Economic background does not affect the clinical course or long-term seizure outcome of childhood epilepsy, according to a study in Nova Scotia, Canada, published online ahead of print November 4 in Epilepsia. Researchers examined data for 421 patients with childhood epilepsy and 10 or more years of follow-up. Overall, 33% of families had poor income, 38% had adequate income, and 30% were well-off. Terminal remission occurred in 65% of the poor, 61% of the adequate, and 61% of the well-off populations. Intractable epilepsy, status epilepticus, number of antiepileptic drugs used, and the number of generalized tonic-clonic or focal with secondary generalization seizures through the clinical course was the same in all groups. Neither paternal nor maternal education was associated with remission. Poor children had significantly more adverse social outcomes, however.

A genetic variant near melatonin receptor 1A (MTNR1A) may be associated with job-related exhaustion in shift workers, according to a study published online ahead of print October 10 in Sleep. Researchers assessed intolerance to shift work with job-related exhaustion symptoms in shift workers using the emotional exhaustion subscale of the Maslach Burnout Inventory-General Survey and performed a genome-wide association study. Job-related exhaustion was associated with the rs12506228 variation, located downstream of MTNR1A, in shift workers included in the Finnish national Health 2000 survey. The risk allele was also associated with reduced in silico gene expression levels of MTNR1A in brain tissue and with changes in DNA methylation in the 5' regulatory region of MTNR1A. The risk variant may lead to reduced melatonin signaling in the brain. 

In healthy postmenopausal women, reproductive life events related to sex hormones are positively related to aspects of cognition in later life, according to a study published November 7 in the Journal of the American Geriatrics Society. Researchers evaluated 830 menopausal women using a cognitive battery and a structured reproductive history questionnaire. On multivariable modeling, age at menarche of 13 or older was inversely associated with global cognition. Having a last pregnancy after age 35 was positively associated with verbal memory. Use of hormonal contraceptives was positively associated with global cognition and verbal memory. The association between hormonal contraceptive use and verbal memory and executive function was strongest for more than 10 years of use. Reproductive period was positively associated with global cognition and executive function. 

Physical fitness, BMI, IQ, and stress resilience in young adulthood may be associated with the development of amyotrophic lateral sclerosis (ALS) at an early age, according to a study published in the October issue of the European Journal of Neurology. Data on physical fitness, BMI, IQ, and stress resilience were collected from 1,838,376 Swedish men ages 17 to 20 at conscription from 1968 to 2010. During follow-up, 439 participants developed ALS. People with physical fitness above the highest tertile had a higher risk of ALS before age 45. People with BMI greater than or equal to 25 had a lower risk of ALS at all ages. Individuals with IQ above the highest tertile had a significantly increased risk of ALS at an age of 56 and older. 

Short sleep is associated with greater intake of sugared caffeinated sodas, according to a study published online ahead of print November 9 in Sleep Health. Using data from the 2005 to 2012 National Health and Nutrition Examination Survey, researchers examined self-reported sleep duration and beverage intake from two 24-hour dietary recalls among 18,779 adults. Adults who slept for seven to eight hours each night were considered the reference group. In fully adjusted models, people who slept for five hours or less had 21% higher sugar-sweetened beverage consumption. When analyzed by beverage type, this difference was attributed to caffeinated sugary beverages. Longer sleepers consumed fewer servings of coffee and water. There were no associations between self-reported sleep duration and consumption of 100% juice, tea, or diet drinks.

Treadmill training plus virtual reality reduces fall rates, compared with treadmill training alone, according to a study published September 17 in the Lancet. Adults ages 60 to 90 with motor and cognitive deficits and a high risk of falls were randomly assigned to receive six weeks of treadmill training plus virtual reality or treadmill training alone. Data from 282 participants were included in the prespecified, modified intention-to-treat analysis. In the six months after training, the incident rate of falls was significantly lower in the treadmill-training-plus-virtual-reality group than it had been before training. The incident rate did not decrease significantly in the treadmill-training-alone group. Six months after training, the incident rate of falls was also significantly lower in the treadmill-training-plus-virtual-reality group than in the treadmill-training group. 

Current research does not support specific recommendations for treating hypertension to preserve cognition, according to a scientific statement by the American Heart Association published online ahead of print October 10 in Hypertension. A panel of experts reviewed the literature on hypertension, the treatment of hypertension, and the relationship between hypertension and cognition, and summarized the available data. They found that hypertension disrupts the structure and function of cerebral blood vessels, leads to ischemic damage of white matter regions critical for cognitive function, and may promote Alzheimer pathology. They found strong evidence of a negative influence of mid-life hypertension on late-life cognitive function, but the cognitive effect of late-life hypertension is unclear. Observational studies indicate that high blood pressure damages the brain's blood vessels, leading to reduced blood flow to brain cells. 

Manual-based cognitive behavioral therapy for insomnia delivered by nonclinician sleep coaches improves sleep in older adults with chronic insomnia, according to a study published in the September issue of the Journal of the American Geriatrics Society. Researchers studied veterans age 60 or older who met diagnostic criteria for insomnia of three months' duration or longer. Nonclinician sleep coaches delivered five sessions of manual-based cognitive behavioral therapy for insomnia, including stimulus control, sleep restriction, sleep hygiene, and cognitive therapy, with weekly telephone behavioral sleep medicine supervision. Controls received sleep education. Intervention subjects had greater improvement than controls between baseline and post-treatment, baseline and six months, and baseline and 12 months in sleep onset latency, total wake time, sleep efficiency, Pittsburgh Sleep Quality Index, and Insomnia Severity Index. 

Antioxidants, carotenes, fruits, and vegetables are associated with higher amyotrophic lateral sclerosis (ALS) function at baseline, according to a study published online ahead of print October 24 in JAMA Neurology. A cross-sectional baseline analysis of the ALS Multicenter Cohort Study of Oxidative Stress was conducted at 16 ALS clinics throughout the United States. Baseline data were available on 302 patients (124 women) with ALS (median age, 63.2). Regression analysis of nutrients found that higher intakes of antioxidants and carotenes from vegetables were associated with higher ALS Functional Rating Scale-Revised (ALSFRS-R) scores or percentage forced vital capacity. Empirically weighted indices using the weighted quantile sum regression method of "good" micronutrients and "good" food groups were positively associated with ALSFRS-R scores and percentage forced vital capacity. 

Fluselenamyl detects amyloid clumps better than current FDA-approved compounds, according to a study published online ahead of print November 2 in Scientific Reports. To determine whether fluselenamyl can detect amyloid beta plaques in the brain, researchers used the compound to stain brain slices from people who had died of Alzheimer's disease and from people of similar ages who had died of other causes (ie, controls). Fluselenamyl labeled diffuse and fibrillar plaques in brain sections of patients with Alzheimer's disease, but did not interact with biomarker proteins of other neurodegenerative diseases, thereby indicating specificity for detecting amyloid beta in Alzheimer's disease. Overall, fluselenamyl demonstrated potent binding affinity to autopsy-confirmed Alzheimer's disease homogenates. The binding affinity was superior to that of [¹⁸F]-AV-45, [¹⁸F]-florbetaben, and [¹⁸F]-flutemetamol. 

Preserved hippocampal volumes are associated with increased risk of probable dementia with Lewy bodies, rather than Alzheimer's disease, in patients with mild cognitive impairment (MCI), according to a study published online ahead of print November 2 in Neurology. In the study, 160 people with MCI underwent MRI to measure hippocampal size. During a median follow-up of two years, 38% of people developed Alzheimer's disease, and 13% of people developed probable dementia with Lewy bodies. The people who had no hippocampal shrinkage were 5.8 times more likely to develop probable dementia with Lewy bodies than people who had hippocampal atrophy. Approximately 85% of people who developed dementia with Lewy bodies had a normal hippocampal volume. Furthermore, 61% of people who developed Alzheimer's disease had hippocampal atrophy.

Use of a media device at bedtime is significantly associated with inadequate sleep quantity, poor sleep quality, and excessive daytime sleepiness, according to a systematic review published online ahead of print October 31 in JAMA Pediatrics. Researchers examined published studies of school-age children between ages six and 19 with information about portable screen-based media devices and sleep outcomes. The final analysis included 125,198 children with an average age of 14.5. Children who had access to, but did not use, media devices at night were more likely to have inadequate sleep quantity, poor sleep quality, and excessive daytime sleepiness. Teachers, health care professionals, and parents should cooperate to minimize device access at bedtime, according to the researchers. Future studies should evaluate devices' influence on sleep hygiene, they added. 

The FDA has approved the Amplatzer Patent Foramen Ovale (PFO) Occluder device, which reduces the risk of stroke in patients who previously had a stroke believed to be caused by a blood clot that passed through a PFO. The Amplatzer PFO Occluder is inserted through a catheter that is placed in a leg vein and advanced to the heart. In a randomized study, 499 participants ages 18 to 60 were treated with the Amplatzer PFO Occluder and blood-thinning medications and compared with 481 participants treated with blood-thinning medications alone. There was a 50% reduction in the rate of new strokes in participants using the Amplatzer PFO Occluder and blood-thinning medications, compared with participants taking medications alone. St. Jude Medical, headquartered in Plymouth, Minnesota, markets the Amplatzer PFO Occluder.     

