Thrombus

Credit: Andre E.X. Brown

The US Food and Drug Administration (FDA) has again decided not to approve the anticoagulant rivaroxaban (Xarelto) for use in patients with acute coronary syndromes (ACS).

The drug’s developers are seeking approval of rivaroxaban to reduce the risk of secondary cardiovascular events—heart attack, stroke, or death—and to reduce the risk of stent thrombosis in ACS patients.

For both indications, the drug would be given in combination with standard antiplatelet therapy.

This is not the first time the FDA has decided against approving rivaroxaban for use in ACS patients. The agency rejected the drug as prophylaxis for cardiovascular events in June 2012 and March 2013. And the drug was denied approval for stent thrombosis in June 2013.

Nevertheless, it seems the companies developing rivaroxaban—Janssen Research & Development, LLC and Bayer HealthCare—plan to continue pursuing approvals for these indications.

“We remain committed to providing patients who have suffered from acute coronary syndrome with additional protection against stent thrombosis and secondary, life-threatening cardiovascular events,” said Paul Burton, MD, PhD, Vice President, Clinical Development, Janssen Research & Development.

“We are evaluating the contents of the [FDA’s complete response] letters and will determine the appropriate next steps.”

Both applications for expanding rivaroxaban use were based on results from the phase 3 ATLAS ACS 2 TIMI 51 trial, which were published in NEJM in November 2011.

The study showed that rivaroxaban, when given in combination with standard antiplatelet therapy, reduced the composite endpoint of cardiovascular death, myocardial infarction, and stroke in ACS patients, compared to placebo. But rivaroxaban also increased the risk of major bleeding and intracranial hemorrhage.

In past evaluations of rivaroxaban, the FDA and its advisors expressed concerns about data from this trial, particularly the risk of bleeding associated with rivaroxaban and some gaps in trial data.

Although Janssen submitted the missing data, the FDA still had reservations about rivaroxaban’s safety and efficacy in ACS patients. The FDA recently suggested the company limit the proposed duration of rivaroxaban treatment, as the drug might be safer and more effective when given for a shorter period.

So Janssen changed the suggested treatment duration to 90 days. But last month, an FDA advisory committee still recommended against expanding the drug’s indication. And the agency seems to have taken that recommendation to heart.

Rivaroxaban is currently FDA-approved to treat patients with venous thromboembolism (VTE) and to reduce the risk of VTE recurrence following an initial 6-month treatment for acute VTE. The drug is also approved for use as thromboprophylaxis for patients with non-valvular atrial fibrillation, those who have undergone knee replacement surgery, and patients who have had hip replacement surgery.

Thrombus

Credit: Andre E.X. Brown

The US Food and Drug Administration (FDA) has again decided not to approve the anticoagulant rivaroxaban (Xarelto) for use in patients with acute coronary syndromes (ACS).

The drug’s developers are seeking approval of rivaroxaban to reduce the risk of secondary cardiovascular events—heart attack, stroke, or death—and to reduce the risk of stent thrombosis in ACS patients.

For both indications, the drug would be given in combination with standard antiplatelet therapy.

This is not the first time the FDA has decided against approving rivaroxaban for use in ACS patients. The agency rejected the drug as prophylaxis for cardiovascular events in June 2012 and March 2013. And the drug was denied approval for stent thrombosis in June 2013.

Nevertheless, it seems the companies developing rivaroxaban—Janssen Research & Development, LLC and Bayer HealthCare—plan to continue pursuing approvals for these indications.

“We remain committed to providing patients who have suffered from acute coronary syndrome with additional protection against stent thrombosis and secondary, life-threatening cardiovascular events,” said Paul Burton, MD, PhD, Vice President, Clinical Development, Janssen Research & Development.

“We are evaluating the contents of the [FDA’s complete response] letters and will determine the appropriate next steps.”

Both applications for expanding rivaroxaban use were based on results from the phase 3 ATLAS ACS 2 TIMI 51 trial, which were published in NEJM in November 2011.

The study showed that rivaroxaban, when given in combination with standard antiplatelet therapy, reduced the composite endpoint of cardiovascular death, myocardial infarction, and stroke in ACS patients, compared to placebo. But rivaroxaban also increased the risk of major bleeding and intracranial hemorrhage.

In past evaluations of rivaroxaban, the FDA and its advisors expressed concerns about data from this trial, particularly the risk of bleeding associated with rivaroxaban and some gaps in trial data.

Although Janssen submitted the missing data, the FDA still had reservations about rivaroxaban’s safety and efficacy in ACS patients. The FDA recently suggested the company limit the proposed duration of rivaroxaban treatment, as the drug might be safer and more effective when given for a shorter period.

So Janssen changed the suggested treatment duration to 90 days. But last month, an FDA advisory committee still recommended against expanding the drug’s indication. And the agency seems to have taken that recommendation to heart.

Rivaroxaban is currently FDA-approved to treat patients with venous thromboembolism (VTE) and to reduce the risk of VTE recurrence following an initial 6-month treatment for acute VTE. The drug is also approved for use as thromboprophylaxis for patients with non-valvular atrial fibrillation, those who have undergone knee replacement surgery, and patients who have had hip replacement surgery.

Thrombus

Credit: Andre E.X. Brown

The US Food and Drug Administration (FDA) has again decided not to approve the anticoagulant rivaroxaban (Xarelto) for use in patients with acute coronary syndromes (ACS).

