Doctor with a clipboard

Institutional Review Boards (IRBs) at academic health centers have gotten better at managing members’ industry relationships in the last several years, but issues persist, according to a new study.

The research is a follow-up to a study published in 2006.

The new study showed improvements in the management of industry relationships, with increased levels of disclosure and fewer “problematic relationships” than were reported in the previous study.

However, nearly a third of IRB members in the new study said they were unaware of their board’s conflict of interest policies. And a quarter of IRB members reported voting on protocols with which they have conflicts of interest, which is a violation of federal regulations.

“IRBs are the primary mechanisms by which institutions oversee research that involves human participants, and industry relationships of IRB members have the potential to impact their IRB-related activities in both positive and negative ways,” said Eric G. Campbell, PhD, of the Mongan Institute for Health Policy at Massachusetts General Hospital in Boston.

“While our principal findings are that, compared to a decade ago, IRBs appear to be doing a much better job at managing their members’ industry relationships, there still are findings that are concerning.”

Dr Campbell and his colleagues described these findings in JAMA Internal Medicine.

Every US institution that conducts research involving human participants must have an IRB, which reviews proposed studies to ensure their design is scientifically valid and does not violate ethical and regulatory guidelines. IRBs also monitor ongoing studies to make sure they maintain appropriate practices.

The first study to examine industry relationships of IRB members, conducted by Dr Campbell and his colleagues, was based on a survey of IRB members at 100 institutions that was published in NEJM in November 2006.

That study showed that more than a third of IRB members had some sort of financial relationship with commercial firms. And while most respondents did not believe that such relationships had an inappropriate impact on IRB decision making, significant percentages were not aware of institutional guidelines for disclosing industry relationships or defining conflicts of interest.

The current study involved an identical survey administered in 2014 to nearly 500 IRB members at 115 medical schools and teaching hospitals around the country.

As in the 2006 study, respondents were asked about specific types of relationships with commercial companies, whether they received any industry funding and for what purposes, and how many protocols had come before their IRB that involved companies with which they had a relationship.

For protocols with which IRB members had a conflict—relating either to companies they had relationships with or to competitors—they were asked whether they had disclosed their relationships to the IRB, whether they participated in discussion of those protocols, and whether they voted on the protocols.

Results

There was no significant difference between the current study and the previous study in the percentage of IRB members who reported having industry relationships overall—37% and 32%, respectively.

However, the percentage of respondents who reported receiving payments for attending meetings and conferences or for serving on speakers’ bureaus—relationships that are considered problematic—dropped significantly. The percentages fell from 16% to 9% for meeting/conference participation and from 14% to 4% for speakers’ bureaus.

“We were encouraged to see that the prevalence of potentially beneficial relationships—such as industry funding to support research studies—was essentially unchanged, indicating IRBs have not tried to eliminate members’ industry relationships across the board,” said Christine Vogeli, PhD, also of the Mongan Institute.

Survey respondents were more likely in the current study than in the previous one to say that their IRB had a written definition of conflicts of interest—63% compared with 46%. In addition, the percentage of respondents who reported their IRB had no policy related to conflicts dropped from 14% to 5%.

However, the researchers were concerned by the fact that 32% of respondents still did not know whether or not their IRB had a policy on conflicts, even though that number had dropped from 41% in the previous study.

The percentage of respondents who handled their conflicts of interest in an appropriate manner increased. Eighty percent of respondents with conflicts reported them to the IRB, up from 55% in the previous study.

And 68% of respondents said they always left the room when a protocol with which they had a conflict was being discussed, up from 38% in the previous study.

However, a quarter of respondents with conflicts indicated they had voted on protocols with which they had a conflict. While that was a drop from what was reported in the previous study, it was not statistically significant.

The percentage of respondents who felt that at least one protocol had been presented to their IRB in a biased fashion because of another member’s industry relationships dropped from 14% in the previous study to 8% in this study.

And when asked about the types of bias they perceived in the presentation—questions not included in the previous survey—8% of respondents reported a pro-industry bias, and 14% reported an anti-industry bias.

“The fact that we found any bias—either pro- or anti-industry—is an issue, since bias is antithetical to research and should be eliminated,” Dr Campbell said. “IRBs should address that issue, along with increasing efforts to educate their members about what constitutes a conflict of interest and the inappropriateness of voting on protocols with which they have a conflict.”

Doctor with a clipboard

Institutional Review Boards (IRBs) at academic health centers have gotten better at managing members’ industry relationships in the last several years, but issues persist, according to a new study.

The research is a follow-up to a study published in 2006.

The new study showed improvements in the management of industry relationships, with increased levels of disclosure and fewer “problematic relationships” than were reported in the previous study.

However, nearly a third of IRB members in the new study said they were unaware of their board’s conflict of interest policies. And a quarter of IRB members reported voting on protocols with which they have conflicts of interest, which is a violation of federal regulations.

“IRBs are the primary mechanisms by which institutions oversee research that involves human participants, and industry relationships of IRB members have the potential to impact their IRB-related activities in both positive and negative ways,” said Eric G. Campbell, PhD, of the Mongan Institute for Health Policy at Massachusetts General Hospital in Boston.

“While our principal findings are that, compared to a decade ago, IRBs appear to be doing a much better job at managing their members’ industry relationships, there still are findings that are concerning.”

Dr Campbell and his colleagues described these findings in JAMA Internal Medicine.

Every US institution that conducts research involving human participants must have an IRB, which reviews proposed studies to ensure their design is scientifically valid and does not violate ethical and regulatory guidelines. IRBs also monitor ongoing studies to make sure they maintain appropriate practices.

The first study to examine industry relationships of IRB members, conducted by Dr Campbell and his colleagues, was based on a survey of IRB members at 100 institutions that was published in NEJM in November 2006.

That study showed that more than a third of IRB members had some sort of financial relationship with commercial firms. And while most respondents did not believe that such relationships had an inappropriate impact on IRB decision making, significant percentages were not aware of institutional guidelines for disclosing industry relationships or defining conflicts of interest.

The current study involved an identical survey administered in 2014 to nearly 500 IRB members at 115 medical schools and teaching hospitals around the country.

As in the 2006 study, respondents were asked about specific types of relationships with commercial companies, whether they received any industry funding and for what purposes, and how many protocols had come before their IRB that involved companies with which they had a relationship.

For protocols with which IRB members had a conflict—relating either to companies they had relationships with or to competitors—they were asked whether they had disclosed their relationships to the IRB, whether they participated in discussion of those protocols, and whether they voted on the protocols.

Results

There was no significant difference between the current study and the previous study in the percentage of IRB members who reported having industry relationships overall—37% and 32%, respectively.

However, the percentage of respondents who reported receiving payments for attending meetings and conferences or for serving on speakers’ bureaus—relationships that are considered problematic—dropped significantly. The percentages fell from 16% to 9% for meeting/conference participation and from 14% to 4% for speakers’ bureaus.

“We were encouraged to see that the prevalence of potentially beneficial relationships—such as industry funding to support research studies—was essentially unchanged, indicating IRBs have not tried to eliminate members’ industry relationships across the board,” said Christine Vogeli, PhD, also of the Mongan Institute.

Survey respondents were more likely in the current study than in the previous one to say that their IRB had a written definition of conflicts of interest—63% compared with 46%. In addition, the percentage of respondents who reported their IRB had no policy related to conflicts dropped from 14% to 5%.

However, the researchers were concerned by the fact that 32% of respondents still did not know whether or not their IRB had a policy on conflicts, even though that number had dropped from 41% in the previous study.

The percentage of respondents who handled their conflicts of interest in an appropriate manner increased. Eighty percent of respondents with conflicts reported them to the IRB, up from 55% in the previous study.

And 68% of respondents said they always left the room when a protocol with which they had a conflict was being discussed, up from 38% in the previous study.

However, a quarter of respondents with conflicts indicated they had voted on protocols with which they had a conflict. While that was a drop from what was reported in the previous study, it was not statistically significant.

The percentage of respondents who felt that at least one protocol had been presented to their IRB in a biased fashion because of another member’s industry relationships dropped from 14% in the previous study to 8% in this study.

And when asked about the types of bias they perceived in the presentation—questions not included in the previous survey—8% of respondents reported a pro-industry bias, and 14% reported an anti-industry bias.

“The fact that we found any bias—either pro- or anti-industry—is an issue, since bias is antithetical to research and should be eliminated,” Dr Campbell said. “IRBs should address that issue, along with increasing efforts to educate their members about what constitutes a conflict of interest and the inappropriateness of voting on protocols with which they have a conflict.”

Doctor with a clipboard

Institutional Review Boards (IRBs) at academic health centers have gotten better at managing members’ industry relationships in the last several years, but issues persist, according to a new study.

The research is a follow-up to a study published in 2006.

The new study showed improvements in the management of industry relationships, with increased levels of disclosure and fewer “problematic relationships” than were reported in the previous study.

