Earning credit for continuing medical education (CME) is a little easier for hospitalists and other physicians.

A collaboration between the American Board of Internal Medicine (ABIM) and the Accreditation Council for Continuing Medical Education (ACCME) will enable physicians who are engaged in lifelong learning to use those activities toward completion of requirements for ABIM’s Maintenance of Certification (MOC) program.

The collaboration expands physicians’ options to receive MOC credit and helps CME providers to “offer more lifelong learning options with MOC credit to internists and subspecialties,” according to an ABIM announcement.

The ABIM-ACCME collaboration exempts CME providers from applying for ABIM approval for each MOC activity. Instead, CME providers can use a shared system to record information about CME and ABIM MOC activities.

“I think the ABIM wanted to recognize this CME as fulfilling the spirit of MOC, but up until now, it was really hard to ensure that the ‘CME’ was meaningful and not tainted by third-party sponsorship,” writes ABIM Council member and former SHM President Jeffrey Wiese, MD, MHM, in an email to The Hospitalist. “This collaboration enables physicians to get MOC credit for the CME that they are acquiring and, importantly, ensures that the CME that counts toward MOC meets the standards of the ABIM without having to go through an extensive approval process.”

Hospitalists also have the option to use the Focused Practice in Hospital Medicine exam, but not all do. Therefore, the streamlined network for reporting activity means that hospitalists will see a real benefit.

“There haven’t been a lot of modules built for hospital medicine like there have been for ambulatory medicine or the subspecialties,” Dr. Wiese adds. “Hospitalists have struggled to find medical knowledge modules that gave MOC credit and [that] fit with what they were doing in their practice. This collaboration solves that, as it opens a door for many CME activities that will satisfy both MOC credit and speak to the practice of hospital medicine.”

Visit our website for more information on continuing medical education in hospital medicine.

Earning credit for continuing medical education (CME) is a little easier for hospitalists and other physicians.

A collaboration between the American Board of Internal Medicine (ABIM) and the Accreditation Council for Continuing Medical Education (ACCME) will enable physicians who are engaged in lifelong learning to use those activities toward completion of requirements for ABIM’s Maintenance of Certification (MOC) program.

The collaboration expands physicians’ options to receive MOC credit and helps CME providers to “offer more lifelong learning options with MOC credit to internists and subspecialties,” according to an ABIM announcement.

The ABIM-ACCME collaboration exempts CME providers from applying for ABIM approval for each MOC activity. Instead, CME providers can use a shared system to record information about CME and ABIM MOC activities.

“I think the ABIM wanted to recognize this CME as fulfilling the spirit of MOC, but up until now, it was really hard to ensure that the ‘CME’ was meaningful and not tainted by third-party sponsorship,” writes ABIM Council member and former SHM President Jeffrey Wiese, MD, MHM, in an email to The Hospitalist. “This collaboration enables physicians to get MOC credit for the CME that they are acquiring and, importantly, ensures that the CME that counts toward MOC meets the standards of the ABIM without having to go through an extensive approval process.”

Hospitalists also have the option to use the Focused Practice in Hospital Medicine exam, but not all do. Therefore, the streamlined network for reporting activity means that hospitalists will see a real benefit.

“There haven’t been a lot of modules built for hospital medicine like there have been for ambulatory medicine or the subspecialties,” Dr. Wiese adds. “Hospitalists have struggled to find medical knowledge modules that gave MOC credit and [that] fit with what they were doing in their practice. This collaboration solves that, as it opens a door for many CME activities that will satisfy both MOC credit and speak to the practice of hospital medicine.”

Visit our website for more information on continuing medical education in hospital medicine.

Earning credit for continuing medical education (CME) is a little easier for hospitalists and other physicians.

A collaboration between the American Board of Internal Medicine (ABIM) and the Accreditation Council for Continuing Medical Education (ACCME) will enable physicians who are engaged in lifelong learning to use those activities toward completion of requirements for ABIM’s Maintenance of Certification (MOC) program.

The collaboration expands physicians’ options to receive MOC credit and helps CME providers to “offer more lifelong learning options with MOC credit to internists and subspecialties,” according to an ABIM announcement.

The ABIM-ACCME collaboration exempts CME providers from applying for ABIM approval for each MOC activity. Instead, CME providers can use a shared system to record information about CME and ABIM MOC activities.

“I think the ABIM wanted to recognize this CME as fulfilling the spirit of MOC, but up until now, it was really hard to ensure that the ‘CME’ was meaningful and not tainted by third-party sponsorship,” writes ABIM Council member and former SHM President Jeffrey Wiese, MD, MHM, in an email to The Hospitalist. “This collaboration enables physicians to get MOC credit for the CME that they are acquiring and, importantly, ensures that the CME that counts toward MOC meets the standards of the ABIM without having to go through an extensive approval process.”

Hospitalists also have the option to use the Focused Practice in Hospital Medicine exam, but not all do. Therefore, the streamlined network for reporting activity means that hospitalists will see a real benefit.

“There haven’t been a lot of modules built for hospital medicine like there have been for ambulatory medicine or the subspecialties,” Dr. Wiese adds. “Hospitalists have struggled to find medical knowledge modules that gave MOC credit and [that] fit with what they were doing in their practice. This collaboration solves that, as it opens a door for many CME activities that will satisfy both MOC credit and speak to the practice of hospital medicine.”

Visit our website for more information on continuing medical education in hospital medicine.

Clinical question: Does a short, fixed duration of antibiotic therapy for complicated intra-abdominal infections lead to equivalent outcomes and less antibiotic exposure than the traditional approach?

Background: Published guidelines recommend appropriate antimicrobial agents for intra-abdominal infections, but the optimal duration of therapy remains unclear. Most practitioners continue to treat for 10–14 days and until all physiologic evidence of the systemic inflammatory response syndrome (SIRS) has resolved. More recently, small studies have suggested that a shorter course may lead to equivalent outcomes with decreased antibiotic exposure.

Study design: Open-label, multicenter, randomized control trial.

Setting: Twenty-three sites throughout the U.S. and Canada.

Synopsis: In the short-course group, 257 patients were randomized to receive antimicrobial therapy for four full days after their index source-control procedure; 260 patients in the control group received antimicrobial therapy until two days after resolution of the physiological abnormalities related to SIRS. The median duration of therapy was 4.0 days (interquartile range [IQR] 4.0–5.0) for the experimental group and 8.0 days (IQR 5.0–10.0) in the control group (95% CI, -4.7 to -3.3; P<0.001).

There was no significant difference in surgical site infection, recurrent intra-abdominal infection, or death between the experimental and control groups (21.8% vs. 22.3%, 95% CI, -7.0 to 8.0; P=0.92). In the experimental group, 47 patients did not adhere to the protocol, and all of those patients received a longer antimicrobial treatment course than specified in the protocol.

This trial excluded patients without adequate source control and included a small number of immunocompromised hosts. The rate of nonadherence to the protocol was high, at 18% of patients in the experimental group. The calculated sample size to assert equivalence between groups was not achieved, although the results are suggestive of equivalence.

Bottom line: A shorter course of antimicrobial therapy for complicated intra-abdominal infections might lead to equivalent outcomes with less antibiotic exposure compared with current practice; however, it is challenging for providers to stop antimicrobial therapy while patients continue to show physiologic evidence of SIRS.

Citation: Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. NEJM. 2015;372(21):1996–2005.

Visit our website for more reviews of HM-focused research.

Clinical question: Does a short, fixed duration of antibiotic therapy for complicated intra-abdominal infections lead to equivalent outcomes and less antibiotic exposure than the traditional approach?

Background: Published guidelines recommend appropriate antimicrobial agents for intra-abdominal infections, but the optimal duration of therapy remains unclear. Most practitioners continue to treat for 10–14 days and until all physiologic evidence of the systemic inflammatory response syndrome (SIRS) has resolved. More recently, small studies have suggested that a shorter course may lead to equivalent outcomes with decreased antibiotic exposure.

Study design: Open-label, multicenter, randomized control trial.

Setting: Twenty-three sites throughout the U.S. and Canada.

Synopsis: In the short-course group, 257 patients were randomized to receive antimicrobial therapy for four full days after their index source-control procedure; 260 patients in the control group received antimicrobial therapy until two days after resolution of the physiological abnormalities related to SIRS. The median duration of therapy was 4.0 days (interquartile range [IQR] 4.0–5.0) for the experimental group and 8.0 days (IQR 5.0–10.0) in the control group (95% CI, -4.7 to -3.3; P<0.001).

There was no significant difference in surgical site infection, recurrent intra-abdominal infection, or death between the experimental and control groups (21.8% vs. 22.3%, 95% CI, -7.0 to 8.0; P=0.92). In the experimental group, 47 patients did not adhere to the protocol, and all of those patients received a longer antimicrobial treatment course than specified in the protocol.

This trial excluded patients without adequate source control and included a small number of immunocompromised hosts. The rate of nonadherence to the protocol was high, at 18% of patients in the experimental group. The calculated sample size to assert equivalence between groups was not achieved, although the results are suggestive of equivalence.

Bottom line: A shorter course of antimicrobial therapy for complicated intra-abdominal infections might lead to equivalent outcomes with less antibiotic exposure compared with current practice; however, it is challenging for providers to stop antimicrobial therapy while patients continue to show physiologic evidence of SIRS.

Citation: Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. NEJM. 2015;372(21):1996–2005.

Visit our website for more reviews of HM-focused research.

Clinical question: Does a short, fixed duration of antibiotic therapy for complicated intra-abdominal infections lead to equivalent outcomes and less antibiotic exposure than the traditional approach?

Background: Published guidelines recommend appropriate antimicrobial agents for intra-abdominal infections, but the optimal duration of therapy remains unclear. Most practitioners continue to treat for 10–14 days and until all physiologic evidence of the systemic inflammatory response syndrome (SIRS) has resolved. More recently, small studies have suggested that a shorter course may lead to equivalent outcomes with decreased antibiotic exposure.