The drug’s developers are seeking approval of rivaroxaban to reduce the risk of secondary cardiovascular events—heart attack, stroke, or death—and to reduce the risk of stent thrombosis in ACS patients.

For both indications, the drug would be given in combination with standard antiplatelet therapy.

This is not the first time the FDA has decided against approving rivaroxaban for use in ACS patients. The agency rejected the drug as prophylaxis for cardiovascular events in June 2012 and March 2013. And the drug was denied approval for stent thrombosis in June 2013.

Nevertheless, it seems the companies developing rivaroxaban—Janssen Research & Development, LLC and Bayer HealthCare—plan to continue pursuing approvals for these indications.

“We remain committed to providing patients who have suffered from acute coronary syndrome with additional protection against stent thrombosis and secondary, life-threatening cardiovascular events,” said Paul Burton, MD, PhD, Vice President, Clinical Development, Janssen Research & Development.

“We are evaluating the contents of the [FDA’s complete response] letters and will determine the appropriate next steps.”

Both applications for expanding rivaroxaban use were based on results from the phase 3 ATLAS ACS 2 TIMI 51 trial, which were published in NEJM in November 2011.

The study showed that rivaroxaban, when given in combination with standard antiplatelet therapy, reduced the composite endpoint of cardiovascular death, myocardial infarction, and stroke in ACS patients, compared to placebo. But rivaroxaban also increased the risk of major bleeding and intracranial hemorrhage.

In past evaluations of rivaroxaban, the FDA and its advisors expressed concerns about data from this trial, particularly the risk of bleeding associated with rivaroxaban and some gaps in trial data.

Although Janssen submitted the missing data, the FDA still had reservations about rivaroxaban’s safety and efficacy in ACS patients. The FDA recently suggested the company limit the proposed duration of rivaroxaban treatment, as the drug might be safer and more effective when given for a shorter period.

So Janssen changed the suggested treatment duration to 90 days. But last month, an FDA advisory committee still recommended against expanding the drug’s indication. And the agency seems to have taken that recommendation to heart.

Rivaroxaban is currently FDA-approved to treat patients with venous thromboembolism (VTE) and to reduce the risk of VTE recurrence following an initial 6-month treatment for acute VTE. The drug is also approved for use as thromboprophylaxis for patients with non-valvular atrial fibrillation, those who have undergone knee replacement surgery, and patients who have had hip replacement surgery.

When I was a little girl, I enjoyed watching the Brady Bunch on television. For those of you under the age of 30, who may not be familiar with this hit series, Mrs. Brady, played by Florence Henderson, was a stay-at-home mother with six kids, three of her own and three of her husband’s by a prior marriage. Somehow, the house was always immaculate, the kids were always well kept, and she always managed to be level-headed, warm, and nurturing (but Alice, the housekeeper, helped a lot).

Fast forward a few decades. Now women frequently are the primary breadwinners, often working outside the home and then even more when they return after work, tethered to a computer or with smartphone in hand. This is the new work-life balance equation for many of us.

©photo168/iStockphoto

My husband and I are currently seeking to adopt a little girl in the foster care system. If we are successful in 2014, this will be our second adoption in 5 years. Anyone who has ever added to their family this way can attest to the hurdles, stumbling blocks, and utter frustration the journey can hold. In the last 8 months, I have seen thousands of photos of waiting children and found only one child in our self-defined age group (4 or younger) who does not have major developmental or physical challenges. There are over 15 other families who have also inquired about her.

I used to feel guilty that I flipped through the pictures of special-needs children quickly, but when I think about my reality as a full-time hospitalist and a mother, I know I cannot provide a special-needs child with the attention she needs. If I have a patient in the ER with unstable angina and a child at home in the midst of a seizure, I cannot exactly call into work for "family reasons." How idyllic would it be for a physician to adopt a sick child, bringing her into a home already endowed with medical expertise? On its face, and to outsiders, it would be perfect. But I have to be realistic about what I can and cannot handle, and about what choice is caring and considerate to both patients and my existing family.

While I await that life-changing call from a social worker somewhere, who has seen my family profile and thinks we would be a perfect fit for a child in her caseload, I am working toward the future. I have a glimpse of what it will be like with two small children and a demanding job, and it has the potential to be chaotic, hair-raising, and overwhelming, but it can also be calm, joyous, and well organized. I realized it is okay to say, "I can’t do this by myself." Cooking, shopping, washing, homework, tantrums, beepers, ... oh my!

I have no relatives who can help make life more manageable, but I have figured out a few things I can do. In addition to a housekeeper, I decided to enlist the help of a personal assistant – who happens to also be my hairdresser and friend – whom I can pay by the hour ($25) to do a variety of tasks around the house and run errands here and there. A few hours here and there will make a huge difference in my peace of mind. I cannot yet rule out an au pair or live-in nanny, but we are not quite ready to share our space with anyone outside our family. I am thankful, of course, that this is even an option for my household financially.

Whether you are a soon-to-be mom or dad, you too may want to think out of the box about ways to trade a hectic, disorganized life for one far more peaceful and serene, even if it comes with a price tag. What works for me may not work for you, but there is a potential solution for us all. We may just have to search hard and pay for it.

Thoughts? E-mail me at [email protected].

