Sherry Boschert

SAN FRANCISCO – Seven percent of 110 children with autism spectrum disorders had iron depletion before starting antipsychotics for aggression, and rapid weight gain on antipsychotics was associated with further decreases in iron levels.

Eleven percent of 79 children with follow-up data after a mean of 18 months of antipsychotic treatment had low plasma ferritin levels (less than 12 ng/mL). Mean plasma ferritin concentrations in the cohort as a whole decreased from 26 ng/mL at baseline to 17 ng/mL, Dr. Nicole S. Del Castillo reported in a poster presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The mean body mass index (BMI) was 18 kg/m² at baseline and 20 kg/m² after 18 months. The percent increase in BMI was significantly and negatively associated with the decrease in ferritin concentration, change in ferritin, and percent change in ferritin after adjustment for the effects of other factors, reported Dr. Del Castillo, a psychiatry fellow at the University of Iowa, Iowa City.

The investigators adjusted for the effects of age, sex, and the time between baseline and follow-up BMI measurements.

Children with autism spectrum disorders already are at increased risk of iron deficiency, previous studies have shown. Other studies report that two second-generation antipsychotics that are approved to treat aggression associated with autism spectrum disorders – risperidone and aripiprazole – cause significant weight gain, especially in youth. Rapid weight gain can lead to iron deficiency in children when iron absorption is unable to keep pace with the need to form red blood cells to vascularize newly formed tissue, Dr. Del Castillo explained.

Clinicians should consider closely monitoring iron status in children with autism spectrum disorders who are treated with second-generation antipsychotics, especially if they gain substantial weight, she suggested. "Not only test for lipids and glucose, but also look at iron deficiency," which is a potentially treatable problem, she said.

The study analyzed data obtained from a Research Units on Pediatric Psychopharmacology trial in which children with autism spectrum disorders and serious behavior problems were randomized to treatment with risperidone alone or risperidone plus behavior management training for parents. Patients in the current sample averaged 8 years in age. Primary diagnoses included autism in 62%, pervasive developmental disorder not otherwise specified in 32%, and Asperger’s syndrome in 6%.

No significant associations were seen between baseline ferritin concentrations and age, baseline BMI, baseline or follow-up scores on the Aberrant Behavior Checklist, or percent change in ferritin concentration.

Dr. Del Castillo reported having no relevant financial disclosures. Some of her coinvestigators reported relationships with several pharmaceutical companies, including , Eli Lilly, Shire, AstraZeneca, Novartis, Forest Research, and Hoffmann-LaRoche.

SAN FRANCISCO – Seven percent of 110 children with autism spectrum disorders had iron depletion before starting antipsychotics for aggression, and rapid weight gain on antipsychotics was associated with further decreases in iron levels.

Eleven percent of 79 children with follow-up data after a mean of 18 months of antipsychotic treatment had low plasma ferritin levels (less than 12 ng/mL). Mean plasma ferritin concentrations in the cohort as a whole decreased from 26 ng/mL at baseline to 17 ng/mL, Dr. Nicole S. Del Castillo reported in a poster presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The mean body mass index (BMI) was 18 kg/m² at baseline and 20 kg/m² after 18 months. The percent increase in BMI was significantly and negatively associated with the decrease in ferritin concentration, change in ferritin, and percent change in ferritin after adjustment for the effects of other factors, reported Dr. Del Castillo, a psychiatry fellow at the University of Iowa, Iowa City.

The investigators adjusted for the effects of age, sex, and the time between baseline and follow-up BMI measurements.

Children with autism spectrum disorders already are at increased risk of iron deficiency, previous studies have shown. Other studies report that two second-generation antipsychotics that are approved to treat aggression associated with autism spectrum disorders – risperidone and aripiprazole – cause significant weight gain, especially in youth. Rapid weight gain can lead to iron deficiency in children when iron absorption is unable to keep pace with the need to form red blood cells to vascularize newly formed tissue, Dr. Del Castillo explained.

Clinicians should consider closely monitoring iron status in children with autism spectrum disorders who are treated with second-generation antipsychotics, especially if they gain substantial weight, she suggested. "Not only test for lipids and glucose, but also look at iron deficiency," which is a potentially treatable problem, she said.

The study analyzed data obtained from a Research Units on Pediatric Psychopharmacology trial in which children with autism spectrum disorders and serious behavior problems were randomized to treatment with risperidone alone or risperidone plus behavior management training for parents. Patients in the current sample averaged 8 years in age. Primary diagnoses included autism in 62%, pervasive developmental disorder not otherwise specified in 32%, and Asperger’s syndrome in 6%.

No significant associations were seen between baseline ferritin concentrations and age, baseline BMI, baseline or follow-up scores on the Aberrant Behavior Checklist, or percent change in ferritin concentration.

Dr. Del Castillo reported having no relevant financial disclosures. Some of her coinvestigators reported relationships with several pharmaceutical companies, including , Eli Lilly, Shire, AstraZeneca, Novartis, Forest Research, and Hoffmann-LaRoche.

SAN FRANCISCO – Seven percent of 110 children with autism spectrum disorders had iron depletion before starting antipsychotics for aggression, and rapid weight gain on antipsychotics was associated with further decreases in iron levels.

Eleven percent of 79 children with follow-up data after a mean of 18 months of antipsychotic treatment had low plasma ferritin levels (less than 12 ng/mL). Mean plasma ferritin concentrations in the cohort as a whole decreased from 26 ng/mL at baseline to 17 ng/mL, Dr. Nicole S. Del Castillo reported in a poster presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

The mean body mass index (BMI) was 18 kg/m² at baseline and 20 kg/m² after 18 months. The percent increase in BMI was significantly and negatively associated with the decrease in ferritin concentration, change in ferritin, and percent change in ferritin after adjustment for the effects of other factors, reported Dr. Del Castillo, a psychiatry fellow at the University of Iowa, Iowa City.

The investigators adjusted for the effects of age, sex, and the time between baseline and follow-up BMI measurements.

Children with autism spectrum disorders already are at increased risk of iron deficiency, previous studies have shown. Other studies report that two second-generation antipsychotics that are approved to treat aggression associated with autism spectrum disorders – risperidone and aripiprazole – cause significant weight gain, especially in youth. Rapid weight gain can lead to iron deficiency in children when iron absorption is unable to keep pace with the need to form red blood cells to vascularize newly formed tissue, Dr. Del Castillo explained.

Clinicians should consider closely monitoring iron status in children with autism spectrum disorders who are treated with second-generation antipsychotics, especially if they gain substantial weight, she suggested. "Not only test for lipids and glucose, but also look at iron deficiency," which is a potentially treatable problem, she said.

The study analyzed data obtained from a Research Units on Pediatric Psychopharmacology trial in which children with autism spectrum disorders and serious behavior problems were randomized to treatment with risperidone alone or risperidone plus behavior management training for parents. Patients in the current sample averaged 8 years in age. Primary diagnoses included autism in 62%, pervasive developmental disorder not otherwise specified in 32%, and Asperger’s syndrome in 6%.

No significant associations were seen between baseline ferritin concentrations and age, baseline BMI, baseline or follow-up scores on the Aberrant Behavior Checklist, or percent change in ferritin concentration.

Dr. Del Castillo reported having no relevant financial disclosures. Some of her coinvestigators reported relationships with several pharmaceutical companies, including , Eli Lilly, Shire, AstraZeneca, Novartis, Forest Research, and Hoffmann-LaRoche.

SAN FRANCISCO – Hispanic children with autism were nearly twice as likely to have a learning disability or speech problem compared with their peers in an analysis of data on 913 children with autism spectrum disorders.

The presence of these co-occurring conditions might help explain why Hispanic children are diagnosed with autism at lower rates and at older ages compared with white non-Hispanic children, Stephanie E. Bean hypothesized.

The higher rate of diagnosed "speech problems" in Hispanic children is not surprising, since many Hispanic households speak more than one language at home, she said in a poster presentation and interview at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

"Because language delay is a factor of autism, it might be that the speech problem masks the autism spectrum disorder diagnosis," said Ms. Bean, a graduate student in public health at Johns Hopkins University, Baltimore.

The researchers adjusted for the effects of parental education and socioeconomic status.

Ms. Bean and her associates analyzed data from a subset of the National Survey of Children's Health drawn from phone interviews with parents of children aged 3-17 years who had a current autism spectrum disorder diagnosis. Average age was 10 years, and 10% were Hispanic.

Previous data from the Autism and Developmental Disabilities Monitoring Network suggest that the U.S. prevalence of autism spectrum disorders in 2008 was 12 per 1,000 in non-Hispanic white children, 10 per 1,000 in non-Hispanic blacks, and 8 per 1,000 in Hispanics (MMWR 2012;61[SS03]:1-19). A separate study of Medicaid records of children with autism showed that African American children were diagnosed 18 months later than were white children, on average, and Hispanic children received diagnoses even later (J. Am. Acad. Child. Adolesc. Psychiatry 2002;41:1447-53).

Another report suggested that psychiatric and neurodevelopmental conditions co-occurring with autism might lead to diagnostic misclassification and delay some children with autism spectrum disorders from receiving the early interventions that produce the greatest improvements, Ms. Bean said (Pediatrics 2012 Jan. 23 [doi:10.1542/peds.2011-1717]).

In the current study, anxiety disorders were 78% less likely in the 7% of children who were African American, compared with the 82% of white children. (Hispanics can be of any race.) This is in line with a previous study showing lower rates of anxiety diagnoses in African American children, she noted (J. Am. Acad. Child Adolesc. Psychiatry 1995;34:67-72).

No significant associations were found between race/ethnicity and other problems that commonly co-occur with autism, including attention-deficit/hyperactivity disorder, developmental delays, depression, behavior or conduct problems, epilepsy or seizure disorders, or hearing problems.

Learning disability was the most common co-occurring condition in the cohort as a whole, affecting 75% of children, and 87% of the children had an individualized education program. Mothers were the survey respondents in 79% of cases, and 74% of parents had achieved more than a high school diploma. Parents reported that 48% had family incomes greater than 300% of the federal poverty level, that 96% of children were insured at the time of the survey, and that 95% had been insured consistently over the prior year.

Ms. Bean reported having no financial disclosures.

SAN FRANCISCO – Hispanic children with autism were nearly twice as likely to have a learning disability or speech problem compared with their peers in an analysis of data on 913 children with autism spectrum disorders.

The presence of these co-occurring conditions might help explain why Hispanic children are diagnosed with autism at lower rates and at older ages compared with white non-Hispanic children, Stephanie E. Bean hypothesized.

The higher rate of diagnosed "speech problems" in Hispanic children is not surprising, since many Hispanic households speak more than one language at home, she said in a poster presentation and interview at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

"Because language delay is a factor of autism, it might be that the speech problem masks the autism spectrum disorder diagnosis," said Ms. Bean, a graduate student in public health at Johns Hopkins University, Baltimore.

The researchers adjusted for the effects of parental education and socioeconomic status.

Ms. Bean and her associates analyzed data from a subset of the National Survey of Children's Health drawn from phone interviews with parents of children aged 3-17 years who had a current autism spectrum disorder diagnosis. Average age was 10 years, and 10% were Hispanic.

Previous data from the Autism and Developmental Disabilities Monitoring Network suggest that the U.S. prevalence of autism spectrum disorders in 2008 was 12 per 1,000 in non-Hispanic white children, 10 per 1,000 in non-Hispanic blacks, and 8 per 1,000 in Hispanics (MMWR 2012;61[SS03]:1-19). A separate study of Medicaid records of children with autism showed that African American children were diagnosed 18 months later than were white children, on average, and Hispanic children received diagnoses even later (J. Am. Acad. Child. Adolesc. Psychiatry 2002;41:1447-53).

Another report suggested that psychiatric and neurodevelopmental conditions co-occurring with autism might lead to diagnostic misclassification and delay some children with autism spectrum disorders from receiving the early interventions that produce the greatest improvements, Ms. Bean said (Pediatrics 2012 Jan. 23 [doi:10.1542/peds.2011-1717]).

In the current study, anxiety disorders were 78% less likely in the 7% of children who were African American, compared with the 82% of white children. (Hispanics can be of any race.) This is in line with a previous study showing lower rates of anxiety diagnoses in African American children, she noted (J. Am. Acad. Child Adolesc. Psychiatry 1995;34:67-72).

No significant associations were found between race/ethnicity and other problems that commonly co-occur with autism, including attention-deficit/hyperactivity disorder, developmental delays, depression, behavior or conduct problems, epilepsy or seizure disorders, or hearing problems.

Learning disability was the most common co-occurring condition in the cohort as a whole, affecting 75% of children, and 87% of the children had an individualized education program. Mothers were the survey respondents in 79% of cases, and 74% of parents had achieved more than a high school diploma. Parents reported that 48% had family incomes greater than 300% of the federal poverty level, that 96% of children were insured at the time of the survey, and that 95% had been insured consistently over the prior year.

Ms. Bean reported having no financial disclosures.

SAN FRANCISCO – Hispanic children with autism were nearly twice as likely to have a learning disability or speech problem compared with their peers in an analysis of data on 913 children with autism spectrum disorders.

The presence of these co-occurring conditions might help explain why Hispanic children are diagnosed with autism at lower rates and at older ages compared with white non-Hispanic children, Stephanie E. Bean hypothesized.

The higher rate of diagnosed "speech problems" in Hispanic children is not surprising, since many Hispanic households speak more than one language at home, she said in a poster presentation and interview at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

"Because language delay is a factor of autism, it might be that the speech problem masks the autism spectrum disorder diagnosis," said Ms. Bean, a graduate student in public health at Johns Hopkins University, Baltimore.

The researchers adjusted for the effects of parental education and socioeconomic status.

Ms. Bean and her associates analyzed data from a subset of the National Survey of Children's Health drawn from phone interviews with parents of children aged 3-17 years who had a current autism spectrum disorder diagnosis. Average age was 10 years, and 10% were Hispanic.

