A recent study found different approaches used by four popular hospital ratings systems resulted in disagreement about the ranking of many U.S. hospitals.

"Only 10% of hospitals that were rated as a high performer on one of the systems were rated as a high performer on another rating system," says lead author John Matthew Austin, MS, PhD, assistant professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore. "There was no one hospital that was rated as a high performer on all four."

The study, which appeared in Health Affairs, looked at the hospital ratings systems of U.S. News, Healthgrades, The Leapfrog Group, and Consumer Reports, and found none took the same approach to assessing hospital quality. Of the 83 hospitals rated by all four systems, none were universally recognized as either a high performer or a low performer.

"I think the impact, or the influence, on consumers is that these conflicting ratings could generate confusion," Dr. Austin says. "Depending on which rating system you look at, it may give you a different answer on which hospital or where you should seek care. If you look at these four rating systems in a community, you may actually wind up being directed to four different hospitals."

David Pressel, MD, PhD, medical director of inpatient care at Alfred I. duPont Hospital for Children in Wilmington, Del., emphasized the difficulty of defining quality.

"Measuring quality is really difficult and hard, and people, physicians, and hospitals struggle with this," he explains. "I think it's very important that people recognize in rating systems there’s always going to be a top 10% or top 50% and a bottom 10% or 50%, and what's really important is not if you're in the top or bottom but what the scatter of the data is. If the scatter of the data is very narrow, they may not be providing much worse care than the top hospitals. I think that is lost on the public."

Dr. Austin's study identified varying missions and methodologies for each ratings system.

"U.S. News' Best Hospitals is actually intending to identify the best medical centers for the most complicated cases," Dr. Austin says. "The Leapfrog Hospital Safety Score has a very laser focus on patient safety, so freedom from harm, things like errors, infections."

Dr. Austin also noticed that some rating systems were more descriptive about their methods than others.

"Some of the ratings are much more transparent in what they share, in terms of how hospitals are rated, and others are less clear," he notes. "Healthgrades lists the top 100 hospitals. They're supposedly looking at hospital outcomes, but they don't publicly make their methodology available in terms of their risk-adjustment levels."

The rating systems also communicated their ratings differently. Leapfrog issues letter grades A–F; Consumer Reports and U.S. News issue scores from 0–100; and Healthgrades identifies the top 50 and top 100 hospitals but doesn’t rank hospitals, and hospitals that are not in the top 100 are not rated at all.

The study authors outlined possible improvements to eliminate some of these disparities, including reaching out to the sponsoring organizations and encouraging them to be more transparent about their ratings to allow for easier patient interpretation.

"Patients should understand what's being measured," Dr. Austin says. "Hospitals should be able to duplicate their ratings, so full transparency of the measures themselves, of the methodologies, is really important. We feel like these are a great start, but we definitely have some issues that still need to be resolved around measurements. We need better standardized measures."

Visit our website for more information on hospital ratings.

A recent study found different approaches used by four popular hospital ratings systems resulted in disagreement about the ranking of many U.S. hospitals.

"Only 10% of hospitals that were rated as a high performer on one of the systems were rated as a high performer on another rating system," says lead author John Matthew Austin, MS, PhD, assistant professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore. "There was no one hospital that was rated as a high performer on all four."

The study, which appeared in Health Affairs, looked at the hospital ratings systems of U.S. News, Healthgrades, The Leapfrog Group, and Consumer Reports, and found none took the same approach to assessing hospital quality. Of the 83 hospitals rated by all four systems, none were universally recognized as either a high performer or a low performer.

"I think the impact, or the influence, on consumers is that these conflicting ratings could generate confusion," Dr. Austin says. "Depending on which rating system you look at, it may give you a different answer on which hospital or where you should seek care. If you look at these four rating systems in a community, you may actually wind up being directed to four different hospitals."

David Pressel, MD, PhD, medical director of inpatient care at Alfred I. duPont Hospital for Children in Wilmington, Del., emphasized the difficulty of defining quality.

"Measuring quality is really difficult and hard, and people, physicians, and hospitals struggle with this," he explains. "I think it's very important that people recognize in rating systems there’s always going to be a top 10% or top 50% and a bottom 10% or 50%, and what's really important is not if you're in the top or bottom but what the scatter of the data is. If the scatter of the data is very narrow, they may not be providing much worse care than the top hospitals. I think that is lost on the public."

Dr. Austin's study identified varying missions and methodologies for each ratings system.

"U.S. News' Best Hospitals is actually intending to identify the best medical centers for the most complicated cases," Dr. Austin says. "The Leapfrog Hospital Safety Score has a very laser focus on patient safety, so freedom from harm, things like errors, infections."

Dr. Austin also noticed that some rating systems were more descriptive about their methods than others.

"Some of the ratings are much more transparent in what they share, in terms of how hospitals are rated, and others are less clear," he notes. "Healthgrades lists the top 100 hospitals. They're supposedly looking at hospital outcomes, but they don't publicly make their methodology available in terms of their risk-adjustment levels."

The rating systems also communicated their ratings differently. Leapfrog issues letter grades A–F; Consumer Reports and U.S. News issue scores from 0–100; and Healthgrades identifies the top 50 and top 100 hospitals but doesn’t rank hospitals, and hospitals that are not in the top 100 are not rated at all.

The study authors outlined possible improvements to eliminate some of these disparities, including reaching out to the sponsoring organizations and encouraging them to be more transparent about their ratings to allow for easier patient interpretation.

"Patients should understand what's being measured," Dr. Austin says. "Hospitals should be able to duplicate their ratings, so full transparency of the measures themselves, of the methodologies, is really important. We feel like these are a great start, but we definitely have some issues that still need to be resolved around measurements. We need better standardized measures."

Visit our website for more information on hospital ratings.

A recent study found different approaches used by four popular hospital ratings systems resulted in disagreement about the ranking of many U.S. hospitals.

"Only 10% of hospitals that were rated as a high performer on one of the systems were rated as a high performer on another rating system," says lead author John Matthew Austin, MS, PhD, assistant professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore. "There was no one hospital that was rated as a high performer on all four."

The study, which appeared in Health Affairs, looked at the hospital ratings systems of U.S. News, Healthgrades, The Leapfrog Group, and Consumer Reports, and found none took the same approach to assessing hospital quality. Of the 83 hospitals rated by all four systems, none were universally recognized as either a high performer or a low performer.

"I think the impact, or the influence, on consumers is that these conflicting ratings could generate confusion," Dr. Austin says. "Depending on which rating system you look at, it may give you a different answer on which hospital or where you should seek care. If you look at these four rating systems in a community, you may actually wind up being directed to four different hospitals."

David Pressel, MD, PhD, medical director of inpatient care at Alfred I. duPont Hospital for Children in Wilmington, Del., emphasized the difficulty of defining quality.

"Measuring quality is really difficult and hard, and people, physicians, and hospitals struggle with this," he explains. "I think it's very important that people recognize in rating systems there’s always going to be a top 10% or top 50% and a bottom 10% or 50%, and what's really important is not if you're in the top or bottom but what the scatter of the data is. If the scatter of the data is very narrow, they may not be providing much worse care than the top hospitals. I think that is lost on the public."

Dr. Austin's study identified varying missions and methodologies for each ratings system.

