In the June podcast for The Journal of Community and Supportive Oncology, Dr David Henry discusses the approval of alectinib as a new option for ALK-positive patients with NSCLC who have progressed on crizotinib, and a How We Do It article in which the authors the implementation of ipilimumab therapy in a private practice oncology group. The authors describe how they addressed start-up and reimbursement issues related to ipilimumab as a model for other expensive new cancer drugs as well. Also included are research articles on long-term community-based results of breast-conserving therapy in early-stage breast cancer, the use of the neurokinin 1 receptor antagonist in moderately emetogenic chemotherapy, risk assessment for hereditary breast and ovarian cancer in minority women, the impact of a nurse practitioner-led symptom clinic on emergency department use in cancer patients, and assessing outpatient oncology needs. Finally, Dr Henry examines evolving therapeutic strategies in melanoma.

Listen to the podcast below.

In the June podcast for The Journal of Community and Supportive Oncology, Dr David Henry discusses the approval of alectinib as a new option for ALK-positive patients with NSCLC who have progressed on crizotinib, and a How We Do It article in which the authors the implementation of ipilimumab therapy in a private practice oncology group. The authors describe how they addressed start-up and reimbursement issues related to ipilimumab as a model for other expensive new cancer drugs as well. Also included are research articles on long-term community-based results of breast-conserving therapy in early-stage breast cancer, the use of the neurokinin 1 receptor antagonist in moderately emetogenic chemotherapy, risk assessment for hereditary breast and ovarian cancer in minority women, the impact of a nurse practitioner-led symptom clinic on emergency department use in cancer patients, and assessing outpatient oncology needs. Finally, Dr Henry examines evolving therapeutic strategies in melanoma.

Listen to the podcast below.

In the June podcast for The Journal of Community and Supportive Oncology, Dr David Henry discusses the approval of alectinib as a new option for ALK-positive patients with NSCLC who have progressed on crizotinib, and a How We Do It article in which the authors the implementation of ipilimumab therapy in a private practice oncology group. The authors describe how they addressed start-up and reimbursement issues related to ipilimumab as a model for other expensive new cancer drugs as well. Also included are research articles on long-term community-based results of breast-conserving therapy in early-stage breast cancer, the use of the neurokinin 1 receptor antagonist in moderately emetogenic chemotherapy, risk assessment for hereditary breast and ovarian cancer in minority women, the impact of a nurse practitioner-led symptom clinic on emergency department use in cancer patients, and assessing outpatient oncology needs. Finally, Dr Henry examines evolving therapeutic strategies in melanoma.

Listen to the podcast below.

CHICAGO – The phase III CASTOR trial tested addition of daratumumab—an anti-CD38 antibody—to bortezomib and dexamethasone in patients with relapsed or refractory multiple myeloma. Compared with the dual therapy, the triple therapy reduced the risk of progression or death by 61%, with little increase in toxicity, according to data reported at the annual meeting of the American Society of Clinical Oncology.

In an interview at the meeting, lead author Dr. Antonio Palumbo fielded key questions: Do some patients benefit more than others? Does the antibody prolong overall survival? And how much will it cost?

Dr. Palumbo is chief of the multiple myeloma Unit at the University of Torino, Italy.

CHICAGO – The phase III CASTOR trial tested addition of daratumumab—an anti-CD38 antibody—to bortezomib and dexamethasone in patients with relapsed or refractory multiple myeloma. Compared with the dual therapy, the triple therapy reduced the risk of progression or death by 61%, with little increase in toxicity, according to data reported at the annual meeting of the American Society of Clinical Oncology.

In an interview at the meeting, lead author Dr. Antonio Palumbo fielded key questions: Do some patients benefit more than others? Does the antibody prolong overall survival? And how much will it cost?

Dr. Palumbo is chief of the multiple myeloma Unit at the University of Torino, Italy.

CHICAGO – The phase III CASTOR trial tested addition of daratumumab—an anti-CD38 antibody—to bortezomib and dexamethasone in patients with relapsed or refractory multiple myeloma. Compared with the dual therapy, the triple therapy reduced the risk of progression or death by 61%, with little increase in toxicity, according to data reported at the annual meeting of the American Society of Clinical Oncology.

In an interview at the meeting, lead author Dr. Antonio Palumbo fielded key questions: Do some patients benefit more than others? Does the antibody prolong overall survival? And how much will it cost?

Dr. Palumbo is chief of the multiple myeloma Unit at the University of Torino, Italy.

Metabolic surgery should be recommended for obese patients with type 2 diabetes mellitus, according to an international consensus statement from 48 clinicians and scholars issued after the Second Diabetes Surgery Summit held as part of the World Congress on Interventional Therapies for Type 2 Diabetes in London in 2015.

Current treatment plans for patients with type 2 diabetes do no include bariatric/metabolic surgery, despite increasing evidence of improved glycemic control and reduced cardiovascular risk factors in surgically treated patients, wrote Dr. Francesco Rubino and colleagues on behalf of members of the Second Diabetes Surgery Summit (DSS-II). The guidelines were endorsed by 45 global medical and scientific societies at the time of publication. The statement was published in a special edition of Diabetes Care (Diabetes Care. 2016;39:861-77. doi:10.2337/dc16-0236).

©SandraMatic/Thinkstock

The guidelines recommend metabolic surgery for patients with type 2 diabetes who have class III obesity (defined as a body mass index of at least 40 kg/m2) or class II obesity (defined as a BMI of 35 kg/m2-39.9 kg/m2). In addition, metabolic surgery should be considered as a option for those patients with type 2 diabetes whose BMI falls within the 30 kg/m2-34.9 kg/m2 range if hyperglycemia remains uncontrolled after treatment attempts with oral or injectable medications. For Asian patients, the BMI thresholds for surgery should be reduced by 2.5 kg/m2, the researchers noted.

The conclusions are based on a review of published evidence on metabolic surgery and type 2 diabetes from January 1, 2005, through September 30, 2015.

The researchers assessed the evidence based on factors including long-term effects of surgery on glycemic control, effectiveness of surgery compared with nonsurgical interventions, comparisons of surgical procedures, and effects of surgery on diabetes complications, cardiovascular risk factors, and mortality. They also considered the short- and long-term safety of different procedures. The recommendations offer guidance on patient selection, pre- and postoperative workups, choice of procedure, and defining goals and success of surgery.

“The success of metabolic surgery needs to be defined in the larger context of comprehensive diabetes care plans,” the researchers noted. “Metabolic surgery should be considered a means to achieve the glycemic control necessary to reduce risk of microvascular complications and CVD.”

The researchers acknowledged that complications from metabolic surgery may require reoperations and rehospitalizations. Other limitations include a lack of evidence in several areas including: cost-effectiveness, optimal nutrition management after surgery, postoperative lifestyle interventions, and long-term effects of surgery, and further research is needed.

However, “there is now sufficient clinical and mechanistic evidence to support inclusion of GI surgery among antidiabetes interventions for people with type 2 diabetes and obesity,” the researchers said. They called for collaboration between clinicians and regulators to recognize the potential value of metabolic surgery for type 2 diabetes and develop appropriate reimbursement plans.

The DSS-II and WCITD 2015 were sponsored by the International Diabetes Society Task Force, King’s College London, King’s College Hospital, Johnson & Johnson, Medtronic, Medimmune, Fractyl, DIAMOND MetaCure, Gore, Novo Nordisk, and NGM Biopharmaceuticals. The researchers reported no relevant conflicts.

Metabolic surgery should be recommended for obese patients with type 2 diabetes mellitus, according to an international consensus statement from 48 clinicians and scholars issued after the Second Diabetes Surgery Summit held as part of the World Congress on Interventional Therapies for Type 2 Diabetes in London in 2015.

Current treatment plans for patients with type 2 diabetes do no include bariatric/metabolic surgery, despite increasing evidence of improved glycemic control and reduced cardiovascular risk factors in surgically treated patients, wrote Dr. Francesco Rubino and colleagues on behalf of members of the Second Diabetes Surgery Summit (DSS-II). The guidelines were endorsed by 45 global medical and scientific societies at the time of publication. The statement was published in a special edition of Diabetes Care (Diabetes Care. 2016;39:861-77. doi:10.2337/dc16-0236).