—Kimberly Williams

Economic background does not affect the clinical course or long-term seizure outcome of childhood epilepsy, according to a study in Nova Scotia, Canada, published online ahead of print November 4 in Epilepsia. Researchers examined data for 421 patients with childhood epilepsy and 10 or more years of follow-up. Overall, 33% of families had poor income, 38% had adequate income, and 30% were well-off. Terminal remission occurred in 65% of the poor, 61% of the adequate, and 61% of the well-off populations. Intractable epilepsy, status epilepticus, number of antiepileptic drugs used, and the number of generalized tonic-clonic or focal with secondary generalization seizures through the clinical course was the same in all groups. Neither paternal nor maternal education was associated with remission. Poor children had significantly more adverse social outcomes, however.

A genetic variant near melatonin receptor 1A (MTNR1A) may be associated with job-related exhaustion in shift workers, according to a study published online ahead of print October 10 in Sleep. Researchers assessed intolerance to shift work with job-related exhaustion symptoms in shift workers using the emotional exhaustion subscale of the Maslach Burnout Inventory-General Survey and performed a genome-wide association study. Job-related exhaustion was associated with the rs12506228 variation, located downstream of MTNR1A, in shift workers included in the Finnish national Health 2000 survey. The risk allele was also associated with reduced in silico gene expression levels of MTNR1A in brain tissue and with changes in DNA methylation in the 5' regulatory region of MTNR1A. The risk variant may lead to reduced melatonin signaling in the brain. 

In healthy postmenopausal women, reproductive life events related to sex hormones are positively related to aspects of cognition in later life, according to a study published November 7 in the Journal of the American Geriatrics Society. Researchers evaluated 830 menopausal women using a cognitive battery and a structured reproductive history questionnaire. On multivariable modeling, age at menarche of 13 or older was inversely associated with global cognition. Having a last pregnancy after age 35 was positively associated with verbal memory. Use of hormonal contraceptives was positively associated with global cognition and verbal memory. The association between hormonal contraceptive use and verbal memory and executive function was strongest for more than 10 years of use. Reproductive period was positively associated with global cognition and executive function. 

Physical fitness, BMI, IQ, and stress resilience in young adulthood may be associated with the development of amyotrophic lateral sclerosis (ALS) at an early age, according to a study published in the October issue of the European Journal of Neurology. Data on physical fitness, BMI, IQ, and stress resilience were collected from 1,838,376 Swedish men ages 17 to 20 at conscription from 1968 to 2010. During follow-up, 439 participants developed ALS. People with physical fitness above the highest tertile had a higher risk of ALS before age 45. People with BMI greater than or equal to 25 had a lower risk of ALS at all ages. Individuals with IQ above the highest tertile had a significantly increased risk of ALS at an age of 56 and older. 

Short sleep is associated with greater intake of sugared caffeinated sodas, according to a study published online ahead of print November 9 in Sleep Health. Using data from the 2005 to 2012 National Health and Nutrition Examination Survey, researchers examined self-reported sleep duration and beverage intake from two 24-hour dietary recalls among 18,779 adults. Adults who slept for seven to eight hours each night were considered the reference group. In fully adjusted models, people who slept for five hours or less had 21% higher sugar-sweetened beverage consumption. When analyzed by beverage type, this difference was attributed to caffeinated sugary beverages. Longer sleepers consumed fewer servings of coffee and water. There were no associations between self-reported sleep duration and consumption of 100% juice, tea, or diet drinks.

Treadmill training plus virtual reality reduces fall rates, compared with treadmill training alone, according to a study published September 17 in the Lancet. Adults ages 60 to 90 with motor and cognitive deficits and a high risk of falls were randomly assigned to receive six weeks of treadmill training plus virtual reality or treadmill training alone. Data from 282 participants were included in the prespecified, modified intention-to-treat analysis. In the six months after training, the incident rate of falls was significantly lower in the treadmill-training-plus-virtual-reality group than it had been before training. The incident rate did not decrease significantly in the treadmill-training-alone group. Six months after training, the incident rate of falls was also significantly lower in the treadmill-training-plus-virtual-reality group than in the treadmill-training group. 

Current research does not support specific recommendations for treating hypertension to preserve cognition, according to a scientific statement by the American Heart Association published online ahead of print October 10 in Hypertension. A panel of experts reviewed the literature on hypertension, the treatment of hypertension, and the relationship between hypertension and cognition, and summarized the available data. They found that hypertension disrupts the structure and function of cerebral blood vessels, leads to ischemic damage of white matter regions critical for cognitive function, and may promote Alzheimer pathology. They found strong evidence of a negative influence of mid-life hypertension on late-life cognitive function, but the cognitive effect of late-life hypertension is unclear. Observational studies indicate that high blood pressure damages the brain's blood vessels, leading to reduced blood flow to brain cells. 

Manual-based cognitive behavioral therapy for insomnia delivered by nonclinician sleep coaches improves sleep in older adults with chronic insomnia, according to a study published in the September issue of the Journal of the American Geriatrics Society. Researchers studied veterans age 60 or older who met diagnostic criteria for insomnia of three months' duration or longer. Nonclinician sleep coaches delivered five sessions of manual-based cognitive behavioral therapy for insomnia, including stimulus control, sleep restriction, sleep hygiene, and cognitive therapy, with weekly telephone behavioral sleep medicine supervision. Controls received sleep education. Intervention subjects had greater improvement than controls between baseline and post-treatment, baseline and six months, and baseline and 12 months in sleep onset latency, total wake time, sleep efficiency, Pittsburgh Sleep Quality Index, and Insomnia Severity Index. 

Antioxidants, carotenes, fruits, and vegetables are associated with higher amyotrophic lateral sclerosis (ALS) function at baseline, according to a study published online ahead of print October 24 in JAMA Neurology. A cross-sectional baseline analysis of the ALS Multicenter Cohort Study of Oxidative Stress was conducted at 16 ALS clinics throughout the United States. Baseline data were available on 302 patients (124 women) with ALS (median age, 63.2). Regression analysis of nutrients found that higher intakes of antioxidants and carotenes from vegetables were associated with higher ALS Functional Rating Scale-Revised (ALSFRS-R) scores or percentage forced vital capacity. Empirically weighted indices using the weighted quantile sum regression method of "good" micronutrients and "good" food groups were positively associated with ALSFRS-R scores and percentage forced vital capacity. 

Fluselenamyl detects amyloid clumps better than current FDA-approved compounds, according to a study published online ahead of print November 2 in Scientific Reports. To determine whether fluselenamyl can detect amyloid beta plaques in the brain, researchers used the compound to stain brain slices from people who had died of Alzheimer's disease and from people of similar ages who had died of other causes (ie, controls). Fluselenamyl labeled diffuse and fibrillar plaques in brain sections of patients with Alzheimer's disease, but did not interact with biomarker proteins of other neurodegenerative diseases, thereby indicating specificity for detecting amyloid beta in Alzheimer's disease. Overall, fluselenamyl demonstrated potent binding affinity to autopsy-confirmed Alzheimer's disease homogenates. The binding affinity was superior to that of [¹⁸F]-AV-45, [¹⁸F]-florbetaben, and [¹⁸F]-flutemetamol. 

Preserved hippocampal volumes are associated with increased risk of probable dementia with Lewy bodies, rather than Alzheimer's disease, in patients with mild cognitive impairment (MCI), according to a study published online ahead of print November 2 in Neurology. In the study, 160 people with MCI underwent MRI to measure hippocampal size. During a median follow-up of two years, 38% of people developed Alzheimer's disease, and 13% of people developed probable dementia with Lewy bodies. The people who had no hippocampal shrinkage were 5.8 times more likely to develop probable dementia with Lewy bodies than people who had hippocampal atrophy. Approximately 85% of people who developed dementia with Lewy bodies had a normal hippocampal volume. Furthermore, 61% of people who developed Alzheimer's disease had hippocampal atrophy.

Use of a media device at bedtime is significantly associated with inadequate sleep quantity, poor sleep quality, and excessive daytime sleepiness, according to a systematic review published online ahead of print October 31 in JAMA Pediatrics. Researchers examined published studies of school-age children between ages six and 19 with information about portable screen-based media devices and sleep outcomes. The final analysis included 125,198 children with an average age of 14.5. Children who had access to, but did not use, media devices at night were more likely to have inadequate sleep quantity, poor sleep quality, and excessive daytime sleepiness. Teachers, health care professionals, and parents should cooperate to minimize device access at bedtime, according to the researchers. Future studies should evaluate devices' influence on sleep hygiene, they added. 

The FDA has approved the Amplatzer Patent Foramen Ovale (PFO) Occluder device, which reduces the risk of stroke in patients who previously had a stroke believed to be caused by a blood clot that passed through a PFO. The Amplatzer PFO Occluder is inserted through a catheter that is placed in a leg vein and advanced to the heart. In a randomized study, 499 participants ages 18 to 60 were treated with the Amplatzer PFO Occluder and blood-thinning medications and compared with 481 participants treated with blood-thinning medications alone. There was a 50% reduction in the rate of new strokes in participants using the Amplatzer PFO Occluder and blood-thinning medications, compared with participants taking medications alone. St. Jude Medical, headquartered in Plymouth, Minnesota, markets the Amplatzer PFO Occluder.     

