each imaging voxel and, thus, the MTR signal (J Neurosci. 2008 Sep 17;28[38]:9519-24).

In the volume-only assessment, white matter in healthy controls increased at a rate of about 0.5% per year. White matter growth was about 0.2% per year in children with monophasic demyelination, which was significantly lower than in healthy controls.

“The MS children had no white matter growth that we could measure,” with an annual change of about 0.01%, Dr. Brown said. “It looks like a failure of normal development and was significantly lower than what we saw in the children with a demyelination event.”

MTR showed the expected age-associated decreases, which were highest among those with MS: –0.8% per year in healthy controls, –0.6% per year in those with a monophasic event, and –0.9% per year in those with MS.

The signal mass change showed the whole picture, Dr. Brown said. Signal mass declined 0.3% per year in healthy controls, 0.5% per year in the monophasic group, and 0.9% per year in the MS group – a significantly worse trajectory than either the control subjects or those with a monophasic event.

“Signal mass puts it all together and gives us the total picture of tissue loss, with quite severe loss in children with MS. It seems as though both monophasic insult and pediatric-onset MS disrupt brain development.”

Dr. Brown has been a consultant for NeuroRx Research and Biogen.

msullivan@mdedge.com

SOURCE: Brown RA et al. Mult Scler. 2018;24(S2):27-8, Abstract 63.

BERLIN – Demyelinating diseases appear to disrupt white matter development in children, slowing the trajectory of brain growth to almost unmeasurable levels, based on results from a single-center comparison study of 213 individuals.

While children with multiple sclerosis (MS) showed the most severe slowing, even a single demyelinating event slowed white matter growth, Robert A. Brown, PhD, said at the annual congress of the European Committees for Treatment and Research in Multiple Sclerosis.

Dr. Brown of the Montreal Neurological Institute at McGill University, Montreal, employed a signal mass correction of consecutive brain MRIs enhanced with magnetization transfer. Magnetization transfer ratio (MTR) quantifies myelin more effectively than does other imaging enhancement modalities, Dr. Brown said.

“It labels the macromolecules of myelin and correlates almost perfectly with Luxol fast blue stain on histology,” he said. And by measuring myelin instead of whole-brain volume, MTR sidesteps the confounders of inflammation and edema. “When tissue swells, the water dilutes the myelin. MRI is really sensitive to density, so dilution with water lowers that signal.”

But MTR isn’t failsafe either, he said, especially in teens. “A cautionary note: In healthy adolescents, white matter MTR can actually decrease, not increase, not because they are losing myelin but because the axons in brain tissue are growing so fast that they outstrip the production of new myelin. So, we can get another dilution effect here, except that instead of water, axons are diluting the myelin. We have to take that into account when using MTR.”

A volume-corrected MTR calculates both mass and volume to give what Dr. Brown termed signal mass. “We have demonstrated previously that signal mass is about twice as powerful as volume change alone for measuring the differences [in brain volume] between adults with MS and healthy controls.”

The study he presented at ECTRIMS used this technique to examine the trajectory of white matter change in a cohort of children from the Canadian Pediatric Demyelinating Disease Study who were all scanned at the same site in the same center. He compared brain volume at baseline and 1 year in 102 children with a monophasic demyelinating disease, 87 with MS, and 24 healthy, age-matched controls.

The children with MS were a median of about 17 years old at baseline, while those with a monophasic event and healthy controls were a median of about 12 years old. Median follow-up was 1 year in the healthy controls, 2 years in the MS cohort, and 4 years in the monophasic group. The investigators adjusted their comparisons for sex, since both bioavailable testosterone and androgen-receptor activity correlate with decreased MTR in young men. This doesn’t mean, though, that testosterone decreases myelination. Rather, it’s postulated that testosterone increases axonal caliber, which would decrease the number of neurons in each imaging voxel and, thus, the MTR signal (J Neurosci. 2008 Sep 17;28[38]:9519-24).

In the volume-only assessment, white matter in healthy controls increased at a rate of about 0.5% per year. White matter growth was about 0.2% per year in children with monophasic demyelination, which was significantly lower than in healthy controls.

“The MS children had no white matter growth that we could measure,” with an annual change of about 0.01%, Dr. Brown said. “It looks like a failure of normal development and was significantly lower than what we saw in the children with a demyelination event.”

MTR showed the expected age-associated decreases, which were highest among those with MS: –0.8% per year in healthy controls, –0.6% per year in those with a monophasic event, and –0.9% per year in those with MS.

The signal mass change showed the whole picture, Dr. Brown said. Signal mass declined 0.3% per year in healthy controls, 0.5% per year in the monophasic group, and 0.9% per year in the MS group – a significantly worse trajectory than either the control subjects or those with a monophasic event.

“Signal mass puts it all together and gives us the total picture of tissue loss, with quite severe loss in children with MS. It seems as though both monophasic insult and pediatric-onset MS disrupt brain development.”

Dr. Brown has been a consultant for NeuroRx Research and Biogen.

msullivan@mdedge.com

SOURCE: Brown RA et al. Mult Scler. 2018;24(S2):27-8, Abstract 63.

In October of this year, the first ever Integrative Dermatology Symposium was held in Sacramento, Calif., bringing together board-certified dermatologists, and practitioners of Ayurvedic, Naturopathic, and traditional Chinese medicine (TCM), in one place. This was the first time in the United States that practitioners from these different areas of medicine were brought together to discuss and learn different approaches to skin care and treatment of dermatologic diseases.

Daniel Schwen/CCA-SA 3.0

Of all the medical specialties, it is presumed that dermatology is the most inherently holistic. By examining the hair, skin, and nails, we are able to diagnose internal organ diseases such as liver failure (jaundice, veins on stomach), thyroid disease (madarosis), sarcoidosis, and infectious diseases (cutaneous manifestations of HIV), diabetes (acanthosis nigricans, tripe palm), polycystic ovary syndrome (acne, hirsutism), and porphyria, just to name a few. We are also able to treat cutaneous conditions, such as psoriasis, with biologic medications, treatment that in turn, also benefits internal manifestations such as joint, cardiovascular, and metabolic disease. In TCM and Ayurveda, the skin, hair, body type, and tongue can also be analyzed to diagnose and treat disease.

Salves and skin care routines that would be considered natural or holistic have been “prescribed” by Western dermatologists with an MD license for many years. Most medicines initially come from nature, and it is only in the past century, with the boom in the pharmaceutical industry and development of synthetic prescription medications, that people have forgotten this. Some of this boom has been needed to treat enormous populations, as natural resources can be scarce, and in some cases, only an extract of the plant may be needed for treatment, where other elements may be ineffective or even harmful.

Domeboro solution, Epsom salt soaks, and wet to dry soaks are used to draw out and treat infections. Bleach baths are often used to decrease bacterial load and calm inflammation when treating eczema. In Mohs surgery, Fredrick Mohs initially used a zinc chloride paste on nonmelanoma skin cancers in between stages, before frozen section processing and cosmetic reconstruction made Mohs what it is today. In the days of Hippocrates, food was medicine. If you were “red in the face” your blood was deemed too acidic and alkaline-forming foods or “cold foods” were given. This has now again come full circle with rosacea and evidence supporting a link between disease flares or improvement related to foods and the gut microbiome.

On a photography trip to Wyoming, I learned how Native Americans in the United States wiped the white powder from the bark of aspen trees on their skin and used it as sunscreen. In Mongolia, I learned how fat from a sheep’s bottom was used in beauty skin care routines. It is from native and nomadic people that we can often learn how effective natural methods can be used, especially in cases where the treatment regimens may not be written down. With Ayurveda and TCM, we are lucky that textbooks thousands of years old and professors and schools are available to educate us about these ancient practices.