©SandraMatic/Thinkstock

The guidelines recommend metabolic surgery for patients with type 2 diabetes who have class III obesity (defined as a body mass index of at least 40 kg/m2) or class II obesity (defined as a BMI of 35 kg/m2-39.9 kg/m2). In addition, metabolic surgery should be considered as a option for those patients with type 2 diabetes whose BMI falls within the 30 kg/m2-34.9 kg/m2 range if hyperglycemia remains uncontrolled after treatment attempts with oral or injectable medications. For Asian patients, the BMI thresholds for surgery should be reduced by 2.5 kg/m2, the researchers noted.

The conclusions are based on a review of published evidence on metabolic surgery and type 2 diabetes from January 1, 2005, through September 30, 2015.

The researchers assessed the evidence based on factors including long-term effects of surgery on glycemic control, effectiveness of surgery compared with nonsurgical interventions, comparisons of surgical procedures, and effects of surgery on diabetes complications, cardiovascular risk factors, and mortality. They also considered the short- and long-term safety of different procedures. The recommendations offer guidance on patient selection, pre- and postoperative workups, choice of procedure, and defining goals and success of surgery.

“The success of metabolic surgery needs to be defined in the larger context of comprehensive diabetes care plans,” the researchers noted. “Metabolic surgery should be considered a means to achieve the glycemic control necessary to reduce risk of microvascular complications and CVD.”

The researchers acknowledged that complications from metabolic surgery may require reoperations and rehospitalizations. Other limitations include a lack of evidence in several areas including: cost-effectiveness, optimal nutrition management after surgery, postoperative lifestyle interventions, and long-term effects of surgery, and further research is needed.

However, “there is now sufficient clinical and mechanistic evidence to support inclusion of GI surgery among antidiabetes interventions for people with type 2 diabetes and obesity,” the researchers said. They called for collaboration between clinicians and regulators to recognize the potential value of metabolic surgery for type 2 diabetes and develop appropriate reimbursement plans.

The DSS-II and WCITD 2015 were sponsored by the International Diabetes Society Task Force, King’s College London, King’s College Hospital, Johnson & Johnson, Medtronic, Medimmune, Fractyl, DIAMOND MetaCure, Gore, Novo Nordisk, and NGM Biopharmaceuticals. The researchers reported no relevant conflicts.

Metabolic surgery should be recommended for obese patients with type 2 diabetes mellitus, according to an international consensus statement from 48 clinicians and scholars issued after the Second Diabetes Surgery Summit held as part of the World Congress on Interventional Therapies for Type 2 Diabetes in London in 2015.

Current treatment plans for patients with type 2 diabetes do no include bariatric/metabolic surgery, despite increasing evidence of improved glycemic control and reduced cardiovascular risk factors in surgically treated patients, wrote Dr. Francesco Rubino and colleagues on behalf of members of the Second Diabetes Surgery Summit (DSS-II). The guidelines were endorsed by 45 global medical and scientific societies at the time of publication. The statement was published in a special edition of Diabetes Care (Diabetes Care. 2016;39:861-77. doi:10.2337/dc16-0236).

©SandraMatic/Thinkstock

The guidelines recommend metabolic surgery for patients with type 2 diabetes who have class III obesity (defined as a body mass index of at least 40 kg/m2) or class II obesity (defined as a BMI of 35 kg/m2-39.9 kg/m2). In addition, metabolic surgery should be considered as a option for those patients with type 2 diabetes whose BMI falls within the 30 kg/m2-34.9 kg/m2 range if hyperglycemia remains uncontrolled after treatment attempts with oral or injectable medications. For Asian patients, the BMI thresholds for surgery should be reduced by 2.5 kg/m2, the researchers noted.

The conclusions are based on a review of published evidence on metabolic surgery and type 2 diabetes from January 1, 2005, through September 30, 2015.

The researchers assessed the evidence based on factors including long-term effects of surgery on glycemic control, effectiveness of surgery compared with nonsurgical interventions, comparisons of surgical procedures, and effects of surgery on diabetes complications, cardiovascular risk factors, and mortality. They also considered the short- and long-term safety of different procedures. The recommendations offer guidance on patient selection, pre- and postoperative workups, choice of procedure, and defining goals and success of surgery.

“The success of metabolic surgery needs to be defined in the larger context of comprehensive diabetes care plans,” the researchers noted. “Metabolic surgery should be considered a means to achieve the glycemic control necessary to reduce risk of microvascular complications and CVD.”

The researchers acknowledged that complications from metabolic surgery may require reoperations and rehospitalizations. Other limitations include a lack of evidence in several areas including: cost-effectiveness, optimal nutrition management after surgery, postoperative lifestyle interventions, and long-term effects of surgery, and further research is needed.

However, “there is now sufficient clinical and mechanistic evidence to support inclusion of GI surgery among antidiabetes interventions for people with type 2 diabetes and obesity,” the researchers said. They called for collaboration between clinicians and regulators to recognize the potential value of metabolic surgery for type 2 diabetes and develop appropriate reimbursement plans.

The DSS-II and WCITD 2015 were sponsored by the International Diabetes Society Task Force, King’s College London, King’s College Hospital, Johnson & Johnson, Medtronic, Medimmune, Fractyl, DIAMOND MetaCure, Gore, Novo Nordisk, and NGM Biopharmaceuticals. The researchers reported no relevant conflicts.

Individuals with HIV and hepatitis C virus coinfection show significantly higher levels of particular inflammatory cytokines linked to liver damage, according to a study published online in HIV Medicine.

Researchers examined a range of markers of systemic inflammation in 79 HIV-infected patients – 42 of whom were coinfected with hepatitis C – and all of whom had been on antiretroviral therapy and had plasma viral levels suppressed below 50 HIV-1 RNA copies per ml, and compared them to 20 healthy controls.

©grandeduc/Thinkstock

Their analysis initially revealed that the individuals with HIV/HCV coinfection had higher plasma levels of interleukin-6, interferon gamma-induced protein (IP)-10, monocyte/macrophage markers neopterin and sCD163, and soluble tumour necrosis factor receptor-II than individuals with HIV infection alone.

However after adjusting for duration of HIV infection and gender, researchers only found a significant difference between HIV/HCV coinfected individuals and those with HIV alone in plasma levels of IP-10, sCD163 and neopterin (HIV Medicine. 2016 May 17. doi:10.1111/hiv.12357).

The study also undertook to correlate these markers with hepatic damage, and found a highly significant and consistent relationship between aspartate aminotransferase, alanine aminotransferase and AST-to platelet-ratio index, and plasma IP-10, sCD163 and neopterin.

“Although a contribution of ART-induced hepatotoxicity in the setting of HCV/HIV coinfection cannot be excluded, a simpler and more plausible explanation is that the observed effects are related to HCV/HIV-mediated liver damage,” wrote Dr. Konstantin V. Shmagel, from the Institute of Ecology and Genetics of Microorganisms at the Russian Academy of Sciences in Perm, Russia.

“The relationship among these indices remains incompletely understood but it is possible that processes taking place in the liver may play a role in alteration of CD4 T-cell recovery during ART in the setting of HCV/HIV coinfection.”

The analysis also showed the inflammatory markers IL-6, neopterin and sCD14 were also elevated – although not to the same degree – in individuals with HIV monoinfection compared to the healthy controls.

“The drivers of persistent inflammation in treated HIV infection and HIV/HCV coinfection are not entirely clear but, in these settings, damage to the gut epithelial barrier has been implicated in promoting translocation of microbial products from the gut lumen into the systemic circulation,” the authors wrote.

This study was supported by the National Institute of Allergy and Infectious Diseases, the Center for AIDS Research at Case Western Reserve University, and the Russian Science Foundation. No conflicts of interest were declared.

Individuals with HIV and hepatitis C virus coinfection show significantly higher levels of particular inflammatory cytokines linked to liver damage, according to a study published online in HIV Medicine.

Researchers examined a range of markers of systemic inflammation in 79 HIV-infected patients – 42 of whom were coinfected with hepatitis C – and all of whom had been on antiretroviral therapy and had plasma viral levels suppressed below 50 HIV-1 RNA copies per ml, and compared them to 20 healthy controls.

©grandeduc/Thinkstock

Their analysis initially revealed that the individuals with HIV/HCV coinfection had higher plasma levels of interleukin-6, interferon gamma-induced protein (IP)-10, monocyte/macrophage markers neopterin and sCD163, and soluble tumour necrosis factor receptor-II than individuals with HIV infection alone.