—Kimberly Williams

Economic background does not affect the clinical course or long-term seizure outcome of childhood epilepsy, according to a study in Nova Scotia, Canada, published online ahead of print November 4 in Epilepsia. Researchers examined data for 421 patients with childhood epilepsy and 10 or more years of follow-up. Overall, 33% of families had poor income, 38% had adequate income, and 30% were well-off. Terminal remission occurred in 65% of the poor, 61% of the adequate, and 61% of the well-off populations. Intractable epilepsy, status epilepticus, number of antiepileptic drugs used, and the number of generalized tonic-clonic or focal with secondary generalization seizures through the clinical course was the same in all groups. Neither paternal nor maternal education was associated with remission. Poor children had significantly more adverse social outcomes, however.

A genetic variant near melatonin receptor 1A (MTNR1A) may be associated with job-related exhaustion in shift workers, according to a study published online ahead of print October 10 in Sleep. Researchers assessed intolerance to shift work with job-related exhaustion symptoms in shift workers using the emotional exhaustion subscale of the Maslach Burnout Inventory-General Survey and performed a genome-wide association study. Job-related exhaustion was associated with the rs12506228 variation, located downstream of MTNR1A, in shift workers included in the Finnish national Health 2000 survey. The risk allele was also associated with reduced in silico gene expression levels of MTNR1A in brain tissue and with changes in DNA methylation in the 5' regulatory region of MTNR1A. The risk variant may lead to reduced melatonin signaling in the brain. 

In healthy postmenopausal women, reproductive life events related to sex hormones are positively related to aspects of cognition in later life, according to a study published November 7 in the Journal of the American Geriatrics Society. Researchers evaluated 830 menopausal women using a cognitive battery and a structured reproductive history questionnaire. On multivariable modeling, age at menarche of 13 or older was inversely associated with global cognition. Having a last pregnancy after age 35 was positively associated with verbal memory. Use of hormonal contraceptives was positively associated with global cognition and verbal memory. The association between hormonal contraceptive use and verbal memory and executive function was strongest for more than 10 years of use. Reproductive period was positively associated with global cognition and executive function. 

Physical fitness, BMI, IQ, and stress resilience in young adulthood may be associated with the development of amyotrophic lateral sclerosis (ALS) at an early age, according to a study published in the October issue of the European Journal of Neurology. Data on physical fitness, BMI, IQ, and stress resilience were collected from 1,838,376 Swedish men ages 17 to 20 at conscription from 1968 to 2010. During follow-up, 439 participants developed ALS. People with physical fitness above the highest tertile had a higher risk of ALS before age 45. People with BMI greater than or equal to 25 had a lower risk of ALS at all ages. Individuals with IQ above the highest tertile had a significantly increased risk of ALS at an age of 56 and older. 

Short sleep is associated with greater intake of sugared caffeinated sodas, according to a study published online ahead of print November 9 in Sleep Health. Using data from the 2005 to 2012 National Health and Nutrition Examination Survey, researchers examined self-reported sleep duration and beverage intake from two 24-hour dietary recalls among 18,779 adults. Adults who slept for seven to eight hours each night were considered the reference group. In fully adjusted models, people who slept for five hours or less had 21% higher sugar-sweetened beverage consumption. When analyzed by beverage type, this difference was attributed to caffeinated sugary beverages. Longer sleepers consumed fewer servings of coffee and water. There were no associations between self-reported sleep duration and consumption of 100% juice, tea, or diet drinks.

Treadmill training plus virtual reality reduces fall rates, compared with treadmill training alone, according to a study published September 17 in the Lancet. Adults ages 60 to 90 with motor and cognitive deficits and a high risk of falls were randomly assigned to receive six weeks of treadmill training plus virtual reality or treadmill training alone. Data from 282 participants were included in the prespecified, modified intention-to-treat analysis. In the six months after training, the incident rate of falls was significantly lower in the treadmill-training-plus-virtual-reality group than it had been before training. The incident rate did not decrease significantly in the treadmill-training-alone group. Six months after training, the incident rate of falls was also significantly lower in the treadmill-training-plus-virtual-reality group than in the treadmill-training group. 

Current research does not support specific recommendations for treating hypertension to preserve cognition, according to a scientific statement by the American Heart Association published online ahead of print October 10 in Hypertension. A panel of experts reviewed the literature on hypertension, the treatment of hypertension, and the relationship between hypertension and cognition, and summarized the available data. They found that hypertension disrupts the structure and function of cerebral blood vessels, leads to ischemic damage of white matter regions critical for cognitive function, and may promote Alzheimer pathology. They found strong evidence of a negative influence of mid-life hypertension on late-life cognitive function, but the cognitive effect of late-life hypertension is unclear. Observational studies indicate that high blood pressure damages the brain's blood vessels, leading to reduced blood flow to brain cells. 

Manual-based cognitive behavioral therapy for insomnia delivered by nonclinician sleep coaches improves sleep in older adults with chronic insomnia, according to a study published in the September issue of the Journal of the American Geriatrics Society. Researchers studied veterans age 60 or older who met diagnostic criteria for insomnia of three months' duration or longer. Nonclinician sleep coaches delivered five sessions of manual-based cognitive behavioral therapy for insomnia, including stimulus control, sleep restriction, sleep hygiene, and cognitive therapy, with weekly telephone behavioral sleep medicine supervision. Controls received sleep education. Intervention subjects had greater improvement than controls between baseline and post-treatment, baseline and six months, and baseline and 12 months in sleep onset latency, total wake time, sleep efficiency, Pittsburgh Sleep Quality Index, and Insomnia Severity Index. 

Antioxidants, carotenes, fruits, and vegetables are associated with higher amyotrophic lateral sclerosis (ALS) function at baseline, according to a study published online ahead of print October 24 in JAMA Neurology. A cross-sectional baseline analysis of the ALS Multicenter Cohort Study of Oxidative Stress was conducted at 16 ALS clinics throughout the United States. Baseline data were available on 302 patients (124 women) with ALS (median age, 63.2). Regression analysis of nutrients found that higher intakes of antioxidants and carotenes from vegetables were associated with higher ALS Functional Rating Scale-Revised (ALSFRS-R) scores or percentage forced vital capacity. Empirically weighted indices using the weighted quantile sum regression method of "good" micronutrients and "good" food groups were positively associated with ALSFRS-R scores and percentage forced vital capacity. 

Fluselenamyl detects amyloid clumps better than current FDA-approved compounds, according to a study published online ahead of print November 2 in Scientific Reports. To determine whether fluselenamyl can detect amyloid beta plaques in the brain, researchers used the compound to stain brain slices from people who had died of Alzheimer's disease and from people of similar ages who had died of other causes (ie, controls). Fluselenamyl labeled diffuse and fibrillar plaques in brain sections of patients with Alzheimer's disease, but did not interact with biomarker proteins of other neurodegenerative diseases, thereby indicating specificity for detecting amyloid beta in Alzheimer's disease. Overall, fluselenamyl demonstrated potent binding affinity to autopsy-confirmed Alzheimer's disease homogenates. The binding affinity was superior to that of [¹⁸F]-AV-45, [¹⁸F]-florbetaben, and [¹⁸F]-flutemetamol. 

Preserved hippocampal volumes are associated with increased risk of probable dementia with Lewy bodies, rather than Alzheimer's disease, in patients with mild cognitive impairment (MCI), according to a study published online ahead of print November 2 in Neurology. In the study, 160 people with MCI underwent MRI to measure hippocampal size. During a median follow-up of two years, 38% of people developed Alzheimer's disease, and 13% of people developed probable dementia with Lewy bodies. The people who had no hippocampal shrinkage were 5.8 times more likely to develop probable dementia with Lewy bodies than people who had hippocampal atrophy. Approximately 85% of people who developed dementia with Lewy bodies had a normal hippocampal volume. Furthermore, 61% of people who developed Alzheimer's disease had hippocampal atrophy.

Use of a media device at bedtime is significantly associated with inadequate sleep quantity, poor sleep quality, and excessive daytime sleepiness, according to a systematic review published online ahead of print October 31 in JAMA Pediatrics. Researchers examined published studies of school-age children between ages six and 19 with information about portable screen-based media devices and sleep outcomes. The final analysis included 125,198 children with an average age of 14.5. Children who had access to, but did not use, media devices at night were more likely to have inadequate sleep quantity, poor sleep quality, and excessive daytime sleepiness. Teachers, health care professionals, and parents should cooperate to minimize device access at bedtime, according to the researchers. Future studies should evaluate devices' influence on sleep hygiene, they added. 

The FDA has approved the Amplatzer Patent Foramen Ovale (PFO) Occluder device, which reduces the risk of stroke in patients who previously had a stroke believed to be caused by a blood clot that passed through a PFO. The Amplatzer PFO Occluder is inserted through a catheter that is placed in a leg vein and advanced to the heart. In a randomized study, 499 participants ages 18 to 60 were treated with the Amplatzer PFO Occluder and blood-thinning medications and compared with 481 participants treated with blood-thinning medications alone. There was a 50% reduction in the rate of new strokes in participants using the Amplatzer PFO Occluder and blood-thinning medications, compared with participants taking medications alone. St. Jude Medical, headquartered in Plymouth, Minnesota, markets the Amplatzer PFO Occluder.     