The rediscovery of ancient treatments through the study of ethnobotany, Ayurveda, and TCM has been fascinating, as most of these approaches focus not just on the skin, but on treating the patient as a whole, inside and out (often depending on the discipline treating mind, body, and spirit), with the effects ultimately benefiting the skin. With the many advances in Western medicine over the past 2,000 years, starting with Hippocrates, it will be interesting to see how we, in the field of dermatology, can still learn from and potentially integrate medicine that originated 3,000-5,000 plus years ago in Ayurveda and 2,000-plus years ago in TCM that is still practiced today. In the future, we hope to have more columns about these specialties and how they are used in skin and beauty.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.

In October of this year, the first ever Integrative Dermatology Symposium was held in Sacramento, Calif., bringing together board-certified dermatologists, and practitioners of Ayurvedic, Naturopathic, and traditional Chinese medicine (TCM), in one place. This was the first time in the United States that practitioners from these different areas of medicine were brought together to discuss and learn different approaches to skin care and treatment of dermatologic diseases.

Daniel Schwen/CCA-SA 3.0

Of all the medical specialties, it is presumed that dermatology is the most inherently holistic. By examining the hair, skin, and nails, we are able to diagnose internal organ diseases such as liver failure (jaundice, veins on stomach), thyroid disease (madarosis), sarcoidosis, and infectious diseases (cutaneous manifestations of HIV), diabetes (acanthosis nigricans, tripe palm), polycystic ovary syndrome (acne, hirsutism), and porphyria, just to name a few. We are also able to treat cutaneous conditions, such as psoriasis, with biologic medications, treatment that in turn, also benefits internal manifestations such as joint, cardiovascular, and metabolic disease. In TCM and Ayurveda, the skin, hair, body type, and tongue can also be analyzed to diagnose and treat disease.

Salves and skin care routines that would be considered natural or holistic have been “prescribed” by Western dermatologists with an MD license for many years. Most medicines initially come from nature, and it is only in the past century, with the boom in the pharmaceutical industry and development of synthetic prescription medications, that people have forgotten this. Some of this boom has been needed to treat enormous populations, as natural resources can be scarce, and in some cases, only an extract of the plant may be needed for treatment, where other elements may be ineffective or even harmful.

Domeboro solution, Epsom salt soaks, and wet to dry soaks are used to draw out and treat infections. Bleach baths are often used to decrease bacterial load and calm inflammation when treating eczema. In Mohs surgery, Fredrick Mohs initially used a zinc chloride paste on nonmelanoma skin cancers in between stages, before frozen section processing and cosmetic reconstruction made Mohs what it is today. In the days of Hippocrates, food was medicine. If you were “red in the face” your blood was deemed too acidic and alkaline-forming foods or “cold foods” were given. This has now again come full circle with rosacea and evidence supporting a link between disease flares or improvement related to foods and the gut microbiome.

On a photography trip to Wyoming, I learned how Native Americans in the United States wiped the white powder from the bark of aspen trees on their skin and used it as sunscreen. In Mongolia, I learned how fat from a sheep’s bottom was used in beauty skin care routines. It is from native and nomadic people that we can often learn how effective natural methods can be used, especially in cases where the treatment regimens may not be written down. With Ayurveda and TCM, we are lucky that textbooks thousands of years old and professors and schools are available to educate us about these ancient practices.

The rediscovery of ancient treatments through the study of ethnobotany, Ayurveda, and TCM has been fascinating, as most of these approaches focus not just on the skin, but on treating the patient as a whole, inside and out (often depending on the discipline treating mind, body, and spirit), with the effects ultimately benefiting the skin. With the many advances in Western medicine over the past 2,000 years, starting with Hippocrates, it will be interesting to see how we, in the field of dermatology, can still learn from and potentially integrate medicine that originated 3,000-5,000 plus years ago in Ayurveda and 2,000-plus years ago in TCM that is still practiced today. In the future, we hope to have more columns about these specialties and how they are used in skin and beauty.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.

In October of this year, the first ever Integrative Dermatology Symposium was held in Sacramento, Calif., bringing together board-certified dermatologists, and practitioners of Ayurvedic, Naturopathic, and traditional Chinese medicine (TCM), in one place. This was the first time in the United States that practitioners from these different areas of medicine were brought together to discuss and learn different approaches to skin care and treatment of dermatologic diseases.

Daniel Schwen/CCA-SA 3.0

Of all the medical specialties, it is presumed that dermatology is the most inherently holistic. By examining the hair, skin, and nails, we are able to diagnose internal organ diseases such as liver failure (jaundice, veins on stomach), thyroid disease (madarosis), sarcoidosis, and infectious diseases (cutaneous manifestations of HIV), diabetes (acanthosis nigricans, tripe palm), polycystic ovary syndrome (acne, hirsutism), and porphyria, just to name a few. We are also able to treat cutaneous conditions, such as psoriasis, with biologic medications, treatment that in turn, also benefits internal manifestations such as joint, cardiovascular, and metabolic disease. In TCM and Ayurveda, the skin, hair, body type, and tongue can also be analyzed to diagnose and treat disease.

Salves and skin care routines that would be considered natural or holistic have been “prescribed” by Western dermatologists with an MD license for many years. Most medicines initially come from nature, and it is only in the past century, with the boom in the pharmaceutical industry and development of synthetic prescription medications, that people have forgotten this. Some of this boom has been needed to treat enormous populations, as natural resources can be scarce, and in some cases, only an extract of the plant may be needed for treatment, where other elements may be ineffective or even harmful.

Domeboro solution, Epsom salt soaks, and wet to dry soaks are used to draw out and treat infections. Bleach baths are often used to decrease bacterial load and calm inflammation when treating eczema. In Mohs surgery, Fredrick Mohs initially used a zinc chloride paste on nonmelanoma skin cancers in between stages, before frozen section processing and cosmetic reconstruction made Mohs what it is today. In the days of Hippocrates, food was medicine. If you were “red in the face” your blood was deemed too acidic and alkaline-forming foods or “cold foods” were given. This has now again come full circle with rosacea and evidence supporting a link between disease flares or improvement related to foods and the gut microbiome.

On a photography trip to Wyoming, I learned how Native Americans in the United States wiped the white powder from the bark of aspen trees on their skin and used it as sunscreen. In Mongolia, I learned how fat from a sheep’s bottom was used in beauty skin care routines. It is from native and nomadic people that we can often learn how effective natural methods can be used, especially in cases where the treatment regimens may not be written down. With Ayurveda and TCM, we are lucky that textbooks thousands of years old and professors and schools are available to educate us about these ancient practices.

The rediscovery of ancient treatments through the study of ethnobotany, Ayurveda, and TCM has been fascinating, as most of these approaches focus not just on the skin, but on treating the patient as a whole, inside and out (often depending on the discipline treating mind, body, and spirit), with the effects ultimately benefiting the skin. With the many advances in Western medicine over the past 2,000 years, starting with Hippocrates, it will be interesting to see how we, in the field of dermatology, can still learn from and potentially integrate medicine that originated 3,000-5,000 plus years ago in Ayurveda and 2,000-plus years ago in TCM that is still practiced today. In the future, we hope to have more columns about these specialties and how they are used in skin and beauty.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.