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

When I was a little girl, I enjoyed watching the Brady Bunch on television. For those of you under the age of 30, who may not be familiar with this hit series, Mrs. Brady, played by Florence Henderson, was a stay-at-home mother with six kids, three of her own and three of her husband’s by a prior marriage. Somehow, the house was always immaculate, the kids were always well kept, and she always managed to be level-headed, warm, and nurturing (but Alice, the housekeeper, helped a lot).

Fast forward a few decades. Now women frequently are the primary breadwinners, often working outside the home and then even more when they return after work, tethered to a computer or with smartphone in hand. This is the new work-life balance equation for many of us.

©photo168/iStockphoto

My husband and I are currently seeking to adopt a little girl in the foster care system. If we are successful in 2014, this will be our second adoption in 5 years. Anyone who has ever added to their family this way can attest to the hurdles, stumbling blocks, and utter frustration the journey can hold. In the last 8 months, I have seen thousands of photos of waiting children and found only one child in our self-defined age group (4 or younger) who does not have major developmental or physical challenges. There are over 15 other families who have also inquired about her.

I used to feel guilty that I flipped through the pictures of special-needs children quickly, but when I think about my reality as a full-time hospitalist and a mother, I know I cannot provide a special-needs child with the attention she needs. If I have a patient in the ER with unstable angina and a child at home in the midst of a seizure, I cannot exactly call into work for "family reasons." How idyllic would it be for a physician to adopt a sick child, bringing her into a home already endowed with medical expertise? On its face, and to outsiders, it would be perfect. But I have to be realistic about what I can and cannot handle, and about what choice is caring and considerate to both patients and my existing family.

While I await that life-changing call from a social worker somewhere, who has seen my family profile and thinks we would be a perfect fit for a child in her caseload, I am working toward the future. I have a glimpse of what it will be like with two small children and a demanding job, and it has the potential to be chaotic, hair-raising, and overwhelming, but it can also be calm, joyous, and well organized. I realized it is okay to say, "I can’t do this by myself." Cooking, shopping, washing, homework, tantrums, beepers, ... oh my!

I have no relatives who can help make life more manageable, but I have figured out a few things I can do. In addition to a housekeeper, I decided to enlist the help of a personal assistant – who happens to also be my hairdresser and friend – whom I can pay by the hour ($25) to do a variety of tasks around the house and run errands here and there. A few hours here and there will make a huge difference in my peace of mind. I cannot yet rule out an au pair or live-in nanny, but we are not quite ready to share our space with anyone outside our family. I am thankful, of course, that this is even an option for my household financially.

Whether you are a soon-to-be mom or dad, you too may want to think out of the box about ways to trade a hectic, disorganized life for one far more peaceful and serene, even if it comes with a price tag. What works for me may not work for you, but there is a potential solution for us all. We may just have to search hard and pay for it.

Thoughts? E-mail me at [email protected].

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

When I was a little girl, I enjoyed watching the Brady Bunch on television. For those of you under the age of 30, who may not be familiar with this hit series, Mrs. Brady, played by Florence Henderson, was a stay-at-home mother with six kids, three of her own and three of her husband’s by a prior marriage. Somehow, the house was always immaculate, the kids were always well kept, and she always managed to be level-headed, warm, and nurturing (but Alice, the housekeeper, helped a lot).

Fast forward a few decades. Now women frequently are the primary breadwinners, often working outside the home and then even more when they return after work, tethered to a computer or with smartphone in hand. This is the new work-life balance equation for many of us.

©photo168/iStockphoto

My husband and I are currently seeking to adopt a little girl in the foster care system. If we are successful in 2014, this will be our second adoption in 5 years. Anyone who has ever added to their family this way can attest to the hurdles, stumbling blocks, and utter frustration the journey can hold. In the last 8 months, I have seen thousands of photos of waiting children and found only one child in our self-defined age group (4 or younger) who does not have major developmental or physical challenges. There are over 15 other families who have also inquired about her.

I used to feel guilty that I flipped through the pictures of special-needs children quickly, but when I think about my reality as a full-time hospitalist and a mother, I know I cannot provide a special-needs child with the attention she needs. If I have a patient in the ER with unstable angina and a child at home in the midst of a seizure, I cannot exactly call into work for "family reasons." How idyllic would it be for a physician to adopt a sick child, bringing her into a home already endowed with medical expertise? On its face, and to outsiders, it would be perfect. But I have to be realistic about what I can and cannot handle, and about what choice is caring and considerate to both patients and my existing family.

While I await that life-changing call from a social worker somewhere, who has seen my family profile and thinks we would be a perfect fit for a child in her caseload, I am working toward the future. I have a glimpse of what it will be like with two small children and a demanding job, and it has the potential to be chaotic, hair-raising, and overwhelming, but it can also be calm, joyous, and well organized. I realized it is okay to say, "I can’t do this by myself." Cooking, shopping, washing, homework, tantrums, beepers, ... oh my!

I have no relatives who can help make life more manageable, but I have figured out a few things I can do. In addition to a housekeeper, I decided to enlist the help of a personal assistant – who happens to also be my hairdresser and friend – whom I can pay by the hour ($25) to do a variety of tasks around the house and run errands here and there. A few hours here and there will make a huge difference in my peace of mind. I cannot yet rule out an au pair or live-in nanny, but we are not quite ready to share our space with anyone outside our family. I am thankful, of course, that this is even an option for my household financially.