However after adjusting for duration of HIV infection and gender, researchers only found a significant difference between HIV/HCV coinfected individuals and those with HIV alone in plasma levels of IP-10, sCD163 and neopterin (HIV Medicine. 2016 May 17. doi:10.1111/hiv.12357).

The study also undertook to correlate these markers with hepatic damage, and found a highly significant and consistent relationship between aspartate aminotransferase, alanine aminotransferase and AST-to platelet-ratio index, and plasma IP-10, sCD163 and neopterin.

“Although a contribution of ART-induced hepatotoxicity in the setting of HCV/HIV coinfection cannot be excluded, a simpler and more plausible explanation is that the observed effects are related to HCV/HIV-mediated liver damage,” wrote Dr. Konstantin V. Shmagel, from the Institute of Ecology and Genetics of Microorganisms at the Russian Academy of Sciences in Perm, Russia.

“The relationship among these indices remains incompletely understood but it is possible that processes taking place in the liver may play a role in alteration of CD4 T-cell recovery during ART in the setting of HCV/HIV coinfection.”

The analysis also showed the inflammatory markers IL-6, neopterin and sCD14 were also elevated – although not to the same degree – in individuals with HIV monoinfection compared to the healthy controls.

“The drivers of persistent inflammation in treated HIV infection and HIV/HCV coinfection are not entirely clear but, in these settings, damage to the gut epithelial barrier has been implicated in promoting translocation of microbial products from the gut lumen into the systemic circulation,” the authors wrote.

This study was supported by the National Institute of Allergy and Infectious Diseases, the Center for AIDS Research at Case Western Reserve University, and the Russian Science Foundation. No conflicts of interest were declared.

Individuals with HIV and hepatitis C virus coinfection show significantly higher levels of particular inflammatory cytokines linked to liver damage, according to a study published online in HIV Medicine.

Researchers examined a range of markers of systemic inflammation in 79 HIV-infected patients – 42 of whom were coinfected with hepatitis C – and all of whom had been on antiretroviral therapy and had plasma viral levels suppressed below 50 HIV-1 RNA copies per ml, and compared them to 20 healthy controls.

©grandeduc/Thinkstock

Their analysis initially revealed that the individuals with HIV/HCV coinfection had higher plasma levels of interleukin-6, interferon gamma-induced protein (IP)-10, monocyte/macrophage markers neopterin and sCD163, and soluble tumour necrosis factor receptor-II than individuals with HIV infection alone.

However after adjusting for duration of HIV infection and gender, researchers only found a significant difference between HIV/HCV coinfected individuals and those with HIV alone in plasma levels of IP-10, sCD163 and neopterin (HIV Medicine. 2016 May 17. doi:10.1111/hiv.12357).

The study also undertook to correlate these markers with hepatic damage, and found a highly significant and consistent relationship between aspartate aminotransferase, alanine aminotransferase and AST-to platelet-ratio index, and plasma IP-10, sCD163 and neopterin.

“Although a contribution of ART-induced hepatotoxicity in the setting of HCV/HIV coinfection cannot be excluded, a simpler and more plausible explanation is that the observed effects are related to HCV/HIV-mediated liver damage,” wrote Dr. Konstantin V. Shmagel, from the Institute of Ecology and Genetics of Microorganisms at the Russian Academy of Sciences in Perm, Russia.

“The relationship among these indices remains incompletely understood but it is possible that processes taking place in the liver may play a role in alteration of CD4 T-cell recovery during ART in the setting of HCV/HIV coinfection.”

The analysis also showed the inflammatory markers IL-6, neopterin and sCD14 were also elevated – although not to the same degree – in individuals with HIV monoinfection compared to the healthy controls.

“The drivers of persistent inflammation in treated HIV infection and HIV/HCV coinfection are not entirely clear but, in these settings, damage to the gut epithelial barrier has been implicated in promoting translocation of microbial products from the gut lumen into the systemic circulation,” the authors wrote.

This study was supported by the National Institute of Allergy and Infectious Diseases, the Center for AIDS Research at Case Western Reserve University, and the Russian Science Foundation. No conflicts of interest were declared.

NATIONAL HARBOR, MD. – Updated imaging protocols for patients with multiple sclerosis from a panel of North American neurology and radiology experts promise to improve the accuracy of diagnosis and monitoring.

The guidelines emphasize the use of three-dimensional MRI to provide complete coverage of the brain, monitoring for progressive multifocal leukoencephalopathy (PML), and optical orbit MRI for severe optic neuritis.

Key clinical guideline changes include more specific timing of brain MRI when monitoring patients receiving disease modifying therapy, timing of brain MRI to monitor for PML, updated evidence of the value of MRI changes in determining the effectiveness of treatment, and the inclusion of radiologic isolated syndrome.

Dr. Anthony Traboulsee of the University of British Columbia, Vancouver, discussed the latest MRI guidelines at the annual meeting of the Consortium of Multiple Sclerosis Centers.

“MS is a life-long disorder and MRI is one of the best ways to monitor for new lesions that can be occurring in the absence of new symptoms (clinically silent disease activity). These lesions accumulate and lead to future disability. In order to accurately determine if changes are occurring, we need MRIs that are similar in quality over time regardless of where the patient had an MRI performed. A standardized MRI protocol provides this quality of data,” Dr. Traboulsee said.

The guidelines, published in the American Journal of Neuroradiology (Am J Neuroradiol. 2015 Nov 12. doi: 10.3174/ajnr.A4539), recommend a first MRI as soon as a physician suspects MS in a patient, with subsequent MRIs typically done annually to determine whether the disease is stable or progressive, which could prompt a change in treatment. “Breakthrough activity on MRI that is occurring while on treatment can lead to future disability and is an opportunity to consider switching therapy,” Dr. Traboulsee said.

More frequent scans could be appropriate for patients with a more aggressive and active disease course, and when treatment has been changed. More frequent monitoring and diffusion-weighted imaging is also recommended for patients taking natalizumab (Tysabri), since they are at high risk for PML.

Another goal of the guidelines is to describe how best to use MRI to support an early diagnosis of MS and to help avoid misdiagnosis. Early treatment depends on an early diagnosis. “We find the biggest impact of our disease-modifying therapy is in the first decade. The goal is to prevent new injury and optimize brain health through treatment and lifestyle,” said Dr. Traboulsee.

MRI scans alone should not be diagnostic. Clinical information is also needed, such as numbness or problems with balance. Abnormal brain MRIs occur in about 5% of people without MS and white spots in the brain that are unrelated to MS can naturally develop as people age.

If clinically isolated syndrome is suspected, a cervical cord MRI should be done along with a brain MRI. Use of a gadolinium contrast agent is recommended to better determine disease activity and speed diagnosis.

Dr. Traboulsee received grant support from Biogen, Chugai, Hoffman la Roche, and Sanofi Genzyme. He reported being a steering committee member for Hoffman la Roche and has been a consultant to Biogen, Chugai, EMD Serono, Hoffman la Roche, MedImmune, Sanofi Genzyme, and Teva Neuroscience.

NATIONAL HARBOR, MD. – Updated imaging protocols for patients with multiple sclerosis from a panel of North American neurology and radiology experts promise to improve the accuracy of diagnosis and monitoring.

The guidelines emphasize the use of three-dimensional MRI to provide complete coverage of the brain, monitoring for progressive multifocal leukoencephalopathy (PML), and optical orbit MRI for severe optic neuritis.

Key clinical guideline changes include more specific timing of brain MRI when monitoring patients receiving disease modifying therapy, timing of brain MRI to monitor for PML, updated evidence of the value of MRI changes in determining the effectiveness of treatment, and the inclusion of radiologic isolated syndrome.

Dr. Anthony Traboulsee of the University of British Columbia, Vancouver, discussed the latest MRI guidelines at the annual meeting of the Consortium of Multiple Sclerosis Centers.

“MS is a life-long disorder and MRI is one of the best ways to monitor for new lesions that can be occurring in the absence of new symptoms (clinically silent disease activity). These lesions accumulate and lead to future disability. In order to accurately determine if changes are occurring, we need MRIs that are similar in quality over time regardless of where the patient had an MRI performed. A standardized MRI protocol provides this quality of data,” Dr. Traboulsee said.