However, nearly a third of IRB members in the new study said they were unaware of their board’s conflict of interest policies. And a quarter of IRB members reported voting on protocols with which they have conflicts of interest, which is a violation of federal regulations.

“IRBs are the primary mechanisms by which institutions oversee research that involves human participants, and industry relationships of IRB members have the potential to impact their IRB-related activities in both positive and negative ways,” said Eric G. Campbell, PhD, of the Mongan Institute for Health Policy at Massachusetts General Hospital in Boston.

“While our principal findings are that, compared to a decade ago, IRBs appear to be doing a much better job at managing their members’ industry relationships, there still are findings that are concerning.”

Dr Campbell and his colleagues described these findings in JAMA Internal Medicine.

Every US institution that conducts research involving human participants must have an IRB, which reviews proposed studies to ensure their design is scientifically valid and does not violate ethical and regulatory guidelines. IRBs also monitor ongoing studies to make sure they maintain appropriate practices.

The first study to examine industry relationships of IRB members, conducted by Dr Campbell and his colleagues, was based on a survey of IRB members at 100 institutions that was published in NEJM in November 2006.

That study showed that more than a third of IRB members had some sort of financial relationship with commercial firms. And while most respondents did not believe that such relationships had an inappropriate impact on IRB decision making, significant percentages were not aware of institutional guidelines for disclosing industry relationships or defining conflicts of interest.

The current study involved an identical survey administered in 2014 to nearly 500 IRB members at 115 medical schools and teaching hospitals around the country.

As in the 2006 study, respondents were asked about specific types of relationships with commercial companies, whether they received any industry funding and for what purposes, and how many protocols had come before their IRB that involved companies with which they had a relationship.

For protocols with which IRB members had a conflict—relating either to companies they had relationships with or to competitors—they were asked whether they had disclosed their relationships to the IRB, whether they participated in discussion of those protocols, and whether they voted on the protocols.

Results

There was no significant difference between the current study and the previous study in the percentage of IRB members who reported having industry relationships overall—37% and 32%, respectively.

However, the percentage of respondents who reported receiving payments for attending meetings and conferences or for serving on speakers’ bureaus—relationships that are considered problematic—dropped significantly. The percentages fell from 16% to 9% for meeting/conference participation and from 14% to 4% for speakers’ bureaus.

“We were encouraged to see that the prevalence of potentially beneficial relationships—such as industry funding to support research studies—was essentially unchanged, indicating IRBs have not tried to eliminate members’ industry relationships across the board,” said Christine Vogeli, PhD, also of the Mongan Institute.

Survey respondents were more likely in the current study than in the previous one to say that their IRB had a written definition of conflicts of interest—63% compared with 46%. In addition, the percentage of respondents who reported their IRB had no policy related to conflicts dropped from 14% to 5%.

However, the researchers were concerned by the fact that 32% of respondents still did not know whether or not their IRB had a policy on conflicts, even though that number had dropped from 41% in the previous study.

The percentage of respondents who handled their conflicts of interest in an appropriate manner increased. Eighty percent of respondents with conflicts reported them to the IRB, up from 55% in the previous study.

And 68% of respondents said they always left the room when a protocol with which they had a conflict was being discussed, up from 38% in the previous study.

However, a quarter of respondents with conflicts indicated they had voted on protocols with which they had a conflict. While that was a drop from what was reported in the previous study, it was not statistically significant.

The percentage of respondents who felt that at least one protocol had been presented to their IRB in a biased fashion because of another member’s industry relationships dropped from 14% in the previous study to 8% in this study.

And when asked about the types of bias they perceived in the presentation—questions not included in the previous survey—8% of respondents reported a pro-industry bias, and 14% reported an anti-industry bias.

“The fact that we found any bias—either pro- or anti-industry—is an issue, since bias is antithetical to research and should be eliminated,” Dr Campbell said. “IRBs should address that issue, along with increasing efforts to educate their members about what constitutes a conflict of interest and the inappropriateness of voting on protocols with which they have a conflict.”

In 2011, the American Board of Internal Medicine started the Choosing Wisely campaign, a subtly subversive call to curb health care spending. As part of that campaign, the American College of Rheumatology published its own list of five “tests, treatments, or services … whose necessity or value should be questioned” in March 2013.

As it turns out, Canada has also started a Choosing Wisely Canada campaign, and in February of this year the Canadian Rheumatology Association published their list of five. Though the methodology for coming up with the list was the same in these two very similar populations, there is surprisingly little overlap between the two lists. It is likely that the differences are partly explained by how medicine is practiced and paid for in the two countries. How invested physicians are in their respective professional societies may play a role, too. As part of the methodology, surveys were sent out to membership: At the time of the study the ACR had 6,188 members and a 17% response rate, while the CRA had a membership of 484 and a 35% response rate.

The ACR publication reminds us that the initiative is in part a response to a physician charter for medical professionalism, drafted in 2002 by a collaboration of physician organizations, including the ABIM Foundation and the American College of Physicians, outlining principles of professionalism, “including patient welfare, patient autonomy, and social justice” (Ann. Intern. Med. 2002;136:143-6).

Social justice, according to the ACR, “calls on the profession to promote a fair distribution of health care resources and to engage in collective efforts to improve the health care system for the welfare of society.” I wonder if the gap between the survey response rates of the American and the Canadian groups reflects greater indifference to societal welfare, but I certainly hope not.

In any event, I would like to devote some space to reviewing these two lists. They are worth revisiting often. I’ve included some clarifying statements from each publication that I thought were helpful.

The ACR list (Arthritis Care Res. 2013;65:329-39)

• Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjögren syndrome.

• Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.

• Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

• Do not prescribe biologic agents for RA before a trial of methotrexate (or another conventional nonbiologic DMARD)

• Do not routinely repeat DXA scans more often than once every 2 years. DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected.

The CRA list (J. Rheumatol. 2015;42:682-9)

• Do not order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other connective tissue disease. At one center in Canada, ANA testing was positive only 15% of the time and cost more than $800,000 over 3 years when combined with ENA and anti-dsDNA. … An ANA test should be ordered only if the clinician feels there is reasonable clinical suspicion of SLE or CTD based on historical information, physical findings and results of other laboratory tests.

• Do not order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.

• Do not repeat DXA scans more often than every 2 years. If BMD are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered.

• Do not prescribe bisphosphonates for patients at low risk of fracture.

• Do not perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adult population.

Dr. Chan practices rheumatology in Pawtucket, R.I.

In 2011, the American Board of Internal Medicine started the Choosing Wisely campaign, a subtly subversive call to curb health care spending. As part of that campaign, the American College of Rheumatology published its own list of five “tests, treatments, or services … whose necessity or value should be questioned” in March 2013.

As it turns out, Canada has also started a Choosing Wisely Canada campaign, and in February of this year the Canadian Rheumatology Association published their list of five. Though the methodology for coming up with the list was the same in these two very similar populations, there is surprisingly little overlap between the two lists. It is likely that the differences are partly explained by how medicine is practiced and paid for in the two countries. How invested physicians are in their respective professional societies may play a role, too. As part of the methodology, surveys were sent out to membership: At the time of the study the ACR had 6,188 members and a 17% response rate, while the CRA had a membership of 484 and a 35% response rate.

The ACR publication reminds us that the initiative is in part a response to a physician charter for medical professionalism, drafted in 2002 by a collaboration of physician organizations, including the ABIM Foundation and the American College of Physicians, outlining principles of professionalism, “including patient welfare, patient autonomy, and social justice” (Ann. Intern. Med. 2002;136:143-6).

Social justice, according to the ACR, “calls on the profession to promote a fair distribution of health care resources and to engage in collective efforts to improve the health care system for the welfare of society.” I wonder if the gap between the survey response rates of the American and the Canadian groups reflects greater indifference to societal welfare, but I certainly hope not.

In any event, I would like to devote some space to reviewing these two lists. They are worth revisiting often. I’ve included some clarifying statements from each publication that I thought were helpful.

The ACR list (Arthritis Care Res. 2013;65:329-39)

• Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjögren syndrome.

• Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.

• Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

• Do not prescribe biologic agents for RA before a trial of methotrexate (or another conventional nonbiologic DMARD)

• Do not routinely repeat DXA scans more often than once every 2 years. DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected.

The CRA list (J. Rheumatol. 2015;42:682-9)

• Do not order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other connective tissue disease. At one center in Canada, ANA testing was positive only 15% of the time and cost more than $800,000 over 3 years when combined with ENA and anti-dsDNA. … An ANA test should be ordered only if the clinician feels there is reasonable clinical suspicion of SLE or CTD based on historical information, physical findings and results of other laboratory tests.

• Do not order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.

• Do not repeat DXA scans more often than every 2 years. If BMD are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered.

• Do not prescribe bisphosphonates for patients at low risk of fracture.

• Do not perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adult population.

Dr. Chan practices rheumatology in Pawtucket, R.I.