"U.S. News' Best Hospitals is actually intending to identify the best medical centers for the most complicated cases," Dr. Austin says. "The Leapfrog Hospital Safety Score has a very laser focus on patient safety, so freedom from harm, things like errors, infections."

Dr. Austin also noticed that some rating systems were more descriptive about their methods than others.

"Some of the ratings are much more transparent in what they share, in terms of how hospitals are rated, and others are less clear," he notes. "Healthgrades lists the top 100 hospitals. They're supposedly looking at hospital outcomes, but they don't publicly make their methodology available in terms of their risk-adjustment levels."

The rating systems also communicated their ratings differently. Leapfrog issues letter grades A–F; Consumer Reports and U.S. News issue scores from 0–100; and Healthgrades identifies the top 50 and top 100 hospitals but doesn’t rank hospitals, and hospitals that are not in the top 100 are not rated at all.

The study authors outlined possible improvements to eliminate some of these disparities, including reaching out to the sponsoring organizations and encouraging them to be more transparent about their ratings to allow for easier patient interpretation.

"Patients should understand what's being measured," Dr. Austin says. "Hospitals should be able to duplicate their ratings, so full transparency of the measures themselves, of the methodologies, is really important. We feel like these are a great start, but we definitely have some issues that still need to be resolved around measurements. We need better standardized measures."

Visit our website for more information on hospital ratings.

1. Which of the following is an amide-type anesthetic?

a. benzocaine

b. cocaine

c. lidocaine

d. procaine

e. tetracaine

2. A patient is referred for patch testing for suspected allergic contact dermatitis and is found to have positivity to hydrocortisone butyrate. The patient should try to avoid all of the following, except:

a. desonide

b. desoximetasone

c. fluocinolone

d. fluocinonide

e. triamcinolone

3. A patient with a documented contact allergy to neomycin sulfate should avoid all of the following medications, except:

a. bacitracin

b. gentamicin

c. kanamycin

d. mupirocin

e. streptomycin

4. Imidazolidinyl urea can cross-react with all of the following, except:

a. diazolidinyl urea

b. DMDM hydantoin

c. para-aminobenzoic acid

d. quaternium-15

e. tris(hydroxymethyl)nitromethane

5. Mercaptobenzothiazole can coreact with all of the following, except:

a. carbamates

b. dibenzothiazyl disulfide

c. mercapto mix

d. methyldibromo glutaronitrile

e. thiurams

1. Which of the following is an amide-type anesthetic?

a. benzocaine

b. cocaine

c. lidocaine

d. procaine

e. tetracaine

2. A patient is referred for patch testing for suspected allergic contact dermatitis and is found to have positivity to hydrocortisone butyrate. The patient should try to avoid all of the following, except:

a. desonide

b. desoximetasone

c. fluocinolone

d. fluocinonide

e. triamcinolone

3. A patient with a documented contact allergy to neomycin sulfate should avoid all of the following medications, except:

a. bacitracin

b. gentamicin

c. kanamycin

d. mupirocin

e. streptomycin

4. Imidazolidinyl urea can cross-react with all of the following, except:

a. diazolidinyl urea

b. DMDM hydantoin

c. para-aminobenzoic acid

d. quaternium-15

e. tris(hydroxymethyl)nitromethane

5. Mercaptobenzothiazole can coreact with all of the following, except:

a. carbamates

b. dibenzothiazyl disulfide

c. mercapto mix

d. methyldibromo glutaronitrile

e. thiurams

1. Which of the following is an amide-type anesthetic?

a. benzocaine

b. cocaine

c. lidocaine

d. procaine

e. tetracaine

2. A patient is referred for patch testing for suspected allergic contact dermatitis and is found to have positivity to hydrocortisone butyrate. The patient should try to avoid all of the following, except:

a. desonide

b. desoximetasone

c. fluocinolone

d. fluocinonide

e. triamcinolone

3. A patient with a documented contact allergy to neomycin sulfate should avoid all of the following medications, except:

a. bacitracin

b. gentamicin

c. kanamycin

d. mupirocin

e. streptomycin

4. Imidazolidinyl urea can cross-react with all of the following, except:

a. diazolidinyl urea

b. DMDM hydantoin

c. para-aminobenzoic acid

d. quaternium-15

e. tris(hydroxymethyl)nitromethane

5. Mercaptobenzothiazole can coreact with all of the following, except:

a. carbamates

b. dibenzothiazyl disulfide

c. mercapto mix

d. methyldibromo glutaronitrile

e. thiurams

According to the National Hospice Foundation, an estimated 70 million Americans will need hospice and palliative care services in the next 20 years, and most of us cannot even begin to remember all the patients we have treated who were ultimately transferred from a medical ward to some form of hospice.

Hospice care is often a compassionate, appropriate recommendation, but is it not always an easy subject for hospitalists to broach. After all, we went into medicine to cure the sick. At least on a subconscious level, we may feel we have failed our patients when all we have to offer them is hospice. Plus, we are often at the disadvantage of not having enough time with our patients and their families to develop the trust needed to accept such a life-altering recommendation.

It’s important to remember that, even when we can’t cure our patients, we can offer them symptomatic relief and the ability to heal on a certain level. Sometimes, the recommendation of hospice is a much-welcomed release for patients and their families, a way to finally ease the burdens of uncertainty and of pain, both physical and emotional.

Palliative care can be an important addition to the care plan, as it focuses on relieving suffering, regardless of the stage of disease. Palliative care incorporates support, as well as assistance with communication about care needs. Within an integrated care model, palliative care may be provided alongside curative or life-prolonging treatments.

Palliative care can be particularly useful for helping patients to prepare for the emotional transition from seeking aggressive but likely futile care to accepting the ultimate reality of their disease process. Even when death is not imminent, having the appropriate support systems in place for patients and their families can play a significant role in easing their minds and helping them make informed, appropriate treatment decisions.

Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

According to the National Hospice Foundation, an estimated 70 million Americans will need hospice and palliative care services in the next 20 years, and most of us cannot even begin to remember all the patients we have treated who were ultimately transferred from a medical ward to some form of hospice.

Hospice care is often a compassionate, appropriate recommendation, but is it not always an easy subject for hospitalists to broach. After all, we went into medicine to cure the sick. At least on a subconscious level, we may feel we have failed our patients when all we have to offer them is hospice. Plus, we are often at the disadvantage of not having enough time with our patients and their families to develop the trust needed to accept such a life-altering recommendation.

It’s important to remember that, even when we can’t cure our patients, we can offer them symptomatic relief and the ability to heal on a certain level. Sometimes, the recommendation of hospice is a much-welcomed release for patients and their families, a way to finally ease the burdens of uncertainty and of pain, both physical and emotional.

Palliative care can be an important addition to the care plan, as it focuses on relieving suffering, regardless of the stage of disease. Palliative care incorporates support, as well as assistance with communication about care needs. Within an integrated care model, palliative care may be provided alongside curative or life-prolonging treatments.

Palliative care can be particularly useful for helping patients to prepare for the emotional transition from seeking aggressive but likely futile care to accepting the ultimate reality of their disease process. Even when death is not imminent, having the appropriate support systems in place for patients and their families can play a significant role in easing their minds and helping them make informed, appropriate treatment decisions.

Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

According to the National Hospice Foundation, an estimated 70 million Americans will need hospice and palliative care services in the next 20 years, and most of us cannot even begin to remember all the patients we have treated who were ultimately transferred from a medical ward to some form of hospice.

Hospice care is often a compassionate, appropriate recommendation, but is it not always an easy subject for hospitalists to broach. After all, we went into medicine to cure the sick. At least on a subconscious level, we may feel we have failed our patients when all we have to offer them is hospice. Plus, we are often at the disadvantage of not having enough time with our patients and their families to develop the trust needed to accept such a life-altering recommendation.

It’s important to remember that, even when we can’t cure our patients, we can offer them symptomatic relief and the ability to heal on a certain level. Sometimes, the recommendation of hospice is a much-welcomed release for patients and their families, a way to finally ease the burdens of uncertainty and of pain, both physical and emotional.

Palliative care can be an important addition to the care plan, as it focuses on relieving suffering, regardless of the stage of disease. Palliative care incorporates support, as well as assistance with communication about care needs. Within an integrated care model, palliative care may be provided alongside curative or life-prolonging treatments.

Palliative care can be particularly useful for helping patients to prepare for the emotional transition from seeking aggressive but likely futile care to accepting the ultimate reality of their disease process. Even when death is not imminent, having the appropriate support systems in place for patients and their families can play a significant role in easing their minds and helping them make informed, appropriate treatment decisions.

Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at [email protected].

Pill production

Photo courtesy of the FDA

Health Canada has approved ponatinib hydrochloride (Iclusig) to treat adults with any phase of chronic myeloid leukemia (CML) or Philadelphia

chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) for whom other tyrosine kinase inhibitor (TKI) therapy is not appropriate, including CML or Ph+ ALL patients with the T315I mutation and those who have exhibited prior TKI resistance or intolerance.

Ponatinib is approved under the Notice of Compliance with Conditions policy based on promising evidence of clinical effectiveness.

Products approved under this policy are intended for the treatment, prevention, or diagnosis of a serious, life-threatening, or severely debilitating illness. The products must have demonstrated promising benefit, be of high quality, and possess an acceptable safety profile based on a benefit/risk assessment.

These products either respond to a serious unmet medical need in Canada or have demonstrated a significant improvement in the benefit/risk profile over existing therapies.

Ponatinib will be made available in Canada through a controlled distribution program. Prescribers who have completed the certification procedure will be able to prescribe the drug. Trained pharmacies will verify the prescriber’s certified status prior to dispensing ponatinib to the patient.

Health Canada’s decision to approve ponatinib was based on 2-year data from the phase 2 PACE trial.

A trial set to begin in mid-2015 will serve as the confirmatory trial for the Health Canada approval. Investigators will evaluate 3 starting doses of ponatinib in patients with refractory, chronic-phase CML who are resistant to at least 2 approved TKIs.

PACE trial

Researchers conducted this trial in patients with CML or Ph+ ALL who were resistant or intolerant to prior TKI therapy, or who had the T315I mutation.

Ponatinib demonstrated anti-leukemic activity in these patients, prompting a major cytogenetic response (MCyR) in 56% of chronic-phase CML patients and in 70% of patients with the T315I mutation. MCyR within the first 12 months of treatment was the primary endpoint for chronic-phase patients.

In patients with advanced disease, 57% of accelerated-phase CML patients and 31% of blast-phase CML patients achieved a major hematologic response (MaHR). MaHR within the first 6 months was the primary endpoint for patients with advanced disease. In patients with Ph+ ALL, 41% achieved MaHR.

Common non-hematologic adverse events included rash (38%), abdominal pain (38%), headache (35%), dry skin (35%), constipation (34%), fatigue (27%), pyrexia (27%), nausea (26%), arthralgia (25%), hypertension (21%), increased lipase (19%), and increased amylase (7%).

Hematologic events of any grade included thrombocytopenia (42%), neutropenia (24%), and anemia (20%). Serious adverse events of arterial thromboembolism, including arterial stenosis, occurred in patients with cardiovascular risk factors.

Extended follow-up data from the PACE trial, collected in 2013, suggested ponatinib can increase the risk of thrombotic events. When these data came to light, officials in the European Union and the US, where ponatinib had already been approved, began to investigate the drug.

Ponatinib was pulled from the US market for a little over 2 months, and trials of the drug were placed on partial hold while the Food and Drug Administration evaluated the drug’s safety. Ponatinib went back on the market in January 2014, with new safety measures in place.

The drug was not pulled from the market in the European Union, but the European Medicine’s Agency released recommendations for safer use of ponatinib. The Committee for Medicinal Products for Human Use reviewed data on ponatinib and decided the drug’s benefits outweigh its risks.

Pill production

Photo courtesy of the FDA

Health Canada has approved ponatinib hydrochloride (Iclusig) to treat adults with any phase of chronic myeloid leukemia (CML) or Philadelphia

chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) for whom other tyrosine kinase inhibitor (TKI) therapy is not appropriate, including CML or Ph+ ALL patients with the T315I mutation and those who have exhibited prior TKI resistance or intolerance.

Ponatinib is approved under the Notice of Compliance with Conditions policy based on promising evidence of clinical effectiveness.

Products approved under this policy are intended for the treatment, prevention, or diagnosis of a serious, life-threatening, or severely debilitating illness. The products must have demonstrated promising benefit, be of high quality, and possess an acceptable safety profile based on a benefit/risk assessment.

These products either respond to a serious unmet medical need in Canada or have demonstrated a significant improvement in the benefit/risk profile over existing therapies.

Ponatinib will be made available in Canada through a controlled distribution program. Prescribers who have completed the certification procedure will be able to prescribe the drug. Trained pharmacies will verify the prescriber’s certified status prior to dispensing ponatinib to the patient.

Health Canada’s decision to approve ponatinib was based on 2-year data from the phase 2 PACE trial.

A trial set to begin in mid-2015 will serve as the confirmatory trial for the Health Canada approval. Investigators will evaluate 3 starting doses of ponatinib in patients with refractory, chronic-phase CML who are resistant to at least 2 approved TKIs.

PACE trial

Researchers conducted this trial in patients with CML or Ph+ ALL who were resistant or intolerant to prior TKI therapy, or who had the T315I mutation.

Ponatinib demonstrated anti-leukemic activity in these patients, prompting a major cytogenetic response (MCyR) in 56% of chronic-phase CML patients and in 70% of patients with the T315I mutation. MCyR within the first 12 months of treatment was the primary endpoint for chronic-phase patients.

In patients with advanced disease, 57% of accelerated-phase CML patients and 31% of blast-phase CML patients achieved a major hematologic response (MaHR). MaHR within the first 6 months was the primary endpoint for patients with advanced disease. In patients with Ph+ ALL, 41% achieved MaHR.

Common non-hematologic adverse events included rash (38%), abdominal pain (38%), headache (35%), dry skin (35%), constipation (34%), fatigue (27%), pyrexia (27%), nausea (26%), arthralgia (25%), hypertension (21%), increased lipase (19%), and increased amylase (7%).

Hematologic events of any grade included thrombocytopenia (42%), neutropenia (24%), and anemia (20%). Serious adverse events of arterial thromboembolism, including arterial stenosis, occurred in patients with cardiovascular risk factors.

Extended follow-up data from the PACE trial, collected in 2013, suggested ponatinib can increase the risk of thrombotic events. When these data came to light, officials in the European Union and the US, where ponatinib had already been approved, began to investigate the drug.