—Kimberly Williams

Background Tumor lysis syndrome (TLS) is serious complication of anticancer chemotherapy, leading to substantial morbidity and mortality in adults and pediatric patients.

Objective To report the incidence and outcomes of TLS in pediatric patients with hematologic malignancies at a center in Pakistan.

Methods Retrospective chart review of 317 pediatric patients with hematologic malignancies during January 2008-December 2013. Demographic features and clinical and laboratory parameters of TLS, with immediate and 6-month outcomes were determined using a semi-structured questionnaire.

Results Median age at diagnosis was 9 years, with the 79.2% patients being male. Laboratory TLS was present in 36 patients (11.4%), with 27 (8.5%) developing clinical TLS and 13 (4.1%) requiring intensive care support. Hyperphosphatemia was the most frequent metabolic abnormality (14.2%), followed by hypocalcemia (13.9%), hyperuricemia (12.6%), and hyperkalemia (1.3%). 45 patients (14.2%) developed acute kidney injury (AKI). Patients who developed TLS had a signficantly higher white blood cell count at initiation of chemotherapy (142.0 x 109/L [SD, 173.1] vs 31.5 x 109/L [SD, 58.0]; P = .01) and a higher incidence of AKI (58.3% vs 8.5% of patients; P < .001).

Limitations Retrospective design of study, high rate of loss to follow-up, and unavailability of lactate dehydrogenase levels in a majority of patients.

Conclusion The incidence of TLS pediatric hematologic malignancies was 11.4% at our center. The main cause of death was sepsis. Hyperphosphatemia was the common metabolic derangement and hyperkalemia was the least common. TLS warrants intensive supportive care to prevent further morbidity and decrease mortality.

Click on the PDF icon at the top of this introduction to read the full article.

Background Tumor lysis syndrome (TLS) is serious complication of anticancer chemotherapy, leading to substantial morbidity and mortality in adults and pediatric patients.

Objective To report the incidence and outcomes of TLS in pediatric patients with hematologic malignancies at a center in Pakistan.

Methods Retrospective chart review of 317 pediatric patients with hematologic malignancies during January 2008-December 2013. Demographic features and clinical and laboratory parameters of TLS, with immediate and 6-month outcomes were determined using a semi-structured questionnaire.

Results Median age at diagnosis was 9 years, with the 79.2% patients being male. Laboratory TLS was present in 36 patients (11.4%), with 27 (8.5%) developing clinical TLS and 13 (4.1%) requiring intensive care support. Hyperphosphatemia was the most frequent metabolic abnormality (14.2%), followed by hypocalcemia (13.9%), hyperuricemia (12.6%), and hyperkalemia (1.3%). 45 patients (14.2%) developed acute kidney injury (AKI). Patients who developed TLS had a signficantly higher white blood cell count at initiation of chemotherapy (142.0 x 109/L [SD, 173.1] vs 31.5 x 109/L [SD, 58.0]; P = .01) and a higher incidence of AKI (58.3% vs 8.5% of patients; P < .001).

Limitations Retrospective design of study, high rate of loss to follow-up, and unavailability of lactate dehydrogenase levels in a majority of patients.

Conclusion The incidence of TLS pediatric hematologic malignancies was 11.4% at our center. The main cause of death was sepsis. Hyperphosphatemia was the common metabolic derangement and hyperkalemia was the least common. TLS warrants intensive supportive care to prevent further morbidity and decrease mortality.

Click on the PDF icon at the top of this introduction to read the full article.

Background Tumor lysis syndrome (TLS) is serious complication of anticancer chemotherapy, leading to substantial morbidity and mortality in adults and pediatric patients.

Objective To report the incidence and outcomes of TLS in pediatric patients with hematologic malignancies at a center in Pakistan.

Methods Retrospective chart review of 317 pediatric patients with hematologic malignancies during January 2008-December 2013. Demographic features and clinical and laboratory parameters of TLS, with immediate and 6-month outcomes were determined using a semi-structured questionnaire.

Results Median age at diagnosis was 9 years, with the 79.2% patients being male. Laboratory TLS was present in 36 patients (11.4%), with 27 (8.5%) developing clinical TLS and 13 (4.1%) requiring intensive care support. Hyperphosphatemia was the most frequent metabolic abnormality (14.2%), followed by hypocalcemia (13.9%), hyperuricemia (12.6%), and hyperkalemia (1.3%). 45 patients (14.2%) developed acute kidney injury (AKI). Patients who developed TLS had a signficantly higher white blood cell count at initiation of chemotherapy (142.0 x 109/L [SD, 173.1] vs 31.5 x 109/L [SD, 58.0]; P = .01) and a higher incidence of AKI (58.3% vs 8.5% of patients; P < .001).

Limitations Retrospective design of study, high rate of loss to follow-up, and unavailability of lactate dehydrogenase levels in a majority of patients.

Conclusion The incidence of TLS pediatric hematologic malignancies was 11.4% at our center. The main cause of death was sepsis. Hyperphosphatemia was the common metabolic derangement and hyperkalemia was the least common. TLS warrants intensive supportive care to prevent further morbidity and decrease mortality.

Click on the PDF icon at the top of this introduction to read the full article.

The Food and Drug Administration has approved daratumumab in combination with lenalidomide and dexamethasone, or bortezomib and dexamethasone, for the treatment of patients with multiple myeloma who have received at least one prior therapy.

The drug was approved last year as monotherapy for patients with multiple myeloma who have received at least three prior lines of therapy, including a proteasome inhibitor and an immunomodulatory agent, or who are double refractory to a proteasome inhibitor and an immunomodulatory agent.

[email protected]

On Twitter @nikolaideslaura

The Food and Drug Administration has approved daratumumab in combination with lenalidomide and dexamethasone, or bortezomib and dexamethasone, for the treatment of patients with multiple myeloma who have received at least one prior therapy.

The drug was approved last year as monotherapy for patients with multiple myeloma who have received at least three prior lines of therapy, including a proteasome inhibitor and an immunomodulatory agent, or who are double refractory to a proteasome inhibitor and an immunomodulatory agent.

[email protected]

On Twitter @nikolaideslaura

The Food and Drug Administration has approved daratumumab in combination with lenalidomide and dexamethasone, or bortezomib and dexamethasone, for the treatment of patients with multiple myeloma who have received at least one prior therapy.

The drug was approved last year as monotherapy for patients with multiple myeloma who have received at least three prior lines of therapy, including a proteasome inhibitor and an immunomodulatory agent, or who are double refractory to a proteasome inhibitor and an immunomodulatory agent.

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On Twitter @nikolaideslaura

CHICAGO – Smoking appears to be a modifiable risk factor for progression of chronic kidney disease associated with primary hypertension in patients treated with ACE inhibitors, Bethany Roehm, MD, reported at a meeting sponsored by the American Society of Nephrology.

Significantly increased albuminuria was noted in patients with chronic kidney disease who continued to smoke after initiating ACE inhibitor therapy, based on results from a 5-year follow-up study of 108 patients who smoked cigarettes at study entry – 25 of whom quit smoking within the first year of the study – and 108 patients who never smoked.

CHICAGO – Smoking appears to be a modifiable risk factor for progression of chronic kidney disease associated with primary hypertension in patients treated with ACE inhibitors, Bethany Roehm, MD, reported at a meeting sponsored by the American Society of Nephrology.

Significantly increased albuminuria was noted in patients with chronic kidney disease who continued to smoke after initiating ACE inhibitor therapy, based on results from a 5-year follow-up study of 108 patients who smoked cigarettes at study entry – 25 of whom quit smoking within the first year of the study – and 108 patients who never smoked.

CHICAGO – Smoking appears to be a modifiable risk factor for progression of chronic kidney disease associated with primary hypertension in patients treated with ACE inhibitors, Bethany Roehm, MD, reported at a meeting sponsored by the American Society of Nephrology.

Significantly increased albuminuria was noted in patients with chronic kidney disease who continued to smoke after initiating ACE inhibitor therapy, based on results from a 5-year follow-up study of 108 patients who smoked cigarettes at study entry – 25 of whom quit smoking within the first year of the study – and 108 patients who never smoked.

ORLANDO – Port site infiltration during laparoscopic or robot-assisted hysterectomy with extended-release liposomal bupivacaine did not significantly improve most postoperative pain scores, compared with plain 0.25% bupivacaine.

In a randomized trial, the liposomal formulation was associated with 30% less pain on postoperative day 3, a significant difference not seen on postoperative day 1, 2, or 14.

“Liposomal bupivacaine is expected to last about 72 hours but it also comes at a cost,” Kenneth I. Barron, MD, a fellow in advanced minimally invasive gynecologic surgery at Florida Hospital Orlando, said at the meeting sponsored by AAGL. Extended-release bupivacaine costs $280, compared with $1.83 for plain bupivacaine, according to Dr. Barron.

“Based on this study, the routine use of liposomal bupivacaine as a port site local anesthetic in laparoscopic hysterectomy has limited usefulness and is not justified,” he said.

In the blinded study, surgeons at a tertiary-care community hospital performed pre-incision infiltration with undiluted liposomal extended-release bupivacaine for 32 surgery patients and with the short-acting formulation for another 32 surgery patients. All patients underwent either laparoscopic or robot-assisted total hysterectomy for benign indications. They were recruited for the study between July 2015 and January 2016 and there were no significant demographic differences between groups preoperatively.