The guidelines, published in the American Journal of Neuroradiology (Am J Neuroradiol. 2015 Nov 12. doi: 10.3174/ajnr.A4539), recommend a first MRI as soon as a physician suspects MS in a patient, with subsequent MRIs typically done annually to determine whether the disease is stable or progressive, which could prompt a change in treatment. “Breakthrough activity on MRI that is occurring while on treatment can lead to future disability and is an opportunity to consider switching therapy,” Dr. Traboulsee said.

More frequent scans could be appropriate for patients with a more aggressive and active disease course, and when treatment has been changed. More frequent monitoring and diffusion-weighted imaging is also recommended for patients taking natalizumab (Tysabri), since they are at high risk for PML.

Another goal of the guidelines is to describe how best to use MRI to support an early diagnosis of MS and to help avoid misdiagnosis. Early treatment depends on an early diagnosis. “We find the biggest impact of our disease-modifying therapy is in the first decade. The goal is to prevent new injury and optimize brain health through treatment and lifestyle,” said Dr. Traboulsee.

MRI scans alone should not be diagnostic. Clinical information is also needed, such as numbness or problems with balance. Abnormal brain MRIs occur in about 5% of people without MS and white spots in the brain that are unrelated to MS can naturally develop as people age.

If clinically isolated syndrome is suspected, a cervical cord MRI should be done along with a brain MRI. Use of a gadolinium contrast agent is recommended to better determine disease activity and speed diagnosis.

Dr. Traboulsee received grant support from Biogen, Chugai, Hoffman la Roche, and Sanofi Genzyme. He reported being a steering committee member for Hoffman la Roche and has been a consultant to Biogen, Chugai, EMD Serono, Hoffman la Roche, MedImmune, Sanofi Genzyme, and Teva Neuroscience.

NATIONAL HARBOR, MD. – Updated imaging protocols for patients with multiple sclerosis from a panel of North American neurology and radiology experts promise to improve the accuracy of diagnosis and monitoring.

The guidelines emphasize the use of three-dimensional MRI to provide complete coverage of the brain, monitoring for progressive multifocal leukoencephalopathy (PML), and optical orbit MRI for severe optic neuritis.

Key clinical guideline changes include more specific timing of brain MRI when monitoring patients receiving disease modifying therapy, timing of brain MRI to monitor for PML, updated evidence of the value of MRI changes in determining the effectiveness of treatment, and the inclusion of radiologic isolated syndrome.

Dr. Anthony Traboulsee of the University of British Columbia, Vancouver, discussed the latest MRI guidelines at the annual meeting of the Consortium of Multiple Sclerosis Centers.

“MS is a life-long disorder and MRI is one of the best ways to monitor for new lesions that can be occurring in the absence of new symptoms (clinically silent disease activity). These lesions accumulate and lead to future disability. In order to accurately determine if changes are occurring, we need MRIs that are similar in quality over time regardless of where the patient had an MRI performed. A standardized MRI protocol provides this quality of data,” Dr. Traboulsee said.

The guidelines, published in the American Journal of Neuroradiology (Am J Neuroradiol. 2015 Nov 12. doi: 10.3174/ajnr.A4539), recommend a first MRI as soon as a physician suspects MS in a patient, with subsequent MRIs typically done annually to determine whether the disease is stable or progressive, which could prompt a change in treatment. “Breakthrough activity on MRI that is occurring while on treatment can lead to future disability and is an opportunity to consider switching therapy,” Dr. Traboulsee said.

More frequent scans could be appropriate for patients with a more aggressive and active disease course, and when treatment has been changed. More frequent monitoring and diffusion-weighted imaging is also recommended for patients taking natalizumab (Tysabri), since they are at high risk for PML.

Another goal of the guidelines is to describe how best to use MRI to support an early diagnosis of MS and to help avoid misdiagnosis. Early treatment depends on an early diagnosis. “We find the biggest impact of our disease-modifying therapy is in the first decade. The goal is to prevent new injury and optimize brain health through treatment and lifestyle,” said Dr. Traboulsee.

MRI scans alone should not be diagnostic. Clinical information is also needed, such as numbness or problems with balance. Abnormal brain MRIs occur in about 5% of people without MS and white spots in the brain that are unrelated to MS can naturally develop as people age.

If clinically isolated syndrome is suspected, a cervical cord MRI should be done along with a brain MRI. Use of a gadolinium contrast agent is recommended to better determine disease activity and speed diagnosis.

Dr. Traboulsee received grant support from Biogen, Chugai, Hoffman la Roche, and Sanofi Genzyme. He reported being a steering committee member for Hoffman la Roche and has been a consultant to Biogen, Chugai, EMD Serono, Hoffman la Roche, MedImmune, Sanofi Genzyme, and Teva Neuroscience.

Clinical question: Will a multifaceted quality improvement initiative targeted at hospitalists reduce inpatient laboratory costs?

Background: Routine inpatient laboratory testing is a well-recognized area of healthcare waste and was highlighted by the American Board of Internal Medicine Choosing Wisely campaign as a practice that should be questioned. Multifaceted quality improvement interventions, especially those that incorporate interventions beyond education, are more successful at achieving sustainable change.

Study design: Retrospective, controlled, interrupted time series study.

Setting: University of Utah, academic general internal medicine hospitalist service.

Synopsis: The intervention group, a teaching hospitalist service, received targeted education, cost feedback comparing individual provider performance, and divisional financial incentives. Additionally, a standardized rounding checklist was implemented and completed by rotating medical students. The control group included all non-hospitalist services. Approximately 20% of the 31,896 encounters measured in pre-intervention and post-intervention periods took place in the intervention group. Lab cost per day was reduced from $138 to $123 in the intervention group (P<0.001), while cost per day was non-significantly increased in the control group from $130 to $132 (P=0.37). Limitations of this study include the fact that the University of Utah already prioritizes high-value care and utilizes a local tool to provide individual cost and ordering feedback to providers as well as the financial incentives. Additionally, the use of medical students to implement the rounding checklist may not be feasible in many practice settings.

Bottom line: An approach of targeted education, direct provider feedback, consistent use of a rounding checklist, and financial incentives may decrease lab utilization.

Citation: Yarbrough PM, Kukhareva PV, Horton D, Edholm K, Kawamoto K. Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs [published online ahead of print February 4, 2016]. J Hosp Med. doi:10.1002/jhm.2552.

Short Take

aVL ST-Depression Differentiates Inferior Stemi from Pericarditis

This retrospective analysis showed that any aVL ST-depression helps to distinguish inferior myocardial infarctions from pericarditis.

Citation: Bischof JE, Worrall C, Thompson P, Marti D, Smith SW. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016;34(2):149-154.

Clinical question: Will a multifaceted quality improvement initiative targeted at hospitalists reduce inpatient laboratory costs?

Background: Routine inpatient laboratory testing is a well-recognized area of healthcare waste and was highlighted by the American Board of Internal Medicine Choosing Wisely campaign as a practice that should be questioned. Multifaceted quality improvement interventions, especially those that incorporate interventions beyond education, are more successful at achieving sustainable change.

Study design: Retrospective, controlled, interrupted time series study.

Setting: University of Utah, academic general internal medicine hospitalist service.

Synopsis: The intervention group, a teaching hospitalist service, received targeted education, cost feedback comparing individual provider performance, and divisional financial incentives. Additionally, a standardized rounding checklist was implemented and completed by rotating medical students. The control group included all non-hospitalist services. Approximately 20% of the 31,896 encounters measured in pre-intervention and post-intervention periods took place in the intervention group. Lab cost per day was reduced from $138 to $123 in the intervention group (P<0.001), while cost per day was non-significantly increased in the control group from $130 to $132 (P=0.37). Limitations of this study include the fact that the University of Utah already prioritizes high-value care and utilizes a local tool to provide individual cost and ordering feedback to providers as well as the financial incentives. Additionally, the use of medical students to implement the rounding checklist may not be feasible in many practice settings.

Bottom line: An approach of targeted education, direct provider feedback, consistent use of a rounding checklist, and financial incentives may decrease lab utilization.

Citation: Yarbrough PM, Kukhareva PV, Horton D, Edholm K, Kawamoto K. Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs [published online ahead of print February 4, 2016]. J Hosp Med. doi:10.1002/jhm.2552.

Short Take

aVL ST-Depression Differentiates Inferior Stemi from Pericarditis

This retrospective analysis showed that any aVL ST-depression helps to distinguish inferior myocardial infarctions from pericarditis.