In 2011, the American Board of Internal Medicine started the Choosing Wisely campaign, a subtly subversive call to curb health care spending. As part of that campaign, the American College of Rheumatology published its own list of five “tests, treatments, or services … whose necessity or value should be questioned” in March 2013.

As it turns out, Canada has also started a Choosing Wisely Canada campaign, and in February of this year the Canadian Rheumatology Association published their list of five. Though the methodology for coming up with the list was the same in these two very similar populations, there is surprisingly little overlap between the two lists. It is likely that the differences are partly explained by how medicine is practiced and paid for in the two countries. How invested physicians are in their respective professional societies may play a role, too. As part of the methodology, surveys were sent out to membership: At the time of the study the ACR had 6,188 members and a 17% response rate, while the CRA had a membership of 484 and a 35% response rate.

The ACR publication reminds us that the initiative is in part a response to a physician charter for medical professionalism, drafted in 2002 by a collaboration of physician organizations, including the ABIM Foundation and the American College of Physicians, outlining principles of professionalism, “including patient welfare, patient autonomy, and social justice” (Ann. Intern. Med. 2002;136:143-6).

Social justice, according to the ACR, “calls on the profession to promote a fair distribution of health care resources and to engage in collective efforts to improve the health care system for the welfare of society.” I wonder if the gap between the survey response rates of the American and the Canadian groups reflects greater indifference to societal welfare, but I certainly hope not.

In any event, I would like to devote some space to reviewing these two lists. They are worth revisiting often. I’ve included some clarifying statements from each publication that I thought were helpful.

The ACR list (Arthritis Care Res. 2013;65:329-39)

• Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjögren syndrome.

• Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.

• Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

• Do not prescribe biologic agents for RA before a trial of methotrexate (or another conventional nonbiologic DMARD)

• Do not routinely repeat DXA scans more often than once every 2 years. DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected.

The CRA list (J. Rheumatol. 2015;42:682-9)

• Do not order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other connective tissue disease. At one center in Canada, ANA testing was positive only 15% of the time and cost more than $800,000 over 3 years when combined with ENA and anti-dsDNA. … An ANA test should be ordered only if the clinician feels there is reasonable clinical suspicion of SLE or CTD based on historical information, physical findings and results of other laboratory tests.

• Do not order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.

• Do not repeat DXA scans more often than every 2 years. If BMD are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered.

• Do not prescribe bisphosphonates for patients at low risk of fracture.

• Do not perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in the adult population.

Dr. Chan practices rheumatology in Pawtucket, R.I.

Review the PDF of the fact sheet on chemical peels

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

Practice Questions

1. Which one of the following peels produces “frosting” after application?

a. citric acid

b. glycolic acid

c. mandelic acid

d. salicylic acid

e. trichloroacetic acid

2. Which one of the following peels is lipophilic?

a. citric acid

b. glycolic acid

c. mandelic acid

d. salicylic acid

e. trichloroacetic acid

3. A Jessner solution peel contains which of the following 4 components?

a. lactic acid, resorcinol, salicylic acid, ethanol

b. lactic acid, resorcinol, salicylic acid, methanol

c. lactic acid, resorcinol, salicylic acid, retinoic acid

d. retinoic acid, resorcinol, phenol, ethanol

e. retinoic acid, resorcinol, glycolic acid, methanol

4. What is the most serious risk associated with phenol peels?

a. cardiac dysrhythmia

b. hearing loss

c. scarring

d. seizure

e. tinnitus

5. Which one of the following peels self-neutralizes?

a. citric acid

b. glycolic acid

c. lactic acid

d. mandelic acid

e. salicylic acid

The answers appear on the next page.

Practice Question Answers

1. Which one of the following peels produces “frosting” after application?

a. citric acid

b. glycolic acid

c. mandelic acid

d. salicylic acid

e. trichloroacetic acid

2. Which one of the following peels is lipophilic?

a. citric acid

b. glycolic acid

c. mandelic acid

d. salicylic acid

e. trichloroacetic acid

3. A Jessner solution peel contains which of the following 4 components?

a. lactic acid, resorcinol, salicylic acid, ethanol

b. lactic acid, resorcinol, salicylic acid, methanol

c. lactic acid, resorcinol, salicylic acid, retinoic acid

d. retinoic acid, resorcinol, phenol, ethanol

e. retinoic acid, resorcinol, glycolic acid, methanol

4. What is the most serious risk associated with phenol peels?

a. cardiac dysrhythmia

b. hearing loss

c. scarring

d. seizure

e. tinnitus

5. Which one of the following peels self-neutralizes?

a. citric acid

b. glycolic acid

c. lactic acid

d. mandelic acid

e. salicylic acid

Review the PDF of the fact sheet on chemical peels

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

Practice Questions

1. Which one of the following peels produces “frosting” after application?

a. citric acid

b. glycolic acid

c. mandelic acid

d. salicylic acid

e. trichloroacetic acid

2. Which one of the following peels is lipophilic?

a. citric acid

b. glycolic acid

c. mandelic acid

d. salicylic acid

e. trichloroacetic acid

3. A Jessner solution peel contains which of the following 4 components?

a. lactic acid, resorcinol, salicylic acid, ethanol

b. lactic acid, resorcinol, salicylic acid, methanol

c. lactic acid, resorcinol, salicylic acid, retinoic acid

d. retinoic acid, resorcinol, phenol, ethanol

e. retinoic acid, resorcinol, glycolic acid, methanol

4. What is the most serious risk associated with phenol peels?

a. cardiac dysrhythmia

b. hearing loss

c. scarring

d. seizure

e. tinnitus

5. Which one of the following peels self-neutralizes?

a. citric acid

b. glycolic acid

c. lactic acid

d. mandelic acid

e. salicylic acid

The answers appear on the next page.

Practice Question Answers

1. Which one of the following peels produces “frosting” after application?

a. citric acid

b. glycolic acid

c. mandelic acid

d. salicylic acid

e. trichloroacetic acid

2. Which one of the following peels is lipophilic?

a. citric acid

b. glycolic acid

c. mandelic acid

d. salicylic acid

e. trichloroacetic acid

3. A Jessner solution peel contains which of the following 4 components?

a. lactic acid, resorcinol, salicylic acid, ethanol

b. lactic acid, resorcinol, salicylic acid, methanol

c. lactic acid, resorcinol, salicylic acid, retinoic acid

d. retinoic acid, resorcinol, phenol, ethanol

e. retinoic acid, resorcinol, glycolic acid, methanol

4. What is the most serious risk associated with phenol peels?

a. cardiac dysrhythmia

b. hearing loss

c. scarring

d. seizure

e. tinnitus

5. Which one of the following peels self-neutralizes?

a. citric acid

b. glycolic acid

c. lactic acid

d. mandelic acid

e. salicylic acid

Review the PDF of the fact sheet on chemical peels

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

Practice Questions

1. Which one of the following peels produces “frosting” after application?

a. citric acid

b. glycolic acid

c. mandelic acid

d. salicylic acid

e. trichloroacetic acid

2. Which one of the following peels is lipophilic?

a. citric acid

b. glycolic acid

c. mandelic acid

d. salicylic acid

e. trichloroacetic acid

3. A Jessner solution peel contains which of the following 4 components?

a. lactic acid, resorcinol, salicylic acid, ethanol

b. lactic acid, resorcinol, salicylic acid, methanol

c. lactic acid, resorcinol, salicylic acid, retinoic acid

d. retinoic acid, resorcinol, phenol, ethanol

e. retinoic acid, resorcinol, glycolic acid, methanol

4. What is the most serious risk associated with phenol peels?

a. cardiac dysrhythmia

b. hearing loss

c. scarring

d. seizure

e. tinnitus

5. Which one of the following peels self-neutralizes?

a. citric acid

b. glycolic acid

c. lactic acid

d. mandelic acid

e. salicylic acid

The answers appear on the next page.

Practice Question Answers

1. Which one of the following peels produces “frosting” after application?

a. citric acid

b. glycolic acid

c. mandelic acid

d. salicylic acid

e. trichloroacetic acid

2. Which one of the following peels is lipophilic?

a. citric acid

b. glycolic acid

c. mandelic acid

d. salicylic acid

e. trichloroacetic acid

3. A Jessner solution peel contains which of the following 4 components?

a. lactic acid, resorcinol, salicylic acid, ethanol

b. lactic acid, resorcinol, salicylic acid, methanol

c. lactic acid, resorcinol, salicylic acid, retinoic acid

d. retinoic acid, resorcinol, phenol, ethanol

e. retinoic acid, resorcinol, glycolic acid, methanol

4. What is the most serious risk associated with phenol peels?

a. cardiac dysrhythmia

b. hearing loss

c. scarring

d. seizure

e. tinnitus

5. Which one of the following peels self-neutralizes?

a. citric acid

b. glycolic acid

c. lactic acid

d. mandelic acid

e. salicylic acid

Diagnosis: Systemic sclerosis

Systemic sclerosis, or scleroderma, is a rare connective tissue disorder in which excessive collagen is deposited in the skin and internal organs. This disease predominantly affects women (3-6:1) between the ages of 20 and 60 years with no apparent racial predominance. Effective treatment is critical, as scleroderma carries a poor prognosis, with a mortality rate of up to 50% at 5 years in severe cases. The pathogenesis of systemic sclerosis is unknown, but three pathways are implicated, including immune deregulation, vascular abnormalities, and abnormal fibroblast activation.