Ponatinib was pulled from the US market for a little over 2 months, and trials of the drug were placed on partial hold while the Food and Drug Administration evaluated the drug’s safety. Ponatinib went back on the market in January 2014, with new safety measures in place.

The drug was not pulled from the market in the European Union, but the European Medicine’s Agency released recommendations for safer use of ponatinib. The Committee for Medicinal Products for Human Use reviewed data on ponatinib and decided the drug’s benefits outweigh its risks.

Pill production

Photo courtesy of the FDA

Health Canada has approved ponatinib hydrochloride (Iclusig) to treat adults with any phase of chronic myeloid leukemia (CML) or Philadelphia

chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) for whom other tyrosine kinase inhibitor (TKI) therapy is not appropriate, including CML or Ph+ ALL patients with the T315I mutation and those who have exhibited prior TKI resistance or intolerance.

Ponatinib is approved under the Notice of Compliance with Conditions policy based on promising evidence of clinical effectiveness.

Products approved under this policy are intended for the treatment, prevention, or diagnosis of a serious, life-threatening, or severely debilitating illness. The products must have demonstrated promising benefit, be of high quality, and possess an acceptable safety profile based on a benefit/risk assessment.

These products either respond to a serious unmet medical need in Canada or have demonstrated a significant improvement in the benefit/risk profile over existing therapies.

Ponatinib will be made available in Canada through a controlled distribution program. Prescribers who have completed the certification procedure will be able to prescribe the drug. Trained pharmacies will verify the prescriber’s certified status prior to dispensing ponatinib to the patient.

Health Canada’s decision to approve ponatinib was based on 2-year data from the phase 2 PACE trial.

A trial set to begin in mid-2015 will serve as the confirmatory trial for the Health Canada approval. Investigators will evaluate 3 starting doses of ponatinib in patients with refractory, chronic-phase CML who are resistant to at least 2 approved TKIs.

PACE trial

Researchers conducted this trial in patients with CML or Ph+ ALL who were resistant or intolerant to prior TKI therapy, or who had the T315I mutation.

Ponatinib demonstrated anti-leukemic activity in these patients, prompting a major cytogenetic response (MCyR) in 56% of chronic-phase CML patients and in 70% of patients with the T315I mutation. MCyR within the first 12 months of treatment was the primary endpoint for chronic-phase patients.

In patients with advanced disease, 57% of accelerated-phase CML patients and 31% of blast-phase CML patients achieved a major hematologic response (MaHR). MaHR within the first 6 months was the primary endpoint for patients with advanced disease. In patients with Ph+ ALL, 41% achieved MaHR.

Common non-hematologic adverse events included rash (38%), abdominal pain (38%), headache (35%), dry skin (35%), constipation (34%), fatigue (27%), pyrexia (27%), nausea (26%), arthralgia (25%), hypertension (21%), increased lipase (19%), and increased amylase (7%).

Hematologic events of any grade included thrombocytopenia (42%), neutropenia (24%), and anemia (20%). Serious adverse events of arterial thromboembolism, including arterial stenosis, occurred in patients with cardiovascular risk factors.

Extended follow-up data from the PACE trial, collected in 2013, suggested ponatinib can increase the risk of thrombotic events. When these data came to light, officials in the European Union and the US, where ponatinib had already been approved, began to investigate the drug.

Ponatinib was pulled from the US market for a little over 2 months, and trials of the drug were placed on partial hold while the Food and Drug Administration evaluated the drug’s safety. Ponatinib went back on the market in January 2014, with new safety measures in place.

The drug was not pulled from the market in the European Union, but the European Medicine’s Agency released recommendations for safer use of ponatinib. The Committee for Medicinal Products for Human Use reviewed data on ponatinib and decided the drug’s benefits outweigh its risks.

Hematopoietic stem cells

in the bone marrow

New research suggests the cell survival protein MCL-1, a target for a number of new anticancer agents, is essential for hematopoietic recovery.

Investigators found that reducing MCL-1 levels hindered hematopoietic recovery after chemotherapy and radiotherapy caused extensive destruction of mature blood cells.

Reducing MCL-1 also impaired reconstitution of the bone marrow after hematopoietic stem cell transplant (HSCT).

“Our previous research has shown that targeting MCL-1 could be used with great success for treating certain blood cancers,” said Alex Delbridge, PhD, of the Walter and Eliza Hall Institute of Medical Research in Melbourne, Victoria, Australia.

“However, we have now shown that MCL-1 is also critical for emergency recovery of the blood cell system after cancer therapy-induced blood cell loss.”

Dr Delbridge and his colleagues reported these findings in Blood.

Experiments in mice revealed that loss of a single MCL-1 allele, which reduced MCL-1 protein levels, greatly compromised the immune system and hindered red blood cell recovery after treatment with 5-fluorouracil, γ-irradiation, or HSCT.

Further investigation showed that the pro-apoptotic gene PUMA plays a key role in this phenomenon, as MCL-1 inhibits PUMA. In mice, knocking out PUMA alleviated—but did not eliminate—the HSC survival defect caused by deletion of both MCL-1 alleles.

“This exquisite dependency on MCL-1 for emergency blood cell production has important implications for potential cancer treatments involving MCL-1 inhibitors,” Dr Delbridge said.

“If MCL-1 inhibitors are to be used in combination with other cancer therapies, careful monitoring of the blood cell system will be needed,” added Stephanie Grabow, PhD, also of the Walter and Eliza Hall Institute.

“Our institute colleagues are working to evaluate a potential new drug to treat blood cancers by targeting MCL-1. Our findings suggest that MCL-1 inhibitors and chemotherapeutic drugs should not be used simultaneously.”

Dr Delbridge said this research also offers insights that could help improve HSCT.

“Stem cell transplants can be dangerous because, until the blood cell system is functionally restored, patients are vulnerable to infection,” he said. “Our research suggests that increasing levels of MCL-1 or decreasing the activity of opposing proteins could be a viable strategy for speeding up the regeneration process and reducing the risk of infection after stem cell transplantation.”

Hematopoietic stem cells

in the bone marrow

New research suggests the cell survival protein MCL-1, a target for a number of new anticancer agents, is essential for hematopoietic recovery.

Investigators found that reducing MCL-1 levels hindered hematopoietic recovery after chemotherapy and radiotherapy caused extensive destruction of mature blood cells.

Reducing MCL-1 also impaired reconstitution of the bone marrow after hematopoietic stem cell transplant (HSCT).

“Our previous research has shown that targeting MCL-1 could be used with great success for treating certain blood cancers,” said Alex Delbridge, PhD, of the Walter and Eliza Hall Institute of Medical Research in Melbourne, Victoria, Australia.

“However, we have now shown that MCL-1 is also critical for emergency recovery of the blood cell system after cancer therapy-induced blood cell loss.”

Dr Delbridge and his colleagues reported these findings in Blood.

Experiments in mice revealed that loss of a single MCL-1 allele, which reduced MCL-1 protein levels, greatly compromised the immune system and hindered red blood cell recovery after treatment with 5-fluorouracil, γ-irradiation, or HSCT.

Further investigation showed that the pro-apoptotic gene PUMA plays a key role in this phenomenon, as MCL-1 inhibits PUMA. In mice, knocking out PUMA alleviated—but did not eliminate—the HSC survival defect caused by deletion of both MCL-1 alleles.