Previous data from the Autism and Developmental Disabilities Monitoring Network suggest that the U.S. prevalence of autism spectrum disorders in 2008 was 12 per 1,000 in non-Hispanic white children, 10 per 1,000 in non-Hispanic blacks, and 8 per 1,000 in Hispanics (MMWR 2012;61[SS03]:1-19). A separate study of Medicaid records of children with autism showed that African American children were diagnosed 18 months later than were white children, on average, and Hispanic children received diagnoses even later (J. Am. Acad. Child. Adolesc. Psychiatry 2002;41:1447-53).

Another report suggested that psychiatric and neurodevelopmental conditions co-occurring with autism might lead to diagnostic misclassification and delay some children with autism spectrum disorders from receiving the early interventions that produce the greatest improvements, Ms. Bean said (Pediatrics 2012 Jan. 23 [doi:10.1542/peds.2011-1717]).

In the current study, anxiety disorders were 78% less likely in the 7% of children who were African American, compared with the 82% of white children. (Hispanics can be of any race.) This is in line with a previous study showing lower rates of anxiety diagnoses in African American children, she noted (J. Am. Acad. Child Adolesc. Psychiatry 1995;34:67-72).

No significant associations were found between race/ethnicity and other problems that commonly co-occur with autism, including attention-deficit/hyperactivity disorder, developmental delays, depression, behavior or conduct problems, epilepsy or seizure disorders, or hearing problems.

Learning disability was the most common co-occurring condition in the cohort as a whole, affecting 75% of children, and 87% of the children had an individualized education program. Mothers were the survey respondents in 79% of cases, and 74% of parents had achieved more than a high school diploma. Parents reported that 48% had family incomes greater than 300% of the federal poverty level, that 96% of children were insured at the time of the survey, and that 95% had been insured consistently over the prior year.

Ms. Bean reported having no financial disclosures.

SAN FRANCISCO – Thirty-five children with autism or developmental disorders significantly improved their behavioral functioning after an average 40-day stay in a specialized inpatient psychiatry unit, with most of the improvements sustained 2 months later.

The inpatient unit is 1 of 10 in the United States that exclusively serves children with autism or intellectual disabilities from developmental disorders. Until now, the outcomes from these units have not been prospectively studied using standardized measures, Dr. Matthew S. Siegel said.

In this prospective study, a primary caregiver completed the Aberrant Behavior Checklist–Irritability (ABC-I) subscale for a patient at admission, at discharge, and at the 2-month follow-up. Eighteen patients had autism spectrum disorder, and 17 were nonautism youths with intellectual disability attributable to developmental disorders.

The mean ABC-I score decreased significantly by more than 12 points between admission and discharge, Dr. Siegel reported in a poster presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Mean scores for youths with autism decreased from approximately 25 to 13, and were at approximately 14 at the 2-month follow-up. Mean scores for the nonautistic youths decreased from approximately 20 at admissions to approximately 8 at discharge, and rebounded to approximately 16 at the 2-month follow-up.

The treatment effect on the youths, aged 5-12 years, was "greater than that of any particular medication or behavioral treatment that’s been studied. That’s not a surprise, because we’re a multimodal treatment. We apply behavioral analysis, the best-evidenced psychopharmacologic intervention, occupational therapy, [and] speech therapy. It’s a concentrated intervention," he said in an interview at the session.

Comorbid psychiatric diagnoses were decided by expert consensus based on extended daily observation of the patients in the hospital. Validated diagnostic tools are lacking for psychiatric comorbidity in children with autism and other developmental disorders, noted Dr. Siegel, director of the developmental disorders treatment unit at Spring Harbor Hospital, Westbrook, Maine.

Anxiety disorders were present in 68% of autistic youths and 71% of the nonautistic youths. Disruptive behavior disorder was seen in 17% and 88%, respectively, and mood disorders were seen in 11% and 24%. Twenty-two percent in the autism group and 24% in the nonautism group had a disorder of infancy or early childhood such as attachment disturbance, Tourette’s syndrome, or a tic disorder not otherwise specified, said Dr. Siegel, also of Tufts University, Boston.

The outcomes on the ABC-I did not differ significantly between those in the autism group and the nonautism group. The mean age in the autism group was 13 years, and the mean age in the nonautism group was 12 years. Six patients were females, and 29 were males.

The study included no control group because of ethical considerations, he said.

Patients in the study typically had limited speech or were nonverbal, aggressive, or self-injurious on a daily basis, and had failed multiple other interventions.

Dr. Siegel and his associates next will assess outcomes for these patients at 6 months. A future study will compare outcomes between specialized and general psychiatric units, and investigate the longer-term sustainability of outcomes.

Previous studies have reported that children with autism are 11 times more likely to undergo psychiatric hospitalization, compared with neurotypical children, Dr. Siegel said.

The 10 specialized inpatient psychiatric units in the United States (like the one in this study) recently formed a consortium that is talking to potential funders to conduct joint research. "We have a big population of the nonverbal and self-injury subgroup," Dr. Siegel said. "Those are groups that have been ignored in research. I think we have a really exciting opportunity."

Dr. Siegel is employed by the hospital whose program was studied. He reported having no other relevant financial disclosures. The Maine Medical Center Research Institute and the Pond Family Foundation funded the study.

SAN FRANCISCO – Thirty-five children with autism or developmental disorders significantly improved their behavioral functioning after an average 40-day stay in a specialized inpatient psychiatry unit, with most of the improvements sustained 2 months later.

The inpatient unit is 1 of 10 in the United States that exclusively serves children with autism or intellectual disabilities from developmental disorders. Until now, the outcomes from these units have not been prospectively studied using standardized measures, Dr. Matthew S. Siegel said.

In this prospective study, a primary caregiver completed the Aberrant Behavior Checklist–Irritability (ABC-I) subscale for a patient at admission, at discharge, and at the 2-month follow-up. Eighteen patients had autism spectrum disorder, and 17 were nonautism youths with intellectual disability attributable to developmental disorders.

The mean ABC-I score decreased significantly by more than 12 points between admission and discharge, Dr. Siegel reported in a poster presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Mean scores for youths with autism decreased from approximately 25 to 13, and were at approximately 14 at the 2-month follow-up. Mean scores for the nonautistic youths decreased from approximately 20 at admissions to approximately 8 at discharge, and rebounded to approximately 16 at the 2-month follow-up.

The treatment effect on the youths, aged 5-12 years, was "greater than that of any particular medication or behavioral treatment that’s been studied. That’s not a surprise, because we’re a multimodal treatment. We apply behavioral analysis, the best-evidenced psychopharmacologic intervention, occupational therapy, [and] speech therapy. It’s a concentrated intervention," he said in an interview at the session.

Comorbid psychiatric diagnoses were decided by expert consensus based on extended daily observation of the patients in the hospital. Validated diagnostic tools are lacking for psychiatric comorbidity in children with autism and other developmental disorders, noted Dr. Siegel, director of the developmental disorders treatment unit at Spring Harbor Hospital, Westbrook, Maine.

Anxiety disorders were present in 68% of autistic youths and 71% of the nonautistic youths. Disruptive behavior disorder was seen in 17% and 88%, respectively, and mood disorders were seen in 11% and 24%. Twenty-two percent in the autism group and 24% in the nonautism group had a disorder of infancy or early childhood such as attachment disturbance, Tourette’s syndrome, or a tic disorder not otherwise specified, said Dr. Siegel, also of Tufts University, Boston.

The outcomes on the ABC-I did not differ significantly between those in the autism group and the nonautism group. The mean age in the autism group was 13 years, and the mean age in the nonautism group was 12 years. Six patients were females, and 29 were males.

The study included no control group because of ethical considerations, he said.

Patients in the study typically had limited speech or were nonverbal, aggressive, or self-injurious on a daily basis, and had failed multiple other interventions.

Dr. Siegel and his associates next will assess outcomes for these patients at 6 months. A future study will compare outcomes between specialized and general psychiatric units, and investigate the longer-term sustainability of outcomes.

Previous studies have reported that children with autism are 11 times more likely to undergo psychiatric hospitalization, compared with neurotypical children, Dr. Siegel said.

The 10 specialized inpatient psychiatric units in the United States (like the one in this study) recently formed a consortium that is talking to potential funders to conduct joint research. "We have a big population of the nonverbal and self-injury subgroup," Dr. Siegel said. "Those are groups that have been ignored in research. I think we have a really exciting opportunity."

Dr. Siegel is employed by the hospital whose program was studied. He reported having no other relevant financial disclosures. The Maine Medical Center Research Institute and the Pond Family Foundation funded the study.

SAN FRANCISCO – Thirty-five children with autism or developmental disorders significantly improved their behavioral functioning after an average 40-day stay in a specialized inpatient psychiatry unit, with most of the improvements sustained 2 months later.

The inpatient unit is 1 of 10 in the United States that exclusively serves children with autism or intellectual disabilities from developmental disorders. Until now, the outcomes from these units have not been prospectively studied using standardized measures, Dr. Matthew S. Siegel said.

In this prospective study, a primary caregiver completed the Aberrant Behavior Checklist–Irritability (ABC-I) subscale for a patient at admission, at discharge, and at the 2-month follow-up. Eighteen patients had autism spectrum disorder, and 17 were nonautism youths with intellectual disability attributable to developmental disorders.

The mean ABC-I score decreased significantly by more than 12 points between admission and discharge, Dr. Siegel reported in a poster presentation at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Mean scores for youths with autism decreased from approximately 25 to 13, and were at approximately 14 at the 2-month follow-up. Mean scores for the nonautistic youths decreased from approximately 20 at admissions to approximately 8 at discharge, and rebounded to approximately 16 at the 2-month follow-up.

The treatment effect on the youths, aged 5-12 years, was "greater than that of any particular medication or behavioral treatment that’s been studied. That’s not a surprise, because we’re a multimodal treatment. We apply behavioral analysis, the best-evidenced psychopharmacologic intervention, occupational therapy, [and] speech therapy. It’s a concentrated intervention," he said in an interview at the session.

Comorbid psychiatric diagnoses were decided by expert consensus based on extended daily observation of the patients in the hospital. Validated diagnostic tools are lacking for psychiatric comorbidity in children with autism and other developmental disorders, noted Dr. Siegel, director of the developmental disorders treatment unit at Spring Harbor Hospital, Westbrook, Maine.

Anxiety disorders were present in 68% of autistic youths and 71% of the nonautistic youths. Disruptive behavior disorder was seen in 17% and 88%, respectively, and mood disorders were seen in 11% and 24%. Twenty-two percent in the autism group and 24% in the nonautism group had a disorder of infancy or early childhood such as attachment disturbance, Tourette’s syndrome, or a tic disorder not otherwise specified, said Dr. Siegel, also of Tufts University, Boston.

The outcomes on the ABC-I did not differ significantly between those in the autism group and the nonautism group. The mean age in the autism group was 13 years, and the mean age in the nonautism group was 12 years. Six patients were females, and 29 were males.

The study included no control group because of ethical considerations, he said.

Patients in the study typically had limited speech or were nonverbal, aggressive, or self-injurious on a daily basis, and had failed multiple other interventions.

Dr. Siegel and his associates next will assess outcomes for these patients at 6 months. A future study will compare outcomes between specialized and general psychiatric units, and investigate the longer-term sustainability of outcomes.

Previous studies have reported that children with autism are 11 times more likely to undergo psychiatric hospitalization, compared with neurotypical children, Dr. Siegel said.

The 10 specialized inpatient psychiatric units in the United States (like the one in this study) recently formed a consortium that is talking to potential funders to conduct joint research. "We have a big population of the nonverbal and self-injury subgroup," Dr. Siegel said. "Those are groups that have been ignored in research. I think we have a really exciting opportunity."

Dr. Siegel is employed by the hospital whose program was studied. He reported having no other relevant financial disclosures. The Maine Medical Center Research Institute and the Pond Family Foundation funded the study.

SAN DIEGO – A Rapid Quality Reporting System significantly improved oncologists’ adherence to five measures of quality treatment for patients with breast and colon cancer during beta testing involving 64,129 patients at 64 cancer centers.

The system, developed by the American College of Surgeons’ Commission on Cancer, provides next-business-day feedback when centers submit data. Compliance rates climbed as high as 90% by the end of a 5-year period, according to researchers.

Erica J. McNamara and her associates reported the following gains at a symposium on quality care sponsored by the American Society of Clinical Oncology (ASCO):

• The proportion of patients receiving hormone therapy for hormone receptor–positive breast cancer increased from 47% in 2006 to 85% in 2011.

• Treatment with radiation following breast conserving surgery increased from 69% of patients to 90%.

• Use of multi-adjuvant chemotherapy for hormone receptor–negative breast cancer increased from 72% of patients to 90%,

• Treatment with adjuvant chemotherapy for lymph node–positive colon cancer increased from 68% to 86%.

• The proportion of patients with resected colon cancer who had at least 12 regional lymph nodes removed for pathological examination improved from 70% to 90%,

The study gathered data from the National Cancer Database in 2006-2007 for 18,151 patients with breast cancer and 6,369 patients with colon cancer and compared it with data reported to the Rapid Quality Reporting System (RQRS) in 2008-2011 for 31,590 patients with breast cancer and 11,338 patients with colon cancer.

The system monitors the five quality measures using reporting procedures similar to those that hospitals already use to submit patient data to cancer registries. Traditional registries generally report a hospital’s rate of performing quality measures 2 years after data submission, however, while the RQRS allows cancer programs to submit data whenever they want and sends feedback by the next business day, said Ms. McNamara, a quality improvement information analyst for the American College of Surgeons, Chicago.

With as little as a surgical or pathological report, cancer programs can submit a case to the RQRS to get alerts when quality care is not being provided. "What this does is it changes it from looking at retrospective cases to cases that are currently within their first course of therapy," she said in a press conference before the meeting.

Programs participating in the beta-test generally submitted data monthly, and new participants in the RQRS are required to submit data at least quarterly. The RQRS analyzes the data and returns a report in a variety of image formats, such as a year-to-date "dashboard" showing the program’s compliance rates for individual quality measures, and a list of every case submitted and whether the quality measures were applicable to the case or not, or if more information is needed.