For the primary outcome measure, investigators called each participant and asked them to rate their average overall pain on postoperative days 1, 2, 3, and 14. They used the Brief Pain Inventory 0-10 scale. There were no significant differences between groups on a composite score of their average and worst pain on days 1, 2, or 14. However, on day 3, the composite score was 3.26 in the extended-release group, compared with 4.83 for those receiving short-acting bupivacaine (P = .009).

“What this shows, if anything, is one method of local anesthetic is probably not enough to make a significant impact,” Dr. Barron said. What is needed instead is “probably more of a global approach to enhance recovery.”

There were no significant differences between groups in the secondary study outcomes: pain scores during the first 24 hours in the hospital, function based on pain interference scores, opioid use, or adverse events.

Dr. Barron reported having no relevant financial disclosures.

ORLANDO – Port site infiltration during laparoscopic or robot-assisted hysterectomy with extended-release liposomal bupivacaine did not significantly improve most postoperative pain scores, compared with plain 0.25% bupivacaine.

In a randomized trial, the liposomal formulation was associated with 30% less pain on postoperative day 3, a significant difference not seen on postoperative day 1, 2, or 14.

“Liposomal bupivacaine is expected to last about 72 hours but it also comes at a cost,” Kenneth I. Barron, MD, a fellow in advanced minimally invasive gynecologic surgery at Florida Hospital Orlando, said at the meeting sponsored by AAGL. Extended-release bupivacaine costs $280, compared with $1.83 for plain bupivacaine, according to Dr. Barron.

“Based on this study, the routine use of liposomal bupivacaine as a port site local anesthetic in laparoscopic hysterectomy has limited usefulness and is not justified,” he said.

In the blinded study, surgeons at a tertiary-care community hospital performed pre-incision infiltration with undiluted liposomal extended-release bupivacaine for 32 surgery patients and with the short-acting formulation for another 32 surgery patients. All patients underwent either laparoscopic or robot-assisted total hysterectomy for benign indications. They were recruited for the study between July 2015 and January 2016 and there were no significant demographic differences between groups preoperatively.

For the primary outcome measure, investigators called each participant and asked them to rate their average overall pain on postoperative days 1, 2, 3, and 14. They used the Brief Pain Inventory 0-10 scale. There were no significant differences between groups on a composite score of their average and worst pain on days 1, 2, or 14. However, on day 3, the composite score was 3.26 in the extended-release group, compared with 4.83 for those receiving short-acting bupivacaine (P = .009).

“What this shows, if anything, is one method of local anesthetic is probably not enough to make a significant impact,” Dr. Barron said. What is needed instead is “probably more of a global approach to enhance recovery.”

There were no significant differences between groups in the secondary study outcomes: pain scores during the first 24 hours in the hospital, function based on pain interference scores, opioid use, or adverse events.

Dr. Barron reported having no relevant financial disclosures.

ORLANDO – Port site infiltration during laparoscopic or robot-assisted hysterectomy with extended-release liposomal bupivacaine did not significantly improve most postoperative pain scores, compared with plain 0.25% bupivacaine.

In a randomized trial, the liposomal formulation was associated with 30% less pain on postoperative day 3, a significant difference not seen on postoperative day 1, 2, or 14.

“Liposomal bupivacaine is expected to last about 72 hours but it also comes at a cost,” Kenneth I. Barron, MD, a fellow in advanced minimally invasive gynecologic surgery at Florida Hospital Orlando, said at the meeting sponsored by AAGL. Extended-release bupivacaine costs $280, compared with $1.83 for plain bupivacaine, according to Dr. Barron.

“Based on this study, the routine use of liposomal bupivacaine as a port site local anesthetic in laparoscopic hysterectomy has limited usefulness and is not justified,” he said.

In the blinded study, surgeons at a tertiary-care community hospital performed pre-incision infiltration with undiluted liposomal extended-release bupivacaine for 32 surgery patients and with the short-acting formulation for another 32 surgery patients. All patients underwent either laparoscopic or robot-assisted total hysterectomy for benign indications. They were recruited for the study between July 2015 and January 2016 and there were no significant demographic differences between groups preoperatively.

For the primary outcome measure, investigators called each participant and asked them to rate their average overall pain on postoperative days 1, 2, 3, and 14. They used the Brief Pain Inventory 0-10 scale. There were no significant differences between groups on a composite score of their average and worst pain on days 1, 2, or 14. However, on day 3, the composite score was 3.26 in the extended-release group, compared with 4.83 for those receiving short-acting bupivacaine (P = .009).

“What this shows, if anything, is one method of local anesthetic is probably not enough to make a significant impact,” Dr. Barron said. What is needed instead is “probably more of a global approach to enhance recovery.”

There were no significant differences between groups in the secondary study outcomes: pain scores during the first 24 hours in the hospital, function based on pain interference scores, opioid use, or adverse events.

Dr. Barron reported having no relevant financial disclosures.

The recent decision by the US Food and Drug Administration to approve ofatumumab in combination with fludarabine and cyclophosphamide in relapsed disease marks a fourth approved indication for this drug in patients with chronic lymphocytic leukemia (CLL). Ofatumumab is a fully human monoclonal antibody that targets the CD20 protein on the surface of B cells, first approved for the treatment of CLL back in 2009.

Click on the PDF icon at the top of this introduction to read the full article.

The recent decision by the US Food and Drug Administration to approve ofatumumab in combination with fludarabine and cyclophosphamide in relapsed disease marks a fourth approved indication for this drug in patients with chronic lymphocytic leukemia (CLL). Ofatumumab is a fully human monoclonal antibody that targets the CD20 protein on the surface of B cells, first approved for the treatment of CLL back in 2009.

Click on the PDF icon at the top of this introduction to read the full article.

The recent decision by the US Food and Drug Administration to approve ofatumumab in combination with fludarabine and cyclophosphamide in relapsed disease marks a fourth approved indication for this drug in patients with chronic lymphocytic leukemia (CLL). Ofatumumab is a fully human monoclonal antibody that targets the CD20 protein on the surface of B cells, first approved for the treatment of CLL back in 2009.

Click on the PDF icon at the top of this introduction to read the full article.

Intrusive musical imagery (IMI) is characterized by recalling pieces of music,¹ usually repetitions of 15 to 30 seconds,² without pathology of the ear or nervous system.¹ Also known as earworm—ohrwurm in German—or involuntary musical imagery, bits of music can become a constant cause of distress.¹

IMI is prevalent in the general population; in an internet survey >85% of respondents reported experiencing IMI at least weekly.² IMI can be generated by:

• hearing music
• reading song lyrics
• being in contact with an environment or people who are linked to specific song, such as department stores that play holiday music.^2,3

IMI also is associated with stressful situations or neurological insult.¹

Any song or segment of music can be the basis of IMI. The content of IMI change over time (ie, a new song can become a source of IMI).³ The frequency of experiencing IMI is correlated to how much music a person is exposed to and the importance a person places on music.² Most episodes are intermittent; however, continuous musical episodes are known to occur.³ Episodes of IMI with obsessive-compulsive features can be classified as musical obsessions (MO).¹ MO may be part of obsessive-compulsive symptoms, including washing, checking, aggression, sexual obsessions, and religious obsessions or other obsessions.¹

Diagnosing musical obsessions

No current measures are adequate to diagnose MO. The Yale-Brown Obsessive Compulsive Scale does not distinguish MO from other intrusive auditory imagery.¹

It is important to differentiate MO from:

• Musical preoccupations or recollections in which an individual repeatedly listens or recalls a particular song or part of a song, but does not have the urge to listen or recall music in an obsessive-compulsive pattern.¹ These individuals do not display fear and avoidant behaviors that could be seen in patients with MO.¹
• Musical hallucinations lack an input stimulus and the patient believes the music comes from an outside source and interprets it as reality. Misdiagnosing MO as a psychotic symptom is common and can result in improper treatment.¹

Management

Pharmacotherapy. MO responds to the same medications used to treat obsessive-compulsive disorder, such as selective serotonin reuptake inhibitors and clomipramine.¹ Cognitive-behavioral interventions could help patients address dysfunctional beliefs, without trying to suppress them.¹

Distraction. Encourage patients to sing a different song that does not have obsessive quality¹ or engage in a task that uses working memory.³

Exposure and response prevention therapy. Some case reports have reported efficacy in treating MO.¹

Intrusive musical imagery (IMI) is characterized by recalling pieces of music,¹ usually repetitions of 15 to 30 seconds,² without pathology of the ear or nervous system.¹ Also known as earworm—ohrwurm in German—or involuntary musical imagery, bits of music can become a constant cause of distress.¹

IMI is prevalent in the general population; in an internet survey >85% of respondents reported experiencing IMI at least weekly.² IMI can be generated by:

• hearing music
• reading song lyrics
• being in contact with an environment or people who are linked to specific song, such as department stores that play holiday music.^2,3

IMI also is associated with stressful situations or neurological insult.¹

Any song or segment of music can be the basis of IMI. The content of IMI change over time (ie, a new song can become a source of IMI).³ The frequency of experiencing IMI is correlated to how much music a person is exposed to and the importance a person places on music.² Most episodes are intermittent; however, continuous musical episodes are known to occur.³ Episodes of IMI with obsessive-compulsive features can be classified as musical obsessions (MO).¹ MO may be part of obsessive-compulsive symptoms, including washing, checking, aggression, sexual obsessions, and religious obsessions or other obsessions.¹