CHICAGO – Bruton’s tyrosine kinase (BTK) inhibitors are particularly useful in the setting of relapsed mantle cell lymphoma, according to Kristie A. Blum, MD.

Venetoclax and lenalidomide can also be considered in the relapsed mantle cell lymphoma (MCL) setting, Dr. Blum, a professor in the department of hematology and medical oncology at Emory University in Atlanta, said at the American Society of Hematology Meeting on Hematologic Malignancies.

“I tend to favor BTK inhibitors as my first line of therapy,” she said, later qualifying that this applies when clinical trial enrollment is unavailable.
 

Ibrutinib

The BTK inhibitor ibrutinib is well established as a treatment for MCL and for use in the relapsed setting, she said, noting that pooled data from the phase 2 CYC-1104 trial, the phase 2 MCL 2001 (SPARK) trial, and the phase 3 MCL3001 (RAY) trial showed an overall response (OR) rate of 66% in 370 patients and a complete response (CR) rate of 20%.

The median duration of response (DOR) was 18.6 months, median progression-free survival (PFS) was 12.8 months, and median overall survival (OS) was 25 months (Br J Haematol. 2017 Nov;179[3]:430-8).

Adding rituximab to ibrutinib (R-ibrutinib) improved outcomes, at least in one single center phase 2 trial of 50 relapsed patients with a median of three prior therapies, she said. The OR rate in that study was 88%, and the CR rate was 58% (Br J Haematol. 2018 May;182[3]:404-11).

“What was really impressive to me was that the median duration of response was about 46 months. PFS was 43 months, and patients were on [treatment] as long as 56 cycles,” she said.
 

Acalabrutinib

The newer BTK inhibitor acalabrutinib also shows benefit in the relapsed MCL setting, Dr. Blum said.

In a recent multicenter, open-label, phase 2 study of 124 patients with a median age of 68 years and a median of two prior therapies, acalabrutinib at a dose of 100 mg twice daily was associated with an OR rate of 81% and a CR rate of 40% (Lancet. 2018 Feb 17;391:659-67).

“Seems a little better than what you’d expect with single agent ibrutinib,” she said, noting that median DOR and PFS have not been reached in that study.

The main toxicities have been “headache and some diarrhea,” but follow-up is currently only about 15 months, she added.

Venetoclax

Another option in this setting is the B-cell lymphoma 2 (BCL-2) inhibitor venetoclax, which was shown in a recent phase 1 study of patients with various lymphoma subtypes to have activity in relapsed MCL, Dr. Blum said.

The OR rate in 28 relapsed MCL patients in that study was 75%, and the median PFS was 14 months (J Clin Oncol. 2017 Mar;35:826-33).

Additionally, an “intriguing combination study of venetoclax and ibrutinib” was recently published in the New England Journal of Medicine, she noted.

That study included only 23 patients with relapsed MCL, but they were a “pretty high-risk” group with a median age of 68 years, about half having a TP53 abnormality, and 30% having a prior transplant.

The OR and CR rates at 16 weeks by positron emission tomography were 71% and 62%, respectively (N Engl J Med. 2018 Mar 29;378:1211-23).

“Actually, about 40% achieved [minimal residual disease] negativity, but this was only checked in about half the patients,” she said. “So this is an intriguing combination and hopefully something we’ll see more of in the upcoming years.”
 

Lenalidomide

In the randomized phase 2 SPRINT study, patients received either single-agent lenolidamine or the investigator’s choice of single-agent rituximab, gemcitabine, fludarabine, chlorambucil, or cytarabine.

The expected OR rate in 170 patients treated with lenalidomide was 40% versus 11% in 84 patients treated with investigator’s choice of treatment, and the respective CR rates were 5% and 0% (Lancet Oncol. 2016 Mar 1;17(3):319-31).

Median DOR was 16 months versus 10.4 months, PFS was 8.7 versus 5.2 months, and median OS was 27.9 versus 21.1 months in the groups, respectively.
 

Other options

Combination regimens, such as R-CHOP and R-bendamustine, are also options for the treatment of relapsed MCL patients who haven’t received combination therapy in the past, Dr. Blum said. Transplant is another option in some patients.

“I will consider transplants for younger patients if they come to me and they actually hadn’t had one in [their] first CR,” she said.

Dr. Blum is a consultant for Acerta, AstraZeneca, and Molecular Templates and has received research funding from Acerta, AstraZeneca, Celgene, Cephalon, Immunomedics, Janssen, Merck, Millennium, Molecular Templates, Novartis, Pharmacyclics, and Seattle Genetics.

sworcester@mdedge.com

CHICAGO – Bruton’s tyrosine kinase (BTK) inhibitors are particularly useful in the setting of relapsed mantle cell lymphoma, according to Kristie A. Blum, MD.

Venetoclax and lenalidomide can also be considered in the relapsed mantle cell lymphoma (MCL) setting, Dr. Blum, a professor in the department of hematology and medical oncology at Emory University in Atlanta, said at the American Society of Hematology Meeting on Hematologic Malignancies.

“I tend to favor BTK inhibitors as my first line of therapy,” she said, later qualifying that this applies when clinical trial enrollment is unavailable.
 

Ibrutinib

The BTK inhibitor ibrutinib is well established as a treatment for MCL and for use in the relapsed setting, she said, noting that pooled data from the phase 2 CYC-1104 trial, the phase 2 MCL 2001 (SPARK) trial, and the phase 3 MCL3001 (RAY) trial showed an overall response (OR) rate of 66% in 370 patients and a complete response (CR) rate of 20%.

The median duration of response (DOR) was 18.6 months, median progression-free survival (PFS) was 12.8 months, and median overall survival (OS) was 25 months (Br J Haematol. 2017 Nov;179[3]:430-8).

Adding rituximab to ibrutinib (R-ibrutinib) improved outcomes, at least in one single center phase 2 trial of 50 relapsed patients with a median of three prior therapies, she said. The OR rate in that study was 88%, and the CR rate was 58% (Br J Haematol. 2018 May;182[3]:404-11).

“What was really impressive to me was that the median duration of response was about 46 months. PFS was 43 months, and patients were on [treatment] as long as 56 cycles,” she said.
 

Acalabrutinib

The newer BTK inhibitor acalabrutinib also shows benefit in the relapsed MCL setting, Dr. Blum said.

In a recent multicenter, open-label, phase 2 study of 124 patients with a median age of 68 years and a median of two prior therapies, acalabrutinib at a dose of 100 mg twice daily was associated with an OR rate of 81% and a CR rate of 40% (Lancet. 2018 Feb 17;391:659-67).

“Seems a little better than what you’d expect with single agent ibrutinib,” she said, noting that median DOR and PFS have not been reached in that study.

The main toxicities have been “headache and some diarrhea,” but follow-up is currently only about 15 months, she added.

Venetoclax

Another option in this setting is the B-cell lymphoma 2 (BCL-2) inhibitor venetoclax, which was shown in a recent phase 1 study of patients with various lymphoma subtypes to have activity in relapsed MCL, Dr. Blum said.

The OR rate in 28 relapsed MCL patients in that study was 75%, and the median PFS was 14 months (J Clin Oncol. 2017 Mar;35:826-33).

Additionally, an “intriguing combination study of venetoclax and ibrutinib” was recently published in the New England Journal of Medicine, she noted.

That study included only 23 patients with relapsed MCL, but they were a “pretty high-risk” group with a median age of 68 years, about half having a TP53 abnormality, and 30% having a prior transplant.

The OR and CR rates at 16 weeks by positron emission tomography were 71% and 62%, respectively (N Engl J Med. 2018 Mar 29;378:1211-23).