The report also includes color-coded "case alerts" with the colors changing to orange and then red as a patient gets closer to the end of the first course of therapy with either no documentation of adjuvant therapy or no documentation that treatment decision has been made to not provide adjuvant therapy. Participants must log in to a password-protected site to view details of the case.

"For each of the adjuvant therapy measures, there’s a specific amount of time that each patient has to receive their adjuvant therapy," Ms. McNamara said. "We find that after about 6-9 months of using RQRS, about a third of programs tell us that they have seen RQRS prevent patients from slipping through the cracks or not receiving timely adjuvant care."

Breakdowns of the data by race, age, and type of insurance showed that quality care significantly improved in all subgroups. Disparities in quality adherence rates between patients of different races, ages, or insurance status were minimized or eliminated with use of the RQRS.

Two factors appeared to produce these improvements. Use of the RQRS improved the coordination of care and led to more complete reporting of adjuvant therapy data, she said.

More than 400 cancer programs now voluntarily use the RQRS. The American College of Surgeons is working on expanding the RQRS to include other measures of quality care for breast cancer and for lung, stomach, and esophageal cancers.

Ms. McNamara reported having no financial disclosures.

SAN DIEGO – A Rapid Quality Reporting System significantly improved oncologists’ adherence to five measures of quality treatment for patients with breast and colon cancer during beta testing involving 64,129 patients at 64 cancer centers.

The system, developed by the American College of Surgeons’ Commission on Cancer, provides next-business-day feedback when centers submit data. Compliance rates climbed as high as 90% by the end of a 5-year period, according to researchers.

Erica J. McNamara and her associates reported the following gains at a symposium on quality care sponsored by the American Society of Clinical Oncology (ASCO):

• The proportion of patients receiving hormone therapy for hormone receptor–positive breast cancer increased from 47% in 2006 to 85% in 2011.

• Treatment with radiation following breast conserving surgery increased from 69% of patients to 90%.

• Use of multi-adjuvant chemotherapy for hormone receptor–negative breast cancer increased from 72% of patients to 90%,

• Treatment with adjuvant chemotherapy for lymph node–positive colon cancer increased from 68% to 86%.

• The proportion of patients with resected colon cancer who had at least 12 regional lymph nodes removed for pathological examination improved from 70% to 90%,

The study gathered data from the National Cancer Database in 2006-2007 for 18,151 patients with breast cancer and 6,369 patients with colon cancer and compared it with data reported to the Rapid Quality Reporting System (RQRS) in 2008-2011 for 31,590 patients with breast cancer and 11,338 patients with colon cancer.

The system monitors the five quality measures using reporting procedures similar to those that hospitals already use to submit patient data to cancer registries. Traditional registries generally report a hospital’s rate of performing quality measures 2 years after data submission, however, while the RQRS allows cancer programs to submit data whenever they want and sends feedback by the next business day, said Ms. McNamara, a quality improvement information analyst for the American College of Surgeons, Chicago.

With as little as a surgical or pathological report, cancer programs can submit a case to the RQRS to get alerts when quality care is not being provided. "What this does is it changes it from looking at retrospective cases to cases that are currently within their first course of therapy," she said in a press conference before the meeting.

Programs participating in the beta-test generally submitted data monthly, and new participants in the RQRS are required to submit data at least quarterly. The RQRS analyzes the data and returns a report in a variety of image formats, such as a year-to-date "dashboard" showing the program’s compliance rates for individual quality measures, and a list of every case submitted and whether the quality measures were applicable to the case or not, or if more information is needed.

The report also includes color-coded "case alerts" with the colors changing to orange and then red as a patient gets closer to the end of the first course of therapy with either no documentation of adjuvant therapy or no documentation that treatment decision has been made to not provide adjuvant therapy. Participants must log in to a password-protected site to view details of the case.

"For each of the adjuvant therapy measures, there’s a specific amount of time that each patient has to receive their adjuvant therapy," Ms. McNamara said. "We find that after about 6-9 months of using RQRS, about a third of programs tell us that they have seen RQRS prevent patients from slipping through the cracks or not receiving timely adjuvant care."

Breakdowns of the data by race, age, and type of insurance showed that quality care significantly improved in all subgroups. Disparities in quality adherence rates between patients of different races, ages, or insurance status were minimized or eliminated with use of the RQRS.

Two factors appeared to produce these improvements. Use of the RQRS improved the coordination of care and led to more complete reporting of adjuvant therapy data, she said.

More than 400 cancer programs now voluntarily use the RQRS. The American College of Surgeons is working on expanding the RQRS to include other measures of quality care for breast cancer and for lung, stomach, and esophageal cancers.

Ms. McNamara reported having no financial disclosures.

SAN DIEGO – A Rapid Quality Reporting System significantly improved oncologists’ adherence to five measures of quality treatment for patients with breast and colon cancer during beta testing involving 64,129 patients at 64 cancer centers.

The system, developed by the American College of Surgeons’ Commission on Cancer, provides next-business-day feedback when centers submit data. Compliance rates climbed as high as 90% by the end of a 5-year period, according to researchers.

Erica J. McNamara and her associates reported the following gains at a symposium on quality care sponsored by the American Society of Clinical Oncology (ASCO):

• The proportion of patients receiving hormone therapy for hormone receptor–positive breast cancer increased from 47% in 2006 to 85% in 2011.

• Treatment with radiation following breast conserving surgery increased from 69% of patients to 90%.

• Use of multi-adjuvant chemotherapy for hormone receptor–negative breast cancer increased from 72% of patients to 90%,

• Treatment with adjuvant chemotherapy for lymph node–positive colon cancer increased from 68% to 86%.

• The proportion of patients with resected colon cancer who had at least 12 regional lymph nodes removed for pathological examination improved from 70% to 90%,

The study gathered data from the National Cancer Database in 2006-2007 for 18,151 patients with breast cancer and 6,369 patients with colon cancer and compared it with data reported to the Rapid Quality Reporting System (RQRS) in 2008-2011 for 31,590 patients with breast cancer and 11,338 patients with colon cancer.

The system monitors the five quality measures using reporting procedures similar to those that hospitals already use to submit patient data to cancer registries. Traditional registries generally report a hospital’s rate of performing quality measures 2 years after data submission, however, while the RQRS allows cancer programs to submit data whenever they want and sends feedback by the next business day, said Ms. McNamara, a quality improvement information analyst for the American College of Surgeons, Chicago.

With as little as a surgical or pathological report, cancer programs can submit a case to the RQRS to get alerts when quality care is not being provided. "What this does is it changes it from looking at retrospective cases to cases that are currently within their first course of therapy," she said in a press conference before the meeting.

Programs participating in the beta-test generally submitted data monthly, and new participants in the RQRS are required to submit data at least quarterly. The RQRS analyzes the data and returns a report in a variety of image formats, such as a year-to-date "dashboard" showing the program’s compliance rates for individual quality measures, and a list of every case submitted and whether the quality measures were applicable to the case or not, or if more information is needed.

The report also includes color-coded "case alerts" with the colors changing to orange and then red as a patient gets closer to the end of the first course of therapy with either no documentation of adjuvant therapy or no documentation that treatment decision has been made to not provide adjuvant therapy. Participants must log in to a password-protected site to view details of the case.

"For each of the adjuvant therapy measures, there’s a specific amount of time that each patient has to receive their adjuvant therapy," Ms. McNamara said. "We find that after about 6-9 months of using RQRS, about a third of programs tell us that they have seen RQRS prevent patients from slipping through the cracks or not receiving timely adjuvant care."

Breakdowns of the data by race, age, and type of insurance showed that quality care significantly improved in all subgroups. Disparities in quality adherence rates between patients of different races, ages, or insurance status were minimized or eliminated with use of the RQRS.

Two factors appeared to produce these improvements. Use of the RQRS improved the coordination of care and led to more complete reporting of adjuvant therapy data, she said.

More than 400 cancer programs now voluntarily use the RQRS. The American College of Surgeons is working on expanding the RQRS to include other measures of quality care for breast cancer and for lung, stomach, and esophageal cancers.

Ms. McNamara reported having no financial disclosures.

Experts have coined a new term for the next phase of advancing in the quality of medical care: "systemness." You’ll be hearing more about systemness, to be sure.

Last week, the first national conference on creating systemness in health care delivery took place in Washington, convened by the ECRI Institute with help from large, successful medical systems including Kaiser Permanente; the Department of Veterans Affairs, and Sutter Health, to name a few.

So what is systemness? Here’s a graphic representation that conveys the complexity of what Dr. Kenneth W. Kizer calls "the new frontier of health care quality improvement."

If that’s not abstract enough for you, here’s the definition that Dr. Kizer provided at the first national symposium on quality cancer care held Dec. 1 by the American Society of Clinical Oncology: Systemness refers to the functional state of a collection of interconnected discrete parts that behave as a coherent whole in ways that are distinct from the component parts and that predictably and consistently produce results that are superior to the sum of the parts.

Courtesy Wikimedia Commons/U.S. government photo (public domain)

Even though the systemness conference and the quality cancer care conference were firsts, they’re part of at least a 4,000-year history of mankind’s quest to improve medical care. In a keynote address at the ASCO conference, Dr. Kizer picked a few highlights:

If a physician make a large incision with the operating knife and cure it ... he shall receive 10 shekels in money. If a physician make a large incision with the operating knife, and kill him ... his hands shall be cut off. – Code of Hammurabi, circa 1772 B.C.

Florence Nightingale, arguably the first modern health care improvement leader, set the foundation for the course that brought us to systemness today: "... even admitting to the full extent the great value of the hospital improvements in recent years, a vast deal of the suffering, and some at least of the mortality, in these establishments is avoidable."

In 1914, Dr. Ernest A. Codman advanced the idea of weeding out "bad apples" as part of quality control in medicine. By the middle of the 20th century, the health care industry started paying attention to what other industries were doing for quality improvements, including focuses on structure, process, and outcomes.

Courtesy Wikimedia Commons/Public domain

Only in the last 10-15 years have the science and technology of health care quality improvement matured enough to use these tools for advances, said Dr. Kizer, professor and director of the Institute for Population Health Improvement at the University of California, Davis.

The year 1998 was a tipping point, with major reports on the need to improve U.S. health care delivery published by the Institutes of Medicine, a presidential advisory commission, and the Milbank Quarterly, with other major reports on their heels. The quality of U.S. health care falls well below that achieved in other developed nations, and U.S. residents have a 50-50 chance, on average, of receiving recommended care, multiple studies reported.

Oh, and those other developed countries? They’ve got more systemness in health care than we do, apparently. In the United States, health care systems are highly heterogeneous, and many don’t yet show tangible synergies from systematizing, said Dr. Kizer.

As U.S. health care spending skyrockets, achieving systemness is essential for quality and sustainability, he said. It won’t happen on its own but must be intentionally designed and replicated. And because health care operates as a complex adaptive system, efforts to achieve systemness must be mindful of chaos theory – that unintended consequences are unavoidable and should be anticipated with vigilance built into the system.

The evidence for and understanding of systemness in health care is immature, but we know enough to conclude that there’s no single way to achieve it. Instead, 16 operating characteristic have been defined (so far), though most of the attention has fallen on infrastructure (IT, data sharing, etc.) and less on some of the "soft" components, Dr. Kizer said.

"Achieving systemness is about changing culture, fundamentally. It’s more about sociology than technology," and a culture of collaboration will develop in health care delivery only if financial incentives are aligned, he said. Accountable care organizations and bundled payments are mere steps along the way to greater systemness.

If all this is a bit too abstract for your taste, here’s a slightly more concrete and condensed summary: "Payment reform is inevitable," Dr. Kizer said. "Fee for service is dead."

Ms. Boschert is San Francisco Bureau Chief. Follow her on Twitter @sherryboschert.

Experts have coined a new term for the next phase of advancing in the quality of medical care: "systemness." You’ll be hearing more about systemness, to be sure.

Last week, the first national conference on creating systemness in health care delivery took place in Washington, convened by the ECRI Institute with help from large, successful medical systems including Kaiser Permanente; the Department of Veterans Affairs, and Sutter Health, to name a few.

So what is systemness? Here’s a graphic representation that conveys the complexity of what Dr. Kenneth W. Kizer calls "the new frontier of health care quality improvement."

If that’s not abstract enough for you, here’s the definition that Dr. Kizer provided at the first national symposium on quality cancer care held Dec. 1 by the American Society of Clinical Oncology: Systemness refers to the functional state of a collection of interconnected discrete parts that behave as a coherent whole in ways that are distinct from the component parts and that predictably and consistently produce results that are superior to the sum of the parts.

Courtesy Wikimedia Commons/U.S. government photo (public domain)

Even though the systemness conference and the quality cancer care conference were firsts, they’re part of at least a 4,000-year history of mankind’s quest to improve medical care. In a keynote address at the ASCO conference, Dr. Kizer picked a few highlights:

If a physician make a large incision with the operating knife and cure it ... he shall receive 10 shekels in money. If a physician make a large incision with the operating knife, and kill him ... his hands shall be cut off. – Code of Hammurabi, circa 1772 B.C.

Florence Nightingale, arguably the first modern health care improvement leader, set the foundation for the course that brought us to systemness today: "... even admitting to the full extent the great value of the hospital improvements in recent years, a vast deal of the suffering, and some at least of the mortality, in these establishments is avoidable."

In 1914, Dr. Ernest A. Codman advanced the idea of weeding out "bad apples" as part of quality control in medicine. By the middle of the 20th century, the health care industry started paying attention to what other industries were doing for quality improvements, including focuses on structure, process, and outcomes.

Courtesy Wikimedia Commons/Public domain

Only in the last 10-15 years have the science and technology of health care quality improvement matured enough to use these tools for advances, said Dr. Kizer, professor and director of the Institute for Population Health Improvement at the University of California, Davis.

The year 1998 was a tipping point, with major reports on the need to improve U.S. health care delivery published by the Institutes of Medicine, a presidential advisory commission, and the Milbank Quarterly, with other major reports on their heels. The quality of U.S. health care falls well below that achieved in other developed nations, and U.S. residents have a 50-50 chance, on average, of receiving recommended care, multiple studies reported.