“This exquisite dependency on MCL-1 for emergency blood cell production has important implications for potential cancer treatments involving MCL-1 inhibitors,” Dr Delbridge said.

“If MCL-1 inhibitors are to be used in combination with other cancer therapies, careful monitoring of the blood cell system will be needed,” added Stephanie Grabow, PhD, also of the Walter and Eliza Hall Institute.

“Our institute colleagues are working to evaluate a potential new drug to treat blood cancers by targeting MCL-1. Our findings suggest that MCL-1 inhibitors and chemotherapeutic drugs should not be used simultaneously.”

Dr Delbridge said this research also offers insights that could help improve HSCT.

“Stem cell transplants can be dangerous because, until the blood cell system is functionally restored, patients are vulnerable to infection,” he said. “Our research suggests that increasing levels of MCL-1 or decreasing the activity of opposing proteins could be a viable strategy for speeding up the regeneration process and reducing the risk of infection after stem cell transplantation.”

Hematopoietic stem cells

in the bone marrow

New research suggests the cell survival protein MCL-1, a target for a number of new anticancer agents, is essential for hematopoietic recovery.

Investigators found that reducing MCL-1 levels hindered hematopoietic recovery after chemotherapy and radiotherapy caused extensive destruction of mature blood cells.

Reducing MCL-1 also impaired reconstitution of the bone marrow after hematopoietic stem cell transplant (HSCT).

“Our previous research has shown that targeting MCL-1 could be used with great success for treating certain blood cancers,” said Alex Delbridge, PhD, of the Walter and Eliza Hall Institute of Medical Research in Melbourne, Victoria, Australia.

“However, we have now shown that MCL-1 is also critical for emergency recovery of the blood cell system after cancer therapy-induced blood cell loss.”

Dr Delbridge and his colleagues reported these findings in Blood.

Experiments in mice revealed that loss of a single MCL-1 allele, which reduced MCL-1 protein levels, greatly compromised the immune system and hindered red blood cell recovery after treatment with 5-fluorouracil, γ-irradiation, or HSCT.

Further investigation showed that the pro-apoptotic gene PUMA plays a key role in this phenomenon, as MCL-1 inhibits PUMA. In mice, knocking out PUMA alleviated—but did not eliminate—the HSC survival defect caused by deletion of both MCL-1 alleles.

“This exquisite dependency on MCL-1 for emergency blood cell production has important implications for potential cancer treatments involving MCL-1 inhibitors,” Dr Delbridge said.

“If MCL-1 inhibitors are to be used in combination with other cancer therapies, careful monitoring of the blood cell system will be needed,” added Stephanie Grabow, PhD, also of the Walter and Eliza Hall Institute.

“Our institute colleagues are working to evaluate a potential new drug to treat blood cancers by targeting MCL-1. Our findings suggest that MCL-1 inhibitors and chemotherapeutic drugs should not be used simultaneously.”

Dr Delbridge said this research also offers insights that could help improve HSCT.

“Stem cell transplants can be dangerous because, until the blood cell system is functionally restored, patients are vulnerable to infection,” he said. “Our research suggests that increasing levels of MCL-1 or decreasing the activity of opposing proteins could be a viable strategy for speeding up the regeneration process and reducing the risk of infection after stem cell transplantation.”

Unlike for those with acute leukemia, patients with chronic lymphocytic leukemia who had disease progression after undergoing transplantation had a relatively good prognosis, with 2- and 5-year overall survival rates of 67% and 38%, investigators reported online April 6 in the Journal of Clinical Oncology.*

Patients with chronic lymphocytic leukemia (CLL) who experienced acute or chronic graft-versus-host disease (GVHD) had significantly longer overall survival (OS) than those who did not have GVHD (P = .04 and P = .05, respectively). “Nearly half our patients with active CLL after transplantation had chronic GVHD, and the association of chronic GVHD with achieving cure and its power to predict OS among patients for whom transplantation failed suggests that the GVL (graft-versus-leukemia) effect contributes to prolonged survival even in patients with a high burden of disease,” wrote Dr. Uri Rozovski and associates at the University of Texas MD Anderson Cancer Center, Houston (J. Clin. Oncol. 2015 Apr. 6 [doi:10.1200/JCO.2014.58.6750]).

A matched-pair analysis showed that patients who underwent allogeneic stem cell transplant (SCT) about the same time and did not relapse also had higher rates of acute and chronic GVHD (P = .004 and P = .011, respectively).

The retrospective review of the Bone Marrow Transplantation Program database identified 358 patients with CLL or RT who underwent SCT from 1998 to 2011. The study evaluated 72 patients who had disease progression at a median 74 months after SCT, most of whom received one to eight lines of treatment after relapse and had a median OS of almost 3 years from the time of progression. Multivariate analysis showed that low hemoglobin levels and the presence of Richter’s transformation (RT) were associated with shorter OS; chronic GVHD and response to the first post-SCT treatment predicted longer OS.

Patients with RT had a worse prognosis, with a median OS of 15 months (95% confidence interval, 2-28 months) and 2- and 5-year survival rates of 36% and 0%. Transplantation carried a significant risk for transformation: 16 (30%) patients with CLL developed RT after allogeneic SCT. Conversely, four patients with RT developed CLL after transplantation.

The authors note that even in patients who did not maintain a durable response, SCT was beneficial. The study cohort received a variety of salvage treatments, and patients who received ibrutinib responded well. “Because of the favorable outcomes with ibrutinib in relapsed/refractory CLL, we believe that ibrutinib might have a role in the treatment of disease progression following transplantation failure,” they wrote.

*Correction, 4/8/2015: A previous version of this article misstated the type of leukemia referenced in the study.

Unlike for those with acute leukemia, patients with chronic lymphocytic leukemia who had disease progression after undergoing transplantation had a relatively good prognosis, with 2- and 5-year overall survival rates of 67% and 38%, investigators reported online April 6 in the Journal of Clinical Oncology.*

Patients with chronic lymphocytic leukemia (CLL) who experienced acute or chronic graft-versus-host disease (GVHD) had significantly longer overall survival (OS) than those who did not have GVHD (P = .04 and P = .05, respectively). “Nearly half our patients with active CLL after transplantation had chronic GVHD, and the association of chronic GVHD with achieving cure and its power to predict OS among patients for whom transplantation failed suggests that the GVL (graft-versus-leukemia) effect contributes to prolonged survival even in patients with a high burden of disease,” wrote Dr. Uri Rozovski and associates at the University of Texas MD Anderson Cancer Center, Houston (J. Clin. Oncol. 2015 Apr. 6 [doi:10.1200/JCO.2014.58.6750]).

A matched-pair analysis showed that patients who underwent allogeneic stem cell transplant (SCT) about the same time and did not relapse also had higher rates of acute and chronic GVHD (P = .004 and P = .011, respectively).

The retrospective review of the Bone Marrow Transplantation Program database identified 358 patients with CLL or RT who underwent SCT from 1998 to 2011. The study evaluated 72 patients who had disease progression at a median 74 months after SCT, most of whom received one to eight lines of treatment after relapse and had a median OS of almost 3 years from the time of progression. Multivariate analysis showed that low hemoglobin levels and the presence of Richter’s transformation (RT) were associated with shorter OS; chronic GVHD and response to the first post-SCT treatment predicted longer OS.