“Actually, about 40% achieved [minimal residual disease] negativity, but this was only checked in about half the patients,” she said. “So this is an intriguing combination and hopefully something we’ll see more of in the upcoming years.”
 

Lenalidomide

In the randomized phase 2 SPRINT study, patients received either single-agent lenolidamine or the investigator’s choice of single-agent rituximab, gemcitabine, fludarabine, chlorambucil, or cytarabine.

The expected OR rate in 170 patients treated with lenalidomide was 40% versus 11% in 84 patients treated with investigator’s choice of treatment, and the respective CR rates were 5% and 0% (Lancet Oncol. 2016 Mar 1;17(3):319-31).

Median DOR was 16 months versus 10.4 months, PFS was 8.7 versus 5.2 months, and median OS was 27.9 versus 21.1 months in the groups, respectively.
 

Other options

Combination regimens, such as R-CHOP and R-bendamustine, are also options for the treatment of relapsed MCL patients who haven’t received combination therapy in the past, Dr. Blum said. Transplant is another option in some patients.

“I will consider transplants for younger patients if they come to me and they actually hadn’t had one in [their] first CR,” she said.

Dr. Blum is a consultant for Acerta, AstraZeneca, and Molecular Templates and has received research funding from Acerta, AstraZeneca, Celgene, Cephalon, Immunomedics, Janssen, Merck, Millennium, Molecular Templates, Novartis, Pharmacyclics, and Seattle Genetics.

sworcester@mdedge.com

CHICAGO – Bruton’s tyrosine kinase (BTK) inhibitors are particularly useful in the setting of relapsed mantle cell lymphoma, according to Kristie A. Blum, MD.

Venetoclax and lenalidomide can also be considered in the relapsed mantle cell lymphoma (MCL) setting, Dr. Blum, a professor in the department of hematology and medical oncology at Emory University in Atlanta, said at the American Society of Hematology Meeting on Hematologic Malignancies.

“I tend to favor BTK inhibitors as my first line of therapy,” she said, later qualifying that this applies when clinical trial enrollment is unavailable.
 

Ibrutinib

The BTK inhibitor ibrutinib is well established as a treatment for MCL and for use in the relapsed setting, she said, noting that pooled data from the phase 2 CYC-1104 trial, the phase 2 MCL 2001 (SPARK) trial, and the phase 3 MCL3001 (RAY) trial showed an overall response (OR) rate of 66% in 370 patients and a complete response (CR) rate of 20%.

The median duration of response (DOR) was 18.6 months, median progression-free survival (PFS) was 12.8 months, and median overall survival (OS) was 25 months (Br J Haematol. 2017 Nov;179[3]:430-8).

Adding rituximab to ibrutinib (R-ibrutinib) improved outcomes, at least in one single center phase 2 trial of 50 relapsed patients with a median of three prior therapies, she said. The OR rate in that study was 88%, and the CR rate was 58% (Br J Haematol. 2018 May;182[3]:404-11).

“What was really impressive to me was that the median duration of response was about 46 months. PFS was 43 months, and patients were on [treatment] as long as 56 cycles,” she said.
 

Acalabrutinib

The newer BTK inhibitor acalabrutinib also shows benefit in the relapsed MCL setting, Dr. Blum said.

In a recent multicenter, open-label, phase 2 study of 124 patients with a median age of 68 years and a median of two prior therapies, acalabrutinib at a dose of 100 mg twice daily was associated with an OR rate of 81% and a CR rate of 40% (Lancet. 2018 Feb 17;391:659-67).

“Seems a little better than what you’d expect with single agent ibrutinib,” she said, noting that median DOR and PFS have not been reached in that study.

The main toxicities have been “headache and some diarrhea,” but follow-up is currently only about 15 months, she added.

Venetoclax

Another option in this setting is the B-cell lymphoma 2 (BCL-2) inhibitor venetoclax, which was shown in a recent phase 1 study of patients with various lymphoma subtypes to have activity in relapsed MCL, Dr. Blum said.

The OR rate in 28 relapsed MCL patients in that study was 75%, and the median PFS was 14 months (J Clin Oncol. 2017 Mar;35:826-33).

Additionally, an “intriguing combination study of venetoclax and ibrutinib” was recently published in the New England Journal of Medicine, she noted.

That study included only 23 patients with relapsed MCL, but they were a “pretty high-risk” group with a median age of 68 years, about half having a TP53 abnormality, and 30% having a prior transplant.

The OR and CR rates at 16 weeks by positron emission tomography were 71% and 62%, respectively (N Engl J Med. 2018 Mar 29;378:1211-23).

“Actually, about 40% achieved [minimal residual disease] negativity, but this was only checked in about half the patients,” she said. “So this is an intriguing combination and hopefully something we’ll see more of in the upcoming years.”
 

Lenalidomide

In the randomized phase 2 SPRINT study, patients received either single-agent lenolidamine or the investigator’s choice of single-agent rituximab, gemcitabine, fludarabine, chlorambucil, or cytarabine.

The expected OR rate in 170 patients treated with lenalidomide was 40% versus 11% in 84 patients treated with investigator’s choice of treatment, and the respective CR rates were 5% and 0% (Lancet Oncol. 2016 Mar 1;17(3):319-31).

Median DOR was 16 months versus 10.4 months, PFS was 8.7 versus 5.2 months, and median OS was 27.9 versus 21.1 months in the groups, respectively.
 

Other options

Combination regimens, such as R-CHOP and R-bendamustine, are also options for the treatment of relapsed MCL patients who haven’t received combination therapy in the past, Dr. Blum said. Transplant is another option in some patients.

“I will consider transplants for younger patients if they come to me and they actually hadn’t had one in [their] first CR,” she said.

Dr. Blum is a consultant for Acerta, AstraZeneca, and Molecular Templates and has received research funding from Acerta, AstraZeneca, Celgene, Cephalon, Immunomedics, Janssen, Merck, Millennium, Molecular Templates, Novartis, Pharmacyclics, and Seattle Genetics.

sworcester@mdedge.com

Clinical question: For patients who develop a gastrointestinal bleed (GIB) while using direct oral anticoagulant (DOAC) therapy for atrial fibrillation (AF), does the risk of venous thromboembolism (VTE) or recurrent GIB increase after DOAC resumption?

Background: DOACs are increasingly used for stroke prophylaxis in nonvalvular AF and can increase the risk of GIB by 30% compared to warfarin. Although warfarin can be safely resumed within 14 days of GIB cessation, outcomes related to resuming DOAC therapy after hospitalization for GIB are lacking.

Study design: Retrospective analysis of claims data.

Setting: Patients with AF on DOAC therapy admitted for acute GIB in Michigan.

Dr. Naderi is assistant professor in the division of hospital medicine, University of Colorado, Denver.

Clinical question: For patients who develop a gastrointestinal bleed (GIB) while using direct oral anticoagulant (DOAC) therapy for atrial fibrillation (AF), does the risk of venous thromboembolism (VTE) or recurrent GIB increase after DOAC resumption?

Background: DOACs are increasingly used for stroke prophylaxis in nonvalvular AF and can increase the risk of GIB by 30% compared to warfarin. Although warfarin can be safely resumed within 14 days of GIB cessation, outcomes related to resuming DOAC therapy after hospitalization for GIB are lacking.

Study design: Retrospective analysis of claims data.

Setting: Patients with AF on DOAC therapy admitted for acute GIB in Michigan.