Whether you are a soon-to-be mom or dad, you too may want to think out of the box about ways to trade a hectic, disorganized life for one far more peaceful and serene, even if it comes with a price tag. What works for me may not work for you, but there is a potential solution for us all. We may just have to search hard and pay for it.

Thoughts? E-mail me at [email protected].

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care. She is the creator of the Patient Whiz, a patient-engagement app for iOS.

SAN FRANCISCO – Updated guidelines from the American Diabetes Association open the door to using a two-step approach to gestational diabetes screening.

Screening is still recommended for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, and for gestational diabetes mellitus (GDM) between weeks 24 and 28 of gestation.

What’s changed in the 2014 Standards of Medical Care in Diabetes (Diabetes Care 2014;37(suppl 1):S14-80) is how that screening is accomplished, Dr. Richard W. Grant, chair of the ADA professional practice committee, said at the annual advanced postgraduate course held by the American Diabetes Association.

In prior years, the ADA adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) 2009 recommendation that a 2-hour, 75-gram oral glucose tolerance test (OGTT) be performed the morning after a fast of at least an 8 hours.

A two-step approach was added this year to reflect the 2013 National Institutes of Health Consensus Guidelines recommendation for a 1-hour, 50-gram glucose tolerance screening test followed by a fasting OGTT on another day, if the test is abnormal.

One-step vs. two-step approach

"The issues for these two approaches are the sensitivity with which you can diagnose GDM and the difficulty in implementing these two approaches," said Dr. Grant, a research scientist with Kaiser Permanente Northern California, Oakland.

The one-step approach tends to be more sensitive and diagnoses a broader range of GDM, but it may be a barrier to screening because it requires the patient to fast for 8 hours, he said. Though the one-step approach allows for a diagnosis of GDM within the context of a single office visit, critics also argue its tight diagnostic glucose cut points could dramatically increase the prevalence of GDM from about 5%-6% to 15%-20%, and bring added health care costs and interventions without clear evidence of improved outcomes.

On the other hand, the two-step approach may be more palatable to women because it avoids the up-front fasting requirement, but it could miss GDM in women with an abnormal screen who fail to return for a second visit.

"The bottom line is we need to make sure we do gestational diabetes screening, whichever method we use," Dr. Grant said. "What’s more important is that all women in early pregnancy get screened."

During a discussion following the presentation, a Canadian attendee said similar recommendations released last fall in Canada allowing two screening methods, albeit with different diagnostic thresholds, have resulted in confusion, particularly among referring obstetricians and endocrinologists.

Dr. Grant said there shouldn’t be confusion surrounding the new option as long as recommendations are consistent within an institution.

"I don’t think it’s actually going to make people change what they’re doing currently," he said in an interview. "There’s not a good reason to jump from one to another if you’ve already chosen an approach."

In a separate interview, Dr. R. Harsha Rao, with the Center for Diabetes and Endocrinology at the University of Pittsburgh, said he can see the rationale for the one-step method, but that the two-step approach is almost implanted in the DNA of American obstetricians and that this behavior pattern will be difficult to change for practical reasons alone.

"Patients don’t like 75 grams of Glucola; it’s an awful-tasting substance," he said. "I’ve had patients tell me they felt like [vomiting] when they got the 75-gram Glucola load, and as it is, ‘I’m pregnant and already feeling nauseated.’ "

In addition, there’s the added stress of waiting for a second appointment and a definitive diagnosis for women who screen positive.

The ADA’s bimodal approach to gestational screening reflects an overarching theme of individualized care for diabetes in the 2014 standards. The guidelines are updated annually and this year they contain 232 recommendations, of which 52% are based on high level A or B evidence.

Individualized diabetes care

"One of the themes that comes out in looking at the data very carefully is that you can’t have a one-size-fits-all approach," Dr. Grant observed.

To that end, the guidelines maintain an earlier recommendation raising the systolic blood pressure target goal for hypertension to 140 mm Hg, but also allow a target goal of less than 130 mm Hg in certain populations, such as younger patients.

Dr. Grant observed that the ADA’s position was confirmed by the U.S. Preventive Services Task Force’s recent endorsement of GDM screening using the two-step approach.

"The USPSTF said that the two-step method is an accurate approach, which is what the ADA also says," he remarked.

Based on the recently revised 2013 ADA nutrition position paper (described in the next section below), the guidelines also encourage individualized dietary approaches rather recommending one particular diet over another, Dr. Grant said.

Other revisions include:

• Clarification that the hemoglobin A_1c test is just one of three methods to diagnose diabetes in asymptomatic patients, along with the fasting plasma glucose or 75-gram, 2-hour OGTT;

• An expanded chapter on neuropathy screening and treatment, including B level evidentiary support to test for distal symmetric polyneuropathy;

• Added emphasis on the need to ask patients about symptomatic and asymptomatic hypoglycemia and perform ongoing assessments of cognitive function; and

• Added emphasis on a patient-centered communication style that assesses literacy, but also the often overlooked issue of numeracy.

"It’s really quite impressive how many patients don’t get numbers, but we as physicians speak in numbers," Dr. Grant said.

The recent controversial 2013 American College of Cardiology/American Heart Association cholesterol guideline could not be reviewed in time to for this year’s guidelines, but it will be something to keep an eye out for next year.