Citation: Bischof JE, Worrall C, Thompson P, Marti D, Smith SW. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016;34(2):149-154.

Clinical question: Will a multifaceted quality improvement initiative targeted at hospitalists reduce inpatient laboratory costs?

Background: Routine inpatient laboratory testing is a well-recognized area of healthcare waste and was highlighted by the American Board of Internal Medicine Choosing Wisely campaign as a practice that should be questioned. Multifaceted quality improvement interventions, especially those that incorporate interventions beyond education, are more successful at achieving sustainable change.

Study design: Retrospective, controlled, interrupted time series study.

Setting: University of Utah, academic general internal medicine hospitalist service.

Synopsis: The intervention group, a teaching hospitalist service, received targeted education, cost feedback comparing individual provider performance, and divisional financial incentives. Additionally, a standardized rounding checklist was implemented and completed by rotating medical students. The control group included all non-hospitalist services. Approximately 20% of the 31,896 encounters measured in pre-intervention and post-intervention periods took place in the intervention group. Lab cost per day was reduced from $138 to $123 in the intervention group (P<0.001), while cost per day was non-significantly increased in the control group from $130 to $132 (P=0.37). Limitations of this study include the fact that the University of Utah already prioritizes high-value care and utilizes a local tool to provide individual cost and ordering feedback to providers as well as the financial incentives. Additionally, the use of medical students to implement the rounding checklist may not be feasible in many practice settings.

Bottom line: An approach of targeted education, direct provider feedback, consistent use of a rounding checklist, and financial incentives may decrease lab utilization.

Citation: Yarbrough PM, Kukhareva PV, Horton D, Edholm K, Kawamoto K. Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs [published online ahead of print February 4, 2016]. J Hosp Med. doi:10.1002/jhm.2552.

Short Take

aVL ST-Depression Differentiates Inferior Stemi from Pericarditis

This retrospective analysis showed that any aVL ST-depression helps to distinguish inferior myocardial infarctions from pericarditis.

Citation: Bischof JE, Worrall C, Thompson P, Marti D, Smith SW. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis. Am J Emerg Med. 2016;34(2):149-154.

Clinical question: Does discharge planning improve length of stay and reduce readmission rates compared to usual care?

Background: Discharge planning is accomplished to varying degrees for patients admitted to an acute-care hospital. Goals include improving the quality of care transitions as well as cost containment.

Study design: Meta-analysis.

Setting: Thirty studies that examined the effects of discharge planning.

Synopsis: In 12 studies focusing on older patients, discharge planning resulted in a reduction in hospital length of stay by 0.73 days (95% CI, -1.33 to -0.12). Readmission rates for this population were reduced, with approximately three fewer readmissions per 100 patients (relative risk, 0.87; 95% CI, 0.79–0.97). These results were not consistent for other populations, including surgical patients and patients admitted following a fall. No conclusions could be drawn on other outcomes, including patient and provider satisfaction, location of eventual discharge, and mortality. The effect of discharge planning on cost of care was uncertain based on the five trials reporting varied outcomes. Limitations include the varied descriptions of what constituted discharge planning and the lack of reporting on the role of communication in the process. Given the Centers for Medicare & Medicaid Services’ requirements for discharge planning, it is difficult to estimate the effect this study has on clinical practice.

Further study is needed to determine which aspects of discharge planning lead to desired clinical outcomes and the effects on overall cost of care.

Bottom line: Discharge planning in older patients with medical admissions appears to marginally reduce length of stay and readmission rates without a clear effect on cost of care.

Citation: Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database Syst Rev. 2016;1:CD000313. doi:10.1002/14651858.CD000313.pub5.

Clinical question: Does discharge planning improve length of stay and reduce readmission rates compared to usual care?

Background: Discharge planning is accomplished to varying degrees for patients admitted to an acute-care hospital. Goals include improving the quality of care transitions as well as cost containment.

Study design: Meta-analysis.

Setting: Thirty studies that examined the effects of discharge planning.

Synopsis: In 12 studies focusing on older patients, discharge planning resulted in a reduction in hospital length of stay by 0.73 days (95% CI, -1.33 to -0.12). Readmission rates for this population were reduced, with approximately three fewer readmissions per 100 patients (relative risk, 0.87; 95% CI, 0.79–0.97). These results were not consistent for other populations, including surgical patients and patients admitted following a fall. No conclusions could be drawn on other outcomes, including patient and provider satisfaction, location of eventual discharge, and mortality. The effect of discharge planning on cost of care was uncertain based on the five trials reporting varied outcomes. Limitations include the varied descriptions of what constituted discharge planning and the lack of reporting on the role of communication in the process. Given the Centers for Medicare & Medicaid Services’ requirements for discharge planning, it is difficult to estimate the effect this study has on clinical practice.

Further study is needed to determine which aspects of discharge planning lead to desired clinical outcomes and the effects on overall cost of care.

Bottom line: Discharge planning in older patients with medical admissions appears to marginally reduce length of stay and readmission rates without a clear effect on cost of care.

Citation: Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database Syst Rev. 2016;1:CD000313. doi:10.1002/14651858.CD000313.pub5.

Clinical question: Does discharge planning improve length of stay and reduce readmission rates compared to usual care?

Background: Discharge planning is accomplished to varying degrees for patients admitted to an acute-care hospital. Goals include improving the quality of care transitions as well as cost containment.

Study design: Meta-analysis.

Setting: Thirty studies that examined the effects of discharge planning.

Synopsis: In 12 studies focusing on older patients, discharge planning resulted in a reduction in hospital length of stay by 0.73 days (95% CI, -1.33 to -0.12). Readmission rates for this population were reduced, with approximately three fewer readmissions per 100 patients (relative risk, 0.87; 95% CI, 0.79–0.97). These results were not consistent for other populations, including surgical patients and patients admitted following a fall. No conclusions could be drawn on other outcomes, including patient and provider satisfaction, location of eventual discharge, and mortality. The effect of discharge planning on cost of care was uncertain based on the five trials reporting varied outcomes. Limitations include the varied descriptions of what constituted discharge planning and the lack of reporting on the role of communication in the process. Given the Centers for Medicare & Medicaid Services’ requirements for discharge planning, it is difficult to estimate the effect this study has on clinical practice.

Further study is needed to determine which aspects of discharge planning lead to desired clinical outcomes and the effects on overall cost of care.

Bottom line: Discharge planning in older patients with medical admissions appears to marginally reduce length of stay and readmission rates without a clear effect on cost of care.

Citation: Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database Syst Rev. 2016;1:CD000313. doi:10.1002/14651858.CD000313.pub5.

Warfarin tablets

Using an Atrial Fibrillation Decision Support Tool (AFDST), investigators determined that 45% of women and 39% of men in the study population were not being treated according to the tool’s recommended treatments to prevent stroke resulting from atrial fibrillation (AF).

Investigators wanted to achieve a better understanding of the appropriateness of antithrombotic therapy for thromboprophylaxis in women and elderly adults.

So they studied a cohort of individuals with AF to determine whether they were treated according to recommendations.

According to lead author Mark Eckman, MD, of the University of Cincinnati in Ohio, under treatment of patients with AF is a national problem.

And ironically, “[W]omen have a higher risk of AF-related stroke,” he said, “controlling for other risk factors such as hypertension, diabetes, congestive heart failure, yet women are being under treated.”

The team retrospectively studied 1585 adults aged 28 to 93 with nonvalvular AF or flutter cared for in an ambulatory setting in the University of Cincinnati Health primary care network.

The primary care doctors were testing the computerized AFDST, which uses patient information and characteristics to help with decisions about anticoagulant therapy to prevent stroke in AF patients.

The AFDST calculates for the individual patient the risk of AF-related stroke and major bleeding while taking blood thinning therapy. Based on this information, the AFDST makes suggestions for the best treatment to prevent AF-related stroke.

Demographics

Of the 1585 study participants, 46% were women.

Half of the participants were receiving some form of oral anticoagulant, primarily warfarin (39%), 36% were on aspirin only, and 11% were receiving other oral anticoagulants.

The investigators noted a trend in the study population toward lower levels of oral anticoagulant use in women (48%) as compared to men (52%), but the trend was not statistically significant (P=0.06).