Oh, and those other developed countries? They’ve got more systemness in health care than we do, apparently. In the United States, health care systems are highly heterogeneous, and many don’t yet show tangible synergies from systematizing, said Dr. Kizer.

As U.S. health care spending skyrockets, achieving systemness is essential for quality and sustainability, he said. It won’t happen on its own but must be intentionally designed and replicated. And because health care operates as a complex adaptive system, efforts to achieve systemness must be mindful of chaos theory – that unintended consequences are unavoidable and should be anticipated with vigilance built into the system.

The evidence for and understanding of systemness in health care is immature, but we know enough to conclude that there’s no single way to achieve it. Instead, 16 operating characteristic have been defined (so far), though most of the attention has fallen on infrastructure (IT, data sharing, etc.) and less on some of the "soft" components, Dr. Kizer said.

"Achieving systemness is about changing culture, fundamentally. It’s more about sociology than technology," and a culture of collaboration will develop in health care delivery only if financial incentives are aligned, he said. Accountable care organizations and bundled payments are mere steps along the way to greater systemness.

If all this is a bit too abstract for your taste, here’s a slightly more concrete and condensed summary: "Payment reform is inevitable," Dr. Kizer said. "Fee for service is dead."

Ms. Boschert is San Francisco Bureau Chief. Follow her on Twitter @sherryboschert.

Experts have coined a new term for the next phase of advancing in the quality of medical care: "systemness." You’ll be hearing more about systemness, to be sure.

Last week, the first national conference on creating systemness in health care delivery took place in Washington, convened by the ECRI Institute with help from large, successful medical systems including Kaiser Permanente; the Department of Veterans Affairs, and Sutter Health, to name a few.

So what is systemness? Here’s a graphic representation that conveys the complexity of what Dr. Kenneth W. Kizer calls "the new frontier of health care quality improvement."

If that’s not abstract enough for you, here’s the definition that Dr. Kizer provided at the first national symposium on quality cancer care held Dec. 1 by the American Society of Clinical Oncology: Systemness refers to the functional state of a collection of interconnected discrete parts that behave as a coherent whole in ways that are distinct from the component parts and that predictably and consistently produce results that are superior to the sum of the parts.

Courtesy Wikimedia Commons/U.S. government photo (public domain)

Even though the systemness conference and the quality cancer care conference were firsts, they’re part of at least a 4,000-year history of mankind’s quest to improve medical care. In a keynote address at the ASCO conference, Dr. Kizer picked a few highlights:

If a physician make a large incision with the operating knife and cure it ... he shall receive 10 shekels in money. If a physician make a large incision with the operating knife, and kill him ... his hands shall be cut off. – Code of Hammurabi, circa 1772 B.C.

Florence Nightingale, arguably the first modern health care improvement leader, set the foundation for the course that brought us to systemness today: "... even admitting to the full extent the great value of the hospital improvements in recent years, a vast deal of the suffering, and some at least of the mortality, in these establishments is avoidable."

In 1914, Dr. Ernest A. Codman advanced the idea of weeding out "bad apples" as part of quality control in medicine. By the middle of the 20th century, the health care industry started paying attention to what other industries were doing for quality improvements, including focuses on structure, process, and outcomes.

Courtesy Wikimedia Commons/Public domain

Only in the last 10-15 years have the science and technology of health care quality improvement matured enough to use these tools for advances, said Dr. Kizer, professor and director of the Institute for Population Health Improvement at the University of California, Davis.

The year 1998 was a tipping point, with major reports on the need to improve U.S. health care delivery published by the Institutes of Medicine, a presidential advisory commission, and the Milbank Quarterly, with other major reports on their heels. The quality of U.S. health care falls well below that achieved in other developed nations, and U.S. residents have a 50-50 chance, on average, of receiving recommended care, multiple studies reported.

Oh, and those other developed countries? They’ve got more systemness in health care than we do, apparently. In the United States, health care systems are highly heterogeneous, and many don’t yet show tangible synergies from systematizing, said Dr. Kizer.

As U.S. health care spending skyrockets, achieving systemness is essential for quality and sustainability, he said. It won’t happen on its own but must be intentionally designed and replicated. And because health care operates as a complex adaptive system, efforts to achieve systemness must be mindful of chaos theory – that unintended consequences are unavoidable and should be anticipated with vigilance built into the system.

The evidence for and understanding of systemness in health care is immature, but we know enough to conclude that there’s no single way to achieve it. Instead, 16 operating characteristic have been defined (so far), though most of the attention has fallen on infrastructure (IT, data sharing, etc.) and less on some of the "soft" components, Dr. Kizer said.

"Achieving systemness is about changing culture, fundamentally. It’s more about sociology than technology," and a culture of collaboration will develop in health care delivery only if financial incentives are aligned, he said. Accountable care organizations and bundled payments are mere steps along the way to greater systemness.

If all this is a bit too abstract for your taste, here’s a slightly more concrete and condensed summary: "Payment reform is inevitable," Dr. Kizer said. "Fee for service is dead."

Ms. Boschert is San Francisco Bureau Chief. Follow her on Twitter @sherryboschert.

Outpatient oncology practices that voluntarily participated in a quality-improvement program markedly increased their adoption of newly recommended treatments, but continued to do poorly in smoking cessation efforts and in discussing fertility preservation.

From the start and throughout the period studied, 156 oncology practices reported high rates of recommending adjuvant chemotherapy according to guidelines for breast, colorectal, or non–small cell lung cancer, Dr. Michael N. Neuss said in an online press conference sponsored by the American Society of Clinical Oncology (ASCO).

Courtesy American Society of Clinical Oncology

These participants in ASCO’s Quality Oncology Practice Initiative (QOPI) improved their mean overall scores for adherence to recommended care from 71% to 85%, Dr. Neuss and his associates reported. The study was to be presented at ASCO’s Quality Care Symposium in San Diego on Nov. 30, 2012.

Use of new clinical practices based on new guidelines or clinical evidence improved from 5% to 69% between 2006 and 2010. That’s "quite a remarkable improvement," said Dr. Neuss, chief medical officer at the Vanderbilt-Ingram Cancer Center, Vanderbilt University, Nashville, Tenn.

These new practices included pathologic examination of at least 12 regional lymph nodes for surgically resected colon cancer, which zoomed from nonexistent at the start of the study to 60% compliance within 6 months and 100% of practices complying after 5 years. Use of the antinausea drug aprepitant (Emend) improved from 20% of practices to 60%.

Clinicians were quick to adopt two clinical practices that were introduced during the study period. Genetic testing to predict response to treatment in patients with metastatic colorectal cancer increased from just over 60% of practices to more than 80%. Testing for KRAS gene alterations when administering anti–epidermal growth factor receptor therapy increased from approximately 55% to approximately 85% of practices.

Throughout the study, close to 90% or more of physicians reported recommendations for adjuvant chemotherapy that concorded with guidelines. "On many adjuvant treatment measures, it appears that QOPI participants are already doing very well," Dr. Neuss said.

In the areas of smoking and fertility, however, practices were resistant to change despite strong evidence promoting specific care. Although physicians documented patients’ smoking status 90%-95% of the time, rates of smoking cessation counseling topped out at about 35%.

"Similarly, there’s a good reason to tell people who may be rendered infertile by chemotherapy of this problem and of potential solutions to it," but no more than 30% of patients got discussions of infertility risks and only approximately 15% heard about fertility preservation options, Dr. Neuss said.

Data came from a larger cohort of approximately 2,000 physicians in 308 practices (comprising 15%-20% of U.S. oncologists) who participated in QOPI beta testing from 2006-2010. Twice yearly, physicians reviewed patients’ charts and filed a structured online report on an average of 100 preidentified measures that the QOPI uses to assess quality of care. Within 2 weeks, the practice would receive a report from QOPI on how the practice’s rates of compliance with recommended care compared with the ideal, rates for all practices in QOPI, and rates for practices similar to their own.

"It’s entirely up to you how you act on that result or ignore it," he said.

Each practice provided at least two rounds of data (averaging six rounds) and reported on 30 or more patients per round. The analysis looked at 50 measures of quality that did not change during the study period in seven modules – core quality measures, symptom management, end-of-life care, non-Hodgkin’s lymphoma, breast cancer, colorectal cancer, and non–small cell lung cancer.

The study excluded practices that did not provide a full data set, were located outside the United States, or that presented trainee data. The investigators developed a logistic regression model to accommodate varied performance at the start of QOPI, which normalized performance among groups and allowed assessment of each practice’s improvement.

QOPI has moved beyond beta testing and now includes more than 800 registered oncology practices participating, he said.

Dr. Neuss reported having no financial disclosures.

Outpatient oncology practices that voluntarily participated in a quality-improvement program markedly increased their adoption of newly recommended treatments, but continued to do poorly in smoking cessation efforts and in discussing fertility preservation.

From the start and throughout the period studied, 156 oncology practices reported high rates of recommending adjuvant chemotherapy according to guidelines for breast, colorectal, or non–small cell lung cancer, Dr. Michael N. Neuss said in an online press conference sponsored by the American Society of Clinical Oncology (ASCO).

Courtesy American Society of Clinical Oncology

These participants in ASCO’s Quality Oncology Practice Initiative (QOPI) improved their mean overall scores for adherence to recommended care from 71% to 85%, Dr. Neuss and his associates reported. The study was to be presented at ASCO’s Quality Care Symposium in San Diego on Nov. 30, 2012.

Use of new clinical practices based on new guidelines or clinical evidence improved from 5% to 69% between 2006 and 2010. That’s "quite a remarkable improvement," said Dr. Neuss, chief medical officer at the Vanderbilt-Ingram Cancer Center, Vanderbilt University, Nashville, Tenn.

These new practices included pathologic examination of at least 12 regional lymph nodes for surgically resected colon cancer, which zoomed from nonexistent at the start of the study to 60% compliance within 6 months and 100% of practices complying after 5 years. Use of the antinausea drug aprepitant (Emend) improved from 20% of practices to 60%.

Clinicians were quick to adopt two clinical practices that were introduced during the study period. Genetic testing to predict response to treatment in patients with metastatic colorectal cancer increased from just over 60% of practices to more than 80%. Testing for KRAS gene alterations when administering anti–epidermal growth factor receptor therapy increased from approximately 55% to approximately 85% of practices.

Throughout the study, close to 90% or more of physicians reported recommendations for adjuvant chemotherapy that concorded with guidelines. "On many adjuvant treatment measures, it appears that QOPI participants are already doing very well," Dr. Neuss said.

In the areas of smoking and fertility, however, practices were resistant to change despite strong evidence promoting specific care. Although physicians documented patients’ smoking status 90%-95% of the time, rates of smoking cessation counseling topped out at about 35%.

"Similarly, there’s a good reason to tell people who may be rendered infertile by chemotherapy of this problem and of potential solutions to it," but no more than 30% of patients got discussions of infertility risks and only approximately 15% heard about fertility preservation options, Dr. Neuss said.

Data came from a larger cohort of approximately 2,000 physicians in 308 practices (comprising 15%-20% of U.S. oncologists) who participated in QOPI beta testing from 2006-2010. Twice yearly, physicians reviewed patients’ charts and filed a structured online report on an average of 100 preidentified measures that the QOPI uses to assess quality of care. Within 2 weeks, the practice would receive a report from QOPI on how the practice’s rates of compliance with recommended care compared with the ideal, rates for all practices in QOPI, and rates for practices similar to their own.

"It’s entirely up to you how you act on that result or ignore it," he said.

Each practice provided at least two rounds of data (averaging six rounds) and reported on 30 or more patients per round. The analysis looked at 50 measures of quality that did not change during the study period in seven modules – core quality measures, symptom management, end-of-life care, non-Hodgkin’s lymphoma, breast cancer, colorectal cancer, and non–small cell lung cancer.

The study excluded practices that did not provide a full data set, were located outside the United States, or that presented trainee data. The investigators developed a logistic regression model to accommodate varied performance at the start of QOPI, which normalized performance among groups and allowed assessment of each practice’s improvement.

QOPI has moved beyond beta testing and now includes more than 800 registered oncology practices participating, he said.

Dr. Neuss reported having no financial disclosures.

Outpatient oncology practices that voluntarily participated in a quality-improvement program markedly increased their adoption of newly recommended treatments, but continued to do poorly in smoking cessation efforts and in discussing fertility preservation.

From the start and throughout the period studied, 156 oncology practices reported high rates of recommending adjuvant chemotherapy according to guidelines for breast, colorectal, or non–small cell lung cancer, Dr. Michael N. Neuss said in an online press conference sponsored by the American Society of Clinical Oncology (ASCO).

Courtesy American Society of Clinical Oncology

These participants in ASCO’s Quality Oncology Practice Initiative (QOPI) improved their mean overall scores for adherence to recommended care from 71% to 85%, Dr. Neuss and his associates reported. The study was to be presented at ASCO’s Quality Care Symposium in San Diego on Nov. 30, 2012.

Use of new clinical practices based on new guidelines or clinical evidence improved from 5% to 69% between 2006 and 2010. That’s "quite a remarkable improvement," said Dr. Neuss, chief medical officer at the Vanderbilt-Ingram Cancer Center, Vanderbilt University, Nashville, Tenn.

These new practices included pathologic examination of at least 12 regional lymph nodes for surgically resected colon cancer, which zoomed from nonexistent at the start of the study to 60% compliance within 6 months and 100% of practices complying after 5 years. Use of the antinausea drug aprepitant (Emend) improved from 20% of practices to 60%.

Clinicians were quick to adopt two clinical practices that were introduced during the study period. Genetic testing to predict response to treatment in patients with metastatic colorectal cancer increased from just over 60% of practices to more than 80%. Testing for KRAS gene alterations when administering anti–epidermal growth factor receptor therapy increased from approximately 55% to approximately 85% of practices.

Throughout the study, close to 90% or more of physicians reported recommendations for adjuvant chemotherapy that concorded with guidelines. "On many adjuvant treatment measures, it appears that QOPI participants are already doing very well," Dr. Neuss said.

