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Register for the Vascular Annual Meeting Today
The 2018 Vascular Annual Meeting is less than a month away. Join colleagues and friends in Boston for this year’s VAM, June 20 to 23. Scientific sessions are June 21-23 and the Exhibit Hall is open June 21 to 22. Click here to register and here to obtain housing (the deadline for housing currently is today, May 22). To get a full schedule and begin creating your own personal agenda, complete with marking sessions as favorites, see the VAM Planner.
The 2018 Vascular Annual Meeting is less than a month away. Join colleagues and friends in Boston for this year’s VAM, June 20 to 23. Scientific sessions are June 21-23 and the Exhibit Hall is open June 21 to 22. Click here to register and here to obtain housing (the deadline for housing currently is today, May 22). To get a full schedule and begin creating your own personal agenda, complete with marking sessions as favorites, see the VAM Planner.
The 2018 Vascular Annual Meeting is less than a month away. Join colleagues and friends in Boston for this year’s VAM, June 20 to 23. Scientific sessions are June 21-23 and the Exhibit Hall is open June 21 to 22. Click here to register and here to obtain housing (the deadline for housing currently is today, May 22). To get a full schedule and begin creating your own personal agenda, complete with marking sessions as favorites, see the VAM Planner.
Trump proposes cutting Planned Parenthood funds
The planned revival of a policy dating to Ronald Reagan’s presidency may finally present a way for President Donald Trump to fulfill his campaign promise to “defund” Planned Parenthood. Or at least to evict it from the federal family planning program, where it provides care to more than 40% of that program’s 4 million patients.
The rules now under review, according to Trump administration officials, would require facilities receiving federal family planning funds to be physically separate from those that perform abortion; would eliminate the requirement that women with unintended pregnancies be counseled on their full range of reproductive options; and would ban abortion referrals.
All those changes would particularly affect Planned Parenthood.
Planned Parenthood, which provides a broad array of reproductive health services to women and men, also provides abortion services using nonfederal funds. Cutting off funding has been the top priority for anti-abortion groups, which supported candidate Trump.
“A win like this would immediately disentangle taxpayers from the abortion business and energize the grassroots as we head into the critical midterm elections,” Marjorie Dannenfelser, president of the anti-abortion Susan B. Anthony List, said in a statement.
In a conference call with reporters, Planned Parenthood officials said they would fight the new rules.
“We’ve been very clear, Planned Parenthood has an unwavering commitment to ensuring everyone has access to the full range of reproductive health care, and that includes abortion,” said Dawn Laguens, executive vice president of the Planned Parenthood Federation of America.
Here is a guide to what the proposal could do and what it could mean for Planned Parenthood and the family planning program:
What is Title X?
The federal family planning program, known as “Title Ten,” is named for its section in the federal Public Health Service Act. It became law in 1970, 3 years before the Supreme Court legalized abortion in Roe v Wade.
The original bill was sponsored by then Rep. George H.W. Bush (R-Texas) and signed into law by President Richard Nixon.
The program provides wellness exams and comprehensive contraceptive services, as well as screenings for cancer and sexually transmitted diseases for both women and men.
In 2016, the most recent year for which statistics have been published, Title X served 4 million patients at just under 4,000 sites.
Title X patients are overwhelmingly young, female, and low-income. An estimated 11% of Title X patients in 2016 were male; two-thirds of patients were under age 30; and nearly two-thirds had income below the federal poverty line.
What is Planned Parenthood’s relationship to Title X and Medicaid?
Planned Parenthood affiliates account for about 13% of total Title X sites but serve an estimated 40% of its patients. Only about half of Planned Parenthood affiliates perform abortions, although the organization in its entirety is the nation’s leading abortion provider.
Planned Parenthood also gets much more federal funding for services provided to patients on the Medicaid program (although not for abortion) than it does through Title X.
Eliminating Medicaid funding for Planned Parenthood has proved more difficult for lawmakers opposed to the organization because the federal Medicaid law includes the right for patients to select their providers. Changing that also would require a 60-vote majority in the Senate. So that particular line of funding is likely not at risk.
While opponents of federal funding for Planned Parenthood have said that other safety-net clinics could make up the difference if Planned Parenthood no longer participates in Title X, several studies have suggested that in many remote areas Planned Parenthood is the only provider of family planning services and the only provider that regularly stocks all methods of birth control.
Texas, Iowa, and Missouri in recent years have stopped offering family planning services through a special Medicaid program to keep from funding Planned Parenthood. Texas is seeking a waiver from the Trump administration so that its program banning abortion providers could still receive federal funding. No decision has been made yet, federal officials said.
Why is Planned Parenthood’s involvement with Title X controversial?
Even though Planned Parenthood cannot use federal funding for abortions, anti-abortion groups claim that federal funding is “fungible” and there is no way to ensure that some of the funding provided for other services does not cross-subsidize abortion services.
Planned Parenthood has also been a longtime public target for anti-abortion forces because it is such a visible provider and vocal proponent of legal abortion services.
In the early 1980s, the Reagan administration tried to separate the program from its federal funding by requiring parental permission for teens to obtain birth control. That was followed by efforts to eliminate abortion counseling.
Starting in 2011, undercover groups accused the organization of ignoring sex traffickers and selling fetal body parts in an effort to get the organization defunded. Planned Parenthood denies the allegations.
What happened the last time an administration tried to move Planned Parenthood out of Title X?
In 1987, the Reagan administration proposed what came to be known as the “gag rule.” Though the administration’s new proposal is not yet public, because the details are still under review by the Office of Management and Budget, the White House released a summary, saying the new rule will be similar although not identical to the Reagan-era proposal.
The original gag rule would have forbidden Title X providers from abortion counseling or referring patients for abortions, required physical separation of Title X and abortion-providing facilities and forbidden recipients from using nonfederal funds for lobbying, distributing information or in any way advocating or encouraging abortion. (The Planned Parenthood Federation of America, the umbrella group for local affiliates, has a separate political and advocacy arm, the Planned Parenthood Action Fund.)
Those rules were the subject of heated congressional debate through most of the George H.W. Bush administration and were upheld in a 5-4 Supreme Court ruling in 1991, Rust v Sullivan.
Even then, the gag rule did not go into effect because subsequent efforts to relax the rules somewhat to allow doctors (but not other health professionals) to counsel patients on the availability of abortion created another round of legal fights.
Eventually the rule was in effect for only about a month before it was again blocked by a U.S. appeals court. President Bill Clinton canceled the rules by executive order on his second day in office, and no other president tried to revive them until now.
How is the Trump administration’s proposal different from earlier rules?
According to the summary of the new proposal, released May 18, it will require physical separation of family planning and abortion facilities, repeal current counseling requirements, and ban abortion referrals.
One of the biggest differences, however, is that the new rules will not explicitly forbid abortion counseling by Title X providers.
But Planned Parenthood officials say that allowing counseling while banning referrals is a distinction without a difference.
Kashif Syed, a senior policy analyst for the organization said: “Blocking doctors from telling a patient where they can get safe and legal care in this country is the definition of a gag rule.”
What happens next?
All proposed rules are reviewed by the Office of Management and Budget. Sometimes they emerge and are published in a few days; sometimes they are rewritten, and it takes months.
Meanwhile, Planned Parenthood officials said they will not know if they will take legal action until they see the final language of the rule. But they say they do plan to use the regulatory process to fight the changes that have been made public so far.
KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation. Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
The planned revival of a policy dating to Ronald Reagan’s presidency may finally present a way for President Donald Trump to fulfill his campaign promise to “defund” Planned Parenthood. Or at least to evict it from the federal family planning program, where it provides care to more than 40% of that program’s 4 million patients.
The rules now under review, according to Trump administration officials, would require facilities receiving federal family planning funds to be physically separate from those that perform abortion; would eliminate the requirement that women with unintended pregnancies be counseled on their full range of reproductive options; and would ban abortion referrals.
All those changes would particularly affect Planned Parenthood.
Planned Parenthood, which provides a broad array of reproductive health services to women and men, also provides abortion services using nonfederal funds. Cutting off funding has been the top priority for anti-abortion groups, which supported candidate Trump.
“A win like this would immediately disentangle taxpayers from the abortion business and energize the grassroots as we head into the critical midterm elections,” Marjorie Dannenfelser, president of the anti-abortion Susan B. Anthony List, said in a statement.
In a conference call with reporters, Planned Parenthood officials said they would fight the new rules.
“We’ve been very clear, Planned Parenthood has an unwavering commitment to ensuring everyone has access to the full range of reproductive health care, and that includes abortion,” said Dawn Laguens, executive vice president of the Planned Parenthood Federation of America.
Here is a guide to what the proposal could do and what it could mean for Planned Parenthood and the family planning program:
What is Title X?
The federal family planning program, known as “Title Ten,” is named for its section in the federal Public Health Service Act. It became law in 1970, 3 years before the Supreme Court legalized abortion in Roe v Wade.
The original bill was sponsored by then Rep. George H.W. Bush (R-Texas) and signed into law by President Richard Nixon.
The program provides wellness exams and comprehensive contraceptive services, as well as screenings for cancer and sexually transmitted diseases for both women and men.
In 2016, the most recent year for which statistics have been published, Title X served 4 million patients at just under 4,000 sites.
Title X patients are overwhelmingly young, female, and low-income. An estimated 11% of Title X patients in 2016 were male; two-thirds of patients were under age 30; and nearly two-thirds had income below the federal poverty line.
What is Planned Parenthood’s relationship to Title X and Medicaid?
Planned Parenthood affiliates account for about 13% of total Title X sites but serve an estimated 40% of its patients. Only about half of Planned Parenthood affiliates perform abortions, although the organization in its entirety is the nation’s leading abortion provider.
Planned Parenthood also gets much more federal funding for services provided to patients on the Medicaid program (although not for abortion) than it does through Title X.
Eliminating Medicaid funding for Planned Parenthood has proved more difficult for lawmakers opposed to the organization because the federal Medicaid law includes the right for patients to select their providers. Changing that also would require a 60-vote majority in the Senate. So that particular line of funding is likely not at risk.
While opponents of federal funding for Planned Parenthood have said that other safety-net clinics could make up the difference if Planned Parenthood no longer participates in Title X, several studies have suggested that in many remote areas Planned Parenthood is the only provider of family planning services and the only provider that regularly stocks all methods of birth control.