Clinical presentation is variable because of the involvement of multiple organ systems. Common features include cutaneous pruritus, skin thickening, Raynaud's phenomenon, difficulty swallowing, shortness of breath, palpitations, nonproductive cough, and joint pain and swelling, as well as muscle pain and weakness. Laboratory findings may include elevated erythrocyte sedimentation rate, thrombocytopenia, hypergammaglobulinemia, increased urea and creatinine levels, and elevated C-reactive protein. Antinuclear antibodies are usually elevated, especially Scl-70, antimitochondrial, and anticentromere antibodies. Cardiac and pulmonary function should be assessed upon diagnosis. A Doppler echocardiogram may detect cardiac abnormalities, and chest x-ray or high-resolution CT is used to assess for pulmonary fibrosis.

Despite the severity of the disease, there are no Food and Drug Administration-approved disease-modifying agents for the treatment of scleroderma, and management often focuses on symptom relief. For example, patients with kidney involvement should be placed on an ACE inhibitor or angiotensin II inhibitor therapy, and patients with gastrointestinal tract involvement should use proton pump inhibitors and H2 blockers to control reflux. Bosentan and pentoxifylline, which target vascular abnormalities, also may help improve skin fibrosis. Steroids show benefits in the early stages of the disease, but carry a risk of scleroderma renal crisis with doses greater than 15 mg of prednisone daily. Mycophenolate mofetil and sirolimus have immunomodulatory and antifibrotic properties, which may be of benefit in this disease.

Cyclophosphamide is reserved for more severe cases. Other treatment modalities include rituximab, intravenous immunoglobulin, and autologous stem cell transplantation.

Diagnosis: Systemic sclerosis

Systemic sclerosis, or scleroderma, is a rare connective tissue disorder in which excessive collagen is deposited in the skin and internal organs. This disease predominantly affects women (3-6:1) between the ages of 20 and 60 years with no apparent racial predominance. Effective treatment is critical, as scleroderma carries a poor prognosis, with a mortality rate of up to 50% at 5 years in severe cases. The pathogenesis of systemic sclerosis is unknown, but three pathways are implicated, including immune deregulation, vascular abnormalities, and abnormal fibroblast activation.

Clinical presentation is variable because of the involvement of multiple organ systems. Common features include cutaneous pruritus, skin thickening, Raynaud's phenomenon, difficulty swallowing, shortness of breath, palpitations, nonproductive cough, and joint pain and swelling, as well as muscle pain and weakness. Laboratory findings may include elevated erythrocyte sedimentation rate, thrombocytopenia, hypergammaglobulinemia, increased urea and creatinine levels, and elevated C-reactive protein. Antinuclear antibodies are usually elevated, especially Scl-70, antimitochondrial, and anticentromere antibodies. Cardiac and pulmonary function should be assessed upon diagnosis. A Doppler echocardiogram may detect cardiac abnormalities, and chest x-ray or high-resolution CT is used to assess for pulmonary fibrosis.

Despite the severity of the disease, there are no Food and Drug Administration-approved disease-modifying agents for the treatment of scleroderma, and management often focuses on symptom relief. For example, patients with kidney involvement should be placed on an ACE inhibitor or angiotensin II inhibitor therapy, and patients with gastrointestinal tract involvement should use proton pump inhibitors and H2 blockers to control reflux. Bosentan and pentoxifylline, which target vascular abnormalities, also may help improve skin fibrosis. Steroids show benefits in the early stages of the disease, but carry a risk of scleroderma renal crisis with doses greater than 15 mg of prednisone daily. Mycophenolate mofetil and sirolimus have immunomodulatory and antifibrotic properties, which may be of benefit in this disease.

Cyclophosphamide is reserved for more severe cases. Other treatment modalities include rituximab, intravenous immunoglobulin, and autologous stem cell transplantation.

Diagnosis: Systemic sclerosis

Systemic sclerosis, or scleroderma, is a rare connective tissue disorder in which excessive collagen is deposited in the skin and internal organs. This disease predominantly affects women (3-6:1) between the ages of 20 and 60 years with no apparent racial predominance. Effective treatment is critical, as scleroderma carries a poor prognosis, with a mortality rate of up to 50% at 5 years in severe cases. The pathogenesis of systemic sclerosis is unknown, but three pathways are implicated, including immune deregulation, vascular abnormalities, and abnormal fibroblast activation.

Clinical presentation is variable because of the involvement of multiple organ systems. Common features include cutaneous pruritus, skin thickening, Raynaud's phenomenon, difficulty swallowing, shortness of breath, palpitations, nonproductive cough, and joint pain and swelling, as well as muscle pain and weakness. Laboratory findings may include elevated erythrocyte sedimentation rate, thrombocytopenia, hypergammaglobulinemia, increased urea and creatinine levels, and elevated C-reactive protein. Antinuclear antibodies are usually elevated, especially Scl-70, antimitochondrial, and anticentromere antibodies. Cardiac and pulmonary function should be assessed upon diagnosis. A Doppler echocardiogram may detect cardiac abnormalities, and chest x-ray or high-resolution CT is used to assess for pulmonary fibrosis.

Despite the severity of the disease, there are no Food and Drug Administration-approved disease-modifying agents for the treatment of scleroderma, and management often focuses on symptom relief. For example, patients with kidney involvement should be placed on an ACE inhibitor or angiotensin II inhibitor therapy, and patients with gastrointestinal tract involvement should use proton pump inhibitors and H2 blockers to control reflux. Bosentan and pentoxifylline, which target vascular abnormalities, also may help improve skin fibrosis. Steroids show benefits in the early stages of the disease, but carry a risk of scleroderma renal crisis with doses greater than 15 mg of prednisone daily. Mycophenolate mofetil and sirolimus have immunomodulatory and antifibrotic properties, which may be of benefit in this disease.

Cyclophosphamide is reserved for more severe cases. Other treatment modalities include rituximab, intravenous immunoglobulin, and autologous stem cell transplantation.

Woman with a laptop

Photo by Petr Kratochvil

Results of a large study indicate that women who spend their leisure time sitting for prolonged periods—6 or more hours a day—have an increased risk of developing certain cancers.

These women had a significant increase in the risk of overall cancer, multiple myeloma, breast cancer, and ovarian cancer.

The increased risks were present even after taking into account a woman’s body mass index (BMI), frequency of physical activity, and other factors.

For men, there was no association between leisure time spent sitting and any type of cancer.

Alpa Patel, PhD, of the American Cancer Society in Atlanta, Georgia, and her colleagues conducted this research and reported the results in Cancer Epidemiology, Biomarkers & Prevention.

The researchers analyzed data on 69,260 men and 77,462 women who were initially cancer-free and enrolled in the American Cancer Society Cancer Prevention Study II Nutrition Cohort.

In addition to evaluating the amount of leisure time subjects spent sitting, the researchers assessed factors such as age, race, BMI, alcohol use, smoking status, diabetes status, diet, and frequency and type of physical activity.

At baseline, the men enrolled in this study were slightly older, leaner, and more likely to have ever smoked cigarettes compared to the women. Men and women who spent the most leisure time sitting were more likely than their peers to be obese, have type II diabetes mellitus or other chronic diseases, have a higher caloric intake, eat more red/processed meat, and have ever smoked.

Between 1992 and 2009, 18,555 men and 12,236 women were diagnosed with cancer.

In women, longer leisure time spent sitting was associated with a significantly increased risk of cancer overall, even after the researchers adjusted for potential confounders such as overall physical activity and BMI.

The relative risk (RR) of cancer was 1.10 for women who spent an average of 6 or more hours a day sitting, compared to those who spent less than 3 hours a day sitting.

Women who sat for 6 or more hours a day also had a significantly increased risk of multiple myeloma (RR=1.65), invasive breast cancer (RR=1.10), and ovarian cancer (RR=1.43).

Initially, there was a significant association between prolonged sitting and endometrial cancer, but this was attenuated after the researchers adjusted for BMI. The researchers also found positive, but not significant, associations between sitting time and esophageal, head and neck, and gallbladder cancers.

For men, there was no significant association between time spent sitting and overall cancer risk or the risk of individual cancers. The researchers said further study is warranted to better understand this difference between the sexes.

The team also noted that American Cancer Society guidelines for cancer prevention recommend reducing sitting time when possible. And, given the high rate of time spent sitting in the US, even a modest positive association with cancer could have broad public health implications.