In the areas of smoking and fertility, however, practices were resistant to change despite strong evidence promoting specific care. Although physicians documented patients’ smoking status 90%-95% of the time, rates of smoking cessation counseling topped out at about 35%.

"Similarly, there’s a good reason to tell people who may be rendered infertile by chemotherapy of this problem and of potential solutions to it," but no more than 30% of patients got discussions of infertility risks and only approximately 15% heard about fertility preservation options, Dr. Neuss said.

Data came from a larger cohort of approximately 2,000 physicians in 308 practices (comprising 15%-20% of U.S. oncologists) who participated in QOPI beta testing from 2006-2010. Twice yearly, physicians reviewed patients’ charts and filed a structured online report on an average of 100 preidentified measures that the QOPI uses to assess quality of care. Within 2 weeks, the practice would receive a report from QOPI on how the practice’s rates of compliance with recommended care compared with the ideal, rates for all practices in QOPI, and rates for practices similar to their own.

"It’s entirely up to you how you act on that result or ignore it," he said.

Each practice provided at least two rounds of data (averaging six rounds) and reported on 30 or more patients per round. The analysis looked at 50 measures of quality that did not change during the study period in seven modules – core quality measures, symptom management, end-of-life care, non-Hodgkin’s lymphoma, breast cancer, colorectal cancer, and non–small cell lung cancer.

The study excluded practices that did not provide a full data set, were located outside the United States, or that presented trainee data. The investigators developed a logistic regression model to accommodate varied performance at the start of QOPI, which normalized performance among groups and allowed assessment of each practice’s improvement.

QOPI has moved beyond beta testing and now includes more than 800 registered oncology practices participating, he said.

Dr. Neuss reported having no financial disclosures.

SAN FRANCISCO – Attention-retraining therapy works in adolescents with anxiety disorders, the first randomized, controlled trial in this age group has found.

Previous studies of attention-retraining therapy all focused on adults. In this study of 42 adolescents with severe anxiety in a residential treatment program, standard treatment with 25 hours/week of cognitive-behavioral therapy (CBT) significantly improved symptom scores in a control group that got CBT plus a computerized placebo, but scores improved even more in patients randomized to CBT plus computerized attention-retraining therapy.

Scores improved on a broad measure of pediatric anxiety, the SCARED (Self-Report for Child Anxiety Related Emotional Disorder) checklist, from an average of 32 at admission to 21 at discharge in the CBT group and from 34 to 12 in the combination group, Bradley C. Riemann, Ph.D., and his associates reported at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Most patients in each group had a primary diagnosis of obsessive-compulsive disorder (OCD): 17 patients in the control group and 13 in the combination group. Scores improved on the CYBOCS-SR (Children’s Yale-Brown Obsessive Compulsive Scale–Self-Report) symptom checklist from 25 at admission to 12 at discharge in the CBT group and from 26 to 7 in the combination group, reported Dr. Riemann of Rogers Memorial Hospital, Oconomowoc, Wisc.

"What you see is enhancement effects," he said.

In more clinical terms, the CBT group went from scores in the severe range to the mild range. "So, CBT works," he said. In the combination group, patient scores went from the severe range to the "essentially subclinical" range.

This was a complex patient group with high levels of comorbidity and life disruption. Primary diagnoses included OCD, social anxiety disorder, generalized anxiety disorder, panic disorder, and anxiety disorder not otherwise specified. Comorbidities included major depression in a large proportion of patients, attention-deficit/hyperactivity disorder (ADHD), or eating disorders. Characteristics did not differ significantly between groups.

Patients averaged 15-16 years of age and stayed an average of 60-62 days in the residential program.

The attention-retraining group was asked to do the computerized therapy each weekday during "school" time, and patients ended up doing it about 3.5 days/week on average, he said.

The computer exercises presented a screen with a neutral face and a face showing disgust, followed by a screen with no faces but a "probe" where one of the faces had been (such as the letter E indicating that the patient should respond with a left-click of the mouse or the letter F indicating a right click for response). In the attention-retraining group, the probe always followed the neutral face. In the control group, the probe appeared 50% of the time behind each face.

"We weren’t targeting OCD, but keep in mind that there is an area of disgust that you see in OCD. Maybe this was hitting that target as well," Dr. Riemann said.

The attention retraining also seemed to have generalized effects in small subgroups with comorbid ADHD. The six patients with ADHD in the control group showed less improvement in their anxiety than control patients without ADHD, suggesting that the ADHD was interfering with the CBT. But in the combination therapy group, gains were not attenuated in the four patients with comorbid ADHD. The numbers are too small to make too much of this but suggest that perhaps attention-retraining therapy "may be something that could be applied to that even more complicated population" with anxiety and ADHD, he said.

The attention retraining is based on previous research showing that anxious individuals consistently focus their attention where they perceive potential threats, including a meta-analysis of 172 studies (Psychol. Bull. 2007;133:1-24).

At least two studies of single sessions of computerized attention retraining and three studies of multiple treatment sessions in adults have shown significant reductions in anxiety after treatment. The adult multiple-session studies typically involved twice-weekly sessions for 4 weeks, less frequent than in the adolescent trial.

Dr. Riemann reported having no financial disclosures.

SAN FRANCISCO – Attention-retraining therapy works in adolescents with anxiety disorders, the first randomized, controlled trial in this age group has found.

Previous studies of attention-retraining therapy all focused on adults. In this study of 42 adolescents with severe anxiety in a residential treatment program, standard treatment with 25 hours/week of cognitive-behavioral therapy (CBT) significantly improved symptom scores in a control group that got CBT plus a computerized placebo, but scores improved even more in patients randomized to CBT plus computerized attention-retraining therapy.

Scores improved on a broad measure of pediatric anxiety, the SCARED (Self-Report for Child Anxiety Related Emotional Disorder) checklist, from an average of 32 at admission to 21 at discharge in the CBT group and from 34 to 12 in the combination group, Bradley C. Riemann, Ph.D., and his associates reported at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Most patients in each group had a primary diagnosis of obsessive-compulsive disorder (OCD): 17 patients in the control group and 13 in the combination group. Scores improved on the CYBOCS-SR (Children’s Yale-Brown Obsessive Compulsive Scale–Self-Report) symptom checklist from 25 at admission to 12 at discharge in the CBT group and from 26 to 7 in the combination group, reported Dr. Riemann of Rogers Memorial Hospital, Oconomowoc, Wisc.

"What you see is enhancement effects," he said.

In more clinical terms, the CBT group went from scores in the severe range to the mild range. "So, CBT works," he said. In the combination group, patient scores went from the severe range to the "essentially subclinical" range.

This was a complex patient group with high levels of comorbidity and life disruption. Primary diagnoses included OCD, social anxiety disorder, generalized anxiety disorder, panic disorder, and anxiety disorder not otherwise specified. Comorbidities included major depression in a large proportion of patients, attention-deficit/hyperactivity disorder (ADHD), or eating disorders. Characteristics did not differ significantly between groups.

Patients averaged 15-16 years of age and stayed an average of 60-62 days in the residential program.

The attention-retraining group was asked to do the computerized therapy each weekday during "school" time, and patients ended up doing it about 3.5 days/week on average, he said.

The computer exercises presented a screen with a neutral face and a face showing disgust, followed by a screen with no faces but a "probe" where one of the faces had been (such as the letter E indicating that the patient should respond with a left-click of the mouse or the letter F indicating a right click for response). In the attention-retraining group, the probe always followed the neutral face. In the control group, the probe appeared 50% of the time behind each face.

"We weren’t targeting OCD, but keep in mind that there is an area of disgust that you see in OCD. Maybe this was hitting that target as well," Dr. Riemann said.

The attention retraining also seemed to have generalized effects in small subgroups with comorbid ADHD. The six patients with ADHD in the control group showed less improvement in their anxiety than control patients without ADHD, suggesting that the ADHD was interfering with the CBT. But in the combination therapy group, gains were not attenuated in the four patients with comorbid ADHD. The numbers are too small to make too much of this but suggest that perhaps attention-retraining therapy "may be something that could be applied to that even more complicated population" with anxiety and ADHD, he said.

The attention retraining is based on previous research showing that anxious individuals consistently focus their attention where they perceive potential threats, including a meta-analysis of 172 studies (Psychol. Bull. 2007;133:1-24).

At least two studies of single sessions of computerized attention retraining and three studies of multiple treatment sessions in adults have shown significant reductions in anxiety after treatment. The adult multiple-session studies typically involved twice-weekly sessions for 4 weeks, less frequent than in the adolescent trial.

Dr. Riemann reported having no financial disclosures.

SAN FRANCISCO – Attention-retraining therapy works in adolescents with anxiety disorders, the first randomized, controlled trial in this age group has found.

Previous studies of attention-retraining therapy all focused on adults. In this study of 42 adolescents with severe anxiety in a residential treatment program, standard treatment with 25 hours/week of cognitive-behavioral therapy (CBT) significantly improved symptom scores in a control group that got CBT plus a computerized placebo, but scores improved even more in patients randomized to CBT plus computerized attention-retraining therapy.

Scores improved on a broad measure of pediatric anxiety, the SCARED (Self-Report for Child Anxiety Related Emotional Disorder) checklist, from an average of 32 at admission to 21 at discharge in the CBT group and from 34 to 12 in the combination group, Bradley C. Riemann, Ph.D., and his associates reported at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Most patients in each group had a primary diagnosis of obsessive-compulsive disorder (OCD): 17 patients in the control group and 13 in the combination group. Scores improved on the CYBOCS-SR (Children’s Yale-Brown Obsessive Compulsive Scale–Self-Report) symptom checklist from 25 at admission to 12 at discharge in the CBT group and from 26 to 7 in the combination group, reported Dr. Riemann of Rogers Memorial Hospital, Oconomowoc, Wisc.

"What you see is enhancement effects," he said.

In more clinical terms, the CBT group went from scores in the severe range to the mild range. "So, CBT works," he said. In the combination group, patient scores went from the severe range to the "essentially subclinical" range.

This was a complex patient group with high levels of comorbidity and life disruption. Primary diagnoses included OCD, social anxiety disorder, generalized anxiety disorder, panic disorder, and anxiety disorder not otherwise specified. Comorbidities included major depression in a large proportion of patients, attention-deficit/hyperactivity disorder (ADHD), or eating disorders. Characteristics did not differ significantly between groups.

Patients averaged 15-16 years of age and stayed an average of 60-62 days in the residential program.

The attention-retraining group was asked to do the computerized therapy each weekday during "school" time, and patients ended up doing it about 3.5 days/week on average, he said.

The computer exercises presented a screen with a neutral face and a face showing disgust, followed by a screen with no faces but a "probe" where one of the faces had been (such as the letter E indicating that the patient should respond with a left-click of the mouse or the letter F indicating a right click for response). In the attention-retraining group, the probe always followed the neutral face. In the control group, the probe appeared 50% of the time behind each face.

"We weren’t targeting OCD, but keep in mind that there is an area of disgust that you see in OCD. Maybe this was hitting that target as well," Dr. Riemann said.

The attention retraining also seemed to have generalized effects in small subgroups with comorbid ADHD. The six patients with ADHD in the control group showed less improvement in their anxiety than control patients without ADHD, suggesting that the ADHD was interfering with the CBT. But in the combination therapy group, gains were not attenuated in the four patients with comorbid ADHD. The numbers are too small to make too much of this but suggest that perhaps attention-retraining therapy "may be something that could be applied to that even more complicated population" with anxiety and ADHD, he said.

The attention retraining is based on previous research showing that anxious individuals consistently focus their attention where they perceive potential threats, including a meta-analysis of 172 studies (Psychol. Bull. 2007;133:1-24).

At least two studies of single sessions of computerized attention retraining and three studies of multiple treatment sessions in adults have shown significant reductions in anxiety after treatment. The adult multiple-session studies typically involved twice-weekly sessions for 4 weeks, less frequent than in the adolescent trial.

Dr. Riemann reported having no financial disclosures.

Among breast cancer patients, women who worry the most that localized cancer in one breast will spread to the other breast are twice as likely to choose a prophylactic double mastectomy – even though most of them have no clinical indication for the procedure, a study of 1,446 patients showed.

Approximately 80% of the 107 women in the study who chose prophylactic double mastectomy had a very low risk for contralateral disease, Sarah T. Hawley, Ph.D., said in a press conference sponsored by the American Society of Clinical Oncology (ASCO).

She is slated to present the results at a symposium on quality care sponsored by the American Society of Clinical Oncology, taking place Nov. 30 to Dec. 1 in San Diego.

Many women undergo unnecessary surgery out of ungrounded fear that cancer in one breast will lead to cancer in the other, said Dr. Hawley of the division of general medicine at the University of Michigan, Ann Arbor.

Women’s worry about cancer spreading from one breast to the other "really shouldn’t be a reason to get that procedure," she said.

Contralateral prophylactic mastectomy can be considered if a patient is positive for BRCA1 or BRCA2 mutations or has a family history of breast or ovarian cancer in two or more first-degree relatives, according to Society of Surgical Oncology guidelines.

"Despite the small number of women who meet these criteria, rates of contralateral prophylactic mastectomy have been increasing in recent years," Dr. Hawley noted.

Those traditional indications still were powerful drivers in the study – a positive genetic test increased the odds of contralateral prophylactic mastectomy 10-fold, and a family history increased the odds 5-fold.

The doubling in odds of contralateral prophylactic mastectomy in women with a high level of worry (compared with low worry level) is notable because the prophylactic surgery has not been known to reduce the risk of recurrence when those indications are not present, as was the case with the majority of women who chose the procedure in the study.

Among women who chose contralateral prophylactic mastectomy, 90% reported high levels of worry, compared with 80% of the 564 women who underwent single-breast mastectomy, a statistically significant difference, Dr. Hawley reported.

She and her associates studied 1,446 newly diagnosed breast cancer patients who completed two surveys 4 years apart, had not had a recurrence during that time, and had complete data on genetic testing and family history. Contralateral prophylactic mastectomy was considered by 35% of the whole cohort and chosen by 7%. Among women who underwent mastectomy of the cancerous breast, 53% considered contralateral prophylactic mastectomy and 19% underwent the procedure.