Texas, Iowa, and Missouri in recent years have stopped offering family planning services through a special Medicaid program to keep from funding Planned Parenthood. Texas is seeking a waiver from the Trump administration so that its program banning abortion providers could still receive federal funding. No decision has been made yet, federal officials said.
Why is Planned Parenthood’s involvement with Title X controversial?
Even though Planned Parenthood cannot use federal funding for abortions, anti-abortion groups claim that federal funding is “fungible” and there is no way to ensure that some of the funding provided for other services does not cross-subsidize abortion services.
Planned Parenthood has also been a longtime public target for anti-abortion forces because it is such a visible provider and vocal proponent of legal abortion services.
In the early 1980s, the Reagan administration tried to separate the program from its federal funding by requiring parental permission for teens to obtain birth control. That was followed by efforts to eliminate abortion counseling.
Starting in 2011, undercover groups accused the organization of ignoring sex traffickers and selling fetal body parts in an effort to get the organization defunded. Planned Parenthood denies the allegations.
What happened the last time an administration tried to move Planned Parenthood out of Title X?
In 1987, the Reagan administration proposed what came to be known as the “gag rule.” Though the administration’s new proposal is not yet public, because the details are still under review by the Office of Management and Budget, the White House released a summary, saying the new rule will be similar although not identical to the Reagan-era proposal.
The original gag rule would have forbidden Title X providers from abortion counseling or referring patients for abortions, required physical separation of Title X and abortion-providing facilities and forbidden recipients from using nonfederal funds for lobbying, distributing information or in any way advocating or encouraging abortion. (The Planned Parenthood Federation of America, the umbrella group for local affiliates, has a separate political and advocacy arm, the Planned Parenthood Action Fund.)
Those rules were the subject of heated congressional debate through most of the George H.W. Bush administration and were upheld in a 5-4 Supreme Court ruling in 1991, Rust v Sullivan.
Even then, the gag rule did not go into effect because subsequent efforts to relax the rules somewhat to allow doctors (but not other health professionals) to counsel patients on the availability of abortion created another round of legal fights.
Eventually the rule was in effect for only about a month before it was again blocked by a U.S. appeals court. President Bill Clinton canceled the rules by executive order on his second day in office, and no other president tried to revive them until now.
How is the Trump administration’s proposal different from earlier rules?
According to the summary of the new proposal, released May 18, it will require physical separation of family planning and abortion facilities, repeal current counseling requirements, and ban abortion referrals.
One of the biggest differences, however, is that the new rules will not explicitly forbid abortion counseling by Title X providers.
But Planned Parenthood officials say that allowing counseling while banning referrals is a distinction without a difference.
Kashif Syed, a senior policy analyst for the organization said: “Blocking doctors from telling a patient where they can get safe and legal care in this country is the definition of a gag rule.”
What happens next?
All proposed rules are reviewed by the Office of Management and Budget. Sometimes they emerge and are published in a few days; sometimes they are rewritten, and it takes months.
Meanwhile, Planned Parenthood officials said they will not know if they will take legal action until they see the final language of the rule. But they say they do plan to use the regulatory process to fight the changes that have been made public so far.
KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation. Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
The planned revival of a policy dating to Ronald Reagan’s presidency may finally present a way for President Donald Trump to fulfill his campaign promise to “defund” Planned Parenthood. Or at least to evict it from the federal family planning program, where it provides care to more than 40% of that program’s 4 million patients.
The rules now under review, according to Trump administration officials, would require facilities receiving federal family planning funds to be physically separate from those that perform abortion; would eliminate the requirement that women with unintended pregnancies be counseled on their full range of reproductive options; and would ban abortion referrals.
All those changes would particularly affect Planned Parenthood.
Planned Parenthood, which provides a broad array of reproductive health services to women and men, also provides abortion services using nonfederal funds. Cutting off funding has been the top priority for anti-abortion groups, which supported candidate Trump.
“A win like this would immediately disentangle taxpayers from the abortion business and energize the grassroots as we head into the critical midterm elections,” Marjorie Dannenfelser, president of the anti-abortion Susan B. Anthony List, said in a statement.
In a conference call with reporters, Planned Parenthood officials said they would fight the new rules.
“We’ve been very clear, Planned Parenthood has an unwavering commitment to ensuring everyone has access to the full range of reproductive health care, and that includes abortion,” said Dawn Laguens, executive vice president of the Planned Parenthood Federation of America.
Here is a guide to what the proposal could do and what it could mean for Planned Parenthood and the family planning program:
What is Title X?
The federal family planning program, known as “Title Ten,” is named for its section in the federal Public Health Service Act. It became law in 1970, 3 years before the Supreme Court legalized abortion in Roe v Wade.
The original bill was sponsored by then Rep. George H.W. Bush (R-Texas) and signed into law by President Richard Nixon.
The program provides wellness exams and comprehensive contraceptive services, as well as screenings for cancer and sexually transmitted diseases for both women and men.
In 2016, the most recent year for which statistics have been published, Title X served 4 million patients at just under 4,000 sites.
Title X patients are overwhelmingly young, female, and low-income. An estimated 11% of Title X patients in 2016 were male; two-thirds of patients were under age 30; and nearly two-thirds had income below the federal poverty line.
What is Planned Parenthood’s relationship to Title X and Medicaid?
Planned Parenthood affiliates account for about 13% of total Title X sites but serve an estimated 40% of its patients. Only about half of Planned Parenthood affiliates perform abortions, although the organization in its entirety is the nation’s leading abortion provider.
Planned Parenthood also gets much more federal funding for services provided to patients on the Medicaid program (although not for abortion) than it does through Title X.
Eliminating Medicaid funding for Planned Parenthood has proved more difficult for lawmakers opposed to the organization because the federal Medicaid law includes the right for patients to select their providers. Changing that also would require a 60-vote majority in the Senate. So that particular line of funding is likely not at risk.
While opponents of federal funding for Planned Parenthood have said that other safety-net clinics could make up the difference if Planned Parenthood no longer participates in Title X, several studies have suggested that in many remote areas Planned Parenthood is the only provider of family planning services and the only provider that regularly stocks all methods of birth control.
Texas, Iowa, and Missouri in recent years have stopped offering family planning services through a special Medicaid program to keep from funding Planned Parenthood. Texas is seeking a waiver from the Trump administration so that its program banning abortion providers could still receive federal funding. No decision has been made yet, federal officials said.
Why is Planned Parenthood’s involvement with Title X controversial?
Even though Planned Parenthood cannot use federal funding for abortions, anti-abortion groups claim that federal funding is “fungible” and there is no way to ensure that some of the funding provided for other services does not cross-subsidize abortion services.
Planned Parenthood has also been a longtime public target for anti-abortion forces because it is such a visible provider and vocal proponent of legal abortion services.
In the early 1980s, the Reagan administration tried to separate the program from its federal funding by requiring parental permission for teens to obtain birth control. That was followed by efforts to eliminate abortion counseling.
Starting in 2011, undercover groups accused the organization of ignoring sex traffickers and selling fetal body parts in an effort to get the organization defunded. Planned Parenthood denies the allegations.
What happened the last time an administration tried to move Planned Parenthood out of Title X?
In 1987, the Reagan administration proposed what came to be known as the “gag rule.” Though the administration’s new proposal is not yet public, because the details are still under review by the Office of Management and Budget, the White House released a summary, saying the new rule will be similar although not identical to the Reagan-era proposal.
The original gag rule would have forbidden Title X providers from abortion counseling or referring patients for abortions, required physical separation of Title X and abortion-providing facilities and forbidden recipients from using nonfederal funds for lobbying, distributing information or in any way advocating or encouraging abortion. (The Planned Parenthood Federation of America, the umbrella group for local affiliates, has a separate political and advocacy arm, the Planned Parenthood Action Fund.)
Those rules were the subject of heated congressional debate through most of the George H.W. Bush administration and were upheld in a 5-4 Supreme Court ruling in 1991, Rust v Sullivan.
Even then, the gag rule did not go into effect because subsequent efforts to relax the rules somewhat to allow doctors (but not other health professionals) to counsel patients on the availability of abortion created another round of legal fights.
Eventually the rule was in effect for only about a month before it was again blocked by a U.S. appeals court. President Bill Clinton canceled the rules by executive order on his second day in office, and no other president tried to revive them until now.
How is the Trump administration’s proposal different from earlier rules?
According to the summary of the new proposal, released May 18, it will require physical separation of family planning and abortion facilities, repeal current counseling requirements, and ban abortion referrals.
One of the biggest differences, however, is that the new rules will not explicitly forbid abortion counseling by Title X providers.
But Planned Parenthood officials say that allowing counseling while banning referrals is a distinction without a difference.
Kashif Syed, a senior policy analyst for the organization said: “Blocking doctors from telling a patient where they can get safe and legal care in this country is the definition of a gag rule.”
What happens next?
All proposed rules are reviewed by the Office of Management and Budget. Sometimes they emerge and are published in a few days; sometimes they are rewritten, and it takes months.
Meanwhile, Planned Parenthood officials said they will not know if they will take legal action until they see the final language of the rule. But they say they do plan to use the regulatory process to fight the changes that have been made public so far.
KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation. Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
Ropivacaine called top anesthesia for nail surgery
CHICAGO – Ropivacaine has a fast onset of action, longer duration than either lidocaine or bupivacaine, and it’s the only one of the three that’s inherently vasoconstrictive. For Brienne Cressey, MD, those features make ropivacaine the local anesthetic of choice in performing nail surgery.
“Local anesthesia is really key for nail surgery. If you don’t have good anesthesia it’s not a good experience for either the surgeon or the patient,” she observed at the annual meeting of the American College of Mohs Surgery.
Lidocaine has a fast onset – less than 1 minute – but a problematic short duration of 30-120 minutes. Bupivacaine has the disadvantage of a slow onset of up to 5 minutes, albeit with a longer duration of anesthesia at 2-4 hours. Ropivacaine has a fast onset, plus a duration of up to 8 hours. And unlike lidocaine and bupivacaine, which are vasodilatory, ropivacaine is vasoconstrictive.
“With lidocaine, you get a lot of blood right after you take off your tourniquet. With ropivacaine, you get really nice reperfusion, but it’s not too much. You take off the tourniquet, check to see you’ve got reperfusion, then you add a little ropivacaine – about 0.5 mL – on either side of the base of the distal phalanx. It stops the bleeding immediately and you can easily put on a pressure dressing. It’s a nice way to get the patient over the hump of those first hours of pain and lets them drive home in comfort,” explained Dr. Cressey, a dermatologist working in a group practice at Dermatology Professionals in East Greenwich, R.I.