Patients with RT had a worse prognosis, with a median OS of 15 months (95% confidence interval, 2-28 months) and 2- and 5-year survival rates of 36% and 0%. Transplantation carried a significant risk for transformation: 16 (30%) patients with CLL developed RT after allogeneic SCT. Conversely, four patients with RT developed CLL after transplantation.

The authors note that even in patients who did not maintain a durable response, SCT was beneficial. The study cohort received a variety of salvage treatments, and patients who received ibrutinib responded well. “Because of the favorable outcomes with ibrutinib in relapsed/refractory CLL, we believe that ibrutinib might have a role in the treatment of disease progression following transplantation failure,” they wrote.

*Correction, 4/8/2015: A previous version of this article misstated the type of leukemia referenced in the study.

Unlike for those with acute leukemia, patients with chronic lymphocytic leukemia who had disease progression after undergoing transplantation had a relatively good prognosis, with 2- and 5-year overall survival rates of 67% and 38%, investigators reported online April 6 in the Journal of Clinical Oncology.*

Patients with chronic lymphocytic leukemia (CLL) who experienced acute or chronic graft-versus-host disease (GVHD) had significantly longer overall survival (OS) than those who did not have GVHD (P = .04 and P = .05, respectively). “Nearly half our patients with active CLL after transplantation had chronic GVHD, and the association of chronic GVHD with achieving cure and its power to predict OS among patients for whom transplantation failed suggests that the GVL (graft-versus-leukemia) effect contributes to prolonged survival even in patients with a high burden of disease,” wrote Dr. Uri Rozovski and associates at the University of Texas MD Anderson Cancer Center, Houston (J. Clin. Oncol. 2015 Apr. 6 [doi:10.1200/JCO.2014.58.6750]).

A matched-pair analysis showed that patients who underwent allogeneic stem cell transplant (SCT) about the same time and did not relapse also had higher rates of acute and chronic GVHD (P = .004 and P = .011, respectively).

The retrospective review of the Bone Marrow Transplantation Program database identified 358 patients with CLL or RT who underwent SCT from 1998 to 2011. The study evaluated 72 patients who had disease progression at a median 74 months after SCT, most of whom received one to eight lines of treatment after relapse and had a median OS of almost 3 years from the time of progression. Multivariate analysis showed that low hemoglobin levels and the presence of Richter’s transformation (RT) were associated with shorter OS; chronic GVHD and response to the first post-SCT treatment predicted longer OS.

Patients with RT had a worse prognosis, with a median OS of 15 months (95% confidence interval, 2-28 months) and 2- and 5-year survival rates of 36% and 0%. Transplantation carried a significant risk for transformation: 16 (30%) patients with CLL developed RT after allogeneic SCT. Conversely, four patients with RT developed CLL after transplantation.

The authors note that even in patients who did not maintain a durable response, SCT was beneficial. The study cohort received a variety of salvage treatments, and patients who received ibrutinib responded well. “Because of the favorable outcomes with ibrutinib in relapsed/refractory CLL, we believe that ibrutinib might have a role in the treatment of disease progression following transplantation failure,” they wrote.

*Correction, 4/8/2015: A previous version of this article misstated the type of leukemia referenced in the study.

SAN FRANCISCO – Voriconazole increased the risk of squamous cell carcinoma by 73% in a review of 455 lung transplant patients at the University of California, San Francisco.

The increase was for any exposure to the drug after transplant (adjusted hazard ratio, 1.73; P = .03). The investigators also found that each additional 30-day exposure at 200 mg of voriconazole twice daily increased the risk of squamous cell carcinoma (SCC) by 3.0% (HR, 1.03; P < .001). The results were adjusted for age at transplant, sex, and race. Overall, SCC risk was highest among white men aged 50 years or older at the time of transplant.

Although voriconazole did protect against posttransplant Aspergillus colonization (aHR, 0.50; P < .001), it did not reduce the risk of invasive aspergillosis. The drug reduced all-cause mortality only among colonized subjects (aHR, 0.34; P = .03), and offered no mortality benefit among those who were not colonized.

There was no difference in all-cause mortality between patients who had any exposure to voriconazole and those who did not, “but we actually found a 2% increased risk of death for each 1 month on the medication. Patients who weren’t colonized were the ones contributing to this increased risk of death,” said lead investigator Matthew Mansh, now a medical student at Stanford (Calif.) University.

There was no increased risk of SCC with alternative antifungals, including inhaled amphotericin and posaconazole. These alternatives should be considered instead of voriconazole in people at higher risk for skin cancer after lung transplants, according to the study, Mr. Mansh noted.

Voriconazole, which is widely used for antifungal prophylaxis after solid organ transplants, has been linked to skin cancer. The reason for the carcinogenic effect is not known; researchers are working to unravel the molecular mechanisms.

“Physicians should be cautious when using voriconazole in the care of transplant recipients. If you see a patient who is developing phototoxicity” with voriconazole, “and if they don’t have evidence of Aspergillus colonization, you may want to limit exposure to high doses of this drug or suggest an alternative,” Mr. Mansh said.

“We have now demonstrated that the alternatives “don’t carry this increased risk of cutaneous SCC,” Mr. Mansh said at the American Academy of Dermatology annual meeting.

The mean age of the study patients at transplant was 52 years, and the majority of patients were white; slightly more than half were men. Most had bilateral lung transplants, with pulmonary fibrosis at the leading indication.

Voriconazole was used in 85% of the patients for an average of 10 months. A quarter of voriconazole patients developed SCC within 5 years of transplant, and 43% within 10 years. Among patients who did not receive the drug, 15% developed SCC within 5 years of transplant, and 28% developed SCC within 10 years of transplant.

“The benefit of voriconazole in terms of death was limited to patients with evidence of Aspergillus colonization, and it wasn’t dose dependent. Patients who had a higher cumulative exposure did not get more benefit,” Mr. Mansh said.

Mr. Mansh had no relevant disclosures.

[email protected]

SAN FRANCISCO – Voriconazole increased the risk of squamous cell carcinoma by 73% in a review of 455 lung transplant patients at the University of California, San Francisco.

The increase was for any exposure to the drug after transplant (adjusted hazard ratio, 1.73; P = .03). The investigators also found that each additional 30-day exposure at 200 mg of voriconazole twice daily increased the risk of squamous cell carcinoma (SCC) by 3.0% (HR, 1.03; P < .001). The results were adjusted for age at transplant, sex, and race. Overall, SCC risk was highest among white men aged 50 years or older at the time of transplant.

Although voriconazole did protect against posttransplant Aspergillus colonization (aHR, 0.50; P < .001), it did not reduce the risk of invasive aspergillosis. The drug reduced all-cause mortality only among colonized subjects (aHR, 0.34; P = .03), and offered no mortality benefit among those who were not colonized.

There was no difference in all-cause mortality between patients who had any exposure to voriconazole and those who did not, “but we actually found a 2% increased risk of death for each 1 month on the medication. Patients who weren’t colonized were the ones contributing to this increased risk of death,” said lead investigator Matthew Mansh, now a medical student at Stanford (Calif.) University.