Dr. Naderi is assistant professor in the division of hospital medicine, University of Colorado, Denver.

Clinical question: For patients who develop a gastrointestinal bleed (GIB) while using direct oral anticoagulant (DOAC) therapy for atrial fibrillation (AF), does the risk of venous thromboembolism (VTE) or recurrent GIB increase after DOAC resumption?

Background: DOACs are increasingly used for stroke prophylaxis in nonvalvular AF and can increase the risk of GIB by 30% compared to warfarin. Although warfarin can be safely resumed within 14 days of GIB cessation, outcomes related to resuming DOAC therapy after hospitalization for GIB are lacking.

Study design: Retrospective analysis of claims data.

Setting: Patients with AF on DOAC therapy admitted for acute GIB in Michigan.

Dr. Naderi is assistant professor in the division of hospital medicine, University of Colorado, Denver.

The USPSTF advises primary care physicians to screen for unhealthy alcohol use. Also today, dialysis decisions in elderly patients need to account for comorbidities, chronic liver disease is independently linked to increased risk of falls, and barriers to naloxone remain, despite new access laws.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify

The USPSTF advises primary care physicians to screen for unhealthy alcohol use. Also today, dialysis decisions in elderly patients need to account for comorbidities, chronic liver disease is independently linked to increased risk of falls, and barriers to naloxone remain, despite new access laws.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify

The USPSTF advises primary care physicians to screen for unhealthy alcohol use. Also today, dialysis decisions in elderly patients need to account for comorbidities, chronic liver disease is independently linked to increased risk of falls, and barriers to naloxone remain, despite new access laws.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify

Image by Andre E.X. Brown

New research suggests a scoring system can predict the risk of thrombosis in patients with immune thrombocytopenia (ITP) who are taking anticoagulants.

Researchers tested their Thrombosis and Thrombocytopenia (TH2) risk assessment score in a small group of ITP patients on anticoagulants, and the score identified all seven patients who developed thrombosis.

The researchers also found that patients’ TH2 scores changed quickly—within a matter of days—which suggests they should be re-evaluated for thrombosis risk frequently.

Amaris K. Balitsky, MD, of McMaster University in Hamilton, Ontario, Canada, and her colleagues detailed this research in Blood.

About the score

To develop the TH2 score, the researchers conducted a review of the literature and existing tools used to assess the risk of thrombosis and bleeding. The resulting score consists of two thrombosis items and two bleeding items.

The thrombosis items are:

• High thrombotic risk, which includes patients with atrial fibrillation and a CHA2DS2-VASc score greater than five; unprovoked, recurrent, or cancer-associated thrombosis; or antiphospholipid antibody syndrome
• Receipt of ITP therapies known to increase the risk of thrombosis in the previous 14 days or splenectomy in the previous 30 days.

The score’s bleeding items are:

• Platelet count less than 20 x 10⁹/L
• Major bleeding (grade 2 bleeding that does not involve the skin) observed at a clinical encounter.

Each thrombosis item is assigned a score of +1, and each bleeding item is assigned a score of -1. A positive score or score of 0 suggests a net increased risk of thrombosis, and a negative score suggests a net increased risk of bleeding.

Patient population

The researchers tested the TH2 score in patients enrolled in the McMaster ITP Registry from 2010 to 2017.

There were 314 patients enrolled, but only 13 were receiving anticoagulation and had a platelet count less than 50 x 10⁹/L. Six of these patients were receiving anticoagulation for atrial fibrillation and seven for venous thrombosis. Four patients were taking antiplatelet agents as well.

The median follow up was 9 months (interquartile range, 4.5 to 24 months). During that time, there were 41 clinical encounters. Data on treatment decisions and clinical outcomes were available for 32 of these encounters.

Ten of the 13 patients had anticoagulation withheld at some point during their 22 clinical encounters. Major bleeding was present at five of the encounters. At 17 encounters, patients received additional ITP treatments.

Six of the 10 patients who stopped anticoagulation had new thrombotic events, and two of these events were fatal. Three of the patients had thrombotic events even though they resumed anticoagulation.

The remaining three patients (of the 13) did not stop anticoagulation. These patients received additional ITP treatments at six of their 10 clinical encounters.

Major bleeding was present at two of the 10 encounters, and one new thrombotic event occurred in a patient with metastatic squamous cell cancer (despite continued treatment with warfarin).

Testing the score

The TH2 score accurately predicted all seven thrombotic events.

There were four patients who initially had a negative TH2 score, which suggested an increased risk of bleeding.

However, these patients had a positive or 0 score—suggesting an increased risk of thrombosis—when they were assessed again, after their platelet counts increased above 50 x 10⁹/L.

The remaining three patients had initial scores of 0 and subsequent positive scores, both suggesting an increased risk of thrombosis.

The researchers said these findings suggest patients should be re-evaluated for thrombosis risk frequently, as ITP treatments are given and platelet counts increase.

“The results of our study suggest that the risk of thrombosis is high in patients with ITP who have a separate indication for anticoagulation, especially after ITP therapies are administered and the severe thrombocytopenia improves,” the researchers wrote. “Early resumption of anticoagulation should be considered in this population.”

The researchers also noted that this study was limited by its retrospective, single-center design and the small number of patients evaluated. Therefore, the TH2 score should be validated in additional, larger studies.

One researcher reported relationships with Amgen, Novartis, Rigel Pharmaceuticals, UCB, and Principia Biopharma. The other researchers said they had no competing financial interests.

Image by Andre E.X. Brown

New research suggests a scoring system can predict the risk of thrombosis in patients with immune thrombocytopenia (ITP) who are taking anticoagulants.

Researchers tested their Thrombosis and Thrombocytopenia (TH2) risk assessment score in a small group of ITP patients on anticoagulants, and the score identified all seven patients who developed thrombosis.

The researchers also found that patients’ TH2 scores changed quickly—within a matter of days—which suggests they should be re-evaluated for thrombosis risk frequently.

Amaris K. Balitsky, MD, of McMaster University in Hamilton, Ontario, Canada, and her colleagues detailed this research in Blood.

About the score

To develop the TH2 score, the researchers conducted a review of the literature and existing tools used to assess the risk of thrombosis and bleeding. The resulting score consists of two thrombosis items and two bleeding items.

The thrombosis items are:

• High thrombotic risk, which includes patients with atrial fibrillation and a CHA2DS2-VASc score greater than five; unprovoked, recurrent, or cancer-associated thrombosis; or antiphospholipid antibody syndrome
• Receipt of ITP therapies known to increase the risk of thrombosis in the previous 14 days or splenectomy in the previous 30 days.

The score’s bleeding items are:

• Platelet count less than 20 x 10⁹/L
• Major bleeding (grade 2 bleeding that does not involve the skin) observed at a clinical encounter.

Each thrombosis item is assigned a score of +1, and each bleeding item is assigned a score of -1. A positive score or score of 0 suggests a net increased risk of thrombosis, and a negative score suggests a net increased risk of bleeding.

Patient population

The researchers tested the TH2 score in patients enrolled in the McMaster ITP Registry from 2010 to 2017.

There were 314 patients enrolled, but only 13 were receiving anticoagulation and had a platelet count less than 50 x 10⁹/L. Six of these patients were receiving anticoagulation for atrial fibrillation and seven for venous thrombosis. Four patients were taking antiplatelet agents as well.

The median follow up was 9 months (interquartile range, 4.5 to 24 months). During that time, there were 41 clinical encounters. Data on treatment decisions and clinical outcomes were available for 32 of these encounters.