Ropivacaine is less cardiotoxic than bupivacaine. And ropivacaine offers an additional advantage: Its pH is such that no buffering is necessary. “Ropivacaine doesn’t require any compounding. You can just use it at 1% straight out of the bottle. That’s what we do in our office, and we’ve had very good experience with it,” according to the dermatologist.
Achieving smooth sailing with local anesthesia
Dr. Cressey delivers ropivacaine slowly through a 30-gauge needle, which makes for a smaller, less painful puncture. She utilizes a topical cold spray, and places a vibrating machine as a distractant proximal to where she is injecting. She keeps the anesthetic at room temperature or warms it to body temperature in a water bath as another means of reducing the pain of injection.
The distal digital block
This is a cross between a traditional proximal digital block and a wing block. It works well for the second, third, and fourth digits, which are mostly volar dominant. The block bathes the volar nerve branch in anesthesia at the midline of the finger or toe.
Dr. Cressey begins by injecting ropivacaine proximal and lateral to the junction of the proximal nail fold and lateral nail fold. After creating a dermal wheal, she directs her needle perpendicularly downward toward the finger or toe pad, injecting 1-4 mL of anesthesia, depending upon digit size. Visible blanching will progress digitally. If resistance is encountered, it suggests the needle has penetrated a ligament or other fibrous tissue. Simply withdraw the needle and continue injecting.
“What’s nice about the distal digital block is you get an immediate effect, and there’s good hemostasis during the procedure as well,” she said.
Dr. Cressey reported no financial conflicts regarding her presentation.
CHICAGO – Ropivacaine has a fast onset of action, longer duration than either lidocaine or bupivacaine, and it’s the only one of the three that’s inherently vasoconstrictive. For Brienne Cressey, MD, those features make ropivacaine the local anesthetic of choice in performing nail surgery.
“Local anesthesia is really key for nail surgery. If you don’t have good anesthesia it’s not a good experience for either the surgeon or the patient,” she observed at the annual meeting of the American College of Mohs Surgery.
Lidocaine has a fast onset – less than 1 minute – but a problematic short duration of 30-120 minutes. Bupivacaine has the disadvantage of a slow onset of up to 5 minutes, albeit with a longer duration of anesthesia at 2-4 hours. Ropivacaine has a fast onset, plus a duration of up to 8 hours. And unlike lidocaine and bupivacaine, which are vasodilatory, ropivacaine is vasoconstrictive.
“With lidocaine, you get a lot of blood right after you take off your tourniquet. With ropivacaine, you get really nice reperfusion, but it’s not too much. You take off the tourniquet, check to see you’ve got reperfusion, then you add a little ropivacaine – about 0.5 mL – on either side of the base of the distal phalanx. It stops the bleeding immediately and you can easily put on a pressure dressing. It’s a nice way to get the patient over the hump of those first hours of pain and lets them drive home in comfort,” explained Dr. Cressey, a dermatologist working in a group practice at Dermatology Professionals in East Greenwich, R.I.
Ropivacaine is less cardiotoxic than bupivacaine. And ropivacaine offers an additional advantage: Its pH is such that no buffering is necessary. “Ropivacaine doesn’t require any compounding. You can just use it at 1% straight out of the bottle. That’s what we do in our office, and we’ve had very good experience with it,” according to the dermatologist.
Achieving smooth sailing with local anesthesia
Dr. Cressey delivers ropivacaine slowly through a 30-gauge needle, which makes for a smaller, less painful puncture. She utilizes a topical cold spray, and places a vibrating machine as a distractant proximal to where she is injecting. She keeps the anesthetic at room temperature or warms it to body temperature in a water bath as another means of reducing the pain of injection.
The distal digital block
This is a cross between a traditional proximal digital block and a wing block. It works well for the second, third, and fourth digits, which are mostly volar dominant. The block bathes the volar nerve branch in anesthesia at the midline of the finger or toe.
Dr. Cressey begins by injecting ropivacaine proximal and lateral to the junction of the proximal nail fold and lateral nail fold. After creating a dermal wheal, she directs her needle perpendicularly downward toward the finger or toe pad, injecting 1-4 mL of anesthesia, depending upon digit size. Visible blanching will progress digitally. If resistance is encountered, it suggests the needle has penetrated a ligament or other fibrous tissue. Simply withdraw the needle and continue injecting.
“What’s nice about the distal digital block is you get an immediate effect, and there’s good hemostasis during the procedure as well,” she said.
Dr. Cressey reported no financial conflicts regarding her presentation.
CHICAGO – Ropivacaine has a fast onset of action, longer duration than either lidocaine or bupivacaine, and it’s the only one of the three that’s inherently vasoconstrictive. For Brienne Cressey, MD, those features make ropivacaine the local anesthetic of choice in performing nail surgery.
“Local anesthesia is really key for nail surgery. If you don’t have good anesthesia it’s not a good experience for either the surgeon or the patient,” she observed at the annual meeting of the American College of Mohs Surgery.
Lidocaine has a fast onset – less than 1 minute – but a problematic short duration of 30-120 minutes. Bupivacaine has the disadvantage of a slow onset of up to 5 minutes, albeit with a longer duration of anesthesia at 2-4 hours. Ropivacaine has a fast onset, plus a duration of up to 8 hours. And unlike lidocaine and bupivacaine, which are vasodilatory, ropivacaine is vasoconstrictive.
“With lidocaine, you get a lot of blood right after you take off your tourniquet. With ropivacaine, you get really nice reperfusion, but it’s not too much. You take off the tourniquet, check to see you’ve got reperfusion, then you add a little ropivacaine – about 0.5 mL – on either side of the base of the distal phalanx. It stops the bleeding immediately and you can easily put on a pressure dressing. It’s a nice way to get the patient over the hump of those first hours of pain and lets them drive home in comfort,” explained Dr. Cressey, a dermatologist working in a group practice at Dermatology Professionals in East Greenwich, R.I.
Ropivacaine is less cardiotoxic than bupivacaine. And ropivacaine offers an additional advantage: Its pH is such that no buffering is necessary. “Ropivacaine doesn’t require any compounding. You can just use it at 1% straight out of the bottle. That’s what we do in our office, and we’ve had very good experience with it,” according to the dermatologist.
Achieving smooth sailing with local anesthesia
Dr. Cressey delivers ropivacaine slowly through a 30-gauge needle, which makes for a smaller, less painful puncture. She utilizes a topical cold spray, and places a vibrating machine as a distractant proximal to where she is injecting. She keeps the anesthetic at room temperature or warms it to body temperature in a water bath as another means of reducing the pain of injection.
The distal digital block
This is a cross between a traditional proximal digital block and a wing block. It works well for the second, third, and fourth digits, which are mostly volar dominant. The block bathes the volar nerve branch in anesthesia at the midline of the finger or toe.
Dr. Cressey begins by injecting ropivacaine proximal and lateral to the junction of the proximal nail fold and lateral nail fold. After creating a dermal wheal, she directs her needle perpendicularly downward toward the finger or toe pad, injecting 1-4 mL of anesthesia, depending upon digit size. Visible blanching will progress digitally. If resistance is encountered, it suggests the needle has penetrated a ligament or other fibrous tissue. Simply withdraw the needle and continue injecting.
“What’s nice about the distal digital block is you get an immediate effect, and there’s good hemostasis during the procedure as well,” she said.
Dr. Cressey reported no financial conflicts regarding her presentation.
EXPERT ANALYSIS FROM THE ACMS ANNUAL MEETING
Cultural sensitivity key to delivering effective psychiatric care
NEW YORK – A mental health clinic started for an urban Hispanic community in Connecticut in 1972 continues to generate lessons on how to apply cultural sensitivity to improve care, according to a critical assessment of the program presented at the annual meeting of the American Psychiatric Association.
“Reviews of the literature show that there is a difference when clinicians are culturally responsive and sensitive to the populations they serve,” reported Esperanza Díaz, MD, of the department of psychiatry at Yale University and medical director, Latino Behavioral Health System (LBHS), both in New Haven, Conn.
“How can I talk about depression treatment to a patient who does not have a place to live?” Dr. Díaz asked. Citing a variety of evidence that links mental health to social issues, Dr. Díaz explained, “We learned to partner with everyone in the community to achieve treatment goals.”
By “everyone,” Dr. Díaz was referring to primary care clinicians, family members, church community groups, social support groups, and even local politicians. She also credited success to peer counselors, which are prior patients trained to provide supportive care. Not least important, family members are recruited to help.
“In the Latino community, family is central to identity,” Dr. Díaz explained. One of treatment goals is to help patients reestablish ties with family and other community members who were lost during a mental health crisis. For this task, peer counselors have proven particularly effective for mitigating stigma and providing guidance.
All of these strategies are relevant to cultural competence, a concept for delivering effective mental health services that received particular attention in the DSM-5. Of strategies and tools relevant to this topic in the DSM-5, Dr. Díaz indicated that the Cultural Formulation Interview (CFI) should be considered particularly important for aiding clinicians in understanding mental health issues in a cultural context.
“For us as psychiatrists, the interview is our tool. ” Dr. Díaz asked. She led a recent study demonstrating that the CFI can help clinicians identify unique needs and preferences in a Hispanic population (Psychiatr Serv. 2017 Feb 1;68[2]:112-4). She said the principles of the CFI are relevant to any cultural group.
For evaluating and demonstrating efficacy of mental health services developed for a target cultural group, Dr. Díaz recommended identifying goals and then performance measures to track success. At her own center, quarterly reports track effectiveness and communicate value to the community and those providing funding its activities.
In the period during 2008-2017, 950 adult patients received mental health or substance use services from LBHS, Dr. Díaz reported. In addition to the full-time staff, LBHS has provided training to social workers and psychologists. In addition, 11 psychiatric residents in their third or fourth year of training have worked in LBHS during this period. Many of the peer counselors trained at LBHS have been hired away because of the skills they acquired.
Of the many elements that Dr. Díaz believes are important to the success of the LBHS, “confianza” has provided a key to patient willingness to stay with care through recovery. This word, Spanish for trust, recognizes that patients must have confidence in the ability of clinicians to understand and resolve their problems.
Recognizing the importance of collaborating with the community to design effective therapy, Dr. Díaz also emphasized the importance of humility to the success of LBHS.
“Humility to accept recommendations from people who are not supposedly experts, like family members,” Dr. Díaz said. “We learned that we need to know how to partner.”