Study design: Open-label, multicenter, randomized control trial.

Setting: Twenty-three sites throughout the U.S. and Canada.

Synopsis: In the short-course group, 257 patients were randomized to receive antimicrobial therapy for four full days after their index source-control procedure; 260 patients in the control group received antimicrobial therapy until two days after resolution of the physiological abnormalities related to SIRS. The median duration of therapy was 4.0 days (interquartile range [IQR] 4.0–5.0) for the experimental group and 8.0 days (IQR 5.0–10.0) in the control group (95% CI, -4.7 to -3.3; P<0.001).

There was no significant difference in surgical site infection, recurrent intra-abdominal infection, or death between the experimental and control groups (21.8% vs. 22.3%, 95% CI, -7.0 to 8.0; P=0.92). In the experimental group, 47 patients did not adhere to the protocol, and all of those patients received a longer antimicrobial treatment course than specified in the protocol.

This trial excluded patients without adequate source control and included a small number of immunocompromised hosts. The rate of nonadherence to the protocol was high, at 18% of patients in the experimental group. The calculated sample size to assert equivalence between groups was not achieved, although the results are suggestive of equivalence.

Bottom line: A shorter course of antimicrobial therapy for complicated intra-abdominal infections might lead to equivalent outcomes with less antibiotic exposure compared with current practice; however, it is challenging for providers to stop antimicrobial therapy while patients continue to show physiologic evidence of SIRS.

Citation: Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. NEJM. 2015;372(21):1996–2005.

Visit our website for more reviews of HM-focused research.

LAS VEGAS – Damage control laparotomy is a safe and reliable approach to the surgical management of patients with severe nontrauma secondary peritonitis who require bowel resection, according a review of 182 cases.

For example, the deferred ostomy rate was 16.7% among 72 patients who underwent damage control laparotomy (DCL), which was significantly lower than the primary ostomy rate of 53.6% in 110 patients who underwent a definitive surgical procedure (DSP), Dr. Maria P. Garcia-Garcia reported at the annual meeting of the American Association for the Surgery of Trauma.

Ryan McVay/Thinkstock

Further, the fistula rate was lower among 60 DCL patients who underwent delayed anastomosis, compared with 51 DSP patients who underwent primary anastomosis (26.7% vs. 37.2%), and the mortality rate was lower in the DCL vs. DSP patients (16.7% vs. 24.5%). These differences did not meet statistical significance due to the sample size. Deaths in the DCL group all occurred in those who underwent delayed anastomosis; deaths in the DSP group occurred in 14 ostomy patients and 13 anastomosis patients, said Dr. Garcia-Garcia of Fundacion Valle del Lili, Cali, Colombia.

Disease severity, as measured by APACHE II scores, was similar in the two groups (mean of about 17 for each group). Septic shock was present in 37% at the time of admission. Mean hospital length of stay and mean intensive care unit length of stay did not differ significantly between the groups, nor did the systemic complication rate, or the rates of multiple organ failure and acute respiratory distress syndrome.

Small-bowel perforation occurred in 77 (42.3%), and colon perforation occurred in 105 (57.7%).

The patients included teens and adults aged 16 years or older (mean of 60.3 years) with severe nontrauma secondary peritonitis (NSPT) who were undergoing bowel resection after enteric perforations between 2003 and 2013. The DSP patients underwent either primary anastomosis or primary ostomy, and the DCL patients underwent segmental bowel resection, temporary abdominal closure, and subsequent delayed anastomosis or deferred ostomy.

DCL is a recognized strategy for managing bowel injuries in trauma patients. It was developed in response to the poor outcomes associated with attempting definitive repair, but evidence regarding the role and timing of anastomosis in DCL in NTSP – a condition associated with high morbidity and a 30% in-hospital mortality rate – is lacking, Dr. Garcia-Garcia said, noting that the current findings suggest it is the preferred approach.

“When a definite surgical repair is chosen, there is a 50/50 chance of performing anastomosis or ostomy. However, when a damage control abbreviated laparotomy is performed, there is a high bowel reconstruction success rate of about 80%. Therefore, damage control abbreviated laparotomy is a reliable and safe option in critically ill nontrauma secondary peritonitis patients. At the end of the day it’s your choice: Would you rather leave your patient with an ostomy or tube, or would you give your patient a chance of successful reconstruction without an ostomy?” she said.

Dr. Garcia-Garcia reported having no disclosures.

sworcester@frontlinemedcom.com

LAS VEGAS – Damage control laparotomy is a safe and reliable approach to the surgical management of patients with severe nontrauma secondary peritonitis who require bowel resection, according a review of 182 cases.

For example, the deferred ostomy rate was 16.7% among 72 patients who underwent damage control laparotomy (DCL), which was significantly lower than the primary ostomy rate of 53.6% in 110 patients who underwent a definitive surgical procedure (DSP), Dr. Maria P. Garcia-Garcia reported at the annual meeting of the American Association for the Surgery of Trauma.

Ryan McVay/Thinkstock

Further, the fistula rate was lower among 60 DCL patients who underwent delayed anastomosis, compared with 51 DSP patients who underwent primary anastomosis (26.7% vs. 37.2%), and the mortality rate was lower in the DCL vs. DSP patients (16.7% vs. 24.5%). These differences did not meet statistical significance due to the sample size. Deaths in the DCL group all occurred in those who underwent delayed anastomosis; deaths in the DSP group occurred in 14 ostomy patients and 13 anastomosis patients, said Dr. Garcia-Garcia of Fundacion Valle del Lili, Cali, Colombia.

Disease severity, as measured by APACHE II scores, was similar in the two groups (mean of about 17 for each group). Septic shock was present in 37% at the time of admission. Mean hospital length of stay and mean intensive care unit length of stay did not differ significantly between the groups, nor did the systemic complication rate, or the rates of multiple organ failure and acute respiratory distress syndrome.

Small-bowel perforation occurred in 77 (42.3%), and colon perforation occurred in 105 (57.7%).

The patients included teens and adults aged 16 years or older (mean of 60.3 years) with severe nontrauma secondary peritonitis (NSPT) who were undergoing bowel resection after enteric perforations between 2003 and 2013. The DSP patients underwent either primary anastomosis or primary ostomy, and the DCL patients underwent segmental bowel resection, temporary abdominal closure, and subsequent delayed anastomosis or deferred ostomy.

DCL is a recognized strategy for managing bowel injuries in trauma patients. It was developed in response to the poor outcomes associated with attempting definitive repair, but evidence regarding the role and timing of anastomosis in DCL in NTSP – a condition associated with high morbidity and a 30% in-hospital mortality rate – is lacking, Dr. Garcia-Garcia said, noting that the current findings suggest it is the preferred approach.

“When a definite surgical repair is chosen, there is a 50/50 chance of performing anastomosis or ostomy. However, when a damage control abbreviated laparotomy is performed, there is a high bowel reconstruction success rate of about 80%. Therefore, damage control abbreviated laparotomy is a reliable and safe option in critically ill nontrauma secondary peritonitis patients. At the end of the day it’s your choice: Would you rather leave your patient with an ostomy or tube, or would you give your patient a chance of successful reconstruction without an ostomy?” she said.

Dr. Garcia-Garcia reported having no disclosures.

sworcester@frontlinemedcom.com

LAS VEGAS – Damage control laparotomy is a safe and reliable approach to the surgical management of patients with severe nontrauma secondary peritonitis who require bowel resection, according a review of 182 cases.

For example, the deferred ostomy rate was 16.7% among 72 patients who underwent damage control laparotomy (DCL), which was significantly lower than the primary ostomy rate of 53.6% in 110 patients who underwent a definitive surgical procedure (DSP), Dr. Maria P. Garcia-Garcia reported at the annual meeting of the American Association for the Surgery of Trauma.

Ryan McVay/Thinkstock

Further, the fistula rate was lower among 60 DCL patients who underwent delayed anastomosis, compared with 51 DSP patients who underwent primary anastomosis (26.7% vs. 37.2%), and the mortality rate was lower in the DCL vs. DSP patients (16.7% vs. 24.5%). These differences did not meet statistical significance due to the sample size. Deaths in the DCL group all occurred in those who underwent delayed anastomosis; deaths in the DSP group occurred in 14 ostomy patients and 13 anastomosis patients, said Dr. Garcia-Garcia of Fundacion Valle del Lili, Cali, Colombia.

Disease severity, as measured by APACHE II scores, was similar in the two groups (mean of about 17 for each group). Septic shock was present in 37% at the time of admission. Mean hospital length of stay and mean intensive care unit length of stay did not differ significantly between the groups, nor did the systemic complication rate, or the rates of multiple organ failure and acute respiratory distress syndrome.

Small-bowel perforation occurred in 77 (42.3%), and colon perforation occurred in 105 (57.7%).

The patients included teens and adults aged 16 years or older (mean of 60.3 years) with severe nontrauma secondary peritonitis (NSPT) who were undergoing bowel resection after enteric perforations between 2003 and 2013. The DSP patients underwent either primary anastomosis or primary ostomy, and the DCL patients underwent segmental bowel resection, temporary abdominal closure, and subsequent delayed anastomosis or deferred ostomy.

DCL is a recognized strategy for managing bowel injuries in trauma patients. It was developed in response to the poor outcomes associated with attempting definitive repair, but evidence regarding the role and timing of anastomosis in DCL in NTSP – a condition associated with high morbidity and a 30% in-hospital mortality rate – is lacking, Dr. Garcia-Garcia said, noting that the current findings suggest it is the preferred approach.

“When a definite surgical repair is chosen, there is a 50/50 chance of performing anastomosis or ostomy. However, when a damage control abbreviated laparotomy is performed, there is a high bowel reconstruction success rate of about 80%. Therefore, damage control abbreviated laparotomy is a reliable and safe option in critically ill nontrauma secondary peritonitis patients. At the end of the day it’s your choice: Would you rather leave your patient with an ostomy or tube, or would you give your patient a chance of successful reconstruction without an ostomy?” she said.