Ten of the 13 patients had anticoagulation withheld at some point during their 22 clinical encounters. Major bleeding was present at five of the encounters. At 17 encounters, patients received additional ITP treatments.

Six of the 10 patients who stopped anticoagulation had new thrombotic events, and two of these events were fatal. Three of the patients had thrombotic events even though they resumed anticoagulation.

The remaining three patients (of the 13) did not stop anticoagulation. These patients received additional ITP treatments at six of their 10 clinical encounters.

Major bleeding was present at two of the 10 encounters, and one new thrombotic event occurred in a patient with metastatic squamous cell cancer (despite continued treatment with warfarin).

Testing the score

The TH2 score accurately predicted all seven thrombotic events.

There were four patients who initially had a negative TH2 score, which suggested an increased risk of bleeding.

However, these patients had a positive or 0 score—suggesting an increased risk of thrombosis—when they were assessed again, after their platelet counts increased above 50 x 10⁹/L.

The remaining three patients had initial scores of 0 and subsequent positive scores, both suggesting an increased risk of thrombosis.

The researchers said these findings suggest patients should be re-evaluated for thrombosis risk frequently, as ITP treatments are given and platelet counts increase.

“The results of our study suggest that the risk of thrombosis is high in patients with ITP who have a separate indication for anticoagulation, especially after ITP therapies are administered and the severe thrombocytopenia improves,” the researchers wrote. “Early resumption of anticoagulation should be considered in this population.”

The researchers also noted that this study was limited by its retrospective, single-center design and the small number of patients evaluated. Therefore, the TH2 score should be validated in additional, larger studies.

One researcher reported relationships with Amgen, Novartis, Rigel Pharmaceuticals, UCB, and Principia Biopharma. The other researchers said they had no competing financial interests.

Image by Andre E.X. Brown

New research suggests a scoring system can predict the risk of thrombosis in patients with immune thrombocytopenia (ITP) who are taking anticoagulants.

Researchers tested their Thrombosis and Thrombocytopenia (TH2) risk assessment score in a small group of ITP patients on anticoagulants, and the score identified all seven patients who developed thrombosis.

The researchers also found that patients’ TH2 scores changed quickly—within a matter of days—which suggests they should be re-evaluated for thrombosis risk frequently.

Amaris K. Balitsky, MD, of McMaster University in Hamilton, Ontario, Canada, and her colleagues detailed this research in Blood.

About the score

To develop the TH2 score, the researchers conducted a review of the literature and existing tools used to assess the risk of thrombosis and bleeding. The resulting score consists of two thrombosis items and two bleeding items.

The thrombosis items are:

• High thrombotic risk, which includes patients with atrial fibrillation and a CHA2DS2-VASc score greater than five; unprovoked, recurrent, or cancer-associated thrombosis; or antiphospholipid antibody syndrome
• Receipt of ITP therapies known to increase the risk of thrombosis in the previous 14 days or splenectomy in the previous 30 days.

The score’s bleeding items are:

• Platelet count less than 20 x 10⁹/L
• Major bleeding (grade 2 bleeding that does not involve the skin) observed at a clinical encounter.

Each thrombosis item is assigned a score of +1, and each bleeding item is assigned a score of -1. A positive score or score of 0 suggests a net increased risk of thrombosis, and a negative score suggests a net increased risk of bleeding.

Patient population

The researchers tested the TH2 score in patients enrolled in the McMaster ITP Registry from 2010 to 2017.

There were 314 patients enrolled, but only 13 were receiving anticoagulation and had a platelet count less than 50 x 10⁹/L. Six of these patients were receiving anticoagulation for atrial fibrillation and seven for venous thrombosis. Four patients were taking antiplatelet agents as well.

The median follow up was 9 months (interquartile range, 4.5 to 24 months). During that time, there were 41 clinical encounters. Data on treatment decisions and clinical outcomes were available for 32 of these encounters.

Ten of the 13 patients had anticoagulation withheld at some point during their 22 clinical encounters. Major bleeding was present at five of the encounters. At 17 encounters, patients received additional ITP treatments.

Six of the 10 patients who stopped anticoagulation had new thrombotic events, and two of these events were fatal. Three of the patients had thrombotic events even though they resumed anticoagulation.

The remaining three patients (of the 13) did not stop anticoagulation. These patients received additional ITP treatments at six of their 10 clinical encounters.

Major bleeding was present at two of the 10 encounters, and one new thrombotic event occurred in a patient with metastatic squamous cell cancer (despite continued treatment with warfarin).

Testing the score

The TH2 score accurately predicted all seven thrombotic events.

There were four patients who initially had a negative TH2 score, which suggested an increased risk of bleeding.

However, these patients had a positive or 0 score—suggesting an increased risk of thrombosis—when they were assessed again, after their platelet counts increased above 50 x 10⁹/L.

The remaining three patients had initial scores of 0 and subsequent positive scores, both suggesting an increased risk of thrombosis.

The researchers said these findings suggest patients should be re-evaluated for thrombosis risk frequently, as ITP treatments are given and platelet counts increase.

“The results of our study suggest that the risk of thrombosis is high in patients with ITP who have a separate indication for anticoagulation, especially after ITP therapies are administered and the severe thrombocytopenia improves,” the researchers wrote. “Early resumption of anticoagulation should be considered in this population.”

The researchers also noted that this study was limited by its retrospective, single-center design and the small number of patients evaluated. Therefore, the TH2 score should be validated in additional, larger studies.

One researcher reported relationships with Amgen, Novartis, Rigel Pharmaceuticals, UCB, and Principia Biopharma. The other researchers said they had no competing financial interests.

Image by Difu Wu

Health Canada has approved the use of two tests designed to detect BCR-ABL transcripts in patients with chronic myeloid leukemia (CML)—the MRDx® BCR-ABL Test and the QuantideX qPCR BCR-ABL IS Kit.

MolecularMD’s MRDx® BCR-ABL Test is approved as an aid to monitor tyrosine kinase inhibitor (TKI) therapy in Philadelphia chromosome-positive CML patients.

This test is also approved to identify CML patients in the chronic phase being treated with nilotinib who, after sustaining a deep molecular response of MR4.5, may be eligible to stop treatment and be monitored for treatment-free remission.

Asuragen, Inc.’s QuantideX qPCR BCR-ABL IS Kit is approved for use in CML patients, regardless of whether they are taking a TKI or how their disease is being managed.

The kit is designed to detect and quantify major breakpoint (e13a2, e14a2) BCR-ABL1 fusion transcripts for use in monitoring molecular response.

Both the MRDx® BCR-ABL Test and the QuantideX qPCR BCR-ABL IS Kit are approved in the United States as well.

The QuantideX qPCR BCR-ABL IS Kit is also CE marked for clinical use in the European Union.

Image by Difu Wu

Health Canada has approved the use of two tests designed to detect BCR-ABL transcripts in patients with chronic myeloid leukemia (CML)—the MRDx® BCR-ABL Test and the QuantideX qPCR BCR-ABL IS Kit.

MolecularMD’s MRDx® BCR-ABL Test is approved as an aid to monitor tyrosine kinase inhibitor (TKI) therapy in Philadelphia chromosome-positive CML patients.

This test is also approved to identify CML patients in the chronic phase being treated with nilotinib who, after sustaining a deep molecular response of MR4.5, may be eligible to stop treatment and be monitored for treatment-free remission.

Asuragen, Inc.’s QuantideX qPCR BCR-ABL IS Kit is approved for use in CML patients, regardless of whether they are taking a TKI or how their disease is being managed.