NEW YORK – A mental health clinic started for an urban Hispanic community in Connecticut in 1972 continues to generate lessons on how to apply cultural sensitivity to improve care, according to a critical assessment of the program presented at the annual meeting of the American Psychiatric Association.
“Reviews of the literature show that there is a difference when clinicians are culturally responsive and sensitive to the populations they serve,” reported Esperanza Díaz, MD, of the department of psychiatry at Yale University and medical director, Latino Behavioral Health System (LBHS), both in New Haven, Conn.
“How can I talk about depression treatment to a patient who does not have a place to live?” Dr. Díaz asked. Citing a variety of evidence that links mental health to social issues, Dr. Díaz explained, “We learned to partner with everyone in the community to achieve treatment goals.”
By “everyone,” Dr. Díaz was referring to primary care clinicians, family members, church community groups, social support groups, and even local politicians. She also credited success to peer counselors, which are prior patients trained to provide supportive care. Not least important, family members are recruited to help.
“In the Latino community, family is central to identity,” Dr. Díaz explained. One of treatment goals is to help patients reestablish ties with family and other community members who were lost during a mental health crisis. For this task, peer counselors have proven particularly effective for mitigating stigma and providing guidance.
All of these strategies are relevant to cultural competence, a concept for delivering effective mental health services that received particular attention in the DSM-5. Of strategies and tools relevant to this topic in the DSM-5, Dr. Díaz indicated that the Cultural Formulation Interview (CFI) should be considered particularly important for aiding clinicians in understanding mental health issues in a cultural context.
“For us as psychiatrists, the interview is our tool. ” Dr. Díaz asked. She led a recent study demonstrating that the CFI can help clinicians identify unique needs and preferences in a Hispanic population (Psychiatr Serv. 2017 Feb 1;68[2]:112-4). She said the principles of the CFI are relevant to any cultural group.
For evaluating and demonstrating efficacy of mental health services developed for a target cultural group, Dr. Díaz recommended identifying goals and then performance measures to track success. At her own center, quarterly reports track effectiveness and communicate value to the community and those providing funding its activities.
In the period during 2008-2017, 950 adult patients received mental health or substance use services from LBHS, Dr. Díaz reported. In addition to the full-time staff, LBHS has provided training to social workers and psychologists. In addition, 11 psychiatric residents in their third or fourth year of training have worked in LBHS during this period. Many of the peer counselors trained at LBHS have been hired away because of the skills they acquired.
Of the many elements that Dr. Díaz believes are important to the success of the LBHS, “confianza” has provided a key to patient willingness to stay with care through recovery. This word, Spanish for trust, recognizes that patients must have confidence in the ability of clinicians to understand and resolve their problems.
Recognizing the importance of collaborating with the community to design effective therapy, Dr. Díaz also emphasized the importance of humility to the success of LBHS.
“Humility to accept recommendations from people who are not supposedly experts, like family members,” Dr. Díaz said. “We learned that we need to know how to partner.”
NEW YORK – A mental health clinic started for an urban Hispanic community in Connecticut in 1972 continues to generate lessons on how to apply cultural sensitivity to improve care, according to a critical assessment of the program presented at the annual meeting of the American Psychiatric Association.
“Reviews of the literature show that there is a difference when clinicians are culturally responsive and sensitive to the populations they serve,” reported Esperanza Díaz, MD, of the department of psychiatry at Yale University and medical director, Latino Behavioral Health System (LBHS), both in New Haven, Conn.
“How can I talk about depression treatment to a patient who does not have a place to live?” Dr. Díaz asked. Citing a variety of evidence that links mental health to social issues, Dr. Díaz explained, “We learned to partner with everyone in the community to achieve treatment goals.”
By “everyone,” Dr. Díaz was referring to primary care clinicians, family members, church community groups, social support groups, and even local politicians. She also credited success to peer counselors, which are prior patients trained to provide supportive care. Not least important, family members are recruited to help.
“In the Latino community, family is central to identity,” Dr. Díaz explained. One of treatment goals is to help patients reestablish ties with family and other community members who were lost during a mental health crisis. For this task, peer counselors have proven particularly effective for mitigating stigma and providing guidance.
All of these strategies are relevant to cultural competence, a concept for delivering effective mental health services that received particular attention in the DSM-5. Of strategies and tools relevant to this topic in the DSM-5, Dr. Díaz indicated that the Cultural Formulation Interview (CFI) should be considered particularly important for aiding clinicians in understanding mental health issues in a cultural context.
“For us as psychiatrists, the interview is our tool. ” Dr. Díaz asked. She led a recent study demonstrating that the CFI can help clinicians identify unique needs and preferences in a Hispanic population (Psychiatr Serv. 2017 Feb 1;68[2]:112-4). She said the principles of the CFI are relevant to any cultural group.
For evaluating and demonstrating efficacy of mental health services developed for a target cultural group, Dr. Díaz recommended identifying goals and then performance measures to track success. At her own center, quarterly reports track effectiveness and communicate value to the community and those providing funding its activities.
In the period during 2008-2017, 950 adult patients received mental health or substance use services from LBHS, Dr. Díaz reported. In addition to the full-time staff, LBHS has provided training to social workers and psychologists. In addition, 11 psychiatric residents in their third or fourth year of training have worked in LBHS during this period. Many of the peer counselors trained at LBHS have been hired away because of the skills they acquired.
Of the many elements that Dr. Díaz believes are important to the success of the LBHS, “confianza” has provided a key to patient willingness to stay with care through recovery. This word, Spanish for trust, recognizes that patients must have confidence in the ability of clinicians to understand and resolve their problems.
Recognizing the importance of collaborating with the community to design effective therapy, Dr. Díaz also emphasized the importance of humility to the success of LBHS.
“Humility to accept recommendations from people who are not supposedly experts, like family members,” Dr. Díaz said. “We learned that we need to know how to partner.”
REPORTING FROM APA
Automated bone scan index predicts survival in metastatic castration-resistant prostate cancer patients
A system that automatically evaluates bone scans produces a measure that is prognostic for overall survival (OS) in patients with metastatic prostate cancer, investigators are reporting.
The automated bone scan index (BSI) produced by the artificial intelligence–based system provides prognostic discrimination beyond other established risk markers, investigators reported in JAMA Oncology.
The automated BSI also provides significantly greater discriminative ability compared with the current standard, which is manual assessment by counting metastatic lesion numbers, according to Andrew J. Armstrong, MD, of Duke University, Durham, N.C. and his coauthors.
“Incorporating the aBSI into clinical practice to supplement nuclear medicine reports may permit a more objective analysis of bone scan changes over time and their clinical relevance to patient care,” Dr. Armstrong and colleagues said.
The BSI represents tumor burden as a percentage of total skeletal weight. The system used in this study automates BSI methods by using artificial neural networks to detect metastatic hot spots and classify them as malignant or benign.
The automated system was evaluated in a preplanned secondary analysis of a randomized clinical trial of imiquimod in men with chemotherapy-naive metastatic castration-resistant prostate cancer. Evaluable bone scans were available for 721 out of 1,245 total enrollees from 241 sites in 37 countries.
In the secondary analysis, investigators found that baseline aBSI was significantly associated with OS. Risk of death increased by 20% for every doubling of the aBSI score (hazard ratio, 1.20; 95% confidence interval, 1.14-1.26; P less than .001).
The association remained significant in a multivariable model adjusting for five variables associated with OS: albumin, lactate dehydrogenase, C-reactive protein, serum prostate-specific antigen, and Eastern European geographic region.
In addition, the automated BSI had a better discriminating ability in prognosticating OS as compared to manual lesion counting (C-index of 0.63 and 0.60, respectively; P = .03), investigators said.
Secondary analyses showed the automated BSI was also associated with time to symptomatic progression, prostate cancer specific survival, and time to opiate use for cancer pain.
“These data support the clinical utility of the automated BSI, given its association with clinically relevant outcomes that are critically important in patient care,” wrote Dr. Armstrong and his colleagues.
The study was funded by EXINI Diagnostics AB, a subsidiary of Progenics Pharmaceuticals. The researchers reported disclosures related to EXINI Diagnostics AB and Active Biotech.
SOURCE: Armstrong AJ et al. JAMA Oncol. 2018 May 17. doi: 10.1001/jamaoncol.2018.1093.
This study prospectively validates the potential usefulness and establishes the prognostic value of an automated system for evaluating bone metastases, according to Fred Saad, MD.
The automated bone scan index (aBSI) was predictive of overall survival in univariate analysis, and remained significant in multivariate analysis, Dr. Saad noted in an editorial accompanying the study.
Despite some limitations, the system provides an encouraging framework to build on, he noted.
“With ongoing and future work in validating aBSI, this technology could eventually be introduced in clinical practice and research settings for improved stratification,” he wrote in the editorial.
Now, researchers are integrating Prostate Cancer Working Group progression criteria into the aBSI framework, which could be useful for evaluating response and resistance to treatment, if validated.
“This is extremely important for anyone who realizes the time and effort required for comparing bone scans to determine whether or not patients are progressing on clinical trials,” Dr. Saad wrote.
Dr. Saad is the University of Montreal Endowed Chair in Prostate Cancer, Surgery, University of Montreal Hospital Center. These comments are derived from his editorial in JAMA Oncology . Dr. Saad had no reported conflict of interest related to the editorial.
This study prospectively validates the potential usefulness and establishes the prognostic value of an automated system for evaluating bone metastases, according to Fred Saad, MD.
The automated bone scan index (aBSI) was predictive of overall survival in univariate analysis, and remained significant in multivariate analysis, Dr. Saad noted in an editorial accompanying the study.
Despite some limitations, the system provides an encouraging framework to build on, he noted.
“With ongoing and future work in validating aBSI, this technology could eventually be introduced in clinical practice and research settings for improved stratification,” he wrote in the editorial.
Now, researchers are integrating Prostate Cancer Working Group progression criteria into the aBSI framework, which could be useful for evaluating response and resistance to treatment, if validated.
“This is extremely important for anyone who realizes the time and effort required for comparing bone scans to determine whether or not patients are progressing on clinical trials,” Dr. Saad wrote.
Dr. Saad is the University of Montreal Endowed Chair in Prostate Cancer, Surgery, University of Montreal Hospital Center. These comments are derived from his editorial in JAMA Oncology . Dr. Saad had no reported conflict of interest related to the editorial.
This study prospectively validates the potential usefulness and establishes the prognostic value of an automated system for evaluating bone metastases, according to Fred Saad, MD.