Dr. Garcia-Garcia reported having no disclosures.

sworcester@frontlinemedcom.com

Vulvar intraepithelial neoplasia is a premalignant lesion of the vulva frequently encountered by gynecologic providers. There has been an increase in the incidence of VIN in younger women in recent decades thought be to be secondary to human papillomavirus infection, cigarette smoking, and sexual behavior (J Reprod Med. 2000 Aug;45[8]:613-5).

Data from the Surveillance Epidemiology and End Results (SEER) database were significant for a 411% increase in the incidence of in situ carcinoma and a 20% increase in invasive vulvar carcinoma from 1973 to 2000 (Obstet Gynecol. 2006 May;107[5]:1018-22). In addition, younger age groups are seeing an increase of in situ disease until age 49. Vulvar cancer however, continues to be a disease of older age.

Terminology

Previously, the term vulvar intraepithelial neoplasia followed the cervical intraepithelial neoplasia (CIN) designation in the 1960s. Conventions for grading these lesions have changed over time. Most recently, in 2004, the International Society for the Study of Vulvar Disease (ISSVD), composed of dermatologists, pathologists, and gynecologists, agreed to change the classification of squamous VIN from the previous VIN 1-3 classification system. The committee described VIN in two forms, “usual type” and “differentiated type” (J Reprod Med 2005;50:807-10).

In making this transition, it was recognized that VIN 1 is not in fact an oncogenic lesion and is now solely referred to as condyloma acuminatum. Grade 2 and 3 are now collectively referred to as VIN. These changes made by the ISSVD reflect the current literature on grading of VIN. In addition to VIN 1 not having any progression to malignancy, it is a diagnosis that is difficult to reproduce and may, at times, reflect reactive changes or other dermatosis. VIN 2 and 3 are not discriminated from each other in a reproducible manner and clinically have no reason for individual distinction (J Low Genit Tract Dis. 2006 Jul;10[3]:161-9).

VIN, usual type is the most common intraepithelial lesion and is historically referred to as classic VIN or Bowen’s disease. This type is associated with HPV infection and includes the formerly described warty type, basaloid type, and mixed type. The carcinogenic subtypes of HPV, 16, 18, 31, and 33 are the most common HPV subtypes responsible. It should be noted, however, that diagnosis is morphological and not based on HPV testing. Usual type is also traditionally thought to be more closely associated with risk factors such as smoking and immunocompromised states.

VIN, differentiated type is not associated with the HPV virus and is frequently found in older women. This lesion is often associated with other dermatologic conditions such as lichen sclerosis and lichen simplex chronicus. Diagnosis is also made by histology with abnormal cells being confined to the parabasal and basal portion of the rete pegs. This type also finds genetic alterations that are seen in invasive squamous cell carcinoma (Appl Immunohistochem Mol Morphol 2001;9:150-63). Differentiated type is thought to be a precursor for HPV-negative keratinizing squamous cell carcinoma of the vulva (Am J Surg Pathol. 2000 Mar;24[3]:429-41).

As awareness of this distinct form of VIN increases and more is learned about the precursors of HPV-negative squamous cell carcinoma, physicians are encouraged to closely follow up hyperplastic lesions and lichen sclerosis with biopsies and excision. The diagnosis of differentiated VIN is rarely made at present; however, this distinction by the ISSVD may improve the ability of clinicians and pathologists to recognize this HPV-negative precursor before squamous cell carcinoma is present.

The Lower Anogenital Squamous Terminology project of the College of American Pathology and the American Society for Colposcopy and Cervical Pathology advocates for more consistent terminology across lower anogenital tract lesions. This terminology applies only to HPV-related lesions (usual type) and considers the VIN 1 or condyloma accuminatum to be a low-grade lesion (LSIL), and VIN 2-3 or usual type to be high-grade lesions (HSIL) (Int J Gynecol Pathol. 2013 Jan;32[1]:76-115).

Many clinicians and pathologists have not adopted this most recent terminology; however, there is evidence that the ISSVD classification is the most clinically relevant.

Diagnosis

The majority of patients with any VIN will present with complaints of vulvar pruritus. However, women can also present with pain, burning, or dysuria, or can have an asymptomatic lesion found on pelvic exam. There are no recommended screening strategies to diagnose early VIN. Cytologic testing is complicated by the keratinization of the vulva, making this an unreliable diagnostic assessment.

On physical exam, VIN can have a heterogeneous presentation including papules, plaques, color variations, or ulcer. Differentiated type is thought to have a more defined appearance that frequently develops in the setting of other vulvar dermatosis. These are distinct, solitary lesions that are commonly raised, can have an overlying scale, and have ill-defined borders. A distinct lesion with ulceration or erosion is concerning for invasion.

Diagnosis is ultimately made by biopsy. Physicians should have a low threshold to biopsy any suspicious lesions or those unresponsive to therapy. Colposcopy is a frequent adjunct to the physical exam. Acetic acid 3%-5% soaked gauze is allowed to rest on the vulva for several minutes prior to observation with a colposcope or hand-held magnifying glass. Colposcopic findings are usually those of focal “white” epithelium. Vascular changes seen on the cervix (punctuation and mosaicism) are rarely seen on the vulva.

The entire anogenital region shares the same susceptibility to the HPV virus, thus squamous intraepithelial lesions are frequently multifocal. Physicians should have a heightened awareness of other lesions, such as cervical, vaginal, or anal, when managing a patient with VIN (Gynecol Oncol. 1995 Feb;56[2]:276-9). Appropriate cervical screening should be strictly adhered to and a thorough exam done at the time of vulvar colposcopy or exam.

Treatment

The goals of treatment include preventing carcinoma and improving symptoms while maintaining function and preserving anatomy. Treatment options for both types of VIN include excision, ablation, or medical therapy pending an evaluation of concurrent risk factors.

Premalignant disease was traditionally treated surgically. While surgical excision is still the mainstay of therapy, less aggressive techniques and medical therapy are more readily utilized. The goal of surgical excision for VIN is both diagnostic and therapeutic. When an excision for high-grade dysplasia is done (formerly VIN 3), detection of occult carcinoma was found in up to 3.2% in one large review (Gynecol Oncol. 2005;97:645-51).

Using a wide local excision to completely remove lesions with a pathologically clear margin reduces a patient’s risk of recurrence for disease compared to those excisions with positive margins (Obstet Gynecol. 1998;92:962-6). It is therefore critical that physicians carefully counsel patients who desire conservative therapy for VIN.

With any treatment, however, patients and physicians should be aware of the risk of recurrence; for vulvectomy, partial vulvectomy, local excision, and laser ablation, recurrences were seen at rates of 19%, 18%, 22%, and 23%, respectively, in a review of 3,322 patients (Gynecol Oncol. 2005;97:645-51).

CO₂ laser ablation has been used for single lesions as well as multifocal or confluent disease. Many physicians advocate for its use in patients with multifocal lesions as well as those with disease around the clitoris or anus, where excisional therapy is less desirable as laser therapy results in less scarring.

A 2015 Cochrane Database Review of medical therapy for high-grade dysplasia (usual-type VIN, VIN 2/3, or high-grade VIN) found that topical imiquimod can be used as a safe and effective option for high-grade VIN. Physicians should, however, be aware of unfavorable side effects that may require dose reductions. Cidofovir may be an alternative to imiquimod pending more evidence on long-term response and progression (Cochrane Database Syst Rev. 2015 Aug 18;8:CD007924). Topical 5-fluorouracil has fallen out of favor for VIN given its significant chemical desquamation, however response rates are thought to be favorable if tolerated.

As the use of VIN terminology solidifies and information emerges on medical therapy to treat VIN, it is critical that physicians remain current when counseling and providing treatment recommendations for vulvar intraepithelial neoplasia.

Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology and professor in the division of gynecologic oncology at the university. Dr. Sullivan is a fellow in the division of gynecologic oncology at the university. They reported having no relevant financial disclosures. Email them at obnews@frontlinemedcom.com.

Vulvar intraepithelial neoplasia is a premalignant lesion of the vulva frequently encountered by gynecologic providers. There has been an increase in the incidence of VIN in younger women in recent decades thought be to be secondary to human papillomavirus infection, cigarette smoking, and sexual behavior (J Reprod Med. 2000 Aug;45[8]:613-5).

Data from the Surveillance Epidemiology and End Results (SEER) database were significant for a 411% increase in the incidence of in situ carcinoma and a 20% increase in invasive vulvar carcinoma from 1973 to 2000 (Obstet Gynecol. 2006 May;107[5]:1018-22). In addition, younger age groups are seeing an increase of in situ disease until age 49. Vulvar cancer however, continues to be a disease of older age.

Terminology

Previously, the term vulvar intraepithelial neoplasia followed the cervical intraepithelial neoplasia (CIN) designation in the 1960s. Conventions for grading these lesions have changed over time. Most recently, in 2004, the International Society for the Study of Vulvar Disease (ISSVD), composed of dermatologists, pathologists, and gynecologists, agreed to change the classification of squamous VIN from the previous VIN 1-3 classification system. The committee described VIN in two forms, “usual type” and “differentiated type” (J Reprod Med 2005;50:807-10).

In making this transition, it was recognized that VIN 1 is not in fact an oncogenic lesion and is now solely referred to as condyloma acuminatum. Grade 2 and 3 are now collectively referred to as VIN. These changes made by the ISSVD reflect the current literature on grading of VIN. In addition to VIN 1 not having any progression to malignancy, it is a diagnosis that is difficult to reproduce and may, at times, reflect reactive changes or other dermatosis. VIN 2 and 3 are not discriminated from each other in a reproducible manner and clinically have no reason for individual distinction (J Low Genit Tract Dis. 2006 Jul;10[3]:161-9).

VIN, usual type is the most common intraepithelial lesion and is historically referred to as classic VIN or Bowen’s disease. This type is associated with HPV infection and includes the formerly described warty type, basaloid type, and mixed type. The carcinogenic subtypes of HPV, 16, 18, 31, and 33 are the most common HPV subtypes responsible. It should be noted, however, that diagnosis is morphological and not based on HPV testing. Usual type is also traditionally thought to be more closely associated with risk factors such as smoking and immunocompromised states.