When women were considering any mastectomy vs. breast conservation surgery, family history and genetic test results did not significantly affect the odds that they would choose any mastectomy, but their level of worry did. High levels of worry significantly increased the odds of mastectomy by 69% in a subanalysis that controlled for the effects of age, race or ethnicity, education, and cancer stage.

A separate subanalysis found that both clinical indications and worry affected the likelihood of contralateral prophylactic mastectomy compared with unilateral mastectomy. The odds of having the prophylactic surgery increased more than 4-fold with a family history of at least two primary relatives with breast cancer, more than 10-fold with a positive genetic test, and more than 2-fold with a high degree of worry in the multivariate analysis, Dr. Hawley said.

Compared with previous studies on why women are getting contralateral prophylactic mastectomy, the current study is larger; is population-based; contains racial and ethnic samples; and includes data on patient attitudes, genetic testing, and type of family history (not just any family history), she said.

Dr. Jyoti D. Patel, moderator of the press conference, said the findings suggest that "we, as physicians, may not be adequately educating our patients about the risk for recurrent disease."

In general, women with localized breast cancer in one breast have less than a 1% chance of developing a new cancer in the unaffected breast and an 8% chance of recurrence in the affected breast or a nearby lymph node. The risk for developing a new cancer in the contralateral breast rises to approximately 10%-15% if the patient has a history of breast or ovarian cancer in two or more primary relatives, with a similar or slightly greater increased risk from a positive genetic mutation, Dr. Patel estimated. Having both clinical risk factors confers a 10- to 20-fold increase in risk.

Unfortunately, many women overestimate their risk of developing breast cancer in the contralateral breast and undergo unnecessary surgery, she commented. This study suggests that physicians re-examine how they communicate with their patients regarding the decision to undergo prophylactic mastectomy.

"Many women fear recurrence, and they also fear surveillance. They worry about, if they’re 35 years old, what a lifetime of screening for the contralateral breast might look like if they end up getting multiple biopsies. So how we put that in perspective for our young population will become vitally important," said Dr. Patell, a thoracic oncologist at Northwestern University in Chicago and a member of ASCO’s Cancer Communications Committee.

Dr. Hawley reported having no financial disclosures.

Among breast cancer patients, women who worry the most that localized cancer in one breast will spread to the other breast are twice as likely to choose a prophylactic double mastectomy – even though most of them have no clinical indication for the procedure, a study of 1,446 patients showed.

Approximately 80% of the 107 women in the study who chose prophylactic double mastectomy had a very low risk for contralateral disease, Sarah T. Hawley, Ph.D., said in a press conference sponsored by the American Society of Clinical Oncology (ASCO).

She is slated to present the results at a symposium on quality care sponsored by the American Society of Clinical Oncology, taking place Nov. 30 to Dec. 1 in San Diego.

Many women undergo unnecessary surgery out of ungrounded fear that cancer in one breast will lead to cancer in the other, said Dr. Hawley of the division of general medicine at the University of Michigan, Ann Arbor.

Women’s worry about cancer spreading from one breast to the other "really shouldn’t be a reason to get that procedure," she said.

Contralateral prophylactic mastectomy can be considered if a patient is positive for BRCA1 or BRCA2 mutations or has a family history of breast or ovarian cancer in two or more first-degree relatives, according to Society of Surgical Oncology guidelines.

"Despite the small number of women who meet these criteria, rates of contralateral prophylactic mastectomy have been increasing in recent years," Dr. Hawley noted.

Those traditional indications still were powerful drivers in the study – a positive genetic test increased the odds of contralateral prophylactic mastectomy 10-fold, and a family history increased the odds 5-fold.

The doubling in odds of contralateral prophylactic mastectomy in women with a high level of worry (compared with low worry level) is notable because the prophylactic surgery has not been known to reduce the risk of recurrence when those indications are not present, as was the case with the majority of women who chose the procedure in the study.

Among women who chose contralateral prophylactic mastectomy, 90% reported high levels of worry, compared with 80% of the 564 women who underwent single-breast mastectomy, a statistically significant difference, Dr. Hawley reported.

She and her associates studied 1,446 newly diagnosed breast cancer patients who completed two surveys 4 years apart, had not had a recurrence during that time, and had complete data on genetic testing and family history. Contralateral prophylactic mastectomy was considered by 35% of the whole cohort and chosen by 7%. Among women who underwent mastectomy of the cancerous breast, 53% considered contralateral prophylactic mastectomy and 19% underwent the procedure.

When women were considering any mastectomy vs. breast conservation surgery, family history and genetic test results did not significantly affect the odds that they would choose any mastectomy, but their level of worry did. High levels of worry significantly increased the odds of mastectomy by 69% in a subanalysis that controlled for the effects of age, race or ethnicity, education, and cancer stage.

A separate subanalysis found that both clinical indications and worry affected the likelihood of contralateral prophylactic mastectomy compared with unilateral mastectomy. The odds of having the prophylactic surgery increased more than 4-fold with a family history of at least two primary relatives with breast cancer, more than 10-fold with a positive genetic test, and more than 2-fold with a high degree of worry in the multivariate analysis, Dr. Hawley said.

Compared with previous studies on why women are getting contralateral prophylactic mastectomy, the current study is larger; is population-based; contains racial and ethnic samples; and includes data on patient attitudes, genetic testing, and type of family history (not just any family history), she said.

Dr. Jyoti D. Patel, moderator of the press conference, said the findings suggest that "we, as physicians, may not be adequately educating our patients about the risk for recurrent disease."

In general, women with localized breast cancer in one breast have less than a 1% chance of developing a new cancer in the unaffected breast and an 8% chance of recurrence in the affected breast or a nearby lymph node. The risk for developing a new cancer in the contralateral breast rises to approximately 10%-15% if the patient has a history of breast or ovarian cancer in two or more primary relatives, with a similar or slightly greater increased risk from a positive genetic mutation, Dr. Patel estimated. Having both clinical risk factors confers a 10- to 20-fold increase in risk.

Unfortunately, many women overestimate their risk of developing breast cancer in the contralateral breast and undergo unnecessary surgery, she commented. This study suggests that physicians re-examine how they communicate with their patients regarding the decision to undergo prophylactic mastectomy.

"Many women fear recurrence, and they also fear surveillance. They worry about, if they’re 35 years old, what a lifetime of screening for the contralateral breast might look like if they end up getting multiple biopsies. So how we put that in perspective for our young population will become vitally important," said Dr. Patell, a thoracic oncologist at Northwestern University in Chicago and a member of ASCO’s Cancer Communications Committee.

Dr. Hawley reported having no financial disclosures.

Among breast cancer patients, women who worry the most that localized cancer in one breast will spread to the other breast are twice as likely to choose a prophylactic double mastectomy – even though most of them have no clinical indication for the procedure, a study of 1,446 patients showed.

Approximately 80% of the 107 women in the study who chose prophylactic double mastectomy had a very low risk for contralateral disease, Sarah T. Hawley, Ph.D., said in a press conference sponsored by the American Society of Clinical Oncology (ASCO).

She is slated to present the results at a symposium on quality care sponsored by the American Society of Clinical Oncology, taking place Nov. 30 to Dec. 1 in San Diego.

Many women undergo unnecessary surgery out of ungrounded fear that cancer in one breast will lead to cancer in the other, said Dr. Hawley of the division of general medicine at the University of Michigan, Ann Arbor.

Women’s worry about cancer spreading from one breast to the other "really shouldn’t be a reason to get that procedure," she said.

Contralateral prophylactic mastectomy can be considered if a patient is positive for BRCA1 or BRCA2 mutations or has a family history of breast or ovarian cancer in two or more first-degree relatives, according to Society of Surgical Oncology guidelines.

"Despite the small number of women who meet these criteria, rates of contralateral prophylactic mastectomy have been increasing in recent years," Dr. Hawley noted.

Those traditional indications still were powerful drivers in the study – a positive genetic test increased the odds of contralateral prophylactic mastectomy 10-fold, and a family history increased the odds 5-fold.

The doubling in odds of contralateral prophylactic mastectomy in women with a high level of worry (compared with low worry level) is notable because the prophylactic surgery has not been known to reduce the risk of recurrence when those indications are not present, as was the case with the majority of women who chose the procedure in the study.

Among women who chose contralateral prophylactic mastectomy, 90% reported high levels of worry, compared with 80% of the 564 women who underwent single-breast mastectomy, a statistically significant difference, Dr. Hawley reported.

She and her associates studied 1,446 newly diagnosed breast cancer patients who completed two surveys 4 years apart, had not had a recurrence during that time, and had complete data on genetic testing and family history. Contralateral prophylactic mastectomy was considered by 35% of the whole cohort and chosen by 7%. Among women who underwent mastectomy of the cancerous breast, 53% considered contralateral prophylactic mastectomy and 19% underwent the procedure.

When women were considering any mastectomy vs. breast conservation surgery, family history and genetic test results did not significantly affect the odds that they would choose any mastectomy, but their level of worry did. High levels of worry significantly increased the odds of mastectomy by 69% in a subanalysis that controlled for the effects of age, race or ethnicity, education, and cancer stage.

A separate subanalysis found that both clinical indications and worry affected the likelihood of contralateral prophylactic mastectomy compared with unilateral mastectomy. The odds of having the prophylactic surgery increased more than 4-fold with a family history of at least two primary relatives with breast cancer, more than 10-fold with a positive genetic test, and more than 2-fold with a high degree of worry in the multivariate analysis, Dr. Hawley said.

Compared with previous studies on why women are getting contralateral prophylactic mastectomy, the current study is larger; is population-based; contains racial and ethnic samples; and includes data on patient attitudes, genetic testing, and type of family history (not just any family history), she said.

Dr. Jyoti D. Patel, moderator of the press conference, said the findings suggest that "we, as physicians, may not be adequately educating our patients about the risk for recurrent disease."

In general, women with localized breast cancer in one breast have less than a 1% chance of developing a new cancer in the unaffected breast and an 8% chance of recurrence in the affected breast or a nearby lymph node. The risk for developing a new cancer in the contralateral breast rises to approximately 10%-15% if the patient has a history of breast or ovarian cancer in two or more primary relatives, with a similar or slightly greater increased risk from a positive genetic mutation, Dr. Patel estimated. Having both clinical risk factors confers a 10- to 20-fold increase in risk.

Unfortunately, many women overestimate their risk of developing breast cancer in the contralateral breast and undergo unnecessary surgery, she commented. This study suggests that physicians re-examine how they communicate with their patients regarding the decision to undergo prophylactic mastectomy.

"Many women fear recurrence, and they also fear surveillance. They worry about, if they’re 35 years old, what a lifetime of screening for the contralateral breast might look like if they end up getting multiple biopsies. So how we put that in perspective for our young population will become vitally important," said Dr. Patell, a thoracic oncologist at Northwestern University in Chicago and a member of ASCO’s Cancer Communications Committee.

Dr. Hawley reported having no financial disclosures.

SAN FRANCISCO – An innovative family-focused treatment program for complex cases of pediatric obsessive-compulsive disorder that looked promising in a randomized, controlled pilot trial of 20 families has now accumulated experience with 35 families.

"We’re getting increasingly confident that we may have something here," Tara S. Peris, Ph.D., said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

A larger study is being planned of the adjunctive positive family interaction therapy (PFIT), which families in the prospective pilot study seemed to embrace. The study recruited families based on a primary diagnosis of pediatric obsessive-compulsive disorder (OCD) and an assessment of poor family functioning, and then randomized them to receive six sessions of standard therapy with individual child cognitive-behavioral therapy (CBT) or to standard therapy plus PFIT.

Seven of 10 patients in the PFIT group and 4 of 10 in the control group responded after six treatment sessions, as assessed on the Clinical Global Impressions of Improvement (CGI-I) scale by blinded raters. The 40% response rate in the control group "parallels what’s in other studies," noted Dr. Peris of the Semel Institute for Neuroscience and Human Behavior at the University of California, Los Angeles.

On the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS) of symptom severity, 5 of 10 patients in the PFIT group achieved remission, compared with 2 of 10 in the control group, reported Dr. Peris and her colleague at the institute, John Piacentini, Ph.D. (J. Clin. Child. Adolesc. Psychol. 2012 [doi: 10.1080/15374416.2012.673162]).

No families dropped out of the study, and 16 of the 20 families completed 3 months of follow-up. Youths in both groups maintained any gains at the 3-month follow-up. In the PFIT group, mothers and fathers attended 95% of the family therapy sessions together, and among PFIT families with siblings of the youth with OCD, 6 brought a sibling to at least one session.

CBT alone is the front-line treatment for mild to moderate pediatric OCD, "but we’re not here to talk about those kids," Dr. Peris said. Previous studies have shown that 46%-79% of youths with OCD fail treatment with CBT, medication, or a combination of the two, depending on the treatment.

The study targeted treatment-resistant patients who also had dysfunctional families, which previous data identified as a predictor of poor response to CBT treatment for OCD.

Dr. Peris and her associates earlier identified three characteristics of dysfunctional families that interfere with a family’s ability to stop accommodating OCD symptoms: blame, family conflict, and poor family cohesion. These factors have an additive effect: only 14% of youths in families with all three factors responded to CBT, compared with 93% in families with none of these characteristics, Dr. Peris reported (J. Consult. Clin. Psychol. 2012;80:255-63).

"These features argue for some degree of family intervention in pediatric OCD treatment," she said.

PFIT aims to reduce hostility and blame, increase family cohesion, and reduce OCD accommodation to enhance the efficacy of exposure-based CBT. "None of this is meant to blame parents or families. They’re doing their best. We try to give them better ways to cope," she said.

Previous family interventions tended to rely on psychoeducation, with limited success in changing family dynamics, she noted. PFIT provides psychoeducation but also focuses on increasing parental self-efficacy (the sense that one is able to produce and regulate events in one’s life), providing parents with skills training in emotion regulation (including calm disengagement from challenging OCD episodes), and improving parenting skills such as scaffolding (recognizing the level of skill the child has mastered, and thinking of one level beyond that).