The automated bone scan index (aBSI) was predictive of overall survival in univariate analysis, and remained significant in multivariate analysis, Dr. Saad noted in an editorial accompanying the study.
Despite some limitations, the system provides an encouraging framework to build on, he noted.
“With ongoing and future work in validating aBSI, this technology could eventually be introduced in clinical practice and research settings for improved stratification,” he wrote in the editorial.
Now, researchers are integrating Prostate Cancer Working Group progression criteria into the aBSI framework, which could be useful for evaluating response and resistance to treatment, if validated.
“This is extremely important for anyone who realizes the time and effort required for comparing bone scans to determine whether or not patients are progressing on clinical trials,” Dr. Saad wrote.
Dr. Saad is the University of Montreal Endowed Chair in Prostate Cancer, Surgery, University of Montreal Hospital Center. These comments are derived from his editorial in JAMA Oncology . Dr. Saad had no reported conflict of interest related to the editorial.
A system that automatically evaluates bone scans produces a measure that is prognostic for overall survival (OS) in patients with metastatic prostate cancer, investigators are reporting.
The automated bone scan index (BSI) produced by the artificial intelligence–based system provides prognostic discrimination beyond other established risk markers, investigators reported in JAMA Oncology.
The automated BSI also provides significantly greater discriminative ability compared with the current standard, which is manual assessment by counting metastatic lesion numbers, according to Andrew J. Armstrong, MD, of Duke University, Durham, N.C. and his coauthors.
“Incorporating the aBSI into clinical practice to supplement nuclear medicine reports may permit a more objective analysis of bone scan changes over time and their clinical relevance to patient care,” Dr. Armstrong and colleagues said.
The BSI represents tumor burden as a percentage of total skeletal weight. The system used in this study automates BSI methods by using artificial neural networks to detect metastatic hot spots and classify them as malignant or benign.
The automated system was evaluated in a preplanned secondary analysis of a randomized clinical trial of imiquimod in men with chemotherapy-naive metastatic castration-resistant prostate cancer. Evaluable bone scans were available for 721 out of 1,245 total enrollees from 241 sites in 37 countries.
In the secondary analysis, investigators found that baseline aBSI was significantly associated with OS. Risk of death increased by 20% for every doubling of the aBSI score (hazard ratio, 1.20; 95% confidence interval, 1.14-1.26; P less than .001).
The association remained significant in a multivariable model adjusting for five variables associated with OS: albumin, lactate dehydrogenase, C-reactive protein, serum prostate-specific antigen, and Eastern European geographic region.
In addition, the automated BSI had a better discriminating ability in prognosticating OS as compared to manual lesion counting (C-index of 0.63 and 0.60, respectively; P = .03), investigators said.
Secondary analyses showed the automated BSI was also associated with time to symptomatic progression, prostate cancer specific survival, and time to opiate use for cancer pain.
“These data support the clinical utility of the automated BSI, given its association with clinically relevant outcomes that are critically important in patient care,” wrote Dr. Armstrong and his colleagues.
The study was funded by EXINI Diagnostics AB, a subsidiary of Progenics Pharmaceuticals. The researchers reported disclosures related to EXINI Diagnostics AB and Active Biotech.
SOURCE: Armstrong AJ et al. JAMA Oncol. 2018 May 17. doi: 10.1001/jamaoncol.2018.1093.
A system that automatically evaluates bone scans produces a measure that is prognostic for overall survival (OS) in patients with metastatic prostate cancer, investigators are reporting.
The automated bone scan index (BSI) produced by the artificial intelligence–based system provides prognostic discrimination beyond other established risk markers, investigators reported in JAMA Oncology.
The automated BSI also provides significantly greater discriminative ability compared with the current standard, which is manual assessment by counting metastatic lesion numbers, according to Andrew J. Armstrong, MD, of Duke University, Durham, N.C. and his coauthors.
“Incorporating the aBSI into clinical practice to supplement nuclear medicine reports may permit a more objective analysis of bone scan changes over time and their clinical relevance to patient care,” Dr. Armstrong and colleagues said.
The BSI represents tumor burden as a percentage of total skeletal weight. The system used in this study automates BSI methods by using artificial neural networks to detect metastatic hot spots and classify them as malignant or benign.
The automated system was evaluated in a preplanned secondary analysis of a randomized clinical trial of imiquimod in men with chemotherapy-naive metastatic castration-resistant prostate cancer. Evaluable bone scans were available for 721 out of 1,245 total enrollees from 241 sites in 37 countries.
In the secondary analysis, investigators found that baseline aBSI was significantly associated with OS. Risk of death increased by 20% for every doubling of the aBSI score (hazard ratio, 1.20; 95% confidence interval, 1.14-1.26; P less than .001).
The association remained significant in a multivariable model adjusting for five variables associated with OS: albumin, lactate dehydrogenase, C-reactive protein, serum prostate-specific antigen, and Eastern European geographic region.
In addition, the automated BSI had a better discriminating ability in prognosticating OS as compared to manual lesion counting (C-index of 0.63 and 0.60, respectively; P = .03), investigators said.
Secondary analyses showed the automated BSI was also associated with time to symptomatic progression, prostate cancer specific survival, and time to opiate use for cancer pain.
“These data support the clinical utility of the automated BSI, given its association with clinically relevant outcomes that are critically important in patient care,” wrote Dr. Armstrong and his colleagues.
The study was funded by EXINI Diagnostics AB, a subsidiary of Progenics Pharmaceuticals. The researchers reported disclosures related to EXINI Diagnostics AB and Active Biotech.
SOURCE: Armstrong AJ et al. JAMA Oncol. 2018 May 17. doi: 10.1001/jamaoncol.2018.1093.
FROM JAMA Oncology
Key clinical point: For patients with metastatic castration-resistant prostate cancer, an automated bone scan index (BSI) system predicted overall survival even after adjustment for other known prognostic factors.
Major finding: In multivariate analysis, higher automated BSI values remained independently associated with overall survival (hazard ratio, 1.06; 95% CI, 1.01-1.11; P = .03).
Study details: Preplanned secondary analysis of automated BSI in 721 men with bone metastatic, chemotherapy-naive castration-resistant prostate cancer who were enrolled in 10TASQ10, a randomized phase 3 clinical trial of tasquinimod.
Disclosures: The study was funded by EXINI Diagnostics AB, a subsidiary of Progenics Pharmaceuticals. The researchers reported disclosures related to EXINI Diagnostics AB and Active Biotech.
Source: Armstrong AJ et al. JAMA Oncol. 2018 May 17. doi: 10.1001/jamaoncol.2018.1093.
Be Part of the (Larger) Conversation
Providing free and open access to its high-quality peer-reviewed articles has always been important to Federal Practitioner, but finding them hasn’t always been easy for our readers and researchers. That has now changed. The full text of all
To be sure, Federal Practitioner has always made it easy for print and digital subscribers to find our articles. Print journal subscriptions have been—and will remain—free to the 35,000 subscribers. Furthermore, anyone can access articles online (http://mdedge.com/fedprac), in the Federal Practitioner app, or in our digital edition (http://www.fedprac-digital.com/).
However, until now access beyond our base of loyal readers has been limited. Inclusion in PMC provides a much broader audience for Federal Practitioner authors, because PMC is an integral part of the NLM MEDLINE/PubMed database of 28 million biomedical citations and abstracts from more than 5,000 journals. All PMC articles appear in PubMed searches. On a typical day, about 2.5 million users in the US access PubMed to perform about 3 million searches and access 9 million page views.1
Inclusion also means that Federal Practitioner has passed a rigorous scientific and technical review of its content. Being included in PMC is a recognition of the quality of scholarship the journal publishes and a pledge of our continuing commitment to the highest quality of clinical education and research. Young investigators, clinician-educators, midcareer professionals, and others seeking to launch or enhance an academic career may want to consider or reconsider Federal Practitioner as the destination for manuscript submission.
One of the goals of this journal has been to provide a forum for federal health care providers (HCPs) to discuss and share with other federal colleagues. Federal HCPs from the Military Health System (MHS), Veterans Health Administration (VHA), and Indian Health Service (IHS) have addressed questions in Federal Practitioner that might not be explored elsewhere. Yet something important was missing from those conversations—engagement with the larger public health community. PubMed and PMC enable an ongoing conversation among health care researchers and providers. These are the places where researchers go to understand and respond to the questions that shape their research and clinical care. Now, Federal Practitioner authors can contribute more fully in ongoing debates.
As large integrated health care systems, the VHA, MHS, and IHS confront and address key public health care policy issues. Whether it’s the responsible and safe prescribing of opioids, the resource allocation decisions regarding the treatment of hepatitis C, or addressing suicide risk, the experience of federal HCPs must be a part of the public health debate. Moreover, many Federal Practitioner articles focus not just on preliminary research, but on the practical aspects of implementing patient-centered care. All US HCPs may benefit from hearing about federal providers challenges and success in providing patient-centered care.
Making available the complete text of all the articles furthers the Federal Practitioner mission: to educate federal HCPs and provide a forum for sharing health-care related studies, best practices, guidelines, program profiles, and case studies. We are excited to provide even more benefits for publication in Federal Practitioner. This journal welcomes submissions from new authors, well-traveled scholars, and everyone in between. Come on, join the conversation.
1. Fiorini N, Lipman DJ, Lu Z. Towards PubMed 2.0. eLife. 2017;6:e28801.
Providing free and open access to its high-quality peer-reviewed articles has always been important to Federal Practitioner, but finding them hasn’t always been easy for our readers and researchers. That has now changed. The full text of all
To be sure, Federal Practitioner has always made it easy for print and digital subscribers to find our articles. Print journal subscriptions have been—and will remain—free to the 35,000 subscribers. Furthermore, anyone can access articles online (http://mdedge.com/fedprac), in the Federal Practitioner app, or in our digital edition (http://www.fedprac-digital.com/).
However, until now access beyond our base of loyal readers has been limited. Inclusion in PMC provides a much broader audience for Federal Practitioner authors, because PMC is an integral part of the NLM MEDLINE/PubMed database of 28 million biomedical citations and abstracts from more than 5,000 journals. All PMC articles appear in PubMed searches. On a typical day, about 2.5 million users in the US access PubMed to perform about 3 million searches and access 9 million page views.1
Inclusion also means that Federal Practitioner has passed a rigorous scientific and technical review of its content. Being included in PMC is a recognition of the quality of scholarship the journal publishes and a pledge of our continuing commitment to the highest quality of clinical education and research. Young investigators, clinician-educators, midcareer professionals, and others seeking to launch or enhance an academic career may want to consider or reconsider Federal Practitioner as the destination for manuscript submission.