VIN, differentiated type is not associated with the HPV virus and is frequently found in older women. This lesion is often associated with other dermatologic conditions such as lichen sclerosis and lichen simplex chronicus. Diagnosis is also made by histology with abnormal cells being confined to the parabasal and basal portion of the rete pegs. This type also finds genetic alterations that are seen in invasive squamous cell carcinoma (Appl Immunohistochem Mol Morphol 2001;9:150-63). Differentiated type is thought to be a precursor for HPV-negative keratinizing squamous cell carcinoma of the vulva (Am J Surg Pathol. 2000 Mar;24[3]:429-41).

As awareness of this distinct form of VIN increases and more is learned about the precursors of HPV-negative squamous cell carcinoma, physicians are encouraged to closely follow up hyperplastic lesions and lichen sclerosis with biopsies and excision. The diagnosis of differentiated VIN is rarely made at present; however, this distinction by the ISSVD may improve the ability of clinicians and pathologists to recognize this HPV-negative precursor before squamous cell carcinoma is present.

The Lower Anogenital Squamous Terminology project of the College of American Pathology and the American Society for Colposcopy and Cervical Pathology advocates for more consistent terminology across lower anogenital tract lesions. This terminology applies only to HPV-related lesions (usual type) and considers the VIN 1 or condyloma accuminatum to be a low-grade lesion (LSIL), and VIN 2-3 or usual type to be high-grade lesions (HSIL) (Int J Gynecol Pathol. 2013 Jan;32[1]:76-115).

Many clinicians and pathologists have not adopted this most recent terminology; however, there is evidence that the ISSVD classification is the most clinically relevant.

Diagnosis

The majority of patients with any VIN will present with complaints of vulvar pruritus. However, women can also present with pain, burning, or dysuria, or can have an asymptomatic lesion found on pelvic exam. There are no recommended screening strategies to diagnose early VIN. Cytologic testing is complicated by the keratinization of the vulva, making this an unreliable diagnostic assessment.

On physical exam, VIN can have a heterogeneous presentation including papules, plaques, color variations, or ulcer. Differentiated type is thought to have a more defined appearance that frequently develops in the setting of other vulvar dermatosis. These are distinct, solitary lesions that are commonly raised, can have an overlying scale, and have ill-defined borders. A distinct lesion with ulceration or erosion is concerning for invasion.

Diagnosis is ultimately made by biopsy. Physicians should have a low threshold to biopsy any suspicious lesions or those unresponsive to therapy. Colposcopy is a frequent adjunct to the physical exam. Acetic acid 3%-5% soaked gauze is allowed to rest on the vulva for several minutes prior to observation with a colposcope or hand-held magnifying glass. Colposcopic findings are usually those of focal “white” epithelium. Vascular changes seen on the cervix (punctuation and mosaicism) are rarely seen on the vulva.

The entire anogenital region shares the same susceptibility to the HPV virus, thus squamous intraepithelial lesions are frequently multifocal. Physicians should have a heightened awareness of other lesions, such as cervical, vaginal, or anal, when managing a patient with VIN (Gynecol Oncol. 1995 Feb;56[2]:276-9). Appropriate cervical screening should be strictly adhered to and a thorough exam done at the time of vulvar colposcopy or exam.

Treatment

The goals of treatment include preventing carcinoma and improving symptoms while maintaining function and preserving anatomy. Treatment options for both types of VIN include excision, ablation, or medical therapy pending an evaluation of concurrent risk factors.

Premalignant disease was traditionally treated surgically. While surgical excision is still the mainstay of therapy, less aggressive techniques and medical therapy are more readily utilized. The goal of surgical excision for VIN is both diagnostic and therapeutic. When an excision for high-grade dysplasia is done (formerly VIN 3), detection of occult carcinoma was found in up to 3.2% in one large review (Gynecol Oncol. 2005;97:645-51).

Using a wide local excision to completely remove lesions with a pathologically clear margin reduces a patient’s risk of recurrence for disease compared to those excisions with positive margins (Obstet Gynecol. 1998;92:962-6). It is therefore critical that physicians carefully counsel patients who desire conservative therapy for VIN.

With any treatment, however, patients and physicians should be aware of the risk of recurrence; for vulvectomy, partial vulvectomy, local excision, and laser ablation, recurrences were seen at rates of 19%, 18%, 22%, and 23%, respectively, in a review of 3,322 patients (Gynecol Oncol. 2005;97:645-51).

CO₂ laser ablation has been used for single lesions as well as multifocal or confluent disease. Many physicians advocate for its use in patients with multifocal lesions as well as those with disease around the clitoris or anus, where excisional therapy is less desirable as laser therapy results in less scarring.

A 2015 Cochrane Database Review of medical therapy for high-grade dysplasia (usual-type VIN, VIN 2/3, or high-grade VIN) found that topical imiquimod can be used as a safe and effective option for high-grade VIN. Physicians should, however, be aware of unfavorable side effects that may require dose reductions. Cidofovir may be an alternative to imiquimod pending more evidence on long-term response and progression (Cochrane Database Syst Rev. 2015 Aug 18;8:CD007924). Topical 5-fluorouracil has fallen out of favor for VIN given its significant chemical desquamation, however response rates are thought to be favorable if tolerated.

As the use of VIN terminology solidifies and information emerges on medical therapy to treat VIN, it is critical that physicians remain current when counseling and providing treatment recommendations for vulvar intraepithelial neoplasia.

Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology and professor in the division of gynecologic oncology at the university. Dr. Sullivan is a fellow in the division of gynecologic oncology at the university. They reported having no relevant financial disclosures. Email them at obnews@frontlinemedcom.com.

Vulvar intraepithelial neoplasia is a premalignant lesion of the vulva frequently encountered by gynecologic providers. There has been an increase in the incidence of VIN in younger women in recent decades thought be to be secondary to human papillomavirus infection, cigarette smoking, and sexual behavior (J Reprod Med. 2000 Aug;45[8]:613-5).

Data from the Surveillance Epidemiology and End Results (SEER) database were significant for a 411% increase in the incidence of in situ carcinoma and a 20% increase in invasive vulvar carcinoma from 1973 to 2000 (Obstet Gynecol. 2006 May;107[5]:1018-22). In addition, younger age groups are seeing an increase of in situ disease until age 49. Vulvar cancer however, continues to be a disease of older age.

Terminology

Previously, the term vulvar intraepithelial neoplasia followed the cervical intraepithelial neoplasia (CIN) designation in the 1960s. Conventions for grading these lesions have changed over time. Most recently, in 2004, the International Society for the Study of Vulvar Disease (ISSVD), composed of dermatologists, pathologists, and gynecologists, agreed to change the classification of squamous VIN from the previous VIN 1-3 classification system. The committee described VIN in two forms, “usual type” and “differentiated type” (J Reprod Med 2005;50:807-10).

In making this transition, it was recognized that VIN 1 is not in fact an oncogenic lesion and is now solely referred to as condyloma acuminatum. Grade 2 and 3 are now collectively referred to as VIN. These changes made by the ISSVD reflect the current literature on grading of VIN. In addition to VIN 1 not having any progression to malignancy, it is a diagnosis that is difficult to reproduce and may, at times, reflect reactive changes or other dermatosis. VIN 2 and 3 are not discriminated from each other in a reproducible manner and clinically have no reason for individual distinction (J Low Genit Tract Dis. 2006 Jul;10[3]:161-9).

VIN, usual type is the most common intraepithelial lesion and is historically referred to as classic VIN or Bowen’s disease. This type is associated with HPV infection and includes the formerly described warty type, basaloid type, and mixed type. The carcinogenic subtypes of HPV, 16, 18, 31, and 33 are the most common HPV subtypes responsible. It should be noted, however, that diagnosis is morphological and not based on HPV testing. Usual type is also traditionally thought to be more closely associated with risk factors such as smoking and immunocompromised states.

VIN, differentiated type is not associated with the HPV virus and is frequently found in older women. This lesion is often associated with other dermatologic conditions such as lichen sclerosis and lichen simplex chronicus. Diagnosis is also made by histology with abnormal cells being confined to the parabasal and basal portion of the rete pegs. This type also finds genetic alterations that are seen in invasive squamous cell carcinoma (Appl Immunohistochem Mol Morphol 2001;9:150-63). Differentiated type is thought to be a precursor for HPV-negative keratinizing squamous cell carcinoma of the vulva (Am J Surg Pathol. 2000 Mar;24[3]:429-41).

As awareness of this distinct form of VIN increases and more is learned about the precursors of HPV-negative squamous cell carcinoma, physicians are encouraged to closely follow up hyperplastic lesions and lichen sclerosis with biopsies and excision. The diagnosis of differentiated VIN is rarely made at present; however, this distinction by the ISSVD may improve the ability of clinicians and pathologists to recognize this HPV-negative precursor before squamous cell carcinoma is present.

The Lower Anogenital Squamous Terminology project of the College of American Pathology and the American Society for Colposcopy and Cervical Pathology advocates for more consistent terminology across lower anogenital tract lesions. This terminology applies only to HPV-related lesions (usual type) and considers the VIN 1 or condyloma accuminatum to be a low-grade lesion (LSIL), and VIN 2-3 or usual type to be high-grade lesions (HSIL) (Int J Gynecol Pathol. 2013 Jan;32[1]:76-115).

Many clinicians and pathologists have not adopted this most recent terminology; however, there is evidence that the ISSVD classification is the most clinically relevant.

Diagnosis

The majority of patients with any VIN will present with complaints of vulvar pruritus. However, women can also present with pain, burning, or dysuria, or can have an asymptomatic lesion found on pelvic exam. There are no recommended screening strategies to diagnose early VIN. Cytologic testing is complicated by the keratinization of the vulva, making this an unreliable diagnostic assessment.