Diagnosing musical obsessions

No current measures are adequate to diagnose MO. The Yale-Brown Obsessive Compulsive Scale does not distinguish MO from other intrusive auditory imagery.¹

It is important to differentiate MO from:

• Musical preoccupations or recollections in which an individual repeatedly listens or recalls a particular song or part of a song, but does not have the urge to listen or recall music in an obsessive-compulsive pattern.¹ These individuals do not display fear and avoidant behaviors that could be seen in patients with MO.¹
• Musical hallucinations lack an input stimulus and the patient believes the music comes from an outside source and interprets it as reality. Misdiagnosing MO as a psychotic symptom is common and can result in improper treatment.¹

Management

Pharmacotherapy. MO responds to the same medications used to treat obsessive-compulsive disorder, such as selective serotonin reuptake inhibitors and clomipramine.¹ Cognitive-behavioral interventions could help patients address dysfunctional beliefs, without trying to suppress them.¹

Distraction. Encourage patients to sing a different song that does not have obsessive quality¹ or engage in a task that uses working memory.³

Exposure and response prevention therapy. Some case reports have reported efficacy in treating MO.¹

Intrusive musical imagery (IMI) is characterized by recalling pieces of music,¹ usually repetitions of 15 to 30 seconds,² without pathology of the ear or nervous system.¹ Also known as earworm—ohrwurm in German—or involuntary musical imagery, bits of music can become a constant cause of distress.¹

IMI is prevalent in the general population; in an internet survey >85% of respondents reported experiencing IMI at least weekly.² IMI can be generated by:

• hearing music
• reading song lyrics
• being in contact with an environment or people who are linked to specific song, such as department stores that play holiday music.^2,3

IMI also is associated with stressful situations or neurological insult.¹

Any song or segment of music can be the basis of IMI. The content of IMI change over time (ie, a new song can become a source of IMI).³ The frequency of experiencing IMI is correlated to how much music a person is exposed to and the importance a person places on music.² Most episodes are intermittent; however, continuous musical episodes are known to occur.³ Episodes of IMI with obsessive-compulsive features can be classified as musical obsessions (MO).¹ MO may be part of obsessive-compulsive symptoms, including washing, checking, aggression, sexual obsessions, and religious obsessions or other obsessions.¹

Diagnosing musical obsessions

No current measures are adequate to diagnose MO. The Yale-Brown Obsessive Compulsive Scale does not distinguish MO from other intrusive auditory imagery.¹

It is important to differentiate MO from:

• Musical preoccupations or recollections in which an individual repeatedly listens or recalls a particular song or part of a song, but does not have the urge to listen or recall music in an obsessive-compulsive pattern.¹ These individuals do not display fear and avoidant behaviors that could be seen in patients with MO.¹
• Musical hallucinations lack an input stimulus and the patient believes the music comes from an outside source and interprets it as reality. Misdiagnosing MO as a psychotic symptom is common and can result in improper treatment.¹

Management

Pharmacotherapy. MO responds to the same medications used to treat obsessive-compulsive disorder, such as selective serotonin reuptake inhibitors and clomipramine.¹ Cognitive-behavioral interventions could help patients address dysfunctional beliefs, without trying to suppress them.¹

Distraction. Encourage patients to sing a different song that does not have obsessive quality¹ or engage in a task that uses working memory.³

Exposure and response prevention therapy. Some case reports have reported efficacy in treating MO.¹

The business of cancer care is in transition. Driven by the Centers for Medicare & Medicaid Services’ (CMS) Oncology Care Model (OCM) program, practices around the country are working to re-engineer the way they provide services, and the way they charge for those services. The implicit goal of all this is to manage (as in reduce) the overall cost of cancer care. A more frequently stated goal is to improve value, typically defined as outcome (numerator) relative to cost (denominator). Alternative payment models are challenged to assess the value of transformational improvement in cancer care.

Click on the PDF icon at the top of this introduction to read the full article.

The business of cancer care is in transition. Driven by the Centers for Medicare & Medicaid Services’ (CMS) Oncology Care Model (OCM) program, practices around the country are working to re-engineer the way they provide services, and the way they charge for those services. The implicit goal of all this is to manage (as in reduce) the overall cost of cancer care. A more frequently stated goal is to improve value, typically defined as outcome (numerator) relative to cost (denominator). Alternative payment models are challenged to assess the value of transformational improvement in cancer care.

Click on the PDF icon at the top of this introduction to read the full article.

The business of cancer care is in transition. Driven by the Centers for Medicare & Medicaid Services’ (CMS) Oncology Care Model (OCM) program, practices around the country are working to re-engineer the way they provide services, and the way they charge for those services. The implicit goal of all this is to manage (as in reduce) the overall cost of cancer care. A more frequently stated goal is to improve value, typically defined as outcome (numerator) relative to cost (denominator). Alternative payment models are challenged to assess the value of transformational improvement in cancer care.

Click on the PDF icon at the top of this introduction to read the full article.

A fracture occurring after anterior cruciate ligament (ACL) reconstruction is rare, and rarer still when it involves the harvest site of a bone—patellar tendon—bone (BPTB) autograft. The vast majority of fractures described in the literature are patellar, with the weak point along the patellar bone cut. A number of fractures generally also occur through the bone tunnels in both hamstring and BPTB grafts. However, only 2 cases of tibial tubercle fracture after BPTB graft have been published, and we expound on them in this case report.^1,2 The patient provided written informed consent for print and electronic publication of this case report.

Case Report

Eight years after undergoing successful left ACL reconstruction with ipsilateral BPTB graft, a 45-year-old man developed a graft rupture and demonstrated recurrent instability. He requested revision reconstruction, again with a BPTB construct. In the operating room, he was prepared and draped in the usual sterile fashion, and left ACL reconstruction was performed with right-knee central-third BPTB graft.

During surgery, the left knee was arthroscopically examined, and residual ACL graft from the initial reconstruction was removed. Notchplasty was performed, and the residual femoral interference screw was removed from the 12:30 position. A transtibial approach was used, with a 10-mm reamer brought through the proximal tibia, the posterior tibial ACL footprint, and the 2:00 distal femoral position, with 30 mm of femoral condyle drilled, leaving 1 mm of posterior femoral cortex.

After the right leg was exsanguinated, a central-third patellar tendon graft was harvested through a longitudinal incision with a 22-mm × 10-mm patellar plug, a 10-mm patellar graft, and a 22-mm × 11-mm tibial plug. The graft was prepared, the left tibia was overreamed, and the graft was passed. The graft was fixed with a 7-mm × 23-mm biointerference screw in the femur, trialed, and fixed with an 8-mm × 23-mm interference screw in the tibia. Excess bone graft was packed in the patellar defect in the right knee. The rent in the patellar tendon was closed. The rest of the incision was closed, and the patient was placed in an immobilizer and a cold therapy device (Polar Care; Breg, Inc).

At 2-week follow-up, the patient reported having slipped on ice and flexed the right knee, causing a pop, pain, and limitation in range of motion (ROM; 0°-70°).

Discussion

Cases of tibial tubercle fracture after BPTB autograft harvest are extremely rare in the published literature. PubMed and Cochrane Review searches revealed only 2—1 in the ipsilateral knee as ACL fixation¹ and 1 in the contralateral knee.² The middle third of the patellar tendon has been used for ACL reconstruction for more than 50 years, which supports the extreme rarity of this complication.³ Tibial tubercle fractures are so rare that they are not even mentioned in reviews of ACL complications.⁴ These fractures are universally treated with ORIF.^1,2

Far more common but still rare, fracture-type complications involve the extensor mechanism and the tibial plateau. Patellar fractures have been documented as occurring in 0.2% to 2.3% of cases.^5-7 One paper reported a fracture in 1.3% of cases at a mean of 57 days, with roughly half caused by trauma and the other half having atraumatic causes.⁸ Lee and colleagues⁹ found a 0.2% complication rate for all BPTB grafts in 1725 consecutive patients. Although some patients were treated nonoperatively, others underwent operative fixation. Time to clinical and radiographic healing was 7 and 10 weeks, respectively.

Tibial plateau fracture after BPTB harvest is a rare complication, with 11 cases reported in the literature.¹⁰ In 4 of those cases, the proposed mechanism of fracture was a stress riser resulting from the synergistic weakness of the tibial harvest site combined with the tibial tunnel reducing proximal tibial bone strength.^11-14 The mechanism of injury varied from traumatic to insufficiency fracture, with fixation varying with fracture displacement.

Tibial tubercle fracture after BPTB harvest is extremely rare, with the present case being only the third published in the literature. Like most reported post-ACL reconstruction extensor mechanism disruptions, our case resulted from a traumatic event at an interval after surgery. All other tibial tubercle fracture post-ACL reconstruction disruptions occurred within 2 weeks after surgery.^1,2 Sudden tension on the extensor mechanism secondary to hyperflexion caused a fracture through a weakened tibial tubercle with avulsion of the remaining tendon in 2 of the 3 cases, with the third being a lower stress popping noise that occurred during a pivot to stand.¹

The residual defect after tibial bone block harvest could represent a weakening of the tubercle by loss of structural bone and by development of stress risers. The previous reports of tibial tubercle fracture after BPTB harvest documented a similar methodology: Use a bone saw and osteotomes to harvest a trapezoidal tibial bone plug 10 mm to 11 mm wide and 22 cm to 35 cm long. As previously documented, we suggest taking care with saw cuts and osteotomes so as not to weaken the proximal tibia or distal patella more than is necessary.^1,2 Before surgery, patients should be warned about the possibility of extensor mechanism injuries with use of BPTB grafts.