PFIT also addresses broader family dynamics, including reducing criticism, promoting positive problem-solving as a family, increasing cohesion, and creating a common language for communicating about OCD symptoms.

In the study, mothers in the PFIT group reported significantly lower levels of blame at week 24, compared with mothers in the control group. The PFIT families showed significant decreases in accommodation, blame, and family conflict, Dr. Peris reported.

"PFIT may be a better strategy than standard CBT for complex cases of OCD," she said.

Dr. Peris reported having no financial disclosures.

SAN FRANCISCO – An innovative family-focused treatment program for complex cases of pediatric obsessive-compulsive disorder that looked promising in a randomized, controlled pilot trial of 20 families has now accumulated experience with 35 families.

"We’re getting increasingly confident that we may have something here," Tara S. Peris, Ph.D., said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

A larger study is being planned of the adjunctive positive family interaction therapy (PFIT), which families in the prospective pilot study seemed to embrace. The study recruited families based on a primary diagnosis of pediatric obsessive-compulsive disorder (OCD) and an assessment of poor family functioning, and then randomized them to receive six sessions of standard therapy with individual child cognitive-behavioral therapy (CBT) or to standard therapy plus PFIT.

Seven of 10 patients in the PFIT group and 4 of 10 in the control group responded after six treatment sessions, as assessed on the Clinical Global Impressions of Improvement (CGI-I) scale by blinded raters. The 40% response rate in the control group "parallels what’s in other studies," noted Dr. Peris of the Semel Institute for Neuroscience and Human Behavior at the University of California, Los Angeles.

On the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS) of symptom severity, 5 of 10 patients in the PFIT group achieved remission, compared with 2 of 10 in the control group, reported Dr. Peris and her colleague at the institute, John Piacentini, Ph.D. (J. Clin. Child. Adolesc. Psychol. 2012 [doi: 10.1080/15374416.2012.673162]).

No families dropped out of the study, and 16 of the 20 families completed 3 months of follow-up. Youths in both groups maintained any gains at the 3-month follow-up. In the PFIT group, mothers and fathers attended 95% of the family therapy sessions together, and among PFIT families with siblings of the youth with OCD, 6 brought a sibling to at least one session.

CBT alone is the front-line treatment for mild to moderate pediatric OCD, "but we’re not here to talk about those kids," Dr. Peris said. Previous studies have shown that 46%-79% of youths with OCD fail treatment with CBT, medication, or a combination of the two, depending on the treatment.

The study targeted treatment-resistant patients who also had dysfunctional families, which previous data identified as a predictor of poor response to CBT treatment for OCD.

Dr. Peris and her associates earlier identified three characteristics of dysfunctional families that interfere with a family’s ability to stop accommodating OCD symptoms: blame, family conflict, and poor family cohesion. These factors have an additive effect: only 14% of youths in families with all three factors responded to CBT, compared with 93% in families with none of these characteristics, Dr. Peris reported (J. Consult. Clin. Psychol. 2012;80:255-63).

"These features argue for some degree of family intervention in pediatric OCD treatment," she said.

PFIT aims to reduce hostility and blame, increase family cohesion, and reduce OCD accommodation to enhance the efficacy of exposure-based CBT. "None of this is meant to blame parents or families. They’re doing their best. We try to give them better ways to cope," she said.

Previous family interventions tended to rely on psychoeducation, with limited success in changing family dynamics, she noted. PFIT provides psychoeducation but also focuses on increasing parental self-efficacy (the sense that one is able to produce and regulate events in one’s life), providing parents with skills training in emotion regulation (including calm disengagement from challenging OCD episodes), and improving parenting skills such as scaffolding (recognizing the level of skill the child has mastered, and thinking of one level beyond that).

PFIT also addresses broader family dynamics, including reducing criticism, promoting positive problem-solving as a family, increasing cohesion, and creating a common language for communicating about OCD symptoms.

In the study, mothers in the PFIT group reported significantly lower levels of blame at week 24, compared with mothers in the control group. The PFIT families showed significant decreases in accommodation, blame, and family conflict, Dr. Peris reported.

"PFIT may be a better strategy than standard CBT for complex cases of OCD," she said.

Dr. Peris reported having no financial disclosures.

SAN FRANCISCO – An innovative family-focused treatment program for complex cases of pediatric obsessive-compulsive disorder that looked promising in a randomized, controlled pilot trial of 20 families has now accumulated experience with 35 families.

"We’re getting increasingly confident that we may have something here," Tara S. Peris, Ph.D., said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

A larger study is being planned of the adjunctive positive family interaction therapy (PFIT), which families in the prospective pilot study seemed to embrace. The study recruited families based on a primary diagnosis of pediatric obsessive-compulsive disorder (OCD) and an assessment of poor family functioning, and then randomized them to receive six sessions of standard therapy with individual child cognitive-behavioral therapy (CBT) or to standard therapy plus PFIT.

Seven of 10 patients in the PFIT group and 4 of 10 in the control group responded after six treatment sessions, as assessed on the Clinical Global Impressions of Improvement (CGI-I) scale by blinded raters. The 40% response rate in the control group "parallels what’s in other studies," noted Dr. Peris of the Semel Institute for Neuroscience and Human Behavior at the University of California, Los Angeles.

On the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS) of symptom severity, 5 of 10 patients in the PFIT group achieved remission, compared with 2 of 10 in the control group, reported Dr. Peris and her colleague at the institute, John Piacentini, Ph.D. (J. Clin. Child. Adolesc. Psychol. 2012 [doi: 10.1080/15374416.2012.673162]).

No families dropped out of the study, and 16 of the 20 families completed 3 months of follow-up. Youths in both groups maintained any gains at the 3-month follow-up. In the PFIT group, mothers and fathers attended 95% of the family therapy sessions together, and among PFIT families with siblings of the youth with OCD, 6 brought a sibling to at least one session.

CBT alone is the front-line treatment for mild to moderate pediatric OCD, "but we’re not here to talk about those kids," Dr. Peris said. Previous studies have shown that 46%-79% of youths with OCD fail treatment with CBT, medication, or a combination of the two, depending on the treatment.

The study targeted treatment-resistant patients who also had dysfunctional families, which previous data identified as a predictor of poor response to CBT treatment for OCD.

Dr. Peris and her associates earlier identified three characteristics of dysfunctional families that interfere with a family’s ability to stop accommodating OCD symptoms: blame, family conflict, and poor family cohesion. These factors have an additive effect: only 14% of youths in families with all three factors responded to CBT, compared with 93% in families with none of these characteristics, Dr. Peris reported (J. Consult. Clin. Psychol. 2012;80:255-63).

"These features argue for some degree of family intervention in pediatric OCD treatment," she said.

PFIT aims to reduce hostility and blame, increase family cohesion, and reduce OCD accommodation to enhance the efficacy of exposure-based CBT. "None of this is meant to blame parents or families. They’re doing their best. We try to give them better ways to cope," she said.

Previous family interventions tended to rely on psychoeducation, with limited success in changing family dynamics, she noted. PFIT provides psychoeducation but also focuses on increasing parental self-efficacy (the sense that one is able to produce and regulate events in one’s life), providing parents with skills training in emotion regulation (including calm disengagement from challenging OCD episodes), and improving parenting skills such as scaffolding (recognizing the level of skill the child has mastered, and thinking of one level beyond that).

PFIT also addresses broader family dynamics, including reducing criticism, promoting positive problem-solving as a family, increasing cohesion, and creating a common language for communicating about OCD symptoms.

In the study, mothers in the PFIT group reported significantly lower levels of blame at week 24, compared with mothers in the control group. The PFIT families showed significant decreases in accommodation, blame, and family conflict, Dr. Peris reported.

"PFIT may be a better strategy than standard CBT for complex cases of OCD," she said.

Dr. Peris reported having no financial disclosures.

DENVER – Most rashes and other skin conditions are not worrisome, but a few are signs of potentially fatal infections or disease processes.

Recognizing and knowing how best to treat these "death rashes" literally make the difference between life and death, Dr. Heather Murphy-Lavoie said at the annual meeting of the American College of Emergency Physicians.

Courtesy Dr. Heather Murphy-Lavoie

"You don’t want to miss it. You want to make the diagnosis early and use specific interventions that reduce morbidity and mortality," said Dr. Murphy-Lavoie of Louisiana State University, New Orleans.

She co-created a free app for iPhones and iPads colloquially called "EM Rashes" to help emergency physicians who might be puzzled by a patient with an undifferentiated rash. The app user picks from a selection of rash types, then answers a series of simple questions, such as, "Is the patient febrile?" The app then uses an algorithm to narrow the differential diagnoses, discuss possible causes and findings, and list treatments.

Dr. Murphy-Lavoie offered the following pearls for physicians who are thinking about rashes.

Petechiae and fever? Worry! Only about 50% of people with Rocky Mountain spotted fever will recall a tick bite, so you have to be suspecting it if you’re in an appropriate geographic area. Patients get febrile and toxic. The rash starts out on the wrist and ankle as a maculopapular rash and then spreads and becomes petechial.

"The tip-off is that it spreads to the palms and the soles," she said. "It’s a vasculitis, so it’s a palpable petechiae."

Rocky Mountain spotted fever is a bit of a misnomer, because the disease occurs largely in central and eastern states like North Carolina, Georgia, Tennessee, and Arkansas.

"This is a clinical diagnosis," she said. Don’t wait the 4-5 days it takes to get serology results from a laboratory to decide on treatment. Up to 15% of people with Rocky Mountain spotted fever may develop permanent neurologic deficits. Treatment with doxycycline reduces the risk of death from 30% to 5%. In pregnant women consider chloramphenicol instead of doxycycline, she suggested.

Palpable petechiae, vasculitis could mean infection. A patient with fever, mental status changes, vasculitis, and palpable petechiae should scare you, Dr. Murphy-Lavoie said. This could be meningococcemia, which carries a 3%-50% mortality rate depending on the promptness of treatment. Over the last 10 years in the United States, the mortality has hovered around 13%, she said.

Courtesy Dr. Heather Murphy-Lavoie

Ceftriaxone is the drug of choice. "Because of diagnostic uncertainty, any time you have a suspected case of bacterial meningitis, you’re going to add on vancomycin to cover resistant Streptococcus," and dexamethasone has been shown to decrease neurologic sequelae, she said. People exposed to a patient with this disease should get prophylactic therapy

Palpable petechiae also are a feature of many types of bacteremia. Petechiae are the most common skin manifestation of bacterial endocarditis, but it’s only present in 20%-40% of cases. When you suspect bacterial endocarditis, get three sets of blood cultures because nailing down the type of bacteria will inform the long-term treatment strategy. Treat initially with broad-spectrum IV antibiotics such as vancomycin and gentamicin to cover methicillin-resistant Staphylococcus aureus (MRSA).

"If you have a S. aureus–related endocarditis, your mortality is almost double that of a streptococcal endocarditis, so you really, really have to make sure that you’re covering for MRSA," she said.

Nonpalpable petechiae = thrombocytopenia. "If petechiae are not palpable, it’s thrombocytopenia unless proven otherwise," Dr. Murphy-Lavoie said.

A febrile, tachycardic woman came to her emergency room complaining of a rash on both legs comprising diffuse, nonpalpable petechiae. She appeared generally ill, had no past medical or medication history of note, and had a very low platelet count. "You should be scared to death if you get this patient in your ER," because she had thrombotic thrombocytopenia purpura (TTP).

More than 90% of patients will die if TTP is not treated with plasmapheresis (also called exchange transfusion), which reduces the mortality risk to 10%. If this treatment is not available at your institution, transfer the patient, she said. Manage the patient in the ICU, and treat the underlying cause of the TTP. Do not give platelets to patients with TTP, which will trigger increased end-organ damage, she warned.

Hemorrhagic bullae? Ominous! "Nothing good causes hemorrhagic bullae," Dr. Murphy-Lavoie said.

Anything that can cause disseminated intravascular coagulation can cause purpura fulminans, which may present with hemorrhagic bullae, rapid hemorrhagic skin necrosis, ecchymosis, purpura, fever, shock, multiorgan failure, and bleeding from multiple sites.

Lab results will show thrombocytopenia, hemolytic anemia, increases in prothrombin time and partial thromboplastin time, and an increase in fibrin degradation products. As the disease progresses, the fibrinogen level falls.

Treatment starts off similar to treating TTP, with an emergent consultation with hematology/oncology, ICU admission, and treatment of the underlying illness. Add supporting vitamin K and folate. "Then it gets tricky," she said. "You’re going to need to balance how much of their problem is from bleeding and not enough coagulation factors and platelets, and how much is from overactivation of the fibrinolytic system and bleeding, and whether or not you need heparin to treat their thrombus. You really don’t want to be doing this in your emergency department."

Hemorrhagic bullae also are a classic presentation of necrotizing fasciitis, along with pain out of proportion for typical cellulitis, systemic toxicity, crepitus, and rapid spread along fascial planes. Not all cases of necrotizing fasciitis will have hemorrhagic bullae, but worry if you see this, she said.

Treat with strategic debridement and broad-spectrum antibiotics. Studies have shown that adding hyperbaric oxygen therapy decreases mortality risk. It’s not worth transferring someone with necrotizing fasciitis to someplace hours away in order to get hyperbaric oxygen, but if this is available, "please use it," she urged. In the literature, mortality rates with necrotizing fasciitis range from 0% to 75%. "Guess which ones had 0% mortality patients who got hyperbaric oxygen."

Consider steroids for bullous rash with mucosal involvement. A woman came to Dr. Murphy-Lavoie’s emergency department complaining of a rash and pain with swallowing. She appeared moderately toxic, was tachycardic, had a bullous rash, and had dry mucous membranes but with oral lesions. Diagnosis: pemphigus vulgaris, which will involve mucosal surfaces 70% of the time.

The bullae may coalesce, and there may be a positive Nikolsky sign (sloughing of full-thickness skin with lateral pressure) and a positive Asboe-Hansen sign (light lateral pressure on the blister edge spreads the blister into adjacent clinically normal skin).