On physical exam, VIN can have a heterogeneous presentation including papules, plaques, color variations, or ulcer. Differentiated type is thought to have a more defined appearance that frequently develops in the setting of other vulvar dermatosis. These are distinct, solitary lesions that are commonly raised, can have an overlying scale, and have ill-defined borders. A distinct lesion with ulceration or erosion is concerning for invasion.

Diagnosis is ultimately made by biopsy. Physicians should have a low threshold to biopsy any suspicious lesions or those unresponsive to therapy. Colposcopy is a frequent adjunct to the physical exam. Acetic acid 3%-5% soaked gauze is allowed to rest on the vulva for several minutes prior to observation with a colposcope or hand-held magnifying glass. Colposcopic findings are usually those of focal “white” epithelium. Vascular changes seen on the cervix (punctuation and mosaicism) are rarely seen on the vulva.

The entire anogenital region shares the same susceptibility to the HPV virus, thus squamous intraepithelial lesions are frequently multifocal. Physicians should have a heightened awareness of other lesions, such as cervical, vaginal, or anal, when managing a patient with VIN (Gynecol Oncol. 1995 Feb;56[2]:276-9). Appropriate cervical screening should be strictly adhered to and a thorough exam done at the time of vulvar colposcopy or exam.

Treatment

The goals of treatment include preventing carcinoma and improving symptoms while maintaining function and preserving anatomy. Treatment options for both types of VIN include excision, ablation, or medical therapy pending an evaluation of concurrent risk factors.

Premalignant disease was traditionally treated surgically. While surgical excision is still the mainstay of therapy, less aggressive techniques and medical therapy are more readily utilized. The goal of surgical excision for VIN is both diagnostic and therapeutic. When an excision for high-grade dysplasia is done (formerly VIN 3), detection of occult carcinoma was found in up to 3.2% in one large review (Gynecol Oncol. 2005;97:645-51).

Using a wide local excision to completely remove lesions with a pathologically clear margin reduces a patient’s risk of recurrence for disease compared to those excisions with positive margins (Obstet Gynecol. 1998;92:962-6). It is therefore critical that physicians carefully counsel patients who desire conservative therapy for VIN.

With any treatment, however, patients and physicians should be aware of the risk of recurrence; for vulvectomy, partial vulvectomy, local excision, and laser ablation, recurrences were seen at rates of 19%, 18%, 22%, and 23%, respectively, in a review of 3,322 patients (Gynecol Oncol. 2005;97:645-51).

CO₂ laser ablation has been used for single lesions as well as multifocal or confluent disease. Many physicians advocate for its use in patients with multifocal lesions as well as those with disease around the clitoris or anus, where excisional therapy is less desirable as laser therapy results in less scarring.

A 2015 Cochrane Database Review of medical therapy for high-grade dysplasia (usual-type VIN, VIN 2/3, or high-grade VIN) found that topical imiquimod can be used as a safe and effective option for high-grade VIN. Physicians should, however, be aware of unfavorable side effects that may require dose reductions. Cidofovir may be an alternative to imiquimod pending more evidence on long-term response and progression (Cochrane Database Syst Rev. 2015 Aug 18;8:CD007924). Topical 5-fluorouracil has fallen out of favor for VIN given its significant chemical desquamation, however response rates are thought to be favorable if tolerated.

As the use of VIN terminology solidifies and information emerges on medical therapy to treat VIN, it is critical that physicians remain current when counseling and providing treatment recommendations for vulvar intraepithelial neoplasia.

Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology and professor in the division of gynecologic oncology at the university. Dr. Sullivan is a fellow in the division of gynecologic oncology at the university. They reported having no relevant financial disclosures. Email them at obnews@frontlinemedcom.com.

In this month’s podcast for The Journal of Community and Supportive Oncology, Dr David Henry highlights a Review article on the role of targeted therapy in HIV-positive patients with lung cancer and 2 Original Reports, one on the impact of bladder volume on radiation dose to the rectum in patients with prostate cancer and a second on treatment outcomes in stage IIIA non-small-cell lung cancer in a community cancer center setting. Also discussed are a Commentary by David Cella and Lynne Wagner about re-personalizing precision medicine, and a Feature article on genomic oncology, the foundation of targeted, personalized therapies.  A Community Translations article on the recent approval of the histone deacetylase inhibitor panobinostat demonstrates how a novel mechanism of action has been harnessed to produce a therapy that can extend progression-free survival in patients with relapsed multiple myeloma, and 2 Case Reports document the presentation and treatment of 2 patients with rare conditions – nonislet cell tumor-induced hypoglycemia and drug-induced immune hemolytic anemia.

In this month’s podcast for The Journal of Community and Supportive Oncology, Dr David Henry highlights a Review article on the role of targeted therapy in HIV-positive patients with lung cancer and 2 Original Reports, one on the impact of bladder volume on radiation dose to the rectum in patients with prostate cancer and a second on treatment outcomes in stage IIIA non-small-cell lung cancer in a community cancer center setting. Also discussed are a Commentary by David Cella and Lynne Wagner about re-personalizing precision medicine, and a Feature article on genomic oncology, the foundation of targeted, personalized therapies.  A Community Translations article on the recent approval of the histone deacetylase inhibitor panobinostat demonstrates how a novel mechanism of action has been harnessed to produce a therapy that can extend progression-free survival in patients with relapsed multiple myeloma, and 2 Case Reports document the presentation and treatment of 2 patients with rare conditions – nonislet cell tumor-induced hypoglycemia and drug-induced immune hemolytic anemia.

In this month’s podcast for The Journal of Community and Supportive Oncology, Dr David Henry highlights a Review article on the role of targeted therapy in HIV-positive patients with lung cancer and 2 Original Reports, one on the impact of bladder volume on radiation dose to the rectum in patients with prostate cancer and a second on treatment outcomes in stage IIIA non-small-cell lung cancer in a community cancer center setting. Also discussed are a Commentary by David Cella and Lynne Wagner about re-personalizing precision medicine, and a Feature article on genomic oncology, the foundation of targeted, personalized therapies.  A Community Translations article on the recent approval of the histone deacetylase inhibitor panobinostat demonstrates how a novel mechanism of action has been harnessed to produce a therapy that can extend progression-free survival in patients with relapsed multiple myeloma, and 2 Case Reports document the presentation and treatment of 2 patients with rare conditions – nonislet cell tumor-induced hypoglycemia and drug-induced immune hemolytic anemia.

Review the PDF of the fact sheet on dermatoses of pregnancy

After, test your knowledge by answering the 5 practice questions.

Practice Questions

1. Which dermatosis of pregnancy occurs during the third trimester and is associated with multiple gestation pregnancies?

a. atopic eruption of pregnancy

b. gestational pemphigoid

c. intrahepatic cholestasis of pregnancy

d. prurigo of pregnancy

e. pruritic urticarial papules and plaques of pregnancy

2. Which dermatosis of pregnancy frequently flares after delivery?

a. atopic eruption of pregnancy

b. gestational pemphigoid

c. polymorphic eruption of pregnancy

d. prurigo gravidarum

e. prurigo of pregnancy

3. Which dermatosis of pregnancy has lesions that have a predilection for the abdominal striae?

a. cholestasis of pregnancy

b. gestational pemphigoid

c. prurigo gestationis

d. prurigo of pregnancy

e. pruritic urticarial papules and plaques of pregnancy

4. Which dermatosis of pregnancy has a risk for the development of hydatidiform moles and choriocarcinomas?

a. atopic eruption of pregnancy

b. cholestasis of pregnancy

c. gestational pemphigoid

d. pruritic urticarial papules and plaques of pregnancy

e. toxic erythema of pregnancy

5. Intrahepatic cholestasis of pregnancy has been associated with:

a. fetal mortality as high as 13%

b. jaundice in 20% of cases

c. onset in the third trimester of pregnancy

d. recurrence in subsequent pregnancies

e. all of the above
 

The answers appear on the next page.

1. Which dermatosis of pregnancy occurs during the third trimester and is associated with multiple gestation pregnancies?

a. atopic eruption of pregnancy

b. gestational pemphigoid

c. intrahepatic cholestasis of pregnancy

d. prurigo of pregnancy

e. pruritic urticarial papules and plaques of pregnancy

2. Which dermatosis of pregnancy frequently flares after delivery?

a. atopic eruption of pregnancy

b. gestational pemphigoid

c. polymorphic eruption of pregnancy

d. prurigo gravidarum

e. prurigo of pregnancy

3. Which dermatosis of pregnancy has lesions that have a predilection for the abdominal striae?

a. cholestasis of pregnancy

b. gestational pemphigoid

c. prurigo gestationis

d. prurigo of pregnancy

e. pruritic urticarial papules and plaques of pregnancy

4. Which dermatosis of pregnancy has a risk for the development of hydatidiform moles and choriocarcinomas?

a. atopic eruption of pregnancy

b. cholestasis of pregnancy

c. gestational pemphigoid

d. pruritic urticarial papules and plaques of pregnancy

e. toxic erythema of pregnancy

5. Intrahepatic cholestasis of pregnancy has been associated with:

a. fetal mortality as high as 13%

b. jaundice in 20% of cases

c. onset in the third trimester of pregnancy

d. recurrence in subsequent pregnancies

e. all of the above

Review the PDF of the fact sheet on dermatoses of pregnancy

After, test your knowledge by answering the 5 practice questions.