Results

The AFDST recommended oral anticoagulation for 87% of the participants, aspirin for 4%,  and no antithrombitic therapy for 9%.

Patients' antithrombotic therapy was concordant with the AFDST recommendation in 58% of the participants.

Of the 42% for whom therapy was discordant with the AFDST, 37% were receiving aspirin only or no antithrombotic therapy when the tool recommended oral anticoagulation; 2% were receiving no antithrombotic therapy when the tool recommended aspirin; and 3% were receiving aspirin or oral anticoagulation when the tool recommended no antithrombotic therapy.

And as mentioned above, current treatment was discordant from recommended treatment in 45% of women and 39% of men (P=0.02).

Forty-four percent of women were under treated, receiving aspirin only when oral anticoagulation was recommended, compared with 31% of men who were under treated (P<0.001). Women were 1.8 times as likely to be under treated as men.

"Doctors need to realize we have mental biases that women are healthier and at lower risk of stroke,” Dr Eckman said. 

“We think women are at lower risk and we ignore warning signs,” he continued. “Thus, when we are making decisions for blood thinning therapy for patients with atrial fibrillation, we need to remember that women are at higher risk and we need to make sure we treat them aggressively enough to prevent stroke."

Overall, the use of oral anticoagulants did not differ significantly by age, with 55% of the patients 85 years and older receiving anticoagulation and 49% of the patients younger than 85 receiving it (P=0.13).

In 35% of the older population, treatment was discordant with recommendations compared with 43% in the younger (P = 0.009). Similar proportions in the younger and older groups were undertreated (P=0.30).

According to investigators, one surprising finding was that the proportion of patients receiving discordant treatment was larger in the younger group than in the over-85 group. They attributed this largely to overtreatment in the 31 to 50 age group.

Dr Eckman and colleagues published these findings in Journal of the American Geriatrics Society.

The research was supported in part by grants from Bristol-Myers Squibb/Pfizer Education Consortium, Pfizer Medical Education Group, Informed Medical Decisions Foundation, and the National Institutes of Health/National Center for Advancing Translational Sciences.

Warfarin tablets

Using an Atrial Fibrillation Decision Support Tool (AFDST), investigators determined that 45% of women and 39% of men in the study population were not being treated according to the tool’s recommended treatments to prevent stroke resulting from atrial fibrillation (AF).

Investigators wanted to achieve a better understanding of the appropriateness of antithrombotic therapy for thromboprophylaxis in women and elderly adults.

So they studied a cohort of individuals with AF to determine whether they were treated according to recommendations.

According to lead author Mark Eckman, MD, of the University of Cincinnati in Ohio, under treatment of patients with AF is a national problem.

And ironically, “[W]omen have a higher risk of AF-related stroke,” he said, “controlling for other risk factors such as hypertension, diabetes, congestive heart failure, yet women are being under treated.”

The team retrospectively studied 1585 adults aged 28 to 93 with nonvalvular AF or flutter cared for in an ambulatory setting in the University of Cincinnati Health primary care network.

The primary care doctors were testing the computerized AFDST, which uses patient information and characteristics to help with decisions about anticoagulant therapy to prevent stroke in AF patients.

The AFDST calculates for the individual patient the risk of AF-related stroke and major bleeding while taking blood thinning therapy. Based on this information, the AFDST makes suggestions for the best treatment to prevent AF-related stroke.

Demographics

Of the 1585 study participants, 46% were women.

Half of the participants were receiving some form of oral anticoagulant, primarily warfarin (39%), 36% were on aspirin only, and 11% were receiving other oral anticoagulants.

The investigators noted a trend in the study population toward lower levels of oral anticoagulant use in women (48%) as compared to men (52%), but the trend was not statistically significant (P=0.06).

Results

The AFDST recommended oral anticoagulation for 87% of the participants, aspirin for 4%,  and no antithrombitic therapy for 9%.

Patients' antithrombotic therapy was concordant with the AFDST recommendation in 58% of the participants.

Of the 42% for whom therapy was discordant with the AFDST, 37% were receiving aspirin only or no antithrombotic therapy when the tool recommended oral anticoagulation; 2% were receiving no antithrombotic therapy when the tool recommended aspirin; and 3% were receiving aspirin or oral anticoagulation when the tool recommended no antithrombotic therapy.

And as mentioned above, current treatment was discordant from recommended treatment in 45% of women and 39% of men (P=0.02).

Forty-four percent of women were under treated, receiving aspirin only when oral anticoagulation was recommended, compared with 31% of men who were under treated (P<0.001). Women were 1.8 times as likely to be under treated as men.

"Doctors need to realize we have mental biases that women are healthier and at lower risk of stroke,” Dr Eckman said. 

“We think women are at lower risk and we ignore warning signs,” he continued. “Thus, when we are making decisions for blood thinning therapy for patients with atrial fibrillation, we need to remember that women are at higher risk and we need to make sure we treat them aggressively enough to prevent stroke."

Overall, the use of oral anticoagulants did not differ significantly by age, with 55% of the patients 85 years and older receiving anticoagulation and 49% of the patients younger than 85 receiving it (P=0.13).

In 35% of the older population, treatment was discordant with recommendations compared with 43% in the younger (P = 0.009). Similar proportions in the younger and older groups were undertreated (P=0.30).

According to investigators, one surprising finding was that the proportion of patients receiving discordant treatment was larger in the younger group than in the over-85 group. They attributed this largely to overtreatment in the 31 to 50 age group.

Dr Eckman and colleagues published these findings in Journal of the American Geriatrics Society.

The research was supported in part by grants from Bristol-Myers Squibb/Pfizer Education Consortium, Pfizer Medical Education Group, Informed Medical Decisions Foundation, and the National Institutes of Health/National Center for Advancing Translational Sciences.

Warfarin tablets

Using an Atrial Fibrillation Decision Support Tool (AFDST), investigators determined that 45% of women and 39% of men in the study population were not being treated according to the tool’s recommended treatments to prevent stroke resulting from atrial fibrillation (AF).

Investigators wanted to achieve a better understanding of the appropriateness of antithrombotic therapy for thromboprophylaxis in women and elderly adults.

So they studied a cohort of individuals with AF to determine whether they were treated according to recommendations.

According to lead author Mark Eckman, MD, of the University of Cincinnati in Ohio, under treatment of patients with AF is a national problem.

And ironically, “[W]omen have a higher risk of AF-related stroke,” he said, “controlling for other risk factors such as hypertension, diabetes, congestive heart failure, yet women are being under treated.”

The team retrospectively studied 1585 adults aged 28 to 93 with nonvalvular AF or flutter cared for in an ambulatory setting in the University of Cincinnati Health primary care network.

The primary care doctors were testing the computerized AFDST, which uses patient information and characteristics to help with decisions about anticoagulant therapy to prevent stroke in AF patients.

The AFDST calculates for the individual patient the risk of AF-related stroke and major bleeding while taking blood thinning therapy. Based on this information, the AFDST makes suggestions for the best treatment to prevent AF-related stroke.

Demographics

Of the 1585 study participants, 46% were women.

Half of the participants were receiving some form of oral anticoagulant, primarily warfarin (39%), 36% were on aspirin only, and 11% were receiving other oral anticoagulants.

The investigators noted a trend in the study population toward lower levels of oral anticoagulant use in women (48%) as compared to men (52%), but the trend was not statistically significant (P=0.06).

Results

The AFDST recommended oral anticoagulation for 87% of the participants, aspirin for 4%,  and no antithrombitic therapy for 9%.

Patients' antithrombotic therapy was concordant with the AFDST recommendation in 58% of the participants.

Of the 42% for whom therapy was discordant with the AFDST, 37% were receiving aspirin only or no antithrombotic therapy when the tool recommended oral anticoagulation; 2% were receiving no antithrombotic therapy when the tool recommended aspirin; and 3% were receiving aspirin or oral anticoagulation when the tool recommended no antithrombotic therapy.

And as mentioned above, current treatment was discordant from recommended treatment in 45% of women and 39% of men (P=0.02).

Forty-four percent of women were under treated, receiving aspirin only when oral anticoagulation was recommended, compared with 31% of men who were under treated (P<0.001). Women were 1.8 times as likely to be under treated as men.

"Doctors need to realize we have mental biases that women are healthier and at lower risk of stroke,” Dr Eckman said. 