There was no increased risk of SCC with alternative antifungals, including inhaled amphotericin and posaconazole. These alternatives should be considered instead of voriconazole in people at higher risk for skin cancer after lung transplants, according to the study, Mr. Mansh noted.

Voriconazole, which is widely used for antifungal prophylaxis after solid organ transplants, has been linked to skin cancer. The reason for the carcinogenic effect is not known; researchers are working to unravel the molecular mechanisms.

“Physicians should be cautious when using voriconazole in the care of transplant recipients. If you see a patient who is developing phototoxicity” with voriconazole, “and if they don’t have evidence of Aspergillus colonization, you may want to limit exposure to high doses of this drug or suggest an alternative,” Mr. Mansh said.

“We have now demonstrated that the alternatives “don’t carry this increased risk of cutaneous SCC,” Mr. Mansh said at the American Academy of Dermatology annual meeting.

The mean age of the study patients at transplant was 52 years, and the majority of patients were white; slightly more than half were men. Most had bilateral lung transplants, with pulmonary fibrosis at the leading indication.

Voriconazole was used in 85% of the patients for an average of 10 months. A quarter of voriconazole patients developed SCC within 5 years of transplant, and 43% within 10 years. Among patients who did not receive the drug, 15% developed SCC within 5 years of transplant, and 28% developed SCC within 10 years of transplant.

“The benefit of voriconazole in terms of death was limited to patients with evidence of Aspergillus colonization, and it wasn’t dose dependent. Patients who had a higher cumulative exposure did not get more benefit,” Mr. Mansh said.

Mr. Mansh had no relevant disclosures.

[email protected]

SAN FRANCISCO – Voriconazole increased the risk of squamous cell carcinoma by 73% in a review of 455 lung transplant patients at the University of California, San Francisco.

The increase was for any exposure to the drug after transplant (adjusted hazard ratio, 1.73; P = .03). The investigators also found that each additional 30-day exposure at 200 mg of voriconazole twice daily increased the risk of squamous cell carcinoma (SCC) by 3.0% (HR, 1.03; P < .001). The results were adjusted for age at transplant, sex, and race. Overall, SCC risk was highest among white men aged 50 years or older at the time of transplant.

Although voriconazole did protect against posttransplant Aspergillus colonization (aHR, 0.50; P < .001), it did not reduce the risk of invasive aspergillosis. The drug reduced all-cause mortality only among colonized subjects (aHR, 0.34; P = .03), and offered no mortality benefit among those who were not colonized.

There was no difference in all-cause mortality between patients who had any exposure to voriconazole and those who did not, “but we actually found a 2% increased risk of death for each 1 month on the medication. Patients who weren’t colonized were the ones contributing to this increased risk of death,” said lead investigator Matthew Mansh, now a medical student at Stanford (Calif.) University.

There was no increased risk of SCC with alternative antifungals, including inhaled amphotericin and posaconazole. These alternatives should be considered instead of voriconazole in people at higher risk for skin cancer after lung transplants, according to the study, Mr. Mansh noted.

Voriconazole, which is widely used for antifungal prophylaxis after solid organ transplants, has been linked to skin cancer. The reason for the carcinogenic effect is not known; researchers are working to unravel the molecular mechanisms.

“Physicians should be cautious when using voriconazole in the care of transplant recipients. If you see a patient who is developing phototoxicity” with voriconazole, “and if they don’t have evidence of Aspergillus colonization, you may want to limit exposure to high doses of this drug or suggest an alternative,” Mr. Mansh said.

“We have now demonstrated that the alternatives “don’t carry this increased risk of cutaneous SCC,” Mr. Mansh said at the American Academy of Dermatology annual meeting.

The mean age of the study patients at transplant was 52 years, and the majority of patients were white; slightly more than half were men. Most had bilateral lung transplants, with pulmonary fibrosis at the leading indication.

Voriconazole was used in 85% of the patients for an average of 10 months. A quarter of voriconazole patients developed SCC within 5 years of transplant, and 43% within 10 years. Among patients who did not receive the drug, 15% developed SCC within 5 years of transplant, and 28% developed SCC within 10 years of transplant.

“The benefit of voriconazole in terms of death was limited to patients with evidence of Aspergillus colonization, and it wasn’t dose dependent. Patients who had a higher cumulative exposure did not get more benefit,” Mr. Mansh said.

Mr. Mansh had no relevant disclosures.

[email protected]

A smartphone application was less effective at correctly diagnosing malignant melanoma than clinical diagnosis by dermatologists, based on data from a study evaluating 195 melanocytic lesions.

The app, which used fractal image analysis, was 73% specific and 83% sensitive, whereas the dermatologists’ clinical examinations were 88% sensitive and 97% specific.

Both diagnostic methods’ results were compared to histopathologic analyses of the nevi. The histopathologic analyses found 40 melanomas, 42 dysplastic nevi, and 113 benign nevi.

“The smartphone application ... might be a promising tool in the pre-evaluation of pigmented moles by laypersons,” although the current technology falls short, compared with clinical diagnosis by a dermatologist, according to the study’s researchers.

Find the full study in Journal of the European Academy of Dermatology and Venereology (doi:10.1111/jdv.12648).

A smartphone application was less effective at correctly diagnosing malignant melanoma than clinical diagnosis by dermatologists, based on data from a study evaluating 195 melanocytic lesions.

The app, which used fractal image analysis, was 73% specific and 83% sensitive, whereas the dermatologists’ clinical examinations were 88% sensitive and 97% specific.

Both diagnostic methods’ results were compared to histopathologic analyses of the nevi. The histopathologic analyses found 40 melanomas, 42 dysplastic nevi, and 113 benign nevi.

“The smartphone application ... might be a promising tool in the pre-evaluation of pigmented moles by laypersons,” although the current technology falls short, compared with clinical diagnosis by a dermatologist, according to the study’s researchers.

Find the full study in Journal of the European Academy of Dermatology and Venereology (doi:10.1111/jdv.12648).

A smartphone application was less effective at correctly diagnosing malignant melanoma than clinical diagnosis by dermatologists, based on data from a study evaluating 195 melanocytic lesions.

The app, which used fractal image analysis, was 73% specific and 83% sensitive, whereas the dermatologists’ clinical examinations were 88% sensitive and 97% specific.

Both diagnostic methods’ results were compared to histopathologic analyses of the nevi. The histopathologic analyses found 40 melanomas, 42 dysplastic nevi, and 113 benign nevi.

“The smartphone application ... might be a promising tool in the pre-evaluation of pigmented moles by laypersons,” although the current technology falls short, compared with clinical diagnosis by a dermatologist, according to the study’s researchers.

Find the full study in Journal of the European Academy of Dermatology and Venereology (doi:10.1111/jdv.12648).

A substantial number of nursing home residents undergo lower-extremity revascularization each year, but very few of them gain any function and approximately half die within the year, according to a report published online April 6 in JAMA Internal Medicine.

In a population-based analysis of Medicare claims and a database that tracks virtually all U.S. nursing homes, 82% of residents who underwent the procedure during a 3-year period had either died or were unable to walk a year afterward. Most showed a clinically significant decline in function within 3 months of having the procedure, said Dr. Lawrence Oresanya of the department of surgery, University of California, San Francisco, and his associates.