Practice Questions

1. Which dermatosis of pregnancy occurs during the third trimester and is associated with multiple gestation pregnancies?

a. atopic eruption of pregnancy

b. gestational pemphigoid

c. intrahepatic cholestasis of pregnancy

d. prurigo of pregnancy

e. pruritic urticarial papules and plaques of pregnancy

2. Which dermatosis of pregnancy frequently flares after delivery?

a. atopic eruption of pregnancy

b. gestational pemphigoid

c. polymorphic eruption of pregnancy

d. prurigo gravidarum

e. prurigo of pregnancy

3. Which dermatosis of pregnancy has lesions that have a predilection for the abdominal striae?

a. cholestasis of pregnancy

b. gestational pemphigoid

c. prurigo gestationis

d. prurigo of pregnancy

e. pruritic urticarial papules and plaques of pregnancy

4. Which dermatosis of pregnancy has a risk for the development of hydatidiform moles and choriocarcinomas?

a. atopic eruption of pregnancy

b. cholestasis of pregnancy

c. gestational pemphigoid

d. pruritic urticarial papules and plaques of pregnancy

e. toxic erythema of pregnancy

5. Intrahepatic cholestasis of pregnancy has been associated with:

a. fetal mortality as high as 13%

b. jaundice in 20% of cases

c. onset in the third trimester of pregnancy

d. recurrence in subsequent pregnancies

e. all of the above
 

The answers appear on the next page.

1. Which dermatosis of pregnancy occurs during the third trimester and is associated with multiple gestation pregnancies?

a. atopic eruption of pregnancy

b. gestational pemphigoid

c. intrahepatic cholestasis of pregnancy

d. prurigo of pregnancy

e. pruritic urticarial papules and plaques of pregnancy

2. Which dermatosis of pregnancy frequently flares after delivery?

a. atopic eruption of pregnancy

b. gestational pemphigoid

c. polymorphic eruption of pregnancy

d. prurigo gravidarum

e. prurigo of pregnancy

3. Which dermatosis of pregnancy has lesions that have a predilection for the abdominal striae?

a. cholestasis of pregnancy

b. gestational pemphigoid

c. prurigo gestationis

d. prurigo of pregnancy

e. pruritic urticarial papules and plaques of pregnancy

4. Which dermatosis of pregnancy has a risk for the development of hydatidiform moles and choriocarcinomas?

a. atopic eruption of pregnancy

b. cholestasis of pregnancy

c. gestational pemphigoid

d. pruritic urticarial papules and plaques of pregnancy

e. toxic erythema of pregnancy

5. Intrahepatic cholestasis of pregnancy has been associated with:

a. fetal mortality as high as 13%

b. jaundice in 20% of cases

c. onset in the third trimester of pregnancy

d. recurrence in subsequent pregnancies

e. all of the above

Review the PDF of the fact sheet on dermatoses of pregnancy

After, test your knowledge by answering the 5 practice questions.

Practice Questions

1. Which dermatosis of pregnancy occurs during the third trimester and is associated with multiple gestation pregnancies?

a. atopic eruption of pregnancy

b. gestational pemphigoid

c. intrahepatic cholestasis of pregnancy

d. prurigo of pregnancy

e. pruritic urticarial papules and plaques of pregnancy

2. Which dermatosis of pregnancy frequently flares after delivery?

a. atopic eruption of pregnancy

b. gestational pemphigoid

c. polymorphic eruption of pregnancy

d. prurigo gravidarum

e. prurigo of pregnancy

3. Which dermatosis of pregnancy has lesions that have a predilection for the abdominal striae?

a. cholestasis of pregnancy

b. gestational pemphigoid

c. prurigo gestationis

d. prurigo of pregnancy

e. pruritic urticarial papules and plaques of pregnancy

4. Which dermatosis of pregnancy has a risk for the development of hydatidiform moles and choriocarcinomas?

a. atopic eruption of pregnancy

b. cholestasis of pregnancy

c. gestational pemphigoid

d. pruritic urticarial papules and plaques of pregnancy

e. toxic erythema of pregnancy

5. Intrahepatic cholestasis of pregnancy has been associated with:

a. fetal mortality as high as 13%

b. jaundice in 20% of cases

c. onset in the third trimester of pregnancy

d. recurrence in subsequent pregnancies

e. all of the above
 

The answers appear on the next page.

1. Which dermatosis of pregnancy occurs during the third trimester and is associated with multiple gestation pregnancies?

a. atopic eruption of pregnancy

b. gestational pemphigoid

c. intrahepatic cholestasis of pregnancy

d. prurigo of pregnancy

e. pruritic urticarial papules and plaques of pregnancy

2. Which dermatosis of pregnancy frequently flares after delivery?

a. atopic eruption of pregnancy

b. gestational pemphigoid

c. polymorphic eruption of pregnancy

d. prurigo gravidarum

e. prurigo of pregnancy

3. Which dermatosis of pregnancy has lesions that have a predilection for the abdominal striae?

a. cholestasis of pregnancy

b. gestational pemphigoid

c. prurigo gestationis

d. prurigo of pregnancy

e. pruritic urticarial papules and plaques of pregnancy

4. Which dermatosis of pregnancy has a risk for the development of hydatidiform moles and choriocarcinomas?

a. atopic eruption of pregnancy

b. cholestasis of pregnancy

c. gestational pemphigoid

d. pruritic urticarial papules and plaques of pregnancy

e. toxic erythema of pregnancy

5. Intrahepatic cholestasis of pregnancy has been associated with:

a. fetal mortality as high as 13%

b. jaundice in 20% of cases

c. onset in the third trimester of pregnancy

d. recurrence in subsequent pregnancies

e. all of the above

Purpose: Determine the utility of fusion positron emission tomography/computed tomography (PET/CT) in mapping surgical procedures for suspicious colorectal masses in the era of minimally invasive surgery—laparoscopy/robotics where haptic feedback is absent.

Background: The National Comprehensive Cancer Network (NCCN) guidelines recommend using CT of the chest, abdomen, and pelvis for colorectal cancer staging. This is largely because PET/CT is not widely available, thus limiting access. Colonoscopy is used to locate/diagnose colorectal masses. Gastroenterologists often “guestimate” the location of the lesion either by anatomical landmarks or by measurement on the colonoscope itself. These are often inaccurate. It is the standard of care to ink the location of the lesion as well. This is not always done or easy to identify. It is often necessary to perform an intraoperative colonoscopy to locate the lesion in question and then make incisions or dock the robot accordingly.

Methods: Retrospective data from a colorectal surgeon were reviewed. Surgeries performed at the Raymond G. Murphy VAMC from March 2012 to June 2015 were included. Data were reviewed for these patients to evaluate for the efficacy of fusion PET/CT studies in identifying the lesion in question regardless of benign or cancerous lesion, mapping of the planned procedure, and how it affected planned treatment algorithms.

Results: Fifty patients were referred for evaluation and treatment of a suspicious colorectal mass, and 45 patients underwent PET/CT for staging. The lesion was not PET avid in 9 patients, and 36 patients had positive findings on the study. Thirty-two of those patients had findings fairly consistent with the colonoscopy site identifiers. In 5 patients, the PET/ CT results changed the planned surgery or delayed surgery for neoadjuvant chemoradiotherapy. The nonvisualized patients were either mucinous or no residual tumor remained.

Conclusions: Although PET/CT is not the recommended staging study by NCCN guidelines for colorectal cancers, it is readily available at our VAMC and proves useful in differentiating scar from tumor when compared with CT alone. Our experience showed that PET/CT is often positive in suspicious colorectal masses, helps to map the surgery, and acts as a baseline for ongoing surveillance. It ultimately can change the entire treatment algorithm for our individual patients.

Purpose: Determine the utility of fusion positron emission tomography/computed tomography (PET/CT) in mapping surgical procedures for suspicious colorectal masses in the era of minimally invasive surgery—laparoscopy/robotics where haptic feedback is absent.

Background: The National Comprehensive Cancer Network (NCCN) guidelines recommend using CT of the chest, abdomen, and pelvis for colorectal cancer staging. This is largely because PET/CT is not widely available, thus limiting access. Colonoscopy is used to locate/diagnose colorectal masses. Gastroenterologists often “guestimate” the location of the lesion either by anatomical landmarks or by measurement on the colonoscope itself. These are often inaccurate. It is the standard of care to ink the location of the lesion as well. This is not always done or easy to identify. It is often necessary to perform an intraoperative colonoscopy to locate the lesion in question and then make incisions or dock the robot accordingly.

Methods: Retrospective data from a colorectal surgeon were reviewed. Surgeries performed at the Raymond G. Murphy VAMC from March 2012 to June 2015 were included. Data were reviewed for these patients to evaluate for the efficacy of fusion PET/CT studies in identifying the lesion in question regardless of benign or cancerous lesion, mapping of the planned procedure, and how it affected planned treatment algorithms.

Results: Fifty patients were referred for evaluation and treatment of a suspicious colorectal mass, and 45 patients underwent PET/CT for staging. The lesion was not PET avid in 9 patients, and 36 patients had positive findings on the study. Thirty-two of those patients had findings fairly consistent with the colonoscopy site identifiers. In 5 patients, the PET/ CT results changed the planned surgery or delayed surgery for neoadjuvant chemoradiotherapy. The nonvisualized patients were either mucinous or no residual tumor remained.

Conclusions: Although PET/CT is not the recommended staging study by NCCN guidelines for colorectal cancers, it is readily available at our VAMC and proves useful in differentiating scar from tumor when compared with CT alone. Our experience showed that PET/CT is often positive in suspicious colorectal masses, helps to map the surgery, and acts as a baseline for ongoing surveillance. It ultimately can change the entire treatment algorithm for our individual patients.

Purpose: Determine the utility of fusion positron emission tomography/computed tomography (PET/CT) in mapping surgical procedures for suspicious colorectal masses in the era of minimally invasive surgery—laparoscopy/robotics where haptic feedback is absent.

Background: The National Comprehensive Cancer Network (NCCN) guidelines recommend using CT of the chest, abdomen, and pelvis for colorectal cancer staging. This is largely because PET/CT is not widely available, thus limiting access. Colonoscopy is used to locate/diagnose colorectal masses. Gastroenterologists often “guestimate” the location of the lesion either by anatomical landmarks or by measurement on the colonoscope itself. These are often inaccurate. It is the standard of care to ink the location of the lesion as well. This is not always done or easy to identify. It is often necessary to perform an intraoperative colonoscopy to locate the lesion in question and then make incisions or dock the robot accordingly.