Woman with a laptop

Photo by Petr Kratochvil

Results of a large study indicate that women who spend their leisure time sitting for prolonged periods—6 or more hours a day—have an increased risk of developing certain cancers.

These women had a significant increase in the risk of overall cancer, multiple myeloma, breast cancer, and ovarian cancer.

The increased risks were present even after taking into account a woman’s body mass index (BMI), frequency of physical activity, and other factors.

For men, there was no association between leisure time spent sitting and any type of cancer.

Alpa Patel, PhD, of the American Cancer Society in Atlanta, Georgia, and her colleagues conducted this research and reported the results in Cancer Epidemiology, Biomarkers & Prevention.

The researchers analyzed data on 69,260 men and 77,462 women who were initially cancer-free and enrolled in the American Cancer Society Cancer Prevention Study II Nutrition Cohort.

In addition to evaluating the amount of leisure time subjects spent sitting, the researchers assessed factors such as age, race, BMI, alcohol use, smoking status, diabetes status, diet, and frequency and type of physical activity.

At baseline, the men enrolled in this study were slightly older, leaner, and more likely to have ever smoked cigarettes compared to the women. Men and women who spent the most leisure time sitting were more likely than their peers to be obese, have type II diabetes mellitus or other chronic diseases, have a higher caloric intake, eat more red/processed meat, and have ever smoked.

Between 1992 and 2009, 18,555 men and 12,236 women were diagnosed with cancer.

In women, longer leisure time spent sitting was associated with a significantly increased risk of cancer overall, even after the researchers adjusted for potential confounders such as overall physical activity and BMI.

The relative risk (RR) of cancer was 1.10 for women who spent an average of 6 or more hours a day sitting, compared to those who spent less than 3 hours a day sitting.

Women who sat for 6 or more hours a day also had a significantly increased risk of multiple myeloma (RR=1.65), invasive breast cancer (RR=1.10), and ovarian cancer (RR=1.43).

Initially, there was a significant association between prolonged sitting and endometrial cancer, but this was attenuated after the researchers adjusted for BMI. The researchers also found positive, but not significant, associations between sitting time and esophageal, head and neck, and gallbladder cancers.

For men, there was no significant association between time spent sitting and overall cancer risk or the risk of individual cancers. The researchers said further study is warranted to better understand this difference between the sexes.

The team also noted that American Cancer Society guidelines for cancer prevention recommend reducing sitting time when possible. And, given the high rate of time spent sitting in the US, even a modest positive association with cancer could have broad public health implications.

Woman with a laptop

Photo by Petr Kratochvil

Results of a large study indicate that women who spend their leisure time sitting for prolonged periods—6 or more hours a day—have an increased risk of developing certain cancers.

These women had a significant increase in the risk of overall cancer, multiple myeloma, breast cancer, and ovarian cancer.

The increased risks were present even after taking into account a woman’s body mass index (BMI), frequency of physical activity, and other factors.

For men, there was no association between leisure time spent sitting and any type of cancer.

Alpa Patel, PhD, of the American Cancer Society in Atlanta, Georgia, and her colleagues conducted this research and reported the results in Cancer Epidemiology, Biomarkers & Prevention.

The researchers analyzed data on 69,260 men and 77,462 women who were initially cancer-free and enrolled in the American Cancer Society Cancer Prevention Study II Nutrition Cohort.

In addition to evaluating the amount of leisure time subjects spent sitting, the researchers assessed factors such as age, race, BMI, alcohol use, smoking status, diabetes status, diet, and frequency and type of physical activity.

At baseline, the men enrolled in this study were slightly older, leaner, and more likely to have ever smoked cigarettes compared to the women. Men and women who spent the most leisure time sitting were more likely than their peers to be obese, have type II diabetes mellitus or other chronic diseases, have a higher caloric intake, eat more red/processed meat, and have ever smoked.

Between 1992 and 2009, 18,555 men and 12,236 women were diagnosed with cancer.

In women, longer leisure time spent sitting was associated with a significantly increased risk of cancer overall, even after the researchers adjusted for potential confounders such as overall physical activity and BMI.

The relative risk (RR) of cancer was 1.10 for women who spent an average of 6 or more hours a day sitting, compared to those who spent less than 3 hours a day sitting.

Women who sat for 6 or more hours a day also had a significantly increased risk of multiple myeloma (RR=1.65), invasive breast cancer (RR=1.10), and ovarian cancer (RR=1.43).

Initially, there was a significant association between prolonged sitting and endometrial cancer, but this was attenuated after the researchers adjusted for BMI. The researchers also found positive, but not significant, associations between sitting time and esophageal, head and neck, and gallbladder cancers.

For men, there was no significant association between time spent sitting and overall cancer risk or the risk of individual cancers. The researchers said further study is warranted to better understand this difference between the sexes.

The team also noted that American Cancer Society guidelines for cancer prevention recommend reducing sitting time when possible. And, given the high rate of time spent sitting in the US, even a modest positive association with cancer could have broad public health implications.

Thrombus

Image by Keven MacKenzie

The UK’s National Institute for Health and Care Excellence (NICE) has issued a draft guidance recommending the oral anticoagulant edoxaban tosylate (Lixiana) as an option for treating and preventing the recurrence of venous thromboembolism (VTE).

A committee advising NICE concluded that edoxaban is clinically effective, and the drug will be a cost-effective use of National Health Service resources.

“The newer oral anticoagulants like edoxaban tosylate are an alternative to warfarin as the mainstay of treatment to prevent recurrent blood clots,” said Carole Longson, NICE Health Technology Evaluation Centre Director.

“The committee concluded that patients value newer oral anticoagulants such as edoxaban tosylate, which cause less disruption to their day-to-day lives than warfarin. We are pleased, therefore, to be able to recommend edoxaban tosylate as a further cost-effective option for treating [VTE] and preventing further episodes in adults.”

Clinical effectiveness

Edoxaban was recently approved in the European Union to treat and prevent deep vein thrombosis (DVT) and pulmonary embolism (PE). This approval was based on results of the Hokusai-VTE trial. The committee advising NICE analyzed data from this trial when considering the clinical effectiveness of edoxaban.

For Hokusai-VTE, researchers evaluated edoxaban in 4921 patients with DVT and 3319 with PE. Patients received initial treatment with low-molecular-weight heparin and were then randomized to receive edoxaban or warfarin daily for 3 to 12 months.

Overall, edoxaban proved as effective as warfarin. Recurrent, symptomatic VTE occurred in 3.2% and 3.5% of patients, respectively (P<0.001 for non-inferiority).

In addition, the incidence of clinically relevant bleeding was significantly lower in the edoxaban arm than the warfarin arm—8.5% and 10.3%, respectively (P=0.004 for superiority).

Cost-effectiveness

The recommended dose of edoxaban is 60 mg once daily, or 30 mg once daily in specific patient groups—those with renal impairment, low body weight (60 kg or less), or concomitant use of potent permeability glycoprotein inhibitors—following treatment with a parenteral anticoagulant for at least 5 days.

Edoxaban costs £2.10 per 15 mg, 30 mg, or 60 mg tablet (excluding value-added tax). Costs may vary in different settings because of negotiated procurement discounts.

Taking into account the lack of any clear evidence that edoxaban is significantly different from the other new oral anticoagulants, as well as the testimony of experts, the committee advising NICE concluded that the most plausible incremental cost-effectiveness ratio for edoxaban was likely to be in line with the other oral anticoagulants already recommended by NICE.

The draft guidance for edoxaban is now with consultees, who have the opportunity to appeal against it. Once NICE issues its final guidance on a technology, it replaces local recommendations.

Thrombus

Image by Keven MacKenzie

The UK’s National Institute for Health and Care Excellence (NICE) has issued a draft guidance recommending the oral anticoagulant edoxaban tosylate (Lixiana) as an option for treating and preventing the recurrence of venous thromboembolism (VTE).

A committee advising NICE concluded that edoxaban is clinically effective, and the drug will be a cost-effective use of National Health Service resources.

“The newer oral anticoagulants like edoxaban tosylate are an alternative to warfarin as the mainstay of treatment to prevent recurrent blood clots,” said Carole Longson, NICE Health Technology Evaluation Centre Director.

“The committee concluded that patients value newer oral anticoagulants such as edoxaban tosylate, which cause less disruption to their day-to-day lives than warfarin. We are pleased, therefore, to be able to recommend edoxaban tosylate as a further cost-effective option for treating [VTE] and preventing further episodes in adults.”

Clinical effectiveness

Edoxaban was recently approved in the European Union to treat and prevent deep vein thrombosis (DVT) and pulmonary embolism (PE). This approval was based on results of the Hokusai-VTE trial. The committee advising NICE analyzed data from this trial when considering the clinical effectiveness of edoxaban.