ADA dodges dietary dogma

Highlights of the American Diabetes Association’s nutrition recommendations, updated in late 2013, and also presented at the meeting by Patti Urbanski, M.Ed., a member of the ADA Nutrition Recommendations Writing Group Committee, include:

• Select an "eating pattern" based on an individual’s personal and cultural preferences; literacy and numeracy; readiness; and ability to change, because no one dietary plan – be it the Mediterranean, low-carb, or DASH (Dietary Approaches to Stop Hypertension) diet – is best.

• In the absence of evidence supporting an ideal percentage of calories from carbohydrates, protein, or fat for all patients with diabetes, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and goals.

• Reduce energy intake/carbohydrate portions and number of servings per meal, as indicated by individual assessment.

• Early referral to registered dietitians and nutritionists for nutrition therapy.

• First-ever call to avoid sugar-sweetened beverages.

• Continued support to limit sodium intake to 2,300 mg/day, as recommended for the general population, with lower sodium targets an option for those with comorbid hypertension.

• Routine supplementation with oxidants, such as vitamin E and C and carotene, is not advised, nor is routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control.

Dr. Grant disclosed no conflicts of interest.

[email protected]

SAN FRANCISCO – Updated guidelines from the American Diabetes Association open the door to using a two-step approach to gestational diabetes screening.

Screening is still recommended for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, and for gestational diabetes mellitus (GDM) between weeks 24 and 28 of gestation.

What’s changed in the 2014 Standards of Medical Care in Diabetes (Diabetes Care 2014;37(suppl 1):S14-80) is how that screening is accomplished, Dr. Richard W. Grant, chair of the ADA professional practice committee, said at the annual advanced postgraduate course held by the American Diabetes Association.

In prior years, the ADA adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) 2009 recommendation that a 2-hour, 75-gram oral glucose tolerance test (OGTT) be performed the morning after a fast of at least an 8 hours.

A two-step approach was added this year to reflect the 2013 National Institutes of Health Consensus Guidelines recommendation for a 1-hour, 50-gram glucose tolerance screening test followed by a fasting OGTT on another day, if the test is abnormal.

One-step vs. two-step approach

"The issues for these two approaches are the sensitivity with which you can diagnose GDM and the difficulty in implementing these two approaches," said Dr. Grant, a research scientist with Kaiser Permanente Northern California, Oakland.

The one-step approach tends to be more sensitive and diagnoses a broader range of GDM, but it may be a barrier to screening because it requires the patient to fast for 8 hours, he said. Though the one-step approach allows for a diagnosis of GDM within the context of a single office visit, critics also argue its tight diagnostic glucose cut points could dramatically increase the prevalence of GDM from about 5%-6% to 15%-20%, and bring added health care costs and interventions without clear evidence of improved outcomes.

On the other hand, the two-step approach may be more palatable to women because it avoids the up-front fasting requirement, but it could miss GDM in women with an abnormal screen who fail to return for a second visit.

"The bottom line is we need to make sure we do gestational diabetes screening, whichever method we use," Dr. Grant said. "What’s more important is that all women in early pregnancy get screened."

During a discussion following the presentation, a Canadian attendee said similar recommendations released last fall in Canada allowing two screening methods, albeit with different diagnostic thresholds, have resulted in confusion, particularly among referring obstetricians and endocrinologists.

Dr. Grant said there shouldn’t be confusion surrounding the new option as long as recommendations are consistent within an institution.

"I don’t think it’s actually going to make people change what they’re doing currently," he said in an interview. "There’s not a good reason to jump from one to another if you’ve already chosen an approach."

In a separate interview, Dr. R. Harsha Rao, with the Center for Diabetes and Endocrinology at the University of Pittsburgh, said he can see the rationale for the one-step method, but that the two-step approach is almost implanted in the DNA of American obstetricians and that this behavior pattern will be difficult to change for practical reasons alone.

"Patients don’t like 75 grams of Glucola; it’s an awful-tasting substance," he said. "I’ve had patients tell me they felt like [vomiting] when they got the 75-gram Glucola load, and as it is, ‘I’m pregnant and already feeling nauseated.’ "

In addition, there’s the added stress of waiting for a second appointment and a definitive diagnosis for women who screen positive.

The ADA’s bimodal approach to gestational screening reflects an overarching theme of individualized care for diabetes in the 2014 standards. The guidelines are updated annually and this year they contain 232 recommendations, of which 52% are based on high level A or B evidence.

Individualized diabetes care

"One of the themes that comes out in looking at the data very carefully is that you can’t have a one-size-fits-all approach," Dr. Grant observed.

To that end, the guidelines maintain an earlier recommendation raising the systolic blood pressure target goal for hypertension to 140 mm Hg, but also allow a target goal of less than 130 mm Hg in certain populations, such as younger patients.

Dr. Grant observed that the ADA’s position was confirmed by the U.S. Preventive Services Task Force’s recent endorsement of GDM screening using the two-step approach.

"The USPSTF said that the two-step method is an accurate approach, which is what the ADA also says," he remarked.

Based on the recently revised 2013 ADA nutrition position paper (described in the next section below), the guidelines also encourage individualized dietary approaches rather recommending one particular diet over another, Dr. Grant said.

Other revisions include:

• Clarification that the hemoglobin A_1c test is just one of three methods to diagnose diabetes in asymptomatic patients, along with the fasting plasma glucose or 75-gram, 2-hour OGTT;

• An expanded chapter on neuropathy screening and treatment, including B level evidentiary support to test for distal symmetric polyneuropathy;

• Added emphasis on the need to ask patients about symptomatic and asymptomatic hypoglycemia and perform ongoing assessments of cognitive function; and

• Added emphasis on a patient-centered communication style that assesses literacy, but also the often overlooked issue of numeracy.