Methods: Retrospective data from a colorectal surgeon were reviewed. Surgeries performed at the Raymond G. Murphy VAMC from March 2012 to June 2015 were included. Data were reviewed for these patients to evaluate for the efficacy of fusion PET/CT studies in identifying the lesion in question regardless of benign or cancerous lesion, mapping of the planned procedure, and how it affected planned treatment algorithms.

Results: Fifty patients were referred for evaluation and treatment of a suspicious colorectal mass, and 45 patients underwent PET/CT for staging. The lesion was not PET avid in 9 patients, and 36 patients had positive findings on the study. Thirty-two of those patients had findings fairly consistent with the colonoscopy site identifiers. In 5 patients, the PET/ CT results changed the planned surgery or delayed surgery for neoadjuvant chemoradiotherapy. The nonvisualized patients were either mucinous or no residual tumor remained.

Conclusions: Although PET/CT is not the recommended staging study by NCCN guidelines for colorectal cancers, it is readily available at our VAMC and proves useful in differentiating scar from tumor when compared with CT alone. Our experience showed that PET/CT is often positive in suspicious colorectal masses, helps to map the surgery, and acts as a baseline for ongoing surveillance. It ultimately can change the entire treatment algorithm for our individual patients.

Purpose: On average, VA patients are older and sicker than is the general population. Our objectives were to provide an overview of VA colorectal (CRC) incidence and make comparisons with the Surveillance, Epidemiology, and End Results (SEER) data, which provides U.S. cancer statistics.

Background: About 3,400 incidents of CRC are reported in the Veterans Affairs Central Cancer Registry (VACCR) annually. This equates to nearly 9% of VA cancers.

Methods/Data Analysis: Data were obtained from VACCR for incident CRC diagnosed/treated in VA from fiscal year (FY) 2009 to 2012. Using VHA Support Service Center information about the distribution of VA health care system enrollees for corresponding years, we made age and gender adjustments for the underlying VA population. Colorectal incidence among VA patients was descriptively compared with projected national 2014 CRC-specific SEER and supporting data sources.

Results: From FY 2009 to 2012, we identified 15,205 VA patients nationwide. For analysis, there were 12,551 patients (n = 322, 2.6% women; n = 12,229, 97.4% men). Among patients in the VACCR, the most common tumor location was proximal colon (n = 4,830, 38%), followed by rectum (n = 3,907, 31%), distal colon (n = 3,240, 26%), and other colon (n = 574, 5%). These percentages are comparable with those of SEER, in which proximal colon and rectum are most common. Among patients in the VACCR, SEER summary stage distribution was 44% (n = 5,517) local, 36% (n = 4,488) regional, 17% (n = 2,091) distant, and 4% (n = 455) unknown. These percentages also align with those of SEER, in which about 40% of CRC cases are diagnosed locally. Mirroring SEER, among the VACCR, overall CRC incidence rate decreased from 0.22 to 0.16 cases per 1,000 veterans in FYs 2009 and 2012, respectively.

Implications: VACCR data indicate that incident CRC in FY 2009 to 2012 approximated SEER projections during a similar time frame. National VA CRC incidence, location, and stage distribution are also similar. This suggests that despite VA patients being more complex than their general population counterparts, VA patients are generally diagnosed with comparable CRC locations and stages. This analysis also suggests that, like SEER, the VACCR may have utility for epidemiologic tracking and research.

Purpose: On average, VA patients are older and sicker than is the general population. Our objectives were to provide an overview of VA colorectal (CRC) incidence and make comparisons with the Surveillance, Epidemiology, and End Results (SEER) data, which provides U.S. cancer statistics.

Background: About 3,400 incidents of CRC are reported in the Veterans Affairs Central Cancer Registry (VACCR) annually. This equates to nearly 9% of VA cancers.

Methods/Data Analysis: Data were obtained from VACCR for incident CRC diagnosed/treated in VA from fiscal year (FY) 2009 to 2012. Using VHA Support Service Center information about the distribution of VA health care system enrollees for corresponding years, we made age and gender adjustments for the underlying VA population. Colorectal incidence among VA patients was descriptively compared with projected national 2014 CRC-specific SEER and supporting data sources.

Results: From FY 2009 to 2012, we identified 15,205 VA patients nationwide. For analysis, there were 12,551 patients (n = 322, 2.6% women; n = 12,229, 97.4% men). Among patients in the VACCR, the most common tumor location was proximal colon (n = 4,830, 38%), followed by rectum (n = 3,907, 31%), distal colon (n = 3,240, 26%), and other colon (n = 574, 5%). These percentages are comparable with those of SEER, in which proximal colon and rectum are most common. Among patients in the VACCR, SEER summary stage distribution was 44% (n = 5,517) local, 36% (n = 4,488) regional, 17% (n = 2,091) distant, and 4% (n = 455) unknown. These percentages also align with those of SEER, in which about 40% of CRC cases are diagnosed locally. Mirroring SEER, among the VACCR, overall CRC incidence rate decreased from 0.22 to 0.16 cases per 1,000 veterans in FYs 2009 and 2012, respectively.

Implications: VACCR data indicate that incident CRC in FY 2009 to 2012 approximated SEER projections during a similar time frame. National VA CRC incidence, location, and stage distribution are also similar. This suggests that despite VA patients being more complex than their general population counterparts, VA patients are generally diagnosed with comparable CRC locations and stages. This analysis also suggests that, like SEER, the VACCR may have utility for epidemiologic tracking and research.

Purpose: On average, VA patients are older and sicker than is the general population. Our objectives were to provide an overview of VA colorectal (CRC) incidence and make comparisons with the Surveillance, Epidemiology, and End Results (SEER) data, which provides U.S. cancer statistics.

Background: About 3,400 incidents of CRC are reported in the Veterans Affairs Central Cancer Registry (VACCR) annually. This equates to nearly 9% of VA cancers.

Methods/Data Analysis: Data were obtained from VACCR for incident CRC diagnosed/treated in VA from fiscal year (FY) 2009 to 2012. Using VHA Support Service Center information about the distribution of VA health care system enrollees for corresponding years, we made age and gender adjustments for the underlying VA population. Colorectal incidence among VA patients was descriptively compared with projected national 2014 CRC-specific SEER and supporting data sources.

Results: From FY 2009 to 2012, we identified 15,205 VA patients nationwide. For analysis, there were 12,551 patients (n = 322, 2.6% women; n = 12,229, 97.4% men). Among patients in the VACCR, the most common tumor location was proximal colon (n = 4,830, 38%), followed by rectum (n = 3,907, 31%), distal colon (n = 3,240, 26%), and other colon (n = 574, 5%). These percentages are comparable with those of SEER, in which proximal colon and rectum are most common. Among patients in the VACCR, SEER summary stage distribution was 44% (n = 5,517) local, 36% (n = 4,488) regional, 17% (n = 2,091) distant, and 4% (n = 455) unknown. These percentages also align with those of SEER, in which about 40% of CRC cases are diagnosed locally. Mirroring SEER, among the VACCR, overall CRC incidence rate decreased from 0.22 to 0.16 cases per 1,000 veterans in FYs 2009 and 2012, respectively.

Implications: VACCR data indicate that incident CRC in FY 2009 to 2012 approximated SEER projections during a similar time frame. National VA CRC incidence, location, and stage distribution are also similar. This suggests that despite VA patients being more complex than their general population counterparts, VA patients are generally diagnosed with comparable CRC locations and stages. This analysis also suggests that, like SEER, the VACCR may have utility for epidemiologic tracking and research.

Background: Currently there are no FDA-approved imaging biomarkers capable of accurately identifying and quantitatively differentiating estrogen receptor (ER) status in breast cancer. The current preclinical study evaluated the ability of a Ga-68 positron emission tomography (PET) imaging biomarker and the analogous Lu-177 theranostic peptide construct to target and determine the status of ER expression.

Methods: Five human breast cancer cell line xenograft models were established in severe combined immunodeficiency mice. Western blot analysis confirmed the BB2r expression. The BB2r antagonist peptide construct was radiolabeled with Ga-68 and Lu-177, using fully automated radiochemistry labeling techniques. Pharmacokinetic, micro-SPECT/CT, and micro-PET/CT studies were performed.

Results: Pharmacokinetic studies confirmed that the Lu-177 construct targeted BB2r positive tissue in ER+ tumor xenograft models to a much greater extent than in ER- tumor xenograft models. In contrast, the ER-tumor xenografts demonstrated low initial uptake, followed by nearly complete washout from all tumor tissue within 24-hours after injection. The variances in tracer uptake by the tumor tissue correlated with BB2r expression via western blot analysis. Ga-68 micro-PET/CT data also correlated with the Lu-177 pharma-cokinetic studies, demonstrating visualization of BB2r+ tumor tissue with trends in standardized uptake values correlating directly with BB2r expression and ER status.

Conclusions: In summary, our study demonstrates selective tumor targeting for both a Ga-68 PET imaging biomarker and a Lu-177 theranostic agent in all breast cancer models studied. The Ga-68 PET SUV data suggest that PET imaging with this tracer or an analog of this tracer may have the potential to noninvasively differentiate ER status in vivo. Further studies are required involving an expanded panel of human cell lines and correlation with BB2 receptor expression/ER status obtained from biopsy data to confirm the potential validity of this finding.

Background: Currently there are no FDA-approved imaging biomarkers capable of accurately identifying and quantitatively differentiating estrogen receptor (ER) status in breast cancer. The current preclinical study evaluated the ability of a Ga-68 positron emission tomography (PET) imaging biomarker and the analogous Lu-177 theranostic peptide construct to target and determine the status of ER expression.

Methods: Five human breast cancer cell line xenograft models were established in severe combined immunodeficiency mice. Western blot analysis confirmed the BB2r expression. The BB2r antagonist peptide construct was radiolabeled with Ga-68 and Lu-177, using fully automated radiochemistry labeling techniques. Pharmacokinetic, micro-SPECT/CT, and micro-PET/CT studies were performed.