For Hokusai-VTE, researchers evaluated edoxaban in 4921 patients with DVT and 3319 with PE. Patients received initial treatment with low-molecular-weight heparin and were then randomized to receive edoxaban or warfarin daily for 3 to 12 months.

Overall, edoxaban proved as effective as warfarin. Recurrent, symptomatic VTE occurred in 3.2% and 3.5% of patients, respectively (P<0.001 for non-inferiority).

In addition, the incidence of clinically relevant bleeding was significantly lower in the edoxaban arm than the warfarin arm—8.5% and 10.3%, respectively (P=0.004 for superiority).

Cost-effectiveness

The recommended dose of edoxaban is 60 mg once daily, or 30 mg once daily in specific patient groups—those with renal impairment, low body weight (60 kg or less), or concomitant use of potent permeability glycoprotein inhibitors—following treatment with a parenteral anticoagulant for at least 5 days.

Edoxaban costs £2.10 per 15 mg, 30 mg, or 60 mg tablet (excluding value-added tax). Costs may vary in different settings because of negotiated procurement discounts.

Taking into account the lack of any clear evidence that edoxaban is significantly different from the other new oral anticoagulants, as well as the testimony of experts, the committee advising NICE concluded that the most plausible incremental cost-effectiveness ratio for edoxaban was likely to be in line with the other oral anticoagulants already recommended by NICE.

The draft guidance for edoxaban is now with consultees, who have the opportunity to appeal against it. Once NICE issues its final guidance on a technology, it replaces local recommendations.

Thrombus

Image by Keven MacKenzie

The UK’s National Institute for Health and Care Excellence (NICE) has issued a draft guidance recommending the oral anticoagulant edoxaban tosylate (Lixiana) as an option for treating and preventing the recurrence of venous thromboembolism (VTE).

A committee advising NICE concluded that edoxaban is clinically effective, and the drug will be a cost-effective use of National Health Service resources.

“The newer oral anticoagulants like edoxaban tosylate are an alternative to warfarin as the mainstay of treatment to prevent recurrent blood clots,” said Carole Longson, NICE Health Technology Evaluation Centre Director.

“The committee concluded that patients value newer oral anticoagulants such as edoxaban tosylate, which cause less disruption to their day-to-day lives than warfarin. We are pleased, therefore, to be able to recommend edoxaban tosylate as a further cost-effective option for treating [VTE] and preventing further episodes in adults.”

Clinical effectiveness

Edoxaban was recently approved in the European Union to treat and prevent deep vein thrombosis (DVT) and pulmonary embolism (PE). This approval was based on results of the Hokusai-VTE trial. The committee advising NICE analyzed data from this trial when considering the clinical effectiveness of edoxaban.

For Hokusai-VTE, researchers evaluated edoxaban in 4921 patients with DVT and 3319 with PE. Patients received initial treatment with low-molecular-weight heparin and were then randomized to receive edoxaban or warfarin daily for 3 to 12 months.

Overall, edoxaban proved as effective as warfarin. Recurrent, symptomatic VTE occurred in 3.2% and 3.5% of patients, respectively (P<0.001 for non-inferiority).

In addition, the incidence of clinically relevant bleeding was significantly lower in the edoxaban arm than the warfarin arm—8.5% and 10.3%, respectively (P=0.004 for superiority).

Cost-effectiveness

The recommended dose of edoxaban is 60 mg once daily, or 30 mg once daily in specific patient groups—those with renal impairment, low body weight (60 kg or less), or concomitant use of potent permeability glycoprotein inhibitors—following treatment with a parenteral anticoagulant for at least 5 days.

Edoxaban costs £2.10 per 15 mg, 30 mg, or 60 mg tablet (excluding value-added tax). Costs may vary in different settings because of negotiated procurement discounts.

Taking into account the lack of any clear evidence that edoxaban is significantly different from the other new oral anticoagulants, as well as the testimony of experts, the committee advising NICE concluded that the most plausible incremental cost-effectiveness ratio for edoxaban was likely to be in line with the other oral anticoagulants already recommended by NICE.

The draft guidance for edoxaban is now with consultees, who have the opportunity to appeal against it. Once NICE issues its final guidance on a technology, it replaces local recommendations.

 

 

Pregnant woman

Photo by Nina Matthews

 

Researchers have again found evidence to suggest that tests used to identify chromosomal fetal disorders can detect occult malignancies in pregnant women.

In a study made public last month, non-invasive prenatal tests (NIPTs) revealed 2 cases of lymphoma and a case of ovarian cancer in expectant mothers.

In the new study, researchers showed that positive NIPT results were due to leukemia, lymphoma, or solid tumors in 10 expectant mothers.

The research was published in JAMA and presented at the 19th International Conference on Prenatal Diagnosis and Therapy in Washington, DC. Funding for the study was provided by Illumina, and company employees were involved in the research.

“We did this study because noninvasive prenatal testing using sequencing of cell-free DNA in the mother’s plasma is the fastest-growing area of prenatal testing and, indeed, of genomic medicine,” said study author Diana W. Bianchi, MD, of Tufts Medical Center in Boston, Massachusetts.

“As the volume of tests has expanded, we’ve become increasingly aware of the so-called “false-positive” cases. [A]pproximately 0.2% of the time, there is a discrepancy between the results of the prenatal test—in which an aneuploidy is reported—and the result from the diagnostic fetal procedure, the amniocentesis or the chorionic villus sampling.”

“So we’re interested in the situation where the fetal chromosomes are normal, but the prenatal test shows that there’s an aneuploidy detected. We’re interested in the possible explanations for that discrepancy.”

To gain some insight, Dr Bianchi and her colleagues evaluated 125,426 samples from asymptomatic pregnant women who underwent plasma cell-free DNA sequencing for clinical prenatal aneuploidy screening using Illumina’s verifi Prenatal Test.

In all, 3757 samples (3%) were positive for 1 or more aneuploidies involving chromosomes 13, 18, 21, X, or Y. These were reported to the ordering physician with recommendations for further evaluation.

“In a small minority of women, [subsequent tests analyzing only fetal DNA] showed that the fetal chromosomes were normal, and that disagreed with [results of the NIPT],” Dr Bianchi said. “We were examining whether cancer could explain the discrepancy between these two test results.”

The researchers found that 10 of the women with discordant test results were subsequently diagnosed with cancer. There were 3 cases of B-cell lymphoma and 1 case each of T-cell leukemia, Hodgkin lymphoma, unspecified adenocarcinoma, leiomyosarcoma, and neuroendocrine, colorectal, and anal carcinomas.

Dr Bianchi and her colleagues were able to obtain detailed clinical and sequencing data for 8 of these cases. In the other 2 cases (leiomyosarcoma and unspecified adenocarcinoma), the women were critically ill and were not approached about participating in the study.

The researchers found that maternal cancers most frequently occurred when the NIPT detected more than 1 aneuploidy. There were 7 known cancers among 39 cases of multiple aneuploidies by NIPT. In 1 case, blood was sampled after the patient completed treatment for colorectal cancer, and the abnormal pattern was no longer evident.

When the researchers examined additional genetic information for the women with cancer, they found unique patterns of nonspecific copy-number gains and losses across multiple chromosomes.

“[These women] had DNA imbalances all across the genome,” Dr Bianchi said. “The [NIPT] normally is only looking at DNA material from the chromosomes of clinical interest—chromosomes 13, 18, 21, X, and Y.”

“When we opened up their results to look at all of the chromosomes, there were multiple abnormalities in other places, such as chromosome 8, chromosome 6, etc. Each woman had a unique pattern that was abnormal in many places. This suggested that it was the tumor DNA that was being shed into her blood and was contributing to the abnormal pattern.”

Dr Bianchi stressed that the tumor DNA did not affect the babies. She said all were born healthy, although labor was induced early in one mother to facilitate her cancer treatment.

 

 

Pregnant woman

Photo by Nina Matthews

 

Researchers have again found evidence to suggest that tests used to identify chromosomal fetal disorders can detect occult malignancies in pregnant women.

In a study made public last month, non-invasive prenatal tests (NIPTs) revealed 2 cases of lymphoma and a case of ovarian cancer in expectant mothers.

In the new study, researchers showed that positive NIPT results were due to leukemia, lymphoma, or solid tumors in 10 expectant mothers.

The research was published in JAMA and presented at the 19th International Conference on Prenatal Diagnosis and Therapy in Washington, DC. Funding for the study was provided by Illumina, and company employees were involved in the research.

“We did this study because noninvasive prenatal testing using sequencing of cell-free DNA in the mother’s plasma is the fastest-growing area of prenatal testing and, indeed, of genomic medicine,” said study author Diana W. Bianchi, MD, of Tufts Medical Center in Boston, Massachusetts.

“As the volume of tests has expanded, we’ve become increasingly aware of the so-called “false-positive” cases. [A]pproximately 0.2% of the time, there is a discrepancy between the results of the prenatal test—in which an aneuploidy is reported—and the result from the diagnostic fetal procedure, the amniocentesis or the chorionic villus sampling.”