One of the goals of this journal has been to provide a forum for federal health care providers (HCPs) to discuss and share with other federal colleagues. Federal HCPs from the Military Health System (MHS), Veterans Health Administration (VHA), and Indian Health Service (IHS) have addressed questions in Federal Practitioner that might not be explored elsewhere. Yet something important was missing from those conversations—engagement with the larger public health community. PubMed and PMC enable an ongoing conversation among health care researchers and providers. These are the places where researchers go to understand and respond to the questions that shape their research and clinical care. Now, Federal Practitioner authors can contribute more fully in ongoing debates.
As large integrated health care systems, the VHA, MHS, and IHS confront and address key public health care policy issues. Whether it’s the responsible and safe prescribing of opioids, the resource allocation decisions regarding the treatment of hepatitis C, or addressing suicide risk, the experience of federal HCPs must be a part of the public health debate. Moreover, many Federal Practitioner articles focus not just on preliminary research, but on the practical aspects of implementing patient-centered care. All US HCPs may benefit from hearing about federal providers challenges and success in providing patient-centered care.
Making available the complete text of all the articles furthers the Federal Practitioner mission: to educate federal HCPs and provide a forum for sharing health-care related studies, best practices, guidelines, program profiles, and case studies. We are excited to provide even more benefits for publication in Federal Practitioner. This journal welcomes submissions from new authors, well-traveled scholars, and everyone in between. Come on, join the conversation.
Providing free and open access to its high-quality peer-reviewed articles has always been important to Federal Practitioner, but finding them hasn’t always been easy for our readers and researchers. That has now changed. The full text of all
To be sure, Federal Practitioner has always made it easy for print and digital subscribers to find our articles. Print journal subscriptions have been—and will remain—free to the 35,000 subscribers. Furthermore, anyone can access articles online (http://mdedge.com/fedprac), in the Federal Practitioner app, or in our digital edition (http://www.fedprac-digital.com/).
However, until now access beyond our base of loyal readers has been limited. Inclusion in PMC provides a much broader audience for Federal Practitioner authors, because PMC is an integral part of the NLM MEDLINE/PubMed database of 28 million biomedical citations and abstracts from more than 5,000 journals. All PMC articles appear in PubMed searches. On a typical day, about 2.5 million users in the US access PubMed to perform about 3 million searches and access 9 million page views.1
Inclusion also means that Federal Practitioner has passed a rigorous scientific and technical review of its content. Being included in PMC is a recognition of the quality of scholarship the journal publishes and a pledge of our continuing commitment to the highest quality of clinical education and research. Young investigators, clinician-educators, midcareer professionals, and others seeking to launch or enhance an academic career may want to consider or reconsider Federal Practitioner as the destination for manuscript submission.
One of the goals of this journal has been to provide a forum for federal health care providers (HCPs) to discuss and share with other federal colleagues. Federal HCPs from the Military Health System (MHS), Veterans Health Administration (VHA), and Indian Health Service (IHS) have addressed questions in Federal Practitioner that might not be explored elsewhere. Yet something important was missing from those conversations—engagement with the larger public health community. PubMed and PMC enable an ongoing conversation among health care researchers and providers. These are the places where researchers go to understand and respond to the questions that shape their research and clinical care. Now, Federal Practitioner authors can contribute more fully in ongoing debates.
As large integrated health care systems, the VHA, MHS, and IHS confront and address key public health care policy issues. Whether it’s the responsible and safe prescribing of opioids, the resource allocation decisions regarding the treatment of hepatitis C, or addressing suicide risk, the experience of federal HCPs must be a part of the public health debate. Moreover, many Federal Practitioner articles focus not just on preliminary research, but on the practical aspects of implementing patient-centered care. All US HCPs may benefit from hearing about federal providers challenges and success in providing patient-centered care.
Making available the complete text of all the articles furthers the Federal Practitioner mission: to educate federal HCPs and provide a forum for sharing health-care related studies, best practices, guidelines, program profiles, and case studies. We are excited to provide even more benefits for publication in Federal Practitioner. This journal welcomes submissions from new authors, well-traveled scholars, and everyone in between. Come on, join the conversation.
1. Fiorini N, Lipman DJ, Lu Z. Towards PubMed 2.0. eLife. 2017;6:e28801.
1. Fiorini N, Lipman DJ, Lu Z. Towards PubMed 2.0. eLife. 2017;6:e28801.
HCV Patient on Tacrolimus? Keep an Eye on RBCs
When interpreting tacrolimus levels, it is important to monitor changes in red blood cells (RBC). A patient who had hepatitis C virus (HCV) genotype 3A lesson reinforced that lesson for clinicians in the dialysis unit at Fraser Health in Abbotsford, Canada who authored a recent case report. Ribavirin-induced anemia reduced the level of tacrolimus in the patien, the authors reported.
The patient, a 37-year-old man, developed renal failure and received a kidney transplant, which subsequently failed (due to complications likely related to HCV). He had been started on tacrolimus while waiting to go back on the transplant list. Eight years later, the patient restarted hemodialysis (HD), with a regimen of sofosbuvir and ribavirin (SOF/RBV). His whole-blood tacrolimus level was 6.6 ng/mL (target 4–6); his hemoglobin (Hb) level was 10.3 g/dL. Two months later, the patient left for a 1-month vacation. When he returned, his Hb was “dramatically low,” at 3.7 g/dL.
The clinicians put the ribavirin on hold and increased darbepoetin. The patient was given packed RBCs; a bone marrow biopsy ruled out myeloproliferative disorder. Two weeks later, the tacrolimus level was 1.0 mg/mL and then dropped to an undetectable level 5 days later. The clinicians increased the dose. During the next month, the patient’s Hb “gradually bounced back,” to > 10 g/dL, whereupon the clinicians restarted RBV. When the tacrolimus level reached 7.2 ng/mL, the dosages were gradually cut back. Sofosbuvir and RBV were stopped a couple of months later. The patient’s HCV RNA level was undetectable 12 weeks after therapy finished.
Practitioners are always facing the dilemma of risk (anemia) vs benefit (efficacy) in deciding whether and how much RBV should be reduced in renal impairment, the case report authors say. They note that the guidelines for treatment-naïve genotype 3 patients have changed. The recommendation for SOF/RBV has been replaced by one for glecaprevir/pibrentasvir or SOF/velpatasvir.
With the availability of newer direct antivirals, they add, the case again supports the abandoning of RBV-containing regimens. In the “very unlikely instance” that RBV is warranted in a patient on HD, the clinicians advise careful monitoring of Hb, especially 1 month after RBV therapy has started. Consider increasing the dosage of erythropoietin-stimulating agents if the patient’s Hb is at the lower end of the target range.
The decision to increase tacrolimus dosage based on a lower tacrolimus whole-blood concentration induced by anemia is “debatable,” the clinicians say. Nevertheless, this case reminds practitioners to take account of changes in RBC counts when interpreting tacrolimus levels—especially when a drastic change is not expected.
Source:
Liu HY, Cheung CYS, Cooper SE. BMJ Case Rep. 2018;2018. pii: bcr-2017-222477.
doi: 10.1136/bcr-2017-222477.
When interpreting tacrolimus levels, it is important to monitor changes in red blood cells (RBC). A patient who had hepatitis C virus (HCV) genotype 3A lesson reinforced that lesson for clinicians in the dialysis unit at Fraser Health in Abbotsford, Canada who authored a recent case report. Ribavirin-induced anemia reduced the level of tacrolimus in the patien, the authors reported.
The patient, a 37-year-old man, developed renal failure and received a kidney transplant, which subsequently failed (due to complications likely related to HCV). He had been started on tacrolimus while waiting to go back on the transplant list. Eight years later, the patient restarted hemodialysis (HD), with a regimen of sofosbuvir and ribavirin (SOF/RBV). His whole-blood tacrolimus level was 6.6 ng/mL (target 4–6); his hemoglobin (Hb) level was 10.3 g/dL. Two months later, the patient left for a 1-month vacation. When he returned, his Hb was “dramatically low,” at 3.7 g/dL.
The clinicians put the ribavirin on hold and increased darbepoetin. The patient was given packed RBCs; a bone marrow biopsy ruled out myeloproliferative disorder. Two weeks later, the tacrolimus level was 1.0 mg/mL and then dropped to an undetectable level 5 days later. The clinicians increased the dose. During the next month, the patient’s Hb “gradually bounced back,” to > 10 g/dL, whereupon the clinicians restarted RBV. When the tacrolimus level reached 7.2 ng/mL, the dosages were gradually cut back. Sofosbuvir and RBV were stopped a couple of months later. The patient’s HCV RNA level was undetectable 12 weeks after therapy finished.
Practitioners are always facing the dilemma of risk (anemia) vs benefit (efficacy) in deciding whether and how much RBV should be reduced in renal impairment, the case report authors say. They note that the guidelines for treatment-naïve genotype 3 patients have changed. The recommendation for SOF/RBV has been replaced by one for glecaprevir/pibrentasvir or SOF/velpatasvir.
With the availability of newer direct antivirals, they add, the case again supports the abandoning of RBV-containing regimens. In the “very unlikely instance” that RBV is warranted in a patient on HD, the clinicians advise careful monitoring of Hb, especially 1 month after RBV therapy has started. Consider increasing the dosage of erythropoietin-stimulating agents if the patient’s Hb is at the lower end of the target range.
The decision to increase tacrolimus dosage based on a lower tacrolimus whole-blood concentration induced by anemia is “debatable,” the clinicians say. Nevertheless, this case reminds practitioners to take account of changes in RBC counts when interpreting tacrolimus levels—especially when a drastic change is not expected.
Source:
Liu HY, Cheung CYS, Cooper SE. BMJ Case Rep. 2018;2018. pii: bcr-2017-222477.
doi: 10.1136/bcr-2017-222477.
When interpreting tacrolimus levels, it is important to monitor changes in red blood cells (RBC). A patient who had hepatitis C virus (HCV) genotype 3A lesson reinforced that lesson for clinicians in the dialysis unit at Fraser Health in Abbotsford, Canada who authored a recent case report. Ribavirin-induced anemia reduced the level of tacrolimus in the patien, the authors reported.