Conclusion

Tibial tubercle fracture after BPTB harvest for ACL reconstruction is an extremely rare complication. Treatment is ORIF of the tubercle fragment, with a delay in ACL rehabilitation in cases involving the ipsilateral knee.

Am J Orthop. 2016;45(7):E469-E471. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

A fracture occurring after anterior cruciate ligament (ACL) reconstruction is rare, and rarer still when it involves the harvest site of a bone—patellar tendon—bone (BPTB) autograft. The vast majority of fractures described in the literature are patellar, with the weak point along the patellar bone cut. A number of fractures generally also occur through the bone tunnels in both hamstring and BPTB grafts. However, only 2 cases of tibial tubercle fracture after BPTB graft have been published, and we expound on them in this case report.^1,2 The patient provided written informed consent for print and electronic publication of this case report.

Case Report

Eight years after undergoing successful left ACL reconstruction with ipsilateral BPTB graft, a 45-year-old man developed a graft rupture and demonstrated recurrent instability. He requested revision reconstruction, again with a BPTB construct. In the operating room, he was prepared and draped in the usual sterile fashion, and left ACL reconstruction was performed with right-knee central-third BPTB graft.

During surgery, the left knee was arthroscopically examined, and residual ACL graft from the initial reconstruction was removed. Notchplasty was performed, and the residual femoral interference screw was removed from the 12:30 position. A transtibial approach was used, with a 10-mm reamer brought through the proximal tibia, the posterior tibial ACL footprint, and the 2:00 distal femoral position, with 30 mm of femoral condyle drilled, leaving 1 mm of posterior femoral cortex.

After the right leg was exsanguinated, a central-third patellar tendon graft was harvested through a longitudinal incision with a 22-mm × 10-mm patellar plug, a 10-mm patellar graft, and a 22-mm × 11-mm tibial plug. The graft was prepared, the left tibia was overreamed, and the graft was passed. The graft was fixed with a 7-mm × 23-mm biointerference screw in the femur, trialed, and fixed with an 8-mm × 23-mm interference screw in the tibia. Excess bone graft was packed in the patellar defect in the right knee. The rent in the patellar tendon was closed. The rest of the incision was closed, and the patient was placed in an immobilizer and a cold therapy device (Polar Care; Breg, Inc).

At 2-week follow-up, the patient reported having slipped on ice and flexed the right knee, causing a pop, pain, and limitation in range of motion (ROM; 0°-70°).

Discussion

Cases of tibial tubercle fracture after BPTB autograft harvest are extremely rare in the published literature. PubMed and Cochrane Review searches revealed only 2—1 in the ipsilateral knee as ACL fixation¹ and 1 in the contralateral knee.² The middle third of the patellar tendon has been used for ACL reconstruction for more than 50 years, which supports the extreme rarity of this complication.³ Tibial tubercle fractures are so rare that they are not even mentioned in reviews of ACL complications.⁴ These fractures are universally treated with ORIF.^1,2

Far more common but still rare, fracture-type complications involve the extensor mechanism and the tibial plateau. Patellar fractures have been documented as occurring in 0.2% to 2.3% of cases.^5-7 One paper reported a fracture in 1.3% of cases at a mean of 57 days, with roughly half caused by trauma and the other half having atraumatic causes.⁸ Lee and colleagues⁹ found a 0.2% complication rate for all BPTB grafts in 1725 consecutive patients. Although some patients were treated nonoperatively, others underwent operative fixation. Time to clinical and radiographic healing was 7 and 10 weeks, respectively.

Tibial plateau fracture after BPTB harvest is a rare complication, with 11 cases reported in the literature.¹⁰ In 4 of those cases, the proposed mechanism of fracture was a stress riser resulting from the synergistic weakness of the tibial harvest site combined with the tibial tunnel reducing proximal tibial bone strength.^11-14 The mechanism of injury varied from traumatic to insufficiency fracture, with fixation varying with fracture displacement.

Tibial tubercle fracture after BPTB harvest is extremely rare, with the present case being only the third published in the literature. Like most reported post-ACL reconstruction extensor mechanism disruptions, our case resulted from a traumatic event at an interval after surgery. All other tibial tubercle fracture post-ACL reconstruction disruptions occurred within 2 weeks after surgery.^1,2 Sudden tension on the extensor mechanism secondary to hyperflexion caused a fracture through a weakened tibial tubercle with avulsion of the remaining tendon in 2 of the 3 cases, with the third being a lower stress popping noise that occurred during a pivot to stand.¹

The residual defect after tibial bone block harvest could represent a weakening of the tubercle by loss of structural bone and by development of stress risers. The previous reports of tibial tubercle fracture after BPTB harvest documented a similar methodology: Use a bone saw and osteotomes to harvest a trapezoidal tibial bone plug 10 mm to 11 mm wide and 22 cm to 35 cm long. As previously documented, we suggest taking care with saw cuts and osteotomes so as not to weaken the proximal tibia or distal patella more than is necessary.^1,2 Before surgery, patients should be warned about the possibility of extensor mechanism injuries with use of BPTB grafts.

Conclusion

Tibial tubercle fracture after BPTB harvest for ACL reconstruction is an extremely rare complication. Treatment is ORIF of the tubercle fragment, with a delay in ACL rehabilitation in cases involving the ipsilateral knee.

Am J Orthop. 2016;45(7):E469-E471. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

A fracture occurring after anterior cruciate ligament (ACL) reconstruction is rare, and rarer still when it involves the harvest site of a bone—patellar tendon—bone (BPTB) autograft. The vast majority of fractures described in the literature are patellar, with the weak point along the patellar bone cut. A number of fractures generally also occur through the bone tunnels in both hamstring and BPTB grafts. However, only 2 cases of tibial tubercle fracture after BPTB graft have been published, and we expound on them in this case report.^1,2 The patient provided written informed consent for print and electronic publication of this case report.

Case Report

Eight years after undergoing successful left ACL reconstruction with ipsilateral BPTB graft, a 45-year-old man developed a graft rupture and demonstrated recurrent instability. He requested revision reconstruction, again with a BPTB construct. In the operating room, he was prepared and draped in the usual sterile fashion, and left ACL reconstruction was performed with right-knee central-third BPTB graft.

During surgery, the left knee was arthroscopically examined, and residual ACL graft from the initial reconstruction was removed. Notchplasty was performed, and the residual femoral interference screw was removed from the 12:30 position. A transtibial approach was used, with a 10-mm reamer brought through the proximal tibia, the posterior tibial ACL footprint, and the 2:00 distal femoral position, with 30 mm of femoral condyle drilled, leaving 1 mm of posterior femoral cortex.

After the right leg was exsanguinated, a central-third patellar tendon graft was harvested through a longitudinal incision with a 22-mm × 10-mm patellar plug, a 10-mm patellar graft, and a 22-mm × 11-mm tibial plug. The graft was prepared, the left tibia was overreamed, and the graft was passed. The graft was fixed with a 7-mm × 23-mm biointerference screw in the femur, trialed, and fixed with an 8-mm × 23-mm interference screw in the tibia. Excess bone graft was packed in the patellar defect in the right knee. The rent in the patellar tendon was closed. The rest of the incision was closed, and the patient was placed in an immobilizer and a cold therapy device (Polar Care; Breg, Inc).

At 2-week follow-up, the patient reported having slipped on ice and flexed the right knee, causing a pop, pain, and limitation in range of motion (ROM; 0°-70°).

Discussion

Cases of tibial tubercle fracture after BPTB autograft harvest are extremely rare in the published literature. PubMed and Cochrane Review searches revealed only 2—1 in the ipsilateral knee as ACL fixation¹ and 1 in the contralateral knee.² The middle third of the patellar tendon has been used for ACL reconstruction for more than 50 years, which supports the extreme rarity of this complication.³ Tibial tubercle fractures are so rare that they are not even mentioned in reviews of ACL complications.⁴ These fractures are universally treated with ORIF.^1,2

Far more common but still rare, fracture-type complications involve the extensor mechanism and the tibial plateau. Patellar fractures have been documented as occurring in 0.2% to 2.3% of cases.^5-7 One paper reported a fracture in 1.3% of cases at a mean of 57 days, with roughly half caused by trauma and the other half having atraumatic causes.⁸ Lee and colleagues⁹ found a 0.2% complication rate for all BPTB grafts in 1725 consecutive patients. Although some patients were treated nonoperatively, others underwent operative fixation. Time to clinical and radiographic healing was 7 and 10 weeks, respectively.

Tibial plateau fracture after BPTB harvest is a rare complication, with 11 cases reported in the literature.¹⁰ In 4 of those cases, the proposed mechanism of fracture was a stress riser resulting from the synergistic weakness of the tibial harvest site combined with the tibial tunnel reducing proximal tibial bone strength.^11-14 The mechanism of injury varied from traumatic to insufficiency fracture, with fixation varying with fracture displacement.