Results: Pharmacokinetic studies confirmed that the Lu-177 construct targeted BB2r positive tissue in ER+ tumor xenograft models to a much greater extent than in ER- tumor xenograft models. In contrast, the ER-tumor xenografts demonstrated low initial uptake, followed by nearly complete washout from all tumor tissue within 24-hours after injection. The variances in tracer uptake by the tumor tissue correlated with BB2r expression via western blot analysis. Ga-68 micro-PET/CT data also correlated with the Lu-177 pharma-cokinetic studies, demonstrating visualization of BB2r+ tumor tissue with trends in standardized uptake values correlating directly with BB2r expression and ER status.

Conclusions: In summary, our study demonstrates selective tumor targeting for both a Ga-68 PET imaging biomarker and a Lu-177 theranostic agent in all breast cancer models studied. The Ga-68 PET SUV data suggest that PET imaging with this tracer or an analog of this tracer may have the potential to noninvasively differentiate ER status in vivo. Further studies are required involving an expanded panel of human cell lines and correlation with BB2 receptor expression/ER status obtained from biopsy data to confirm the potential validity of this finding.

Background: Currently there are no FDA-approved imaging biomarkers capable of accurately identifying and quantitatively differentiating estrogen receptor (ER) status in breast cancer. The current preclinical study evaluated the ability of a Ga-68 positron emission tomography (PET) imaging biomarker and the analogous Lu-177 theranostic peptide construct to target and determine the status of ER expression.

Methods: Five human breast cancer cell line xenograft models were established in severe combined immunodeficiency mice. Western blot analysis confirmed the BB2r expression. The BB2r antagonist peptide construct was radiolabeled with Ga-68 and Lu-177, using fully automated radiochemistry labeling techniques. Pharmacokinetic, micro-SPECT/CT, and micro-PET/CT studies were performed.

Results: Pharmacokinetic studies confirmed that the Lu-177 construct targeted BB2r positive tissue in ER+ tumor xenograft models to a much greater extent than in ER- tumor xenograft models. In contrast, the ER-tumor xenografts demonstrated low initial uptake, followed by nearly complete washout from all tumor tissue within 24-hours after injection. The variances in tracer uptake by the tumor tissue correlated with BB2r expression via western blot analysis. Ga-68 micro-PET/CT data also correlated with the Lu-177 pharma-cokinetic studies, demonstrating visualization of BB2r+ tumor tissue with trends in standardized uptake values correlating directly with BB2r expression and ER status.

Conclusions: In summary, our study demonstrates selective tumor targeting for both a Ga-68 PET imaging biomarker and a Lu-177 theranostic agent in all breast cancer models studied. The Ga-68 PET SUV data suggest that PET imaging with this tracer or an analog of this tracer may have the potential to noninvasively differentiate ER status in vivo. Further studies are required involving an expanded panel of human cell lines and correlation with BB2 receptor expression/ER status obtained from biopsy data to confirm the potential validity of this finding.

NEW YORK - Endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs) is associated with an initial survival advantage over open repair, according to a study of "real-world" data from California.

However, the difference disappears in the long term, researchers report in JAMA Surgery, online September 2.

Dr. David C. Chang of Harvard Medical School in Boston said by email that the study "highlights the importance of looking at real-world data in evaluating surgical options. Clinically, our study found that the survival advantage for EVAR repairs is maintained until 3 years, after which mortality was higher for patients who had EVAR repairs."

The team studied more than 23,000 patients who underwent AAA repair between 2001 and 2009. Just over half had EVAR while the remaining patients underwent open repair. Median follow-up was for three years.

EVAR was associated with improved 30-day all-cause mortality (1.54% vs. 4.74%) and significantly improved survival until three years postoperatively. After that mortality rose, and the researchers found no difference in long-term mortality for the entire cohort after adjusting for confounders (hazard ratio, 0.99; p=0.64).

EVAR was linked with a significantly higher rate of reinterventions and AAA late ruptures. At five years, for instance, the reintervention rate was 6.59% in the EVAR group vs. 1.48% in the open group.

"This is different from data from clinical trials," Dr. Chang pointed out. "The short-term survival advantage of EVAR from clinical trials data likely eroded as patient risk factors exact their toll over time. These are real-world issues and concerns that are often not captured in idealized clinical trials."

Senior author Dr. Samuel E. Wilson, of the University of California-Irvine Medical Center, added by email that EVAR is safer than the open procedure, which it has replaced. The mortality advantage last for three years, "then other morbidity, especially effects of smoking, even out survival."

Dr. Chang went on to note that "our use of data from the State of California also has an important policy implication: That many states actually have better and more complete population data than the federal government when it comes to healthcare quality. While research and policies related to healthcare quality are driven mostly by the federal government

currently (through Medicare), the federal government has limited data on patient care outside of Medicare."

"Therefore," Dr. Chang concluded, "an argument can be made that the federal government should delegate healthcare research and quality improvement responsibilities to individual states, and support state-level efforts to examine and improve healthcare quality. Healthcare, like politics, is all local."

In an accompanying editorial, Drs. Jamie E. Anderson and James W. Holcroft, of the University of California Davis Medical Center, Sacramento, observe that the study "offers a glimpse into the future of population-based health services research methods."

In a joint email, they said, "Harnessing information already captured for patient care or billing purposes to advance medical research makes sense."

NEW YORK - Endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs) is associated with an initial survival advantage over open repair, according to a study of "real-world" data from California.

However, the difference disappears in the long term, researchers report in JAMA Surgery, online September 2.

Dr. David C. Chang of Harvard Medical School in Boston said by email that the study "highlights the importance of looking at real-world data in evaluating surgical options. Clinically, our study found that the survival advantage for EVAR repairs is maintained until 3 years, after which mortality was higher for patients who had EVAR repairs."

The team studied more than 23,000 patients who underwent AAA repair between 2001 and 2009. Just over half had EVAR while the remaining patients underwent open repair. Median follow-up was for three years.

EVAR was associated with improved 30-day all-cause mortality (1.54% vs. 4.74%) and significantly improved survival until three years postoperatively. After that mortality rose, and the researchers found no difference in long-term mortality for the entire cohort after adjusting for confounders (hazard ratio, 0.99; p=0.64).

EVAR was linked with a significantly higher rate of reinterventions and AAA late ruptures. At five years, for instance, the reintervention rate was 6.59% in the EVAR group vs. 1.48% in the open group.

"This is different from data from clinical trials," Dr. Chang pointed out. "The short-term survival advantage of EVAR from clinical trials data likely eroded as patient risk factors exact their toll over time. These are real-world issues and concerns that are often not captured in idealized clinical trials."

Senior author Dr. Samuel E. Wilson, of the University of California-Irvine Medical Center, added by email that EVAR is safer than the open procedure, which it has replaced. The mortality advantage last for three years, "then other morbidity, especially effects of smoking, even out survival."

Dr. Chang went on to note that "our use of data from the State of California also has an important policy implication: That many states actually have better and more complete population data than the federal government when it comes to healthcare quality. While research and policies related to healthcare quality are driven mostly by the federal government

currently (through Medicare), the federal government has limited data on patient care outside of Medicare."

"Therefore," Dr. Chang concluded, "an argument can be made that the federal government should delegate healthcare research and quality improvement responsibilities to individual states, and support state-level efforts to examine and improve healthcare quality. Healthcare, like politics, is all local."

In an accompanying editorial, Drs. Jamie E. Anderson and James W. Holcroft, of the University of California Davis Medical Center, Sacramento, observe that the study "offers a glimpse into the future of population-based health services research methods."

In a joint email, they said, "Harnessing information already captured for patient care or billing purposes to advance medical research makes sense."

NEW YORK - Endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs) is associated with an initial survival advantage over open repair, according to a study of "real-world" data from California.

However, the difference disappears in the long term, researchers report in JAMA Surgery, online September 2.

Dr. David C. Chang of Harvard Medical School in Boston said by email that the study "highlights the importance of looking at real-world data in evaluating surgical options. Clinically, our study found that the survival advantage for EVAR repairs is maintained until 3 years, after which mortality was higher for patients who had EVAR repairs."

The team studied more than 23,000 patients who underwent AAA repair between 2001 and 2009. Just over half had EVAR while the remaining patients underwent open repair. Median follow-up was for three years.

EVAR was associated with improved 30-day all-cause mortality (1.54% vs. 4.74%) and significantly improved survival until three years postoperatively. After that mortality rose, and the researchers found no difference in long-term mortality for the entire cohort after adjusting for confounders (hazard ratio, 0.99; p=0.64).

EVAR was linked with a significantly higher rate of reinterventions and AAA late ruptures. At five years, for instance, the reintervention rate was 6.59% in the EVAR group vs. 1.48% in the open group.

"This is different from data from clinical trials," Dr. Chang pointed out. "The short-term survival advantage of EVAR from clinical trials data likely eroded as patient risk factors exact their toll over time. These are real-world issues and concerns that are often not captured in idealized clinical trials."

Senior author Dr. Samuel E. Wilson, of the University of California-Irvine Medical Center, added by email that EVAR is safer than the open procedure, which it has replaced. The mortality advantage last for three years, "then other morbidity, especially effects of smoking, even out survival."

Dr. Chang went on to note that "our use of data from the State of California also has an important policy implication: That many states actually have better and more complete population data than the federal government when it comes to healthcare quality. While research and policies related to healthcare quality are driven mostly by the federal government

currently (through Medicare), the federal government has limited data on patient care outside of Medicare."

"Therefore," Dr. Chang concluded, "an argument can be made that the federal government should delegate healthcare research and quality improvement responsibilities to individual states, and support state-level efforts to examine and improve healthcare quality. Healthcare, like politics, is all local."

In an accompanying editorial, Drs. Jamie E. Anderson and James W. Holcroft, of the University of California Davis Medical Center, Sacramento, observe that the study "offers a glimpse into the future of population-based health services research methods."

In a joint email, they said, "Harnessing information already captured for patient care or billing purposes to advance medical research makes sense."