The kit is designed to detect and quantify major breakpoint (e13a2, e14a2) BCR-ABL1 fusion transcripts for use in monitoring molecular response.

Both the MRDx® BCR-ABL Test and the QuantideX qPCR BCR-ABL IS Kit are approved in the United States as well.

The QuantideX qPCR BCR-ABL IS Kit is also CE marked for clinical use in the European Union.

Image by Difu Wu

Health Canada has approved the use of two tests designed to detect BCR-ABL transcripts in patients with chronic myeloid leukemia (CML)—the MRDx® BCR-ABL Test and the QuantideX qPCR BCR-ABL IS Kit.

MolecularMD’s MRDx® BCR-ABL Test is approved as an aid to monitor tyrosine kinase inhibitor (TKI) therapy in Philadelphia chromosome-positive CML patients.

This test is also approved to identify CML patients in the chronic phase being treated with nilotinib who, after sustaining a deep molecular response of MR4.5, may be eligible to stop treatment and be monitored for treatment-free remission.

Asuragen, Inc.’s QuantideX qPCR BCR-ABL IS Kit is approved for use in CML patients, regardless of whether they are taking a TKI or how their disease is being managed.

The kit is designed to detect and quantify major breakpoint (e13a2, e14a2) BCR-ABL1 fusion transcripts for use in monitoring molecular response.

Both the MRDx® BCR-ABL Test and the QuantideX qPCR BCR-ABL IS Kit are approved in the United States as well.

The QuantideX qPCR BCR-ABL IS Kit is also CE marked for clinical use in the European Union.

Photo by Neil Osterweil

BOSTON—Results of a pilot program suggest preoperative management of anemia can reduce transfusion rates and cut costs, but the effect on patient outcomes isn’t clear.

For this program, anemic patients received dietary guidance and supplementation prior to surgery.

This increased day-of-surgery hemoglobin levels, reduced intraoperative and postoperative transfusions, and resulted in a cost savings of more than $100,000 over the life of the program.

Christine M. Cahill, BSN, MS, RN, of the University of Rochester and Strong Memorial Hospital in Rochester, New York, presented these results at AABB 2018 (abstract PBM4-ST4-22*).

“Anemia has been thought of as a relatively benign thing our patients live with, traditionally, but what we have been finding lately is that anemia is actually more serious than we once thought and is an independent risk factor for hospitalization, readmission, increased patient length of stay, loss of function, and diminished quality of life,” Cahill said.

She added that anemia also increases the likelihood that a patient will require transfusions.

The pilot program was implemented with this in mind. The program, which ran from February 2016 through September 2017, was designed to test the feasibility of diagnosing anemia during a cardiology consult visit and implementing an anemia management plan.

During the study period, 240 patients presenting for elective cardiac surgery were screened for anemia, and 58 were diagnosed as anemic (hemoglobin <12 g/dL). These patients were referred for anemia workups, which showed that 33 patients had iron-deficiency anemia, and 25 had anemia from other causes.

Preoperative anemia management for the iron-deficient patients included oral iron for seven patients, intravenous (IV) iron with or without folate for 20 patients, and oral folate with or without vitamin B12 for five patients. One iron-deficient patient could not have surgery delayed for anemia management.

Of the iron-replete patients, one received oral iron, 17 received folate with or without B12, and seven patients were not treated for anemia.

One iron-deficient patient had a reaction to the infusion and did not receive a scheduled second dose due to the need for immediate surgery. A second patient scheduled for IV iron and folate broke an arm and therefore missed an IV infusion appointment. No other complications or reactions occurred.

Results

The researchers compared the 58 patients from the pilot program to control subjects—patients who underwent cardiac surgery from March through July 2015, matched by age, sex, and procedures.

The anemia management group received 10 red blood cell (RBC) units intraoperatively, compared to 68 intraoperative RBC units for controls. The total number of postoperative RBC units was 13 and 22, respectively.

The rate of RBC transfusions was 24% in the anemia management group and 60% in controls (P<0.0001). The average RBC units per patient was 0.4 and 2.07, respectively (P<0.0001).

Patients in the anemia management program also had significantly higher day-of-surgery hemoglobin than controls—11.01 and 10.16 g/dL, respectively (P<0.001).

The program provided an average per-patient savings in acquisition costs of $367.40, an average transfusion cost savings of $1,837, and a total cost savings of $106,546 over the life of the program.

The key to success of a similar program is “to make sure you do your homework,” Cahill said.

Specifically, she recommended feasibility studies, evaluation of the potential impact of infusions on the service, work flow analyses, and cost analyses. It’s also important to get high-level administrative support as well as buy-in from surgeons and patients, she added.

Future studies should include assessment of patient outcomes, safety, and length of intensive care unit and hospital stay, Cahill emphasized.

This study was internally funded. Cahill reported no conflicts of interest.

*The data in the presentation differ from the abstract.

Photo by Neil Osterweil

BOSTON—Results of a pilot program suggest preoperative management of anemia can reduce transfusion rates and cut costs, but the effect on patient outcomes isn’t clear.

For this program, anemic patients received dietary guidance and supplementation prior to surgery.

This increased day-of-surgery hemoglobin levels, reduced intraoperative and postoperative transfusions, and resulted in a cost savings of more than $100,000 over the life of the program.

Christine M. Cahill, BSN, MS, RN, of the University of Rochester and Strong Memorial Hospital in Rochester, New York, presented these results at AABB 2018 (abstract PBM4-ST4-22*).

“Anemia has been thought of as a relatively benign thing our patients live with, traditionally, but what we have been finding lately is that anemia is actually more serious than we once thought and is an independent risk factor for hospitalization, readmission, increased patient length of stay, loss of function, and diminished quality of life,” Cahill said.

She added that anemia also increases the likelihood that a patient will require transfusions.

The pilot program was implemented with this in mind. The program, which ran from February 2016 through September 2017, was designed to test the feasibility of diagnosing anemia during a cardiology consult visit and implementing an anemia management plan.

During the study period, 240 patients presenting for elective cardiac surgery were screened for anemia, and 58 were diagnosed as anemic (hemoglobin <12 g/dL). These patients were referred for anemia workups, which showed that 33 patients had iron-deficiency anemia, and 25 had anemia from other causes.

Preoperative anemia management for the iron-deficient patients included oral iron for seven patients, intravenous (IV) iron with or without folate for 20 patients, and oral folate with or without vitamin B12 for five patients. One iron-deficient patient could not have surgery delayed for anemia management.

Of the iron-replete patients, one received oral iron, 17 received folate with or without B12, and seven patients were not treated for anemia.

One iron-deficient patient had a reaction to the infusion and did not receive a scheduled second dose due to the need for immediate surgery. A second patient scheduled for IV iron and folate broke an arm and therefore missed an IV infusion appointment. No other complications or reactions occurred.

Results

The researchers compared the 58 patients from the pilot program to control subjects—patients who underwent cardiac surgery from March through July 2015, matched by age, sex, and procedures.

The anemia management group received 10 red blood cell (RBC) units intraoperatively, compared to 68 intraoperative RBC units for controls. The total number of postoperative RBC units was 13 and 22, respectively.

The rate of RBC transfusions was 24% in the anemia management group and 60% in controls (P<0.0001). The average RBC units per patient was 0.4 and 2.07, respectively (P<0.0001).

Patients in the anemia management program also had significantly higher day-of-surgery hemoglobin than controls—11.01 and 10.16 g/dL, respectively (P<0.001).