Tibial tubercle fracture after BPTB harvest is extremely rare, with the present case being only the third published in the literature. Like most reported post-ACL reconstruction extensor mechanism disruptions, our case resulted from a traumatic event at an interval after surgery. All other tibial tubercle fracture post-ACL reconstruction disruptions occurred within 2 weeks after surgery.^1,2 Sudden tension on the extensor mechanism secondary to hyperflexion caused a fracture through a weakened tibial tubercle with avulsion of the remaining tendon in 2 of the 3 cases, with the third being a lower stress popping noise that occurred during a pivot to stand.¹

The residual defect after tibial bone block harvest could represent a weakening of the tubercle by loss of structural bone and by development of stress risers. The previous reports of tibial tubercle fracture after BPTB harvest documented a similar methodology: Use a bone saw and osteotomes to harvest a trapezoidal tibial bone plug 10 mm to 11 mm wide and 22 cm to 35 cm long. As previously documented, we suggest taking care with saw cuts and osteotomes so as not to weaken the proximal tibia or distal patella more than is necessary.^1,2 Before surgery, patients should be warned about the possibility of extensor mechanism injuries with use of BPTB grafts.

Conclusion

Tibial tubercle fracture after BPTB harvest for ACL reconstruction is an extremely rare complication. Treatment is ORIF of the tubercle fragment, with a delay in ACL rehabilitation in cases involving the ipsilateral knee.

Am J Orthop. 2016;45(7):E469-E471. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

Primary and emergency care providers must step up prevention efforts and the use of state-of-the-art medicine when treating patients with addiction, according to the first-ever U.S. Surgeon General’s report on alcohol, drugs, and health.

In the report, “Facing Addiction in America,” Surgeon General Vivek H. Murthy, MD, called on health care providers to increase access to care and approach addiction and substance use disorders as they would any other chronic health condition.

“We must help everyone see that addiction is not a character flaw – it is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer,” Dr. Murthy explained.

In addition to offering an action plan to address substance use of all kinds, the surgeon general’s report updates the public on the state of the art of addiction science, and includes chapters on neurobiology, prevention, treatment, recovery, health systems integration, and recommendations for the future.

Data from 2015 show that more than 27 million people in the United States used illicit drugs or misuse prescription medications, while a quarter of the entire adult and adolescent population reported binge drinking in the past month. However, only 10% of those with a substance use disorder received relevant specialty care.

For the more than 40% of those with substance use disorders who have a comorbid mental health condition, less than half were treated for either, according to the federal Substance Abuse and Mental Health Services Administration.

That treatment gap is the direct result of lack of access to affordable care, shame, discrimination, and the lack of screening for substance misuse and substance use disorders in the primary care setting, Dr. Murthy wrote.

To address the gap, the surgeon general laid out a plan that starts with increasing community-wide substance use prevention efforts, such as enforcement of underage drinking laws and DUI laws, and offering needle exchange programs.

Dr. Murthy also called for a coordinated public health response to addiction, including an overhaul of criminal justice where substance use is concerned, and an emphasis on preventing known risk factors for substance misuse.

The report underscores the need for a better trained and integrated health care workforce equipped to treat addiction as a chronic disease in the general health care setting, enforcement of addiction and mental health parity laws, and the delivery of services based on the latest research into the psychosocial and biological underpinnings of substance use.

Surgeon General Murthy also used the report to urge professional medical associations to advocate for more access to medication-assisted treatment and prescription drug monitoring programs, and to create evidence-based guidelines for integrating substance use disorder treatment.

The American Medical Association responded positively to the report. In a statement, AMA President Andrew W. Gurman, MD, called it a “crucial starting point” and praised its “important guidance for the nation to see that addiction is a chronic disease and must be treated as such.”

While also supporting the report, others in the addiction medicine field pointed out that such starting points had come and gone before.

“As a profession, we saw what was happening 10 years ago, but there was no strong [push] to respond, for a variety of factors,” Ako Jacintho, MD, director of addiction medicine for HealthRIGHT 360, a California community health network, said in an interview.

[email protected]

On Twitter @whitneymcknight

Primary and emergency care providers must step up prevention efforts and the use of state-of-the-art medicine when treating patients with addiction, according to the first-ever U.S. Surgeon General’s report on alcohol, drugs, and health.

In the report, “Facing Addiction in America,” Surgeon General Vivek H. Murthy, MD, called on health care providers to increase access to care and approach addiction and substance use disorders as they would any other chronic health condition.

“We must help everyone see that addiction is not a character flaw – it is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer,” Dr. Murthy explained.

In addition to offering an action plan to address substance use of all kinds, the surgeon general’s report updates the public on the state of the art of addiction science, and includes chapters on neurobiology, prevention, treatment, recovery, health systems integration, and recommendations for the future.

Data from 2015 show that more than 27 million people in the United States used illicit drugs or misuse prescription medications, while a quarter of the entire adult and adolescent population reported binge drinking in the past month. However, only 10% of those with a substance use disorder received relevant specialty care.

For the more than 40% of those with substance use disorders who have a comorbid mental health condition, less than half were treated for either, according to the federal Substance Abuse and Mental Health Services Administration.

That treatment gap is the direct result of lack of access to affordable care, shame, discrimination, and the lack of screening for substance misuse and substance use disorders in the primary care setting, Dr. Murthy wrote.

To address the gap, the surgeon general laid out a plan that starts with increasing community-wide substance use prevention efforts, such as enforcement of underage drinking laws and DUI laws, and offering needle exchange programs.

Dr. Murthy also called for a coordinated public health response to addiction, including an overhaul of criminal justice where substance use is concerned, and an emphasis on preventing known risk factors for substance misuse.

The report underscores the need for a better trained and integrated health care workforce equipped to treat addiction as a chronic disease in the general health care setting, enforcement of addiction and mental health parity laws, and the delivery of services based on the latest research into the psychosocial and biological underpinnings of substance use.

Surgeon General Murthy also used the report to urge professional medical associations to advocate for more access to medication-assisted treatment and prescription drug monitoring programs, and to create evidence-based guidelines for integrating substance use disorder treatment.

The American Medical Association responded positively to the report. In a statement, AMA President Andrew W. Gurman, MD, called it a “crucial starting point” and praised its “important guidance for the nation to see that addiction is a chronic disease and must be treated as such.”

While also supporting the report, others in the addiction medicine field pointed out that such starting points had come and gone before.

“As a profession, we saw what was happening 10 years ago, but there was no strong [push] to respond, for a variety of factors,” Ako Jacintho, MD, director of addiction medicine for HealthRIGHT 360, a California community health network, said in an interview.

[email protected]

On Twitter @whitneymcknight

Primary and emergency care providers must step up prevention efforts and the use of state-of-the-art medicine when treating patients with addiction, according to the first-ever U.S. Surgeon General’s report on alcohol, drugs, and health.

In the report, “Facing Addiction in America,” Surgeon General Vivek H. Murthy, MD, called on health care providers to increase access to care and approach addiction and substance use disorders as they would any other chronic health condition.

“We must help everyone see that addiction is not a character flaw – it is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer,” Dr. Murthy explained.

In addition to offering an action plan to address substance use of all kinds, the surgeon general’s report updates the public on the state of the art of addiction science, and includes chapters on neurobiology, prevention, treatment, recovery, health systems integration, and recommendations for the future.

Data from 2015 show that more than 27 million people in the United States used illicit drugs or misuse prescription medications, while a quarter of the entire adult and adolescent population reported binge drinking in the past month. However, only 10% of those with a substance use disorder received relevant specialty care.

For the more than 40% of those with substance use disorders who have a comorbid mental health condition, less than half were treated for either, according to the federal Substance Abuse and Mental Health Services Administration.

That treatment gap is the direct result of lack of access to affordable care, shame, discrimination, and the lack of screening for substance misuse and substance use disorders in the primary care setting, Dr. Murthy wrote.

To address the gap, the surgeon general laid out a plan that starts with increasing community-wide substance use prevention efforts, such as enforcement of underage drinking laws and DUI laws, and offering needle exchange programs.

Dr. Murthy also called for a coordinated public health response to addiction, including an overhaul of criminal justice where substance use is concerned, and an emphasis on preventing known risk factors for substance misuse.

The report underscores the need for a better trained and integrated health care workforce equipped to treat addiction as a chronic disease in the general health care setting, enforcement of addiction and mental health parity laws, and the delivery of services based on the latest research into the psychosocial and biological underpinnings of substance use.

Surgeon General Murthy also used the report to urge professional medical associations to advocate for more access to medication-assisted treatment and prescription drug monitoring programs, and to create evidence-based guidelines for integrating substance use disorder treatment.

The American Medical Association responded positively to the report. In a statement, AMA President Andrew W. Gurman, MD, called it a “crucial starting point” and praised its “important guidance for the nation to see that addiction is a chronic disease and must be treated as such.”

While also supporting the report, others in the addiction medicine field pointed out that such starting points had come and gone before.

“As a profession, we saw what was happening 10 years ago, but there was no strong [push] to respond, for a variety of factors,” Ako Jacintho, MD, director of addiction medicine for HealthRIGHT 360, a California community health network, said in an interview.

[email protected]

On Twitter @whitneymcknight