"It’s really quite impressive how many patients don’t get numbers, but we as physicians speak in numbers," Dr. Grant said.

The recent controversial 2013 American College of Cardiology/American Heart Association cholesterol guideline could not be reviewed in time to for this year’s guidelines, but it will be something to keep an eye out for next year.

ADA dodges dietary dogma

Highlights of the American Diabetes Association’s nutrition recommendations, updated in late 2013, and also presented at the meeting by Patti Urbanski, M.Ed., a member of the ADA Nutrition Recommendations Writing Group Committee, include:

• Select an "eating pattern" based on an individual’s personal and cultural preferences; literacy and numeracy; readiness; and ability to change, because no one dietary plan – be it the Mediterranean, low-carb, or DASH (Dietary Approaches to Stop Hypertension) diet – is best.

• In the absence of evidence supporting an ideal percentage of calories from carbohydrates, protein, or fat for all patients with diabetes, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and goals.

• Reduce energy intake/carbohydrate portions and number of servings per meal, as indicated by individual assessment.

• Early referral to registered dietitians and nutritionists for nutrition therapy.

• First-ever call to avoid sugar-sweetened beverages.

• Continued support to limit sodium intake to 2,300 mg/day, as recommended for the general population, with lower sodium targets an option for those with comorbid hypertension.

• Routine supplementation with oxidants, such as vitamin E and C and carotene, is not advised, nor is routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control.

Dr. Grant disclosed no conflicts of interest.

[email protected]

SAN FRANCISCO – Updated guidelines from the American Diabetes Association open the door to using a two-step approach to gestational diabetes screening.

Screening is still recommended for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, and for gestational diabetes mellitus (GDM) between weeks 24 and 28 of gestation.

What’s changed in the 2014 Standards of Medical Care in Diabetes (Diabetes Care 2014;37(suppl 1):S14-80) is how that screening is accomplished, Dr. Richard W. Grant, chair of the ADA professional practice committee, said at the annual advanced postgraduate course held by the American Diabetes Association.

In prior years, the ADA adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) 2009 recommendation that a 2-hour, 75-gram oral glucose tolerance test (OGTT) be performed the morning after a fast of at least an 8 hours.

A two-step approach was added this year to reflect the 2013 National Institutes of Health Consensus Guidelines recommendation for a 1-hour, 50-gram glucose tolerance screening test followed by a fasting OGTT on another day, if the test is abnormal.

One-step vs. two-step approach

"The issues for these two approaches are the sensitivity with which you can diagnose GDM and the difficulty in implementing these two approaches," said Dr. Grant, a research scientist with Kaiser Permanente Northern California, Oakland.

The one-step approach tends to be more sensitive and diagnoses a broader range of GDM, but it may be a barrier to screening because it requires the patient to fast for 8 hours, he said. Though the one-step approach allows for a diagnosis of GDM within the context of a single office visit, critics also argue its tight diagnostic glucose cut points could dramatically increase the prevalence of GDM from about 5%-6% to 15%-20%, and bring added health care costs and interventions without clear evidence of improved outcomes.

On the other hand, the two-step approach may be more palatable to women because it avoids the up-front fasting requirement, but it could miss GDM in women with an abnormal screen who fail to return for a second visit.

"The bottom line is we need to make sure we do gestational diabetes screening, whichever method we use," Dr. Grant said. "What’s more important is that all women in early pregnancy get screened."

During a discussion following the presentation, a Canadian attendee said similar recommendations released last fall in Canada allowing two screening methods, albeit with different diagnostic thresholds, have resulted in confusion, particularly among referring obstetricians and endocrinologists.

Dr. Grant said there shouldn’t be confusion surrounding the new option as long as recommendations are consistent within an institution.

"I don’t think it’s actually going to make people change what they’re doing currently," he said in an interview. "There’s not a good reason to jump from one to another if you’ve already chosen an approach."

In a separate interview, Dr. R. Harsha Rao, with the Center for Diabetes and Endocrinology at the University of Pittsburgh, said he can see the rationale for the one-step method, but that the two-step approach is almost implanted in the DNA of American obstetricians and that this behavior pattern will be difficult to change for practical reasons alone.

"Patients don’t like 75 grams of Glucola; it’s an awful-tasting substance," he said. "I’ve had patients tell me they felt like [vomiting] when they got the 75-gram Glucola load, and as it is, ‘I’m pregnant and already feeling nauseated.’ "

In addition, there’s the added stress of waiting for a second appointment and a definitive diagnosis for women who screen positive.

The ADA’s bimodal approach to gestational screening reflects an overarching theme of individualized care for diabetes in the 2014 standards. The guidelines are updated annually and this year they contain 232 recommendations, of which 52% are based on high level A or B evidence.

Individualized diabetes care

"One of the themes that comes out in looking at the data very carefully is that you can’t have a one-size-fits-all approach," Dr. Grant observed.

To that end, the guidelines maintain an earlier recommendation raising the systolic blood pressure target goal for hypertension to 140 mm Hg, but also allow a target goal of less than 130 mm Hg in certain populations, such as younger patients.