“Our findings can inform conversations between physicians, patients, and families about the risks and expected outcomes of surgery and whether the surgery is likely to be worthwhile. Our findings also highlight the importance of carefully considering a prognosis independent of vascular disease and assessing the goals of care. Ambulatory function … may be impossible to attain,” they wrote.

Lower-extremity revascularization is usually performed to maintain elderly patients’ functional independence by preserving their limbs. But a closer examination of these procedures is warranted in the nursing home population “because nursing home residents, in general, have high levels of functional dependence unrelated to peripheral arterial disease, and higher rates of mortality after most invasive procedures,” the investigators said.

Dr. Oresanya and his colleagues identified 10,784 nursing home residents across the country who underwent lower-extremity revascularization. The procedure was elective in 67% of cases and emergent or urgent in 33%. An endovascular approach was used in 56%, and an open approach in the remainder, with the endovacular approach being more associated with clinical success than open surgery.

The mean patient age was 82 years, and serious comorbidities were very common: 60% had cognitive impairment, 57% had heart failure, and 29% had renal failure. Three-fourths of the patients were nonambulatory at the time of surgery.

The investigators assumed that most patients in this setting had critical limb ischemia rather than claudication. They did not have information about the severity of the lower-extremity ischemia, or about the prevalence or duration of nonhealing wounds or gangrene.

One year after lower-extremity revascularization, mortality was 51% among ambulatory patients and 53% among nonambulatory patients. Only 13% of the entire cohort were able to walk, and only 18% had maintained or improved their presurgical functional status. “Revascularization rarely allowed a nonambulatory resident to become ambulatory,” Dr. Oresanya and his associates wrote (JAMA Intern. Med. 2015 April 6 [doi:10.1001/jamainternmed.2015.0486]).

The researchers were unable to determine whether these poor outcomes resulted from the surgery itself or were due to these patients’ “insufficient physiologic reserve.”

They also cautioned that they confined their study strictly to functional outcomes of lower-extremity revascularization, namely ambulation and mortality. Some patients may have derived other benefits from the procedure, such as relief of pain, healing of wounds, and avoidance of major amputation.

The authors reported having no relevant financial disclosures.

A substantial number of nursing home residents undergo lower-extremity revascularization each year, but very few of them gain any function and approximately half die within the year, according to a report published online April 6 in JAMA Internal Medicine.

In a population-based analysis of Medicare claims and a database that tracks virtually all U.S. nursing homes, 82% of residents who underwent the procedure during a 3-year period had either died or were unable to walk a year afterward. Most showed a clinically significant decline in function within 3 months of having the procedure, said Dr. Lawrence Oresanya of the department of surgery, University of California, San Francisco, and his associates.

“Our findings can inform conversations between physicians, patients, and families about the risks and expected outcomes of surgery and whether the surgery is likely to be worthwhile. Our findings also highlight the importance of carefully considering a prognosis independent of vascular disease and assessing the goals of care. Ambulatory function … may be impossible to attain,” they wrote.

Lower-extremity revascularization is usually performed to maintain elderly patients’ functional independence by preserving their limbs. But a closer examination of these procedures is warranted in the nursing home population “because nursing home residents, in general, have high levels of functional dependence unrelated to peripheral arterial disease, and higher rates of mortality after most invasive procedures,” the investigators said.

Dr. Oresanya and his colleagues identified 10,784 nursing home residents across the country who underwent lower-extremity revascularization. The procedure was elective in 67% of cases and emergent or urgent in 33%. An endovascular approach was used in 56%, and an open approach in the remainder, with the endovacular approach being more associated with clinical success than open surgery.

The mean patient age was 82 years, and serious comorbidities were very common: 60% had cognitive impairment, 57% had heart failure, and 29% had renal failure. Three-fourths of the patients were nonambulatory at the time of surgery.

The investigators assumed that most patients in this setting had critical limb ischemia rather than claudication. They did not have information about the severity of the lower-extremity ischemia, or about the prevalence or duration of nonhealing wounds or gangrene.

One year after lower-extremity revascularization, mortality was 51% among ambulatory patients and 53% among nonambulatory patients. Only 13% of the entire cohort were able to walk, and only 18% had maintained or improved their presurgical functional status. “Revascularization rarely allowed a nonambulatory resident to become ambulatory,” Dr. Oresanya and his associates wrote (JAMA Intern. Med. 2015 April 6 [doi:10.1001/jamainternmed.2015.0486]).

The researchers were unable to determine whether these poor outcomes resulted from the surgery itself or were due to these patients’ “insufficient physiologic reserve.”

They also cautioned that they confined their study strictly to functional outcomes of lower-extremity revascularization, namely ambulation and mortality. Some patients may have derived other benefits from the procedure, such as relief of pain, healing of wounds, and avoidance of major amputation.

The authors reported having no relevant financial disclosures.

A substantial number of nursing home residents undergo lower-extremity revascularization each year, but very few of them gain any function and approximately half die within the year, according to a report published online April 6 in JAMA Internal Medicine.

In a population-based analysis of Medicare claims and a database that tracks virtually all U.S. nursing homes, 82% of residents who underwent the procedure during a 3-year period had either died or were unable to walk a year afterward. Most showed a clinically significant decline in function within 3 months of having the procedure, said Dr. Lawrence Oresanya of the department of surgery, University of California, San Francisco, and his associates.

“Our findings can inform conversations between physicians, patients, and families about the risks and expected outcomes of surgery and whether the surgery is likely to be worthwhile. Our findings also highlight the importance of carefully considering a prognosis independent of vascular disease and assessing the goals of care. Ambulatory function … may be impossible to attain,” they wrote.

Lower-extremity revascularization is usually performed to maintain elderly patients’ functional independence by preserving their limbs. But a closer examination of these procedures is warranted in the nursing home population “because nursing home residents, in general, have high levels of functional dependence unrelated to peripheral arterial disease, and higher rates of mortality after most invasive procedures,” the investigators said.

Dr. Oresanya and his colleagues identified 10,784 nursing home residents across the country who underwent lower-extremity revascularization. The procedure was elective in 67% of cases and emergent or urgent in 33%. An endovascular approach was used in 56%, and an open approach in the remainder, with the endovacular approach being more associated with clinical success than open surgery.

The mean patient age was 82 years, and serious comorbidities were very common: 60% had cognitive impairment, 57% had heart failure, and 29% had renal failure. Three-fourths of the patients were nonambulatory at the time of surgery.

The investigators assumed that most patients in this setting had critical limb ischemia rather than claudication. They did not have information about the severity of the lower-extremity ischemia, or about the prevalence or duration of nonhealing wounds or gangrene.

One year after lower-extremity revascularization, mortality was 51% among ambulatory patients and 53% among nonambulatory patients. Only 13% of the entire cohort were able to walk, and only 18% had maintained or improved their presurgical functional status. “Revascularization rarely allowed a nonambulatory resident to become ambulatory,” Dr. Oresanya and his associates wrote (JAMA Intern. Med. 2015 April 6 [doi:10.1001/jamainternmed.2015.0486]).

The researchers were unable to determine whether these poor outcomes resulted from the surgery itself or were due to these patients’ “insufficient physiologic reserve.”

They also cautioned that they confined their study strictly to functional outcomes of lower-extremity revascularization, namely ambulation and mortality. Some patients may have derived other benefits from the procedure, such as relief of pain, healing of wounds, and avoidance of major amputation.

The authors reported having no relevant financial disclosures.