“We think women are at lower risk and we ignore warning signs,” he continued. “Thus, when we are making decisions for blood thinning therapy for patients with atrial fibrillation, we need to remember that women are at higher risk and we need to make sure we treat them aggressively enough to prevent stroke."

Overall, the use of oral anticoagulants did not differ significantly by age, with 55% of the patients 85 years and older receiving anticoagulation and 49% of the patients younger than 85 receiving it (P=0.13).

In 35% of the older population, treatment was discordant with recommendations compared with 43% in the younger (P = 0.009). Similar proportions in the younger and older groups were undertreated (P=0.30).

According to investigators, one surprising finding was that the proportion of patients receiving discordant treatment was larger in the younger group than in the over-85 group. They attributed this largely to overtreatment in the 31 to 50 age group.

Dr Eckman and colleagues published these findings in Journal of the American Geriatrics Society.

The research was supported in part by grants from Bristol-Myers Squibb/Pfizer Education Consortium, Pfizer Medical Education Group, Informed Medical Decisions Foundation, and the National Institutes of Health/National Center for Advancing Translational Sciences.

CHICAGO – Lenalidomide maintenance therapy significantly prolonged overall survival after autologous stem cell transplant in newly diagnosed multiple myeloma patients, including patients who had a complete response to ASCT, based on a meta-analysis presented at the annual meeting of the American Society of Clinical Oncology.

While several studies have indicated that lenalidomide maintenance reduces the risk of disease progression or death compared to a control group, none of the individual studies were powered to detect a significant improvement in overall survival, said Dr. Philip L. McCarthy, director of the Blood and Marrow Transplant Center at Roswell Park Cancer Institute, Buffalo, N.Y., who is a co-author of the meta-analysis and reported the results on behalf of Dr. Michel Attal of University Hospital, Toulouse, France.

The researchers found that three randomized controlled trials using lenalidomide post-ASCT (IFM 2005-02, CALGB 100104 [Alliance], GIMEMA RV-209) met the criteria of having patient-level data, a control arm, and primary efficacy data for newly-diagnosed patients with multiple myeloma.

After induction and single (82%) or tandem (18%) ASCT, 55% of patients in the meta-analysis had complete or very good partial responses.

From 2005 to 2009, 605 patients received lenalidomide either 10 mg/day on days 1-21 of a 28-day cycle (GIMEMA) or on days 1-28 of a 28-day cycle (IFM and CALGB); 604 patients were in a control group. With a median follow-up of 6.6 years, 491 patients (41%) had died.

Median overall survival was not reached in the lenolidamide group and was 86 months in the control group (HR = 0.74; 95% CI, 0.62-0.89; log-rank P = .001). Survival was longer in the lenolidamine group as compared to the control group at 5 years (71% vs 66%), 6 years (65% vs 58%), and 7 years (62% vs 50%), reported Dr. McCarthy.

Dr. McCarthy receives research funding from Celgene, the maker of Revlimid (lenalidomide); and is a consultant or advisor to and receives honoraria from Binding Site; Bristol-Myers Squibb; Celgene; Janssen; Karyopharm Therapeutics; and Sanofi. Dr. Attal had no disclosures.

[email protected]

On Twitter @maryjodales

CHICAGO – Lenalidomide maintenance therapy significantly prolonged overall survival after autologous stem cell transplant in newly diagnosed multiple myeloma patients, including patients who had a complete response to ASCT, based on a meta-analysis presented at the annual meeting of the American Society of Clinical Oncology.

While several studies have indicated that lenalidomide maintenance reduces the risk of disease progression or death compared to a control group, none of the individual studies were powered to detect a significant improvement in overall survival, said Dr. Philip L. McCarthy, director of the Blood and Marrow Transplant Center at Roswell Park Cancer Institute, Buffalo, N.Y., who is a co-author of the meta-analysis and reported the results on behalf of Dr. Michel Attal of University Hospital, Toulouse, France.

The researchers found that three randomized controlled trials using lenalidomide post-ASCT (IFM 2005-02, CALGB 100104 [Alliance], GIMEMA RV-209) met the criteria of having patient-level data, a control arm, and primary efficacy data for newly-diagnosed patients with multiple myeloma.

After induction and single (82%) or tandem (18%) ASCT, 55% of patients in the meta-analysis had complete or very good partial responses.

From 2005 to 2009, 605 patients received lenalidomide either 10 mg/day on days 1-21 of a 28-day cycle (GIMEMA) or on days 1-28 of a 28-day cycle (IFM and CALGB); 604 patients were in a control group. With a median follow-up of 6.6 years, 491 patients (41%) had died.

Median overall survival was not reached in the lenolidamide group and was 86 months in the control group (HR = 0.74; 95% CI, 0.62-0.89; log-rank P = .001). Survival was longer in the lenolidamine group as compared to the control group at 5 years (71% vs 66%), 6 years (65% vs 58%), and 7 years (62% vs 50%), reported Dr. McCarthy.

Dr. McCarthy receives research funding from Celgene, the maker of Revlimid (lenalidomide); and is a consultant or advisor to and receives honoraria from Binding Site; Bristol-Myers Squibb; Celgene; Janssen; Karyopharm Therapeutics; and Sanofi. Dr. Attal had no disclosures.

[email protected]

On Twitter @maryjodales

CHICAGO – Lenalidomide maintenance therapy significantly prolonged overall survival after autologous stem cell transplant in newly diagnosed multiple myeloma patients, including patients who had a complete response to ASCT, based on a meta-analysis presented at the annual meeting of the American Society of Clinical Oncology.

While several studies have indicated that lenalidomide maintenance reduces the risk of disease progression or death compared to a control group, none of the individual studies were powered to detect a significant improvement in overall survival, said Dr. Philip L. McCarthy, director of the Blood and Marrow Transplant Center at Roswell Park Cancer Institute, Buffalo, N.Y., who is a co-author of the meta-analysis and reported the results on behalf of Dr. Michel Attal of University Hospital, Toulouse, France.

The researchers found that three randomized controlled trials using lenalidomide post-ASCT (IFM 2005-02, CALGB 100104 [Alliance], GIMEMA RV-209) met the criteria of having patient-level data, a control arm, and primary efficacy data for newly-diagnosed patients with multiple myeloma.

After induction and single (82%) or tandem (18%) ASCT, 55% of patients in the meta-analysis had complete or very good partial responses.

From 2005 to 2009, 605 patients received lenalidomide either 10 mg/day on days 1-21 of a 28-day cycle (GIMEMA) or on days 1-28 of a 28-day cycle (IFM and CALGB); 604 patients were in a control group. With a median follow-up of 6.6 years, 491 patients (41%) had died.

Median overall survival was not reached in the lenolidamide group and was 86 months in the control group (HR = 0.74; 95% CI, 0.62-0.89; log-rank P = .001). Survival was longer in the lenolidamine group as compared to the control group at 5 years (71% vs 66%), 6 years (65% vs 58%), and 7 years (62% vs 50%), reported Dr. McCarthy.

Dr. McCarthy receives research funding from Celgene, the maker of Revlimid (lenalidomide); and is a consultant or advisor to and receives honoraria from Binding Site; Bristol-Myers Squibb; Celgene; Janssen; Karyopharm Therapeutics; and Sanofi. Dr. Attal had no disclosures.

[email protected]

On Twitter @maryjodales

After implementation of surgical safety checklists in a tertiary care hospital, researchers observed a 27% reduction of risk-adjusted all-cause 90-day mortality, but adjusted all-cause 30-day mortality remained unchanged.

In addition, length of stay was reduced but 30-day readmission rate was not, according to the study published online in JAMA Surgery. Those key findings are from an effort to assess the association between the implementation of surgical safety checklists (SSCs) and rates of all-cause 90- and 30-day mortality.

©PixelEmbargo/Thinkstock

Previous studies have analyzed in-hospital mortality or 30-day mortality “but not intermediate-term outcome variables,” said lead author Dr. Matthias Bock of the department of anesthesiology and intensive care medicine at Merano Hospital, Merano, Italy. “Almost one-quarter (23.6%) of the deaths within 30 days after surgery occurred after discharge, and 39.7% of patients undergoing surgery experienced only post-discharge complications. Ninety-day mortality often doubles 30-day mortality. In-hospital mortality and 30-day mortality might therefore underreport the real risk to these patients, especially after tumor surgery or among the elderly. Studies of the effect or the association of the implementation of surgical safety checklists (SSCs) on 90-day mortality are lacking.”