Dr. Grant observed that the ADA’s position was confirmed by the U.S. Preventive Services Task Force’s recent endorsement of GDM screening using the two-step approach.

"The USPSTF said that the two-step method is an accurate approach, which is what the ADA also says," he remarked.

Based on the recently revised 2013 ADA nutrition position paper (described in the next section below), the guidelines also encourage individualized dietary approaches rather recommending one particular diet over another, Dr. Grant said.

Other revisions include:

• Clarification that the hemoglobin A_1c test is just one of three methods to diagnose diabetes in asymptomatic patients, along with the fasting plasma glucose or 75-gram, 2-hour OGTT;

• An expanded chapter on neuropathy screening and treatment, including B level evidentiary support to test for distal symmetric polyneuropathy;

• Added emphasis on the need to ask patients about symptomatic and asymptomatic hypoglycemia and perform ongoing assessments of cognitive function; and

• Added emphasis on a patient-centered communication style that assesses literacy, but also the often overlooked issue of numeracy.

"It’s really quite impressive how many patients don’t get numbers, but we as physicians speak in numbers," Dr. Grant said.

The recent controversial 2013 American College of Cardiology/American Heart Association cholesterol guideline could not be reviewed in time to for this year’s guidelines, but it will be something to keep an eye out for next year.

ADA dodges dietary dogma

Highlights of the American Diabetes Association’s nutrition recommendations, updated in late 2013, and also presented at the meeting by Patti Urbanski, M.Ed., a member of the ADA Nutrition Recommendations Writing Group Committee, include:

• Select an "eating pattern" based on an individual’s personal and cultural preferences; literacy and numeracy; readiness; and ability to change, because no one dietary plan – be it the Mediterranean, low-carb, or DASH (Dietary Approaches to Stop Hypertension) diet – is best.

• In the absence of evidence supporting an ideal percentage of calories from carbohydrates, protein, or fat for all patients with diabetes, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and goals.

• Reduce energy intake/carbohydrate portions and number of servings per meal, as indicated by individual assessment.

• Early referral to registered dietitians and nutritionists for nutrition therapy.

• First-ever call to avoid sugar-sweetened beverages.

• Continued support to limit sodium intake to 2,300 mg/day, as recommended for the general population, with lower sodium targets an option for those with comorbid hypertension.

• Routine supplementation with oxidants, such as vitamin E and C and carotene, is not advised, nor is routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control.

Dr. Grant disclosed no conflicts of interest.

[email protected]

Pregnant woman

Credit: Nina Matthews

SAN DIEGO—A woman’s risk of thrombosis remains significantly elevated for 12 weeks after delivering a baby, according to research presented at the International Stroke Conference 2014.

The study suggested that pregnant and postpartum women have a low absolute risk of experiencing thrombotic events.

However, their risk is nearly 11 times higher than normal for the first 6 weeks after delivery. And they have roughly twice the normal risk of thrombosis in the following 6 weeks.

Hooman Kamel, MD, of Weill Cornell Medical College in New York, presented these findings at the meeting as abstract 216.*

Dr Kamel and his colleagues had analyzed data on 1,687,930 women who were admitted for labor and delivery at California hospitals from 2005 through 2010.

The researchers compared the risk of thrombosis during sequential 6-week periods after delivery to the same 6-week period 1 year later (0-6 weeks, 7-12 weeks, 13-18 weeks, and 19-24 weeks).

In all, 1015 women had a thrombotic event after delivery, including 720 cases of venous thromboembolism, 248 strokes, and 47 cases of myocardial infarction.

In the first 6 weeks after delivery, a woman’s risk of thrombosis was 10.8 times higher than normal. There were 24.4 thrombotic events per 100,000 deliveries in the first 6 weeks after delivery, compared to 2.3 events during the same period 1 year later.

From week 7 to 12 after delivery, the risk of thrombosis was 2.2 times higher than normal. There were 5.6 thrombotic events per 100,000 deliveries in the 7 to 12 weeks after delivery, compared to 2.6 events during the same period 1 year later.

The risk of thrombosis was 1.4 times higher than normal from 13 to 18 weeks after delivery, although this was not a significant increase. And by weeks 19 through 24, the risk of thrombosis had returned to normal.

“While rare, blood clots are a serious cause of disability and death in pregnant and postpartum women . . . ,” Dr Kamel said. “Clinicians should consider our results when caring for high-risk postpartum patients, such as those with previous clots, or postpartum patients with symptoms concerning for thrombosis.”

*Information in the abstract differs from that presented at the meeting.

Pregnant woman

Credit: Nina Matthews

SAN DIEGO—A woman’s risk of thrombosis remains significantly elevated for 12 weeks after delivering a baby, according to research presented at the International Stroke Conference 2014.

The study suggested that pregnant and postpartum women have a low absolute risk of experiencing thrombotic events.

However, their risk is nearly 11 times higher than normal for the first 6 weeks after delivery. And they have roughly twice the normal risk of thrombosis in the following 6 weeks.

Hooman Kamel, MD, of Weill Cornell Medical College in New York, presented these findings at the meeting as abstract 216.*

Dr Kamel and his colleagues had analyzed data on 1,687,930 women who were admitted for labor and delivery at California hospitals from 2005 through 2010.

The researchers compared the risk of thrombosis during sequential 6-week periods after delivery to the same 6-week period 1 year later (0-6 weeks, 7-12 weeks, 13-18 weeks, and 19-24 weeks).