“So we’re interested in the situation where the fetal chromosomes are normal, but the prenatal test shows that there’s an aneuploidy detected. We’re interested in the possible explanations for that discrepancy.”

To gain some insight, Dr Bianchi and her colleagues evaluated 125,426 samples from asymptomatic pregnant women who underwent plasma cell-free DNA sequencing for clinical prenatal aneuploidy screening using Illumina’s verifi Prenatal Test.

In all, 3757 samples (3%) were positive for 1 or more aneuploidies involving chromosomes 13, 18, 21, X, or Y. These were reported to the ordering physician with recommendations for further evaluation.

“In a small minority of women, [subsequent tests analyzing only fetal DNA] showed that the fetal chromosomes were normal, and that disagreed with [results of the NIPT],” Dr Bianchi said. “We were examining whether cancer could explain the discrepancy between these two test results.”

The researchers found that 10 of the women with discordant test results were subsequently diagnosed with cancer. There were 3 cases of B-cell lymphoma and 1 case each of T-cell leukemia, Hodgkin lymphoma, unspecified adenocarcinoma, leiomyosarcoma, and neuroendocrine, colorectal, and anal carcinomas.

Dr Bianchi and her colleagues were able to obtain detailed clinical and sequencing data for 8 of these cases. In the other 2 cases (leiomyosarcoma and unspecified adenocarcinoma), the women were critically ill and were not approached about participating in the study.

The researchers found that maternal cancers most frequently occurred when the NIPT detected more than 1 aneuploidy. There were 7 known cancers among 39 cases of multiple aneuploidies by NIPT. In 1 case, blood was sampled after the patient completed treatment for colorectal cancer, and the abnormal pattern was no longer evident.

When the researchers examined additional genetic information for the women with cancer, they found unique patterns of nonspecific copy-number gains and losses across multiple chromosomes.

“[These women] had DNA imbalances all across the genome,” Dr Bianchi said. “The [NIPT] normally is only looking at DNA material from the chromosomes of clinical interest—chromosomes 13, 18, 21, X, and Y.”

“When we opened up their results to look at all of the chromosomes, there were multiple abnormalities in other places, such as chromosome 8, chromosome 6, etc. Each woman had a unique pattern that was abnormal in many places. This suggested that it was the tumor DNA that was being shed into her blood and was contributing to the abnormal pattern.”

Dr Bianchi stressed that the tumor DNA did not affect the babies. She said all were born healthy, although labor was induced early in one mother to facilitate her cancer treatment.

 

 

Pregnant woman

Photo by Nina Matthews

 

Researchers have again found evidence to suggest that tests used to identify chromosomal fetal disorders can detect occult malignancies in pregnant women.

In a study made public last month, non-invasive prenatal tests (NIPTs) revealed 2 cases of lymphoma and a case of ovarian cancer in expectant mothers.

In the new study, researchers showed that positive NIPT results were due to leukemia, lymphoma, or solid tumors in 10 expectant mothers.

The research was published in JAMA and presented at the 19th International Conference on Prenatal Diagnosis and Therapy in Washington, DC. Funding for the study was provided by Illumina, and company employees were involved in the research.

“We did this study because noninvasive prenatal testing using sequencing of cell-free DNA in the mother’s plasma is the fastest-growing area of prenatal testing and, indeed, of genomic medicine,” said study author Diana W. Bianchi, MD, of Tufts Medical Center in Boston, Massachusetts.

“As the volume of tests has expanded, we’ve become increasingly aware of the so-called “false-positive” cases. [A]pproximately 0.2% of the time, there is a discrepancy between the results of the prenatal test—in which an aneuploidy is reported—and the result from the diagnostic fetal procedure, the amniocentesis or the chorionic villus sampling.”

“So we’re interested in the situation where the fetal chromosomes are normal, but the prenatal test shows that there’s an aneuploidy detected. We’re interested in the possible explanations for that discrepancy.”

To gain some insight, Dr Bianchi and her colleagues evaluated 125,426 samples from asymptomatic pregnant women who underwent plasma cell-free DNA sequencing for clinical prenatal aneuploidy screening using Illumina’s verifi Prenatal Test.

In all, 3757 samples (3%) were positive for 1 or more aneuploidies involving chromosomes 13, 18, 21, X, or Y. These were reported to the ordering physician with recommendations for further evaluation.

“In a small minority of women, [subsequent tests analyzing only fetal DNA] showed that the fetal chromosomes were normal, and that disagreed with [results of the NIPT],” Dr Bianchi said. “We were examining whether cancer could explain the discrepancy between these two test results.”

The researchers found that 10 of the women with discordant test results were subsequently diagnosed with cancer. There were 3 cases of B-cell lymphoma and 1 case each of T-cell leukemia, Hodgkin lymphoma, unspecified adenocarcinoma, leiomyosarcoma, and neuroendocrine, colorectal, and anal carcinomas.

Dr Bianchi and her colleagues were able to obtain detailed clinical and sequencing data for 8 of these cases. In the other 2 cases (leiomyosarcoma and unspecified adenocarcinoma), the women were critically ill and were not approached about participating in the study.

The researchers found that maternal cancers most frequently occurred when the NIPT detected more than 1 aneuploidy. There were 7 known cancers among 39 cases of multiple aneuploidies by NIPT. In 1 case, blood was sampled after the patient completed treatment for colorectal cancer, and the abnormal pattern was no longer evident.

When the researchers examined additional genetic information for the women with cancer, they found unique patterns of nonspecific copy-number gains and losses across multiple chromosomes.

“[These women] had DNA imbalances all across the genome,” Dr Bianchi said. “The [NIPT] normally is only looking at DNA material from the chromosomes of clinical interest—chromosomes 13, 18, 21, X, and Y.”

“When we opened up their results to look at all of the chromosomes, there were multiple abnormalities in other places, such as chromosome 8, chromosome 6, etc. Each woman had a unique pattern that was abnormal in many places. This suggested that it was the tumor DNA that was being shed into her blood and was contributing to the abnormal pattern.”

Dr Bianchi stressed that the tumor DNA did not affect the babies. She said all were born healthy, although labor was induced early in one mother to facilitate her cancer treatment.

Nancy Baxter, MD, PhD

Photo courtesy of

St. Michael’s Hospital

Up to 20 years after they are declared cancer-free, young adult (YA) cancer survivors are still hospitalized more often than the general population, according to research published in the Journal of Clinical Oncology.

Overall, the cancer survivors, who were ages 20 to 44 at diagnosis, were hospitalized about 1.5 times as often as control subjects.

“Even when young adults survive cancer, the cancer still has an impact on their lives and their long-term health, and this age group still has a lot of life to live,” said study author Nancy Baxter, MD, PhD, of St. Michael’s Hospital in Toronto, Ontario, Canada.

To conduct this study, Dr Baxter and her colleagues examined data from the Ontario Cancer Registry spanning the period from 1992 to 1999.

This included 20,275 patients who had their first cancer diagnosis between the ages of 20 and 44 and had lived for 5 years cancer-free. The researchers compared hospitalizations among these patients to hospitalizations in 101,344 non-cancer controls.

During the study period, 34.3% of cancer survivors (n=6948) were admitted to the hospital. The adjusted relative rate (ARR) of hospitalizations in survivors compared to controls was 1.51.

There was a significant decrease in hospitalizations among cancer survivors from the first time point the researchers analyzed to the last time point (P<0.0001).

But hospitalizations were more common among cancer survivors regardless of the time point. The ARR was 1.67 at 5 to 8 years after cancer diagnosis and 1.22 at 18 to 20 years after diagnosis.

When the researchers looked at individual malignancies, they found that survivors of melanoma or testicular cancer did not have higher rates of hospitalization than the control population. The ARRs were 0.97 and 1.07, respectively.

However, the rate of hospitalization was at least twice as high as the control population for survivors of leukemia (ARR=2.23) and lymphoma (ARR=2.02), as well as gastrointestinal (ARR=2.49), urologic (ARR=2.20), colorectal (ARR=2.10), and brain cancers (ARR=2.04).

Dr Baxter said having a better understanding of healthcare utilization and late effects in the YA cancer population may help healthcare providers counsel YA survivors on their future quality of life, identify areas where preventative strategies could be employed, and highlight the need to consider treatments that are not associated with long-term health consequences.

Nancy Baxter, MD, PhD

Photo courtesy of

St. Michael’s Hospital

Up to 20 years after they are declared cancer-free, young adult (YA) cancer survivors are still hospitalized more often than the general population, according to research published in the Journal of Clinical Oncology.

Overall, the cancer survivors, who were ages 20 to 44 at diagnosis, were hospitalized about 1.5 times as often as control subjects.

“Even when young adults survive cancer, the cancer still has an impact on their lives and their long-term health, and this age group still has a lot of life to live,” said study author Nancy Baxter, MD, PhD, of St. Michael’s Hospital in Toronto, Ontario, Canada.