The patient, a 37-year-old man, developed renal failure and received a kidney transplant, which subsequently failed (due to complications likely related to HCV). He had been started on tacrolimus while waiting to go back on the transplant list. Eight years later, the patient restarted hemodialysis (HD), with a regimen of sofosbuvir and ribavirin (SOF/RBV). His whole-blood tacrolimus level was 6.6 ng/mL (target 4–6); his hemoglobin (Hb) level was 10.3 g/dL. Two months later, the patient left for a 1-month vacation. When he returned, his Hb was “dramatically low,” at 3.7 g/dL.
The clinicians put the ribavirin on hold and increased darbepoetin. The patient was given packed RBCs; a bone marrow biopsy ruled out myeloproliferative disorder. Two weeks later, the tacrolimus level was 1.0 mg/mL and then dropped to an undetectable level 5 days later. The clinicians increased the dose. During the next month, the patient’s Hb “gradually bounced back,” to > 10 g/dL, whereupon the clinicians restarted RBV. When the tacrolimus level reached 7.2 ng/mL, the dosages were gradually cut back. Sofosbuvir and RBV were stopped a couple of months later. The patient’s HCV RNA level was undetectable 12 weeks after therapy finished.
Practitioners are always facing the dilemma of risk (anemia) vs benefit (efficacy) in deciding whether and how much RBV should be reduced in renal impairment, the case report authors say. They note that the guidelines for treatment-naïve genotype 3 patients have changed. The recommendation for SOF/RBV has been replaced by one for glecaprevir/pibrentasvir or SOF/velpatasvir.
With the availability of newer direct antivirals, they add, the case again supports the abandoning of RBV-containing regimens. In the “very unlikely instance” that RBV is warranted in a patient on HD, the clinicians advise careful monitoring of Hb, especially 1 month after RBV therapy has started. Consider increasing the dosage of erythropoietin-stimulating agents if the patient’s Hb is at the lower end of the target range.
The decision to increase tacrolimus dosage based on a lower tacrolimus whole-blood concentration induced by anemia is “debatable,” the clinicians say. Nevertheless, this case reminds practitioners to take account of changes in RBC counts when interpreting tacrolimus levels—especially when a drastic change is not expected.
Source:
Liu HY, Cheung CYS, Cooper SE. BMJ Case Rep. 2018;2018. pii: bcr-2017-222477.
doi: 10.1136/bcr-2017-222477.
The hospitalist as intensivist
Clinical question: What roles, training, and support do hospitalists have and perceive in the intensive care unit?
Background: There is a well-documented shortage of intensivists in the United States, which has left hospitalists to help fill the gap of care. Hospitalists, however, have varied levels of critical care knowledge and skills. In some regions, more than 80% of hospitalists deliver care in the ICU. It is unknown how much support hospitalized patients receive from board-certified critical care physicians.
Study design: Multistage cross-section survey.
Setting: Web-based survey initially sent through the Critical Care Task Force professional networks and later sent to 4,000 hospitalists randomly selected from Society of Hospital Medicine’s national electronic mailing list of 12,000 hospitalists.
Synopsis: This study includes 425 responses, approximately 10% of those solicited. Compared with the annual SHM survey, this included more hospitalists from academic hospitals (24% vs. 14.8%) and fewer from nonteaching hospitals (41% vs. 58.7%). A total of 77% of responders provide care in the ICU, with 66% serving as the attending physician.
Rural and nonacademic hospitalists are more prevalent in the ICU (96% rural vs. 73% nonrural; 90% nonacademic vs. 67% academic), are more likely to serve as the primary physician for all or most ICU patients (85% rural vs. 62% nonrural; 81% nonacademic vs. 44% academic), and provide all critical care services (55% rural vs. 10% nonrural; 64% nonacademic vs. 25% academic).
Many rural (43%) and nonacademic (42%) hospitalists feel that they are expected to practice beyond their perceived scope of expertise at least some of the time, which was correlated with perceived difficulty in transferring patients to higher levels of care. About 90% of rural hospitalists report at least insufficient support from board-certified intensivists. Of all responders in the study, 85% indicated interest in additional critical care training in some form, short of fellowship training.
Bottom line: Most hospitalists provide care in the ICU, however hospitalists provide critical care at significantly higher rates in rural and nonacademic hospital settings. This care is being provided with a perceived lack of intensivist support and training.
Citation: Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.
Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.
Clinical question: What roles, training, and support do hospitalists have and perceive in the intensive care unit?
Background: There is a well-documented shortage of intensivists in the United States, which has left hospitalists to help fill the gap of care. Hospitalists, however, have varied levels of critical care knowledge and skills. In some regions, more than 80% of hospitalists deliver care in the ICU. It is unknown how much support hospitalized patients receive from board-certified critical care physicians.
Study design: Multistage cross-section survey.
Setting: Web-based survey initially sent through the Critical Care Task Force professional networks and later sent to 4,000 hospitalists randomly selected from Society of Hospital Medicine’s national electronic mailing list of 12,000 hospitalists.
Synopsis: This study includes 425 responses, approximately 10% of those solicited. Compared with the annual SHM survey, this included more hospitalists from academic hospitals (24% vs. 14.8%) and fewer from nonteaching hospitals (41% vs. 58.7%). A total of 77% of responders provide care in the ICU, with 66% serving as the attending physician.
Rural and nonacademic hospitalists are more prevalent in the ICU (96% rural vs. 73% nonrural; 90% nonacademic vs. 67% academic), are more likely to serve as the primary physician for all or most ICU patients (85% rural vs. 62% nonrural; 81% nonacademic vs. 44% academic), and provide all critical care services (55% rural vs. 10% nonrural; 64% nonacademic vs. 25% academic).
Many rural (43%) and nonacademic (42%) hospitalists feel that they are expected to practice beyond their perceived scope of expertise at least some of the time, which was correlated with perceived difficulty in transferring patients to higher levels of care. About 90% of rural hospitalists report at least insufficient support from board-certified intensivists. Of all responders in the study, 85% indicated interest in additional critical care training in some form, short of fellowship training.
Bottom line: Most hospitalists provide care in the ICU, however hospitalists provide critical care at significantly higher rates in rural and nonacademic hospital settings. This care is being provided with a perceived lack of intensivist support and training.
Citation: Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.
Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.
Clinical question: What roles, training, and support do hospitalists have and perceive in the intensive care unit?
Background: There is a well-documented shortage of intensivists in the United States, which has left hospitalists to help fill the gap of care. Hospitalists, however, have varied levels of critical care knowledge and skills. In some regions, more than 80% of hospitalists deliver care in the ICU. It is unknown how much support hospitalized patients receive from board-certified critical care physicians.
Study design: Multistage cross-section survey.
Setting: Web-based survey initially sent through the Critical Care Task Force professional networks and later sent to 4,000 hospitalists randomly selected from Society of Hospital Medicine’s national electronic mailing list of 12,000 hospitalists.
Synopsis: This study includes 425 responses, approximately 10% of those solicited. Compared with the annual SHM survey, this included more hospitalists from academic hospitals (24% vs. 14.8%) and fewer from nonteaching hospitals (41% vs. 58.7%). A total of 77% of responders provide care in the ICU, with 66% serving as the attending physician.
Rural and nonacademic hospitalists are more prevalent in the ICU (96% rural vs. 73% nonrural; 90% nonacademic vs. 67% academic), are more likely to serve as the primary physician for all or most ICU patients (85% rural vs. 62% nonrural; 81% nonacademic vs. 44% academic), and provide all critical care services (55% rural vs. 10% nonrural; 64% nonacademic vs. 25% academic).
Many rural (43%) and nonacademic (42%) hospitalists feel that they are expected to practice beyond their perceived scope of expertise at least some of the time, which was correlated with perceived difficulty in transferring patients to higher levels of care. About 90% of rural hospitalists report at least insufficient support from board-certified intensivists. Of all responders in the study, 85% indicated interest in additional critical care training in some form, short of fellowship training.
Bottom line: Most hospitalists provide care in the ICU, however hospitalists provide critical care at significantly higher rates in rural and nonacademic hospital settings. This care is being provided with a perceived lack of intensivist support and training.
Citation: Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.
Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.
Protein may be therapeutic target for AML
A signaling protein may be a “potent” therapeutic target for acute myeloid leukemia (AML), according to a paper published in the Journal of Experimental Medicine.
The protein, interleukin-1 receptor accessory protein (IL1RAP), is often highly expressed on the surface of leukemic stem cells (LSCs) but largely absent from normal hematopoietic stem cells.
Despite this, it wasn’t known whether LSCs require IL1RAP to survive and proliferate and whether inhibiting IL1RAP could be a successful way to treat AML.
Ulrich Steidl, MD, PhD, of Albert Einstein College of Medicine in Bronx, New York, and his colleagues conducted research to find out.
The team found that targeting IL1RAP via RNA interference, genetic deletion, or antibodies induced the death of AML cells, including LSCs, in vitro. These effects were seen in the absence of immune effector cells, indicating that AML cells intrinsically depend on IL1RAP.
In contrast, antibodies targeting IL1RAP had no effect on the growth and survival of normal hematopoietic cells.
In mice, IL1RAP antibody treatment inhibited the proliferation of AML cells without causing any negative side effects.
The researchers also found that IL1RAP’s role in AML is not restricted to the IL-1 receptor pathway.
The team found that IL1RAP enhances the activity of 2 other membrane receptor proteins, FLT3 and c-KIT, which are known to stimulate the proliferation of LSCs when activated by their ligands. IL1RAP antibodies inhibited the ability of these ligands to induce proliferation in AML cells.
“Our findings show that IL1RAP can amplify multiple key pathways in AML, demonstrating a much broader role for this protein in disease pathogenesis than previously appreciated,” Dr Steidl noted.
“Importantly, as IL1RAP is also overexpressed in the stem cells of chronic myeloid leukemia and high-risk myelodysplastic syndromes, there is significant therapeutic potential in further developing IL1RAP-directed targeting strategies.”
A signaling protein may be a “potent” therapeutic target for acute myeloid leukemia (AML), according to a paper published in the Journal of Experimental Medicine.
The protein, interleukin-1 receptor accessory protein (IL1RAP), is often highly expressed on the surface of leukemic stem cells (LSCs) but largely absent from normal hematopoietic stem cells.
Despite this, it wasn’t known whether LSCs require IL1RAP to survive and proliferate and whether inhibiting IL1RAP could be a successful way to treat AML.
Ulrich Steidl, MD, PhD, of Albert Einstein College of Medicine in Bronx, New York, and his colleagues conducted research to find out.