The biggest favor that emergency physicians can do for these patients is to start them on steroids. Before the advent of steroid therapy for pemphigus vulgaris, 50%-90% of patients died, compared with 4%-15% who are treated with steroids. Also provide local wound care to prevent secondary infection. Pemphigus vulgaris is associated with autoimmune diseases, and long-term management with immunosuppressive drugs probably will be handled by a rheumatologist, she said.

Dr. Murphy-Lavoie reported having no financial disclosures. She codeveloped the free app "EM Rashes."

DENVER – Most rashes and other skin conditions are not worrisome, but a few are signs of potentially fatal infections or disease processes.

Recognizing and knowing how best to treat these "death rashes" literally make the difference between life and death, Dr. Heather Murphy-Lavoie said at the annual meeting of the American College of Emergency Physicians.

Courtesy Dr. Heather Murphy-Lavoie

"You don’t want to miss it. You want to make the diagnosis early and use specific interventions that reduce morbidity and mortality," said Dr. Murphy-Lavoie of Louisiana State University, New Orleans.

She co-created a free app for iPhones and iPads colloquially called "EM Rashes" to help emergency physicians who might be puzzled by a patient with an undifferentiated rash. The app user picks from a selection of rash types, then answers a series of simple questions, such as, "Is the patient febrile?" The app then uses an algorithm to narrow the differential diagnoses, discuss possible causes and findings, and list treatments.

Dr. Murphy-Lavoie offered the following pearls for physicians who are thinking about rashes.

Petechiae and fever? Worry! Only about 50% of people with Rocky Mountain spotted fever will recall a tick bite, so you have to be suspecting it if you’re in an appropriate geographic area. Patients get febrile and toxic. The rash starts out on the wrist and ankle as a maculopapular rash and then spreads and becomes petechial.

"The tip-off is that it spreads to the palms and the soles," she said. "It’s a vasculitis, so it’s a palpable petechiae."

Rocky Mountain spotted fever is a bit of a misnomer, because the disease occurs largely in central and eastern states like North Carolina, Georgia, Tennessee, and Arkansas.

"This is a clinical diagnosis," she said. Don’t wait the 4-5 days it takes to get serology results from a laboratory to decide on treatment. Up to 15% of people with Rocky Mountain spotted fever may develop permanent neurologic deficits. Treatment with doxycycline reduces the risk of death from 30% to 5%. In pregnant women consider chloramphenicol instead of doxycycline, she suggested.

Palpable petechiae, vasculitis could mean infection. A patient with fever, mental status changes, vasculitis, and palpable petechiae should scare you, Dr. Murphy-Lavoie said. This could be meningococcemia, which carries a 3%-50% mortality rate depending on the promptness of treatment. Over the last 10 years in the United States, the mortality has hovered around 13%, she said.

Courtesy Dr. Heather Murphy-Lavoie

Ceftriaxone is the drug of choice. "Because of diagnostic uncertainty, any time you have a suspected case of bacterial meningitis, you’re going to add on vancomycin to cover resistant Streptococcus," and dexamethasone has been shown to decrease neurologic sequelae, she said. People exposed to a patient with this disease should get prophylactic therapy

Palpable petechiae also are a feature of many types of bacteremia. Petechiae are the most common skin manifestation of bacterial endocarditis, but it’s only present in 20%-40% of cases. When you suspect bacterial endocarditis, get three sets of blood cultures because nailing down the type of bacteria will inform the long-term treatment strategy. Treat initially with broad-spectrum IV antibiotics such as vancomycin and gentamicin to cover methicillin-resistant Staphylococcus aureus (MRSA).

"If you have a S. aureus–related endocarditis, your mortality is almost double that of a streptococcal endocarditis, so you really, really have to make sure that you’re covering for MRSA," she said.

Nonpalpable petechiae = thrombocytopenia. "If petechiae are not palpable, it’s thrombocytopenia unless proven otherwise," Dr. Murphy-Lavoie said.

A febrile, tachycardic woman came to her emergency room complaining of a rash on both legs comprising diffuse, nonpalpable petechiae. She appeared generally ill, had no past medical or medication history of note, and had a very low platelet count. "You should be scared to death if you get this patient in your ER," because she had thrombotic thrombocytopenia purpura (TTP).

More than 90% of patients will die if TTP is not treated with plasmapheresis (also called exchange transfusion), which reduces the mortality risk to 10%. If this treatment is not available at your institution, transfer the patient, she said. Manage the patient in the ICU, and treat the underlying cause of the TTP. Do not give platelets to patients with TTP, which will trigger increased end-organ damage, she warned.

Hemorrhagic bullae? Ominous! "Nothing good causes hemorrhagic bullae," Dr. Murphy-Lavoie said.

Anything that can cause disseminated intravascular coagulation can cause purpura fulminans, which may present with hemorrhagic bullae, rapid hemorrhagic skin necrosis, ecchymosis, purpura, fever, shock, multiorgan failure, and bleeding from multiple sites.

Lab results will show thrombocytopenia, hemolytic anemia, increases in prothrombin time and partial thromboplastin time, and an increase in fibrin degradation products. As the disease progresses, the fibrinogen level falls.

Treatment starts off similar to treating TTP, with an emergent consultation with hematology/oncology, ICU admission, and treatment of the underlying illness. Add supporting vitamin K and folate. "Then it gets tricky," she said. "You’re going to need to balance how much of their problem is from bleeding and not enough coagulation factors and platelets, and how much is from overactivation of the fibrinolytic system and bleeding, and whether or not you need heparin to treat their thrombus. You really don’t want to be doing this in your emergency department."

Hemorrhagic bullae also are a classic presentation of necrotizing fasciitis, along with pain out of proportion for typical cellulitis, systemic toxicity, crepitus, and rapid spread along fascial planes. Not all cases of necrotizing fasciitis will have hemorrhagic bullae, but worry if you see this, she said.

Treat with strategic debridement and broad-spectrum antibiotics. Studies have shown that adding hyperbaric oxygen therapy decreases mortality risk. It’s not worth transferring someone with necrotizing fasciitis to someplace hours away in order to get hyperbaric oxygen, but if this is available, "please use it," she urged. In the literature, mortality rates with necrotizing fasciitis range from 0% to 75%. "Guess which ones had 0% mortality patients who got hyperbaric oxygen."

Consider steroids for bullous rash with mucosal involvement. A woman came to Dr. Murphy-Lavoie’s emergency department complaining of a rash and pain with swallowing. She appeared moderately toxic, was tachycardic, had a bullous rash, and had dry mucous membranes but with oral lesions. Diagnosis: pemphigus vulgaris, which will involve mucosal surfaces 70% of the time.

The bullae may coalesce, and there may be a positive Nikolsky sign (sloughing of full-thickness skin with lateral pressure) and a positive Asboe-Hansen sign (light lateral pressure on the blister edge spreads the blister into adjacent clinically normal skin).

The biggest favor that emergency physicians can do for these patients is to start them on steroids. Before the advent of steroid therapy for pemphigus vulgaris, 50%-90% of patients died, compared with 4%-15% who are treated with steroids. Also provide local wound care to prevent secondary infection. Pemphigus vulgaris is associated with autoimmune diseases, and long-term management with immunosuppressive drugs probably will be handled by a rheumatologist, she said.

Dr. Murphy-Lavoie reported having no financial disclosures. She codeveloped the free app "EM Rashes."

DENVER – Most rashes and other skin conditions are not worrisome, but a few are signs of potentially fatal infections or disease processes.

Recognizing and knowing how best to treat these "death rashes" literally make the difference between life and death, Dr. Heather Murphy-Lavoie said at the annual meeting of the American College of Emergency Physicians.

Courtesy Dr. Heather Murphy-Lavoie

"You don’t want to miss it. You want to make the diagnosis early and use specific interventions that reduce morbidity and mortality," said Dr. Murphy-Lavoie of Louisiana State University, New Orleans.

She co-created a free app for iPhones and iPads colloquially called "EM Rashes" to help emergency physicians who might be puzzled by a patient with an undifferentiated rash. The app user picks from a selection of rash types, then answers a series of simple questions, such as, "Is the patient febrile?" The app then uses an algorithm to narrow the differential diagnoses, discuss possible causes and findings, and list treatments.

Dr. Murphy-Lavoie offered the following pearls for physicians who are thinking about rashes.

Petechiae and fever? Worry! Only about 50% of people with Rocky Mountain spotted fever will recall a tick bite, so you have to be suspecting it if you’re in an appropriate geographic area. Patients get febrile and toxic. The rash starts out on the wrist and ankle as a maculopapular rash and then spreads and becomes petechial.

"The tip-off is that it spreads to the palms and the soles," she said. "It’s a vasculitis, so it’s a palpable petechiae."

Rocky Mountain spotted fever is a bit of a misnomer, because the disease occurs largely in central and eastern states like North Carolina, Georgia, Tennessee, and Arkansas.

"This is a clinical diagnosis," she said. Don’t wait the 4-5 days it takes to get serology results from a laboratory to decide on treatment. Up to 15% of people with Rocky Mountain spotted fever may develop permanent neurologic deficits. Treatment with doxycycline reduces the risk of death from 30% to 5%. In pregnant women consider chloramphenicol instead of doxycycline, she suggested.

Palpable petechiae, vasculitis could mean infection. A patient with fever, mental status changes, vasculitis, and palpable petechiae should scare you, Dr. Murphy-Lavoie said. This could be meningococcemia, which carries a 3%-50% mortality rate depending on the promptness of treatment. Over the last 10 years in the United States, the mortality has hovered around 13%, she said.

Courtesy Dr. Heather Murphy-Lavoie

Ceftriaxone is the drug of choice. "Because of diagnostic uncertainty, any time you have a suspected case of bacterial meningitis, you’re going to add on vancomycin to cover resistant Streptococcus," and dexamethasone has been shown to decrease neurologic sequelae, she said. People exposed to a patient with this disease should get prophylactic therapy

Palpable petechiae also are a feature of many types of bacteremia. Petechiae are the most common skin manifestation of bacterial endocarditis, but it’s only present in 20%-40% of cases. When you suspect bacterial endocarditis, get three sets of blood cultures because nailing down the type of bacteria will inform the long-term treatment strategy. Treat initially with broad-spectrum IV antibiotics such as vancomycin and gentamicin to cover methicillin-resistant Staphylococcus aureus (MRSA).

"If you have a S. aureus–related endocarditis, your mortality is almost double that of a streptococcal endocarditis, so you really, really have to make sure that you’re covering for MRSA," she said.

Nonpalpable petechiae = thrombocytopenia. "If petechiae are not palpable, it’s thrombocytopenia unless proven otherwise," Dr. Murphy-Lavoie said.

A febrile, tachycardic woman came to her emergency room complaining of a rash on both legs comprising diffuse, nonpalpable petechiae. She appeared generally ill, had no past medical or medication history of note, and had a very low platelet count. "You should be scared to death if you get this patient in your ER," because she had thrombotic thrombocytopenia purpura (TTP).

More than 90% of patients will die if TTP is not treated with plasmapheresis (also called exchange transfusion), which reduces the mortality risk to 10%. If this treatment is not available at your institution, transfer the patient, she said. Manage the patient in the ICU, and treat the underlying cause of the TTP. Do not give platelets to patients with TTP, which will trigger increased end-organ damage, she warned.

Hemorrhagic bullae? Ominous! "Nothing good causes hemorrhagic bullae," Dr. Murphy-Lavoie said.

Anything that can cause disseminated intravascular coagulation can cause purpura fulminans, which may present with hemorrhagic bullae, rapid hemorrhagic skin necrosis, ecchymosis, purpura, fever, shock, multiorgan failure, and bleeding from multiple sites.

Lab results will show thrombocytopenia, hemolytic anemia, increases in prothrombin time and partial thromboplastin time, and an increase in fibrin degradation products. As the disease progresses, the fibrinogen level falls.

Treatment starts off similar to treating TTP, with an emergent consultation with hematology/oncology, ICU admission, and treatment of the underlying illness. Add supporting vitamin K and folate. "Then it gets tricky," she said. "You’re going to need to balance how much of their problem is from bleeding and not enough coagulation factors and platelets, and how much is from overactivation of the fibrinolytic system and bleeding, and whether or not you need heparin to treat their thrombus. You really don’t want to be doing this in your emergency department."

Hemorrhagic bullae also are a classic presentation of necrotizing fasciitis, along with pain out of proportion for typical cellulitis, systemic toxicity, crepitus, and rapid spread along fascial planes. Not all cases of necrotizing fasciitis will have hemorrhagic bullae, but worry if you see this, she said.

Treat with strategic debridement and broad-spectrum antibiotics. Studies have shown that adding hyperbaric oxygen therapy decreases mortality risk. It’s not worth transferring someone with necrotizing fasciitis to someplace hours away in order to get hyperbaric oxygen, but if this is available, "please use it," she urged. In the literature, mortality rates with necrotizing fasciitis range from 0% to 75%. "Guess which ones had 0% mortality patients who got hyperbaric oxygen."

Consider steroids for bullous rash with mucosal involvement. A woman came to Dr. Murphy-Lavoie’s emergency department complaining of a rash and pain with swallowing. She appeared moderately toxic, was tachycardic, had a bullous rash, and had dry mucous membranes but with oral lesions. Diagnosis: pemphigus vulgaris, which will involve mucosal surfaces 70% of the time.

The bullae may coalesce, and there may be a positive Nikolsky sign (sloughing of full-thickness skin with lateral pressure) and a positive Asboe-Hansen sign (light lateral pressure on the blister edge spreads the blister into adjacent clinically normal skin).

The biggest favor that emergency physicians can do for these patients is to start them on steroids. Before the advent of steroid therapy for pemphigus vulgaris, 50%-90% of patients died, compared with 4%-15% who are treated with steroids. Also provide local wound care to prevent secondary infection. Pemphigus vulgaris is associated with autoimmune diseases, and long-term management with immunosuppressive drugs probably will be handled by a rheumatologist, she said.

Dr. Murphy-Lavoie reported having no financial disclosures. She codeveloped the free app "EM Rashes."