To conduct this study, Dr Baxter and her colleagues examined data from the Ontario Cancer Registry spanning the period from 1992 to 1999.

This included 20,275 patients who had their first cancer diagnosis between the ages of 20 and 44 and had lived for 5 years cancer-free. The researchers compared hospitalizations among these patients to hospitalizations in 101,344 non-cancer controls.

During the study period, 34.3% of cancer survivors (n=6948) were admitted to the hospital. The adjusted relative rate (ARR) of hospitalizations in survivors compared to controls was 1.51.

There was a significant decrease in hospitalizations among cancer survivors from the first time point the researchers analyzed to the last time point (P<0.0001).

But hospitalizations were more common among cancer survivors regardless of the time point. The ARR was 1.67 at 5 to 8 years after cancer diagnosis and 1.22 at 18 to 20 years after diagnosis.

When the researchers looked at individual malignancies, they found that survivors of melanoma or testicular cancer did not have higher rates of hospitalization than the control population. The ARRs were 0.97 and 1.07, respectively.

However, the rate of hospitalization was at least twice as high as the control population for survivors of leukemia (ARR=2.23) and lymphoma (ARR=2.02), as well as gastrointestinal (ARR=2.49), urologic (ARR=2.20), colorectal (ARR=2.10), and brain cancers (ARR=2.04).

Dr Baxter said having a better understanding of healthcare utilization and late effects in the YA cancer population may help healthcare providers counsel YA survivors on their future quality of life, identify areas where preventative strategies could be employed, and highlight the need to consider treatments that are not associated with long-term health consequences.

Nancy Baxter, MD, PhD

Photo courtesy of

St. Michael’s Hospital

Up to 20 years after they are declared cancer-free, young adult (YA) cancer survivors are still hospitalized more often than the general population, according to research published in the Journal of Clinical Oncology.

Overall, the cancer survivors, who were ages 20 to 44 at diagnosis, were hospitalized about 1.5 times as often as control subjects.

“Even when young adults survive cancer, the cancer still has an impact on their lives and their long-term health, and this age group still has a lot of life to live,” said study author Nancy Baxter, MD, PhD, of St. Michael’s Hospital in Toronto, Ontario, Canada.

To conduct this study, Dr Baxter and her colleagues examined data from the Ontario Cancer Registry spanning the period from 1992 to 1999.

This included 20,275 patients who had their first cancer diagnosis between the ages of 20 and 44 and had lived for 5 years cancer-free. The researchers compared hospitalizations among these patients to hospitalizations in 101,344 non-cancer controls.

During the study period, 34.3% of cancer survivors (n=6948) were admitted to the hospital. The adjusted relative rate (ARR) of hospitalizations in survivors compared to controls was 1.51.

There was a significant decrease in hospitalizations among cancer survivors from the first time point the researchers analyzed to the last time point (P<0.0001).

But hospitalizations were more common among cancer survivors regardless of the time point. The ARR was 1.67 at 5 to 8 years after cancer diagnosis and 1.22 at 18 to 20 years after diagnosis.

When the researchers looked at individual malignancies, they found that survivors of melanoma or testicular cancer did not have higher rates of hospitalization than the control population. The ARRs were 0.97 and 1.07, respectively.

However, the rate of hospitalization was at least twice as high as the control population for survivors of leukemia (ARR=2.23) and lymphoma (ARR=2.02), as well as gastrointestinal (ARR=2.49), urologic (ARR=2.20), colorectal (ARR=2.10), and brain cancers (ARR=2.04).

Dr Baxter said having a better understanding of healthcare utilization and late effects in the YA cancer population may help healthcare providers counsel YA survivors on their future quality of life, identify areas where preventative strategies could be employed, and highlight the need to consider treatments that are not associated with long-term health consequences.

Of all the comorbidities associated with psoriasis, psoriatic arthritis (PsA) is the most common and one of the most problematic. Early recognition, diagnosis, and treatment of PsA can help prevent or limit extensive joint damage that occurs in later stages of the disease. Because cutaneous psoriasis precedes the onset of PsA in 84% of patients with psoriasis, it is incumbent upon dermatologists to be the first line of defense in the screening for joint problems. However, the efficacy of PsA screening remains unknown.

In a recent article published online on June 5 in the Journal of the American Academy of Dermatology, Villani et al performed an analysis to determine the point prevalence of undiagnosed PsA in patients with psoriasis, utilizing a systematic search of the literature and meta-analysis. Searching PubMed, Cochrane, and Embase databases, the authors identified 394 studies for review. None of the studies sought to determine the prevalence of undiagnosed PsA in patients with psoriasis.

The investigators made the assumption that the prevalence of newly diagnosed PsA in patients with psoriasis at the time they sought medical care could be a reasonable estimate of this value. Seven epidemiological studies and 5 studies on PsA screening questionnaires were selected for review and were used to clearly identify patients with newly diagnosed PsA.

The authors found that the prevalence of undiagnosed PsA was 15.5% when all studies were analyzed and 10.1% when only epidemiological studies were included. The high prevalence of undiagnosed PsA in patients with psoriasis reinforces the recommendation that dermatologists need to screen all patients with psoriasis for PsA.

What’s the issue?

The findings of this study are not surprising. Therefore, it is important that we double our efforts to screen patients for PsA to address this comorbidity as early as possible. Improved algorithms for screening of patients for PsA would be a welcome advancement. How will you improve your screening methods for PsA?

We want to know your views! Tell us what you think.

Of all the comorbidities associated with psoriasis, psoriatic arthritis (PsA) is the most common and one of the most problematic. Early recognition, diagnosis, and treatment of PsA can help prevent or limit extensive joint damage that occurs in later stages of the disease. Because cutaneous psoriasis precedes the onset of PsA in 84% of patients with psoriasis, it is incumbent upon dermatologists to be the first line of defense in the screening for joint problems. However, the efficacy of PsA screening remains unknown.

In a recent article published online on June 5 in the Journal of the American Academy of Dermatology, Villani et al performed an analysis to determine the point prevalence of undiagnosed PsA in patients with psoriasis, utilizing a systematic search of the literature and meta-analysis. Searching PubMed, Cochrane, and Embase databases, the authors identified 394 studies for review. None of the studies sought to determine the prevalence of undiagnosed PsA in patients with psoriasis.

The investigators made the assumption that the prevalence of newly diagnosed PsA in patients with psoriasis at the time they sought medical care could be a reasonable estimate of this value. Seven epidemiological studies and 5 studies on PsA screening questionnaires were selected for review and were used to clearly identify patients with newly diagnosed PsA.

The authors found that the prevalence of undiagnosed PsA was 15.5% when all studies were analyzed and 10.1% when only epidemiological studies were included. The high prevalence of undiagnosed PsA in patients with psoriasis reinforces the recommendation that dermatologists need to screen all patients with psoriasis for PsA.

What’s the issue?

The findings of this study are not surprising. Therefore, it is important that we double our efforts to screen patients for PsA to address this comorbidity as early as possible. Improved algorithms for screening of patients for PsA would be a welcome advancement. How will you improve your screening methods for PsA?

We want to know your views! Tell us what you think.

Of all the comorbidities associated with psoriasis, psoriatic arthritis (PsA) is the most common and one of the most problematic. Early recognition, diagnosis, and treatment of PsA can help prevent or limit extensive joint damage that occurs in later stages of the disease. Because cutaneous psoriasis precedes the onset of PsA in 84% of patients with psoriasis, it is incumbent upon dermatologists to be the first line of defense in the screening for joint problems. However, the efficacy of PsA screening remains unknown.

In a recent article published online on June 5 in the Journal of the American Academy of Dermatology, Villani et al performed an analysis to determine the point prevalence of undiagnosed PsA in patients with psoriasis, utilizing a systematic search of the literature and meta-analysis. Searching PubMed, Cochrane, and Embase databases, the authors identified 394 studies for review. None of the studies sought to determine the prevalence of undiagnosed PsA in patients with psoriasis.

The investigators made the assumption that the prevalence of newly diagnosed PsA in patients with psoriasis at the time they sought medical care could be a reasonable estimate of this value. Seven epidemiological studies and 5 studies on PsA screening questionnaires were selected for review and were used to clearly identify patients with newly diagnosed PsA.

The authors found that the prevalence of undiagnosed PsA was 15.5% when all studies were analyzed and 10.1% when only epidemiological studies were included. The high prevalence of undiagnosed PsA in patients with psoriasis reinforces the recommendation that dermatologists need to screen all patients with psoriasis for PsA.

What’s the issue?

The findings of this study are not surprising. Therefore, it is important that we double our efforts to screen patients for PsA to address this comorbidity as early as possible. Improved algorithms for screening of patients for PsA would be a welcome advancement. How will you improve your screening methods for PsA?

We want to know your views! Tell us what you think.