The team found that targeting IL1RAP via RNA interference, genetic deletion, or antibodies induced the death of AML cells, including LSCs, in vitro. These effects were seen in the absence of immune effector cells, indicating that AML cells intrinsically depend on IL1RAP.
In contrast, antibodies targeting IL1RAP had no effect on the growth and survival of normal hematopoietic cells.
In mice, IL1RAP antibody treatment inhibited the proliferation of AML cells without causing any negative side effects.
The researchers also found that IL1RAP’s role in AML is not restricted to the IL-1 receptor pathway.
The team found that IL1RAP enhances the activity of 2 other membrane receptor proteins, FLT3 and c-KIT, which are known to stimulate the proliferation of LSCs when activated by their ligands. IL1RAP antibodies inhibited the ability of these ligands to induce proliferation in AML cells.
“Our findings show that IL1RAP can amplify multiple key pathways in AML, demonstrating a much broader role for this protein in disease pathogenesis than previously appreciated,” Dr Steidl noted.
“Importantly, as IL1RAP is also overexpressed in the stem cells of chronic myeloid leukemia and high-risk myelodysplastic syndromes, there is significant therapeutic potential in further developing IL1RAP-directed targeting strategies.”
A signaling protein may be a “potent” therapeutic target for acute myeloid leukemia (AML), according to a paper published in the Journal of Experimental Medicine.
The protein, interleukin-1 receptor accessory protein (IL1RAP), is often highly expressed on the surface of leukemic stem cells (LSCs) but largely absent from normal hematopoietic stem cells.
Despite this, it wasn’t known whether LSCs require IL1RAP to survive and proliferate and whether inhibiting IL1RAP could be a successful way to treat AML.
Ulrich Steidl, MD, PhD, of Albert Einstein College of Medicine in Bronx, New York, and his colleagues conducted research to find out.
The team found that targeting IL1RAP via RNA interference, genetic deletion, or antibodies induced the death of AML cells, including LSCs, in vitro. These effects were seen in the absence of immune effector cells, indicating that AML cells intrinsically depend on IL1RAP.
In contrast, antibodies targeting IL1RAP had no effect on the growth and survival of normal hematopoietic cells.
In mice, IL1RAP antibody treatment inhibited the proliferation of AML cells without causing any negative side effects.
The researchers also found that IL1RAP’s role in AML is not restricted to the IL-1 receptor pathway.
The team found that IL1RAP enhances the activity of 2 other membrane receptor proteins, FLT3 and c-KIT, which are known to stimulate the proliferation of LSCs when activated by their ligands. IL1RAP antibodies inhibited the ability of these ligands to induce proliferation in AML cells.
“Our findings show that IL1RAP can amplify multiple key pathways in AML, demonstrating a much broader role for this protein in disease pathogenesis than previously appreciated,” Dr Steidl noted.
“Importantly, as IL1RAP is also overexpressed in the stem cells of chronic myeloid leukemia and high-risk myelodysplastic syndromes, there is significant therapeutic potential in further developing IL1RAP-directed targeting strategies.”
Older, cheaper drug formulation to remain available
The 140 mg capsules of Imbruvica® (ibrutinib) will remain on the market, according to Pharmacyclics LLC.
Pharmacyclics (an AbbVie company) and Janssen had planned to discontinue the capsules after introducing a single-tablet formulation of Imbruvica earlier this year.
However, the companies received negative feedback about the discontinuation and decided to keep the 140 mg capsules on the market.
In February, the US Food and Drug Administration (FDA) approved a single-tablet formulation of Imbruvica that is available in 4 doses—140 mg, 280 mg, 420 mg, and 560 mg.
Pharmacyclics and Janssen introduced this formulation to enable a once-a-day dosing regimen. The companies said the goal with the new formulation was to improve adherence because some patients had to take 3 or 4 pills every day to get the recommended dose of Imbruvica.
After introducing the new formulation, Pharmacyclics and Janssen planned to discontinue the 140 mg capsules.
Critics spoke out against this change in an article published in The Cancer Letter. They noted that discontinuing the old formulation would mean price increases for some patients. That’s because the single-tablet formulation of Imbruvica has the same price regardless of dose—$400 per tablet.
Patients on lower doses of Imbruvica would experience an increase in cost if they switched from the capsules to the tablet formulation. In fact, costs could triple for patients on the 140 mg dose.
Pharmacyclics argued that most patients on Imbruvica—those taking the 420 mg and 560 mg doses—would see no increase in out-of-pocket costs when transitioning to the single-tablet formulation. And patients on the 560 mg dose would likely see a decrease in their out-of-pocket costs.
However, critics pointed to results of a recent pilot study, which indicated that the recommended dose of Imbruvica for patients with chronic lymphocytic leukemia (CLL)—420 mg—may be too high. The results suggested that CLL patients could receive lower doses of Imbruvica without a reduction in efficacy.
Therefore, keeping the 140 mg capsules on the market could mean lower costs for some CLL patients.
In addition to voicing concerns about costs, the critics pointed out that discontinuing the 140 mg capsules of Imbruvica would make it more difficult to adjust patients’ doses when needed.
Pharmacyclics said its YOU&i™ Dose Exchange Program can aid healthcare professionals in adjusting doses before patients have finished their current pack of Imbruvica. Patients would receive a “rapid shipment” of their new dose at no additional cost.
But the critics said this program “creates a barrier to optimal prescribing for some patients” and urged the FDA to review the safety of the program.
Roughly a month after the critics made this recommendation in The Cancer Letter article, Pharmacyclics announced that the 140 mg capsules of Imbruvica would remain on the market.
The 140 mg capsules of Imbruvica® (ibrutinib) will remain on the market, according to Pharmacyclics LLC.
Pharmacyclics (an AbbVie company) and Janssen had planned to discontinue the capsules after introducing a single-tablet formulation of Imbruvica earlier this year.
However, the companies received negative feedback about the discontinuation and decided to keep the 140 mg capsules on the market.
In February, the US Food and Drug Administration (FDA) approved a single-tablet formulation of Imbruvica that is available in 4 doses—140 mg, 280 mg, 420 mg, and 560 mg.
Pharmacyclics and Janssen introduced this formulation to enable a once-a-day dosing regimen. The companies said the goal with the new formulation was to improve adherence because some patients had to take 3 or 4 pills every day to get the recommended dose of Imbruvica.
After introducing the new formulation, Pharmacyclics and Janssen planned to discontinue the 140 mg capsules.
Critics spoke out against this change in an article published in The Cancer Letter. They noted that discontinuing the old formulation would mean price increases for some patients. That’s because the single-tablet formulation of Imbruvica has the same price regardless of dose—$400 per tablet.
Patients on lower doses of Imbruvica would experience an increase in cost if they switched from the capsules to the tablet formulation. In fact, costs could triple for patients on the 140 mg dose.
Pharmacyclics argued that most patients on Imbruvica—those taking the 420 mg and 560 mg doses—would see no increase in out-of-pocket costs when transitioning to the single-tablet formulation. And patients on the 560 mg dose would likely see a decrease in their out-of-pocket costs.
However, critics pointed to results of a recent pilot study, which indicated that the recommended dose of Imbruvica for patients with chronic lymphocytic leukemia (CLL)—420 mg—may be too high. The results suggested that CLL patients could receive lower doses of Imbruvica without a reduction in efficacy.
Therefore, keeping the 140 mg capsules on the market could mean lower costs for some CLL patients.
In addition to voicing concerns about costs, the critics pointed out that discontinuing the 140 mg capsules of Imbruvica would make it more difficult to adjust patients’ doses when needed.
Pharmacyclics said its YOU&i™ Dose Exchange Program can aid healthcare professionals in adjusting doses before patients have finished their current pack of Imbruvica. Patients would receive a “rapid shipment” of their new dose at no additional cost.
But the critics said this program “creates a barrier to optimal prescribing for some patients” and urged the FDA to review the safety of the program.
Roughly a month after the critics made this recommendation in The Cancer Letter article, Pharmacyclics announced that the 140 mg capsules of Imbruvica would remain on the market.
The 140 mg capsules of Imbruvica® (ibrutinib) will remain on the market, according to Pharmacyclics LLC.
Pharmacyclics (an AbbVie company) and Janssen had planned to discontinue the capsules after introducing a single-tablet formulation of Imbruvica earlier this year.
However, the companies received negative feedback about the discontinuation and decided to keep the 140 mg capsules on the market.
In February, the US Food and Drug Administration (FDA) approved a single-tablet formulation of Imbruvica that is available in 4 doses—140 mg, 280 mg, 420 mg, and 560 mg.
Pharmacyclics and Janssen introduced this formulation to enable a once-a-day dosing regimen. The companies said the goal with the new formulation was to improve adherence because some patients had to take 3 or 4 pills every day to get the recommended dose of Imbruvica.
After introducing the new formulation, Pharmacyclics and Janssen planned to discontinue the 140 mg capsules.
Critics spoke out against this change in an article published in The Cancer Letter. They noted that discontinuing the old formulation would mean price increases for some patients. That’s because the single-tablet formulation of Imbruvica has the same price regardless of dose—$400 per tablet.
Patients on lower doses of Imbruvica would experience an increase in cost if they switched from the capsules to the tablet formulation. In fact, costs could triple for patients on the 140 mg dose.
Pharmacyclics argued that most patients on Imbruvica—those taking the 420 mg and 560 mg doses—would see no increase in out-of-pocket costs when transitioning to the single-tablet formulation. And patients on the 560 mg dose would likely see a decrease in their out-of-pocket costs.
However, critics pointed to results of a recent pilot study, which indicated that the recommended dose of Imbruvica for patients with chronic lymphocytic leukemia (CLL)—420 mg—may be too high. The results suggested that CLL patients could receive lower doses of Imbruvica without a reduction in efficacy.
Therefore, keeping the 140 mg capsules on the market could mean lower costs for some CLL patients.
In addition to voicing concerns about costs, the critics pointed out that discontinuing the 140 mg capsules of Imbruvica would make it more difficult to adjust patients’ doses when needed.
Pharmacyclics said its YOU&i™ Dose Exchange Program can aid healthcare professionals in adjusting doses before patients have finished their current pack of Imbruvica. Patients would receive a “rapid shipment” of their new dose at no additional cost.
But the critics said this program “creates a barrier to optimal prescribing for some patients” and urged the FDA to review the safety of the program.
Roughly a month after the critics made this recommendation in The Cancer Letter article, Pharmacyclics announced that the 140 mg capsules of Imbruvica would remain on the market.