The program provided an average per-patient savings in acquisition costs of $367.40, an average transfusion cost savings of $1,837, and a total cost savings of $106,546 over the life of the program.

The key to success of a similar program is “to make sure you do your homework,” Cahill said.

Specifically, she recommended feasibility studies, evaluation of the potential impact of infusions on the service, work flow analyses, and cost analyses. It’s also important to get high-level administrative support as well as buy-in from surgeons and patients, she added.

Future studies should include assessment of patient outcomes, safety, and length of intensive care unit and hospital stay, Cahill emphasized.

This study was internally funded. Cahill reported no conflicts of interest.

*The data in the presentation differ from the abstract.

Photo by Neil Osterweil

BOSTON—Results of a pilot program suggest preoperative management of anemia can reduce transfusion rates and cut costs, but the effect on patient outcomes isn’t clear.

For this program, anemic patients received dietary guidance and supplementation prior to surgery.

This increased day-of-surgery hemoglobin levels, reduced intraoperative and postoperative transfusions, and resulted in a cost savings of more than $100,000 over the life of the program.

Christine M. Cahill, BSN, MS, RN, of the University of Rochester and Strong Memorial Hospital in Rochester, New York, presented these results at AABB 2018 (abstract PBM4-ST4-22*).

“Anemia has been thought of as a relatively benign thing our patients live with, traditionally, but what we have been finding lately is that anemia is actually more serious than we once thought and is an independent risk factor for hospitalization, readmission, increased patient length of stay, loss of function, and diminished quality of life,” Cahill said.

She added that anemia also increases the likelihood that a patient will require transfusions.

The pilot program was implemented with this in mind. The program, which ran from February 2016 through September 2017, was designed to test the feasibility of diagnosing anemia during a cardiology consult visit and implementing an anemia management plan.

During the study period, 240 patients presenting for elective cardiac surgery were screened for anemia, and 58 were diagnosed as anemic (hemoglobin <12 g/dL). These patients were referred for anemia workups, which showed that 33 patients had iron-deficiency anemia, and 25 had anemia from other causes.

Preoperative anemia management for the iron-deficient patients included oral iron for seven patients, intravenous (IV) iron with or without folate for 20 patients, and oral folate with or without vitamin B12 for five patients. One iron-deficient patient could not have surgery delayed for anemia management.

Of the iron-replete patients, one received oral iron, 17 received folate with or without B12, and seven patients were not treated for anemia.

One iron-deficient patient had a reaction to the infusion and did not receive a scheduled second dose due to the need for immediate surgery. A second patient scheduled for IV iron and folate broke an arm and therefore missed an IV infusion appointment. No other complications or reactions occurred.

Results

The researchers compared the 58 patients from the pilot program to control subjects—patients who underwent cardiac surgery from March through July 2015, matched by age, sex, and procedures.

The anemia management group received 10 red blood cell (RBC) units intraoperatively, compared to 68 intraoperative RBC units for controls. The total number of postoperative RBC units was 13 and 22, respectively.

The rate of RBC transfusions was 24% in the anemia management group and 60% in controls (P<0.0001). The average RBC units per patient was 0.4 and 2.07, respectively (P<0.0001).

Patients in the anemia management program also had significantly higher day-of-surgery hemoglobin than controls—11.01 and 10.16 g/dL, respectively (P<0.001).

The program provided an average per-patient savings in acquisition costs of $367.40, an average transfusion cost savings of $1,837, and a total cost savings of $106,546 over the life of the program.

The key to success of a similar program is “to make sure you do your homework,” Cahill said.

Specifically, she recommended feasibility studies, evaluation of the potential impact of infusions on the service, work flow analyses, and cost analyses. It’s also important to get high-level administrative support as well as buy-in from surgeons and patients, she added.

Future studies should include assessment of patient outcomes, safety, and length of intensive care unit and hospital stay, Cahill emphasized.

This study was internally funded. Cahill reported no conflicts of interest.

*The data in the presentation differ from the abstract.

Figure 1

While the differential diagnosis for these lesions (FIGURE 1A) included basal cell carcinoma, the FP had reason to suspect that these papules were actually sebaceous hyperplasia.

The FP saw a pattern of crown-like vessels and popcorn-like structures (FIGURE 1B) when he examined the patient with his dermatoscope. None of the vessels crossed the midline, and the popcorn-like structures were hyperplastic sebaceous glands. The FP photographed the largest lesion with a dermatoscope attached to his smart phone and showed the reassuring pattern to the anxious patient. He explained to her why this was not skin cancer and how hyperplasia of sebaceous glands is often normal for aging facial skin. He also offered her treatment if she thought that the lesions were cosmetically unappealing.

The patient said that she would be grateful to have the largest lesion treated because it did bother her when she looked in the mirror. The FP treated this lesion using electrosurgery with a blunt tipped electrode, on a setting of 2.1, without anesthesia. He warned the patient before he applied the activated electrode to the skin, and the patient tolerated the procedure well. The sebaceous glands melted easily with the current. The result appeared gray and was expected to heal with minimal to no scarring. At a future visit, the patient said that she was happy with the result and asked if additional lesions could be treated with the same electrosurgical approach.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

Figure 1

While the differential diagnosis for these lesions (FIGURE 1A) included basal cell carcinoma, the FP had reason to suspect that these papules were actually sebaceous hyperplasia.

The FP saw a pattern of crown-like vessels and popcorn-like structures (FIGURE 1B) when he examined the patient with his dermatoscope. None of the vessels crossed the midline, and the popcorn-like structures were hyperplastic sebaceous glands. The FP photographed the largest lesion with a dermatoscope attached to his smart phone and showed the reassuring pattern to the anxious patient. He explained to her why this was not skin cancer and how hyperplasia of sebaceous glands is often normal for aging facial skin. He also offered her treatment if she thought that the lesions were cosmetically unappealing.

The patient said that she would be grateful to have the largest lesion treated because it did bother her when she looked in the mirror. The FP treated this lesion using electrosurgery with a blunt tipped electrode, on a setting of 2.1, without anesthesia. He warned the patient before he applied the activated electrode to the skin, and the patient tolerated the procedure well. The sebaceous glands melted easily with the current. The result appeared gray and was expected to heal with minimal to no scarring. At a future visit, the patient said that she was happy with the result and asked if additional lesions could be treated with the same electrosurgical approach.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

Figure 1

While the differential diagnosis for these lesions (FIGURE 1A) included basal cell carcinoma, the FP had reason to suspect that these papules were actually sebaceous hyperplasia.

The FP saw a pattern of crown-like vessels and popcorn-like structures (FIGURE 1B) when he examined the patient with his dermatoscope. None of the vessels crossed the midline, and the popcorn-like structures were hyperplastic sebaceous glands. The FP photographed the largest lesion with a dermatoscope attached to his smart phone and showed the reassuring pattern to the anxious patient. He explained to her why this was not skin cancer and how hyperplasia of sebaceous glands is often normal for aging facial skin. He also offered her treatment if she thought that the lesions were cosmetically unappealing.

The patient said that she would be grateful to have the largest lesion treated because it did bother her when she looked in the mirror. The FP treated this lesion using electrosurgery with a blunt tipped electrode, on a setting of 2.1, without anesthesia. He warned the patient before he applied the activated electrode to the skin, and the patient tolerated the procedure well. The sebaceous glands melted easily with the current. The result appeared gray and was expected to heal with minimal to no scarring. At a future visit, the patient said that she was happy with the result and asked if additional lesions could be treated with the same electrosurgical approach.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.