Dr. Bock and his associates retrospectively evaluated the outcomes of surgical procedures performed during the six months before and six months after implementation of SSCs at the 715-bed Central Hospital of Bolzano (CHB) in Italy (Jan. 1-June 30, 2010, and Jan. 1-June 30, 2013, respectively). The key outcome measures were risk-adjusted rates of 90- and 30-day mortality, readmission rate, and LOS (JAMA Surg. 2016 Feb 3. doi:10.1001/jamasurg.2015.5490).

The study sample consisted of 10,741 patients, including 5,444 pre-intervention and 5,297 post-intervention patients. Of these, 53% were female and their mean age was 53 years.

The researchers reported that 90-day all-cause mortality was 2.4% before SSC implementation, compared with 2.2% after implementation, for an adjusted odds ratio (AOR) of 0.73 (P = .02). However, 30-day all-cause mortality was 1.36% before SSC implementation, compared with 1.32% after implementation, for an AOR of 0.79 (P = .17), remaining essentially unchanged.

Dr. Bock and his associates also found that 30-day readmission rates were similar in the pre-implementation and post-implementation groups (14.6% vs. 14.5%, respectively: P = .90), but the adjusted length of stay favored the post-implementation group (a mean of 9.6 days, compared with a mean of 10.4 days in the in the pre-implementation group; P less than .001).

The researchers acknowledged certain limitations of the study, including its single-center design and the lack of a control group. “The study design highly reduces the risk for observation bias (Hawthorne effect),” they wrote. “Furthermore, we did not inform the staff about the purpose of our study. We analyzed only objective outcome data to reduce reporting bias as much as possible.”

The finding of a decline in LOS “suggests potential cost savings after the implementation of SSCs,” they concluded. “Further trials should address this hypothesis and the effect on quality of care owing to a reduction of the costs of complications or unplanned reoperations.”

The study was supported by the Public Health Care Company of South Tyrol, Italy, and by the Autonomous Province of Bolzano, Italy. The researchers reported having no financial disclosures.

[email protected]

After implementation of surgical safety checklists in a tertiary care hospital, researchers observed a 27% reduction of risk-adjusted all-cause 90-day mortality, but adjusted all-cause 30-day mortality remained unchanged.

In addition, length of stay was reduced but 30-day readmission rate was not, according to the study published online in JAMA Surgery. Those key findings are from an effort to assess the association between the implementation of surgical safety checklists (SSCs) and rates of all-cause 90- and 30-day mortality.

©PixelEmbargo/Thinkstock

Previous studies have analyzed in-hospital mortality or 30-day mortality “but not intermediate-term outcome variables,” said lead author Dr. Matthias Bock of the department of anesthesiology and intensive care medicine at Merano Hospital, Merano, Italy. “Almost one-quarter (23.6%) of the deaths within 30 days after surgery occurred after discharge, and 39.7% of patients undergoing surgery experienced only post-discharge complications. Ninety-day mortality often doubles 30-day mortality. In-hospital mortality and 30-day mortality might therefore underreport the real risk to these patients, especially after tumor surgery or among the elderly. Studies of the effect or the association of the implementation of surgical safety checklists (SSCs) on 90-day mortality are lacking.”

Dr. Bock and his associates retrospectively evaluated the outcomes of surgical procedures performed during the six months before and six months after implementation of SSCs at the 715-bed Central Hospital of Bolzano (CHB) in Italy (Jan. 1-June 30, 2010, and Jan. 1-June 30, 2013, respectively). The key outcome measures were risk-adjusted rates of 90- and 30-day mortality, readmission rate, and LOS (JAMA Surg. 2016 Feb 3. doi:10.1001/jamasurg.2015.5490).

The study sample consisted of 10,741 patients, including 5,444 pre-intervention and 5,297 post-intervention patients. Of these, 53% were female and their mean age was 53 years.

The researchers reported that 90-day all-cause mortality was 2.4% before SSC implementation, compared with 2.2% after implementation, for an adjusted odds ratio (AOR) of 0.73 (P = .02). However, 30-day all-cause mortality was 1.36% before SSC implementation, compared with 1.32% after implementation, for an AOR of 0.79 (P = .17), remaining essentially unchanged.

Dr. Bock and his associates also found that 30-day readmission rates were similar in the pre-implementation and post-implementation groups (14.6% vs. 14.5%, respectively: P = .90), but the adjusted length of stay favored the post-implementation group (a mean of 9.6 days, compared with a mean of 10.4 days in the in the pre-implementation group; P less than .001).

The researchers acknowledged certain limitations of the study, including its single-center design and the lack of a control group. “The study design highly reduces the risk for observation bias (Hawthorne effect),” they wrote. “Furthermore, we did not inform the staff about the purpose of our study. We analyzed only objective outcome data to reduce reporting bias as much as possible.”

The finding of a decline in LOS “suggests potential cost savings after the implementation of SSCs,” they concluded. “Further trials should address this hypothesis and the effect on quality of care owing to a reduction of the costs of complications or unplanned reoperations.”

The study was supported by the Public Health Care Company of South Tyrol, Italy, and by the Autonomous Province of Bolzano, Italy. The researchers reported having no financial disclosures.

[email protected]

After implementation of surgical safety checklists in a tertiary care hospital, researchers observed a 27% reduction of risk-adjusted all-cause 90-day mortality, but adjusted all-cause 30-day mortality remained unchanged.

In addition, length of stay was reduced but 30-day readmission rate was not, according to the study published online in JAMA Surgery. Those key findings are from an effort to assess the association between the implementation of surgical safety checklists (SSCs) and rates of all-cause 90- and 30-day mortality.

©PixelEmbargo/Thinkstock

Previous studies have analyzed in-hospital mortality or 30-day mortality “but not intermediate-term outcome variables,” said lead author Dr. Matthias Bock of the department of anesthesiology and intensive care medicine at Merano Hospital, Merano, Italy. “Almost one-quarter (23.6%) of the deaths within 30 days after surgery occurred after discharge, and 39.7% of patients undergoing surgery experienced only post-discharge complications. Ninety-day mortality often doubles 30-day mortality. In-hospital mortality and 30-day mortality might therefore underreport the real risk to these patients, especially after tumor surgery or among the elderly. Studies of the effect or the association of the implementation of surgical safety checklists (SSCs) on 90-day mortality are lacking.”

Dr. Bock and his associates retrospectively evaluated the outcomes of surgical procedures performed during the six months before and six months after implementation of SSCs at the 715-bed Central Hospital of Bolzano (CHB) in Italy (Jan. 1-June 30, 2010, and Jan. 1-June 30, 2013, respectively). The key outcome measures were risk-adjusted rates of 90- and 30-day mortality, readmission rate, and LOS (JAMA Surg. 2016 Feb 3. doi:10.1001/jamasurg.2015.5490).

The study sample consisted of 10,741 patients, including 5,444 pre-intervention and 5,297 post-intervention patients. Of these, 53% were female and their mean age was 53 years.

The researchers reported that 90-day all-cause mortality was 2.4% before SSC implementation, compared with 2.2% after implementation, for an adjusted odds ratio (AOR) of 0.73 (P = .02). However, 30-day all-cause mortality was 1.36% before SSC implementation, compared with 1.32% after implementation, for an AOR of 0.79 (P = .17), remaining essentially unchanged.

Dr. Bock and his associates also found that 30-day readmission rates were similar in the pre-implementation and post-implementation groups (14.6% vs. 14.5%, respectively: P = .90), but the adjusted length of stay favored the post-implementation group (a mean of 9.6 days, compared with a mean of 10.4 days in the in the pre-implementation group; P less than .001).

The researchers acknowledged certain limitations of the study, including its single-center design and the lack of a control group. “The study design highly reduces the risk for observation bias (Hawthorne effect),” they wrote. “Furthermore, we did not inform the staff about the purpose of our study. We analyzed only objective outcome data to reduce reporting bias as much as possible.”

The finding of a decline in LOS “suggests potential cost savings after the implementation of SSCs,” they concluded. “Further trials should address this hypothesis and the effect on quality of care owing to a reduction of the costs of complications or unplanned reoperations.”

The study was supported by the Public Health Care Company of South Tyrol, Italy, and by the Autonomous Province of Bolzano, Italy. The researchers reported having no financial disclosures.

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