In all, 1015 women had a thrombotic event after delivery, including 720 cases of venous thromboembolism, 248 strokes, and 47 cases of myocardial infarction.

In the first 6 weeks after delivery, a woman’s risk of thrombosis was 10.8 times higher than normal. There were 24.4 thrombotic events per 100,000 deliveries in the first 6 weeks after delivery, compared to 2.3 events during the same period 1 year later.

From week 7 to 12 after delivery, the risk of thrombosis was 2.2 times higher than normal. There were 5.6 thrombotic events per 100,000 deliveries in the 7 to 12 weeks after delivery, compared to 2.6 events during the same period 1 year later.

The risk of thrombosis was 1.4 times higher than normal from 13 to 18 weeks after delivery, although this was not a significant increase. And by weeks 19 through 24, the risk of thrombosis had returned to normal.

“While rare, blood clots are a serious cause of disability and death in pregnant and postpartum women . . . ,” Dr Kamel said. “Clinicians should consider our results when caring for high-risk postpartum patients, such as those with previous clots, or postpartum patients with symptoms concerning for thrombosis.”

*Information in the abstract differs from that presented at the meeting.

Pregnant woman

Credit: Nina Matthews

SAN DIEGO—A woman’s risk of thrombosis remains significantly elevated for 12 weeks after delivering a baby, according to research presented at the International Stroke Conference 2014.

The study suggested that pregnant and postpartum women have a low absolute risk of experiencing thrombotic events.

However, their risk is nearly 11 times higher than normal for the first 6 weeks after delivery. And they have roughly twice the normal risk of thrombosis in the following 6 weeks.

Hooman Kamel, MD, of Weill Cornell Medical College in New York, presented these findings at the meeting as abstract 216.*

Dr Kamel and his colleagues had analyzed data on 1,687,930 women who were admitted for labor and delivery at California hospitals from 2005 through 2010.

The researchers compared the risk of thrombosis during sequential 6-week periods after delivery to the same 6-week period 1 year later (0-6 weeks, 7-12 weeks, 13-18 weeks, and 19-24 weeks).

In all, 1015 women had a thrombotic event after delivery, including 720 cases of venous thromboembolism, 248 strokes, and 47 cases of myocardial infarction.

In the first 6 weeks after delivery, a woman’s risk of thrombosis was 10.8 times higher than normal. There were 24.4 thrombotic events per 100,000 deliveries in the first 6 weeks after delivery, compared to 2.3 events during the same period 1 year later.

From week 7 to 12 after delivery, the risk of thrombosis was 2.2 times higher than normal. There were 5.6 thrombotic events per 100,000 deliveries in the 7 to 12 weeks after delivery, compared to 2.6 events during the same period 1 year later.

The risk of thrombosis was 1.4 times higher than normal from 13 to 18 weeks after delivery, although this was not a significant increase. And by weeks 19 through 24, the risk of thrombosis had returned to normal.

“While rare, blood clots are a serious cause of disability and death in pregnant and postpartum women . . . ,” Dr Kamel said. “Clinicians should consider our results when caring for high-risk postpartum patients, such as those with previous clots, or postpartum patients with symptoms concerning for thrombosis.”

*Information in the abstract differs from that presented at the meeting.

Drug release in a cancer cell

Credit: PNAS

New findings suggest drugs can effectively fight K-Ras-mutant cancers—if they have a little help.

Experiments in human cancer cells showed that K-Ras-mutant tumor growth was highly dependent on the cells’ constant need to check and mend their DNA.

However, inhibiting the activity of H-Ras and N-Ras prevented the DNA damage response. And this made the cells more vulnerable to treatment.

“Our finding suggests that K-Ras cancers can be made more susceptible to existing therapies by interfering with their DNA repair mechanisms,” said Dafna Bar-Sagi, PhD, of the New York University School of Medicine.

“What some researchers have described as therapeutic ‘mission impossible’ may now become a ‘mission doable.’”

Dr Bar-Sagi and her colleagues reported this discovery in Cancer Cell.

The group’s research began with experiments to determine how Ras signaling leads to the uncontrolled growth of cancer cells. The team found that downregulation of wild-type H-Ras and N-Ras in mutant K-Ras cells caused the buildup of damaged DNA and slowed cell growth.

In the absence of H-Ras and N-Ras, K-Ras-mutant cancer cells failed to repair their DNA at the G2 phase of cell division. And this defect was caused by failure to properly activate Chk1.

With this in mind, the researchers decided to test the effects of H-Ras or N-Ras knockdown on treatment with DNA-damaging agents.

Knockdown of H-Ras or N-Ras sensitized K-Ras-mutant cancer cells to SN38 and oxaliplatin in vitro. But the same effect did not occur when H-Ras or N-Ras was knocked down in K-Ras-wild-type cancer cells.

K-Ras-mutant cancer cells were also sensitive to treatment with the Chk1/Chk2 inhibitor AZD7726 when H-Ras or N-Ras was knocked down in vitro.

To further support these findings, the researchers conducted experiments in mice with K-Ras-mutant tumors. Mice with H-Ras knockdown experienced tumor growth similar to controls.

But when the mice with H-Ras-suppressed tumors received the chemotherapy drug irinotecan, they experienced tumor regression that lasted up to 18 days post-treatment. On the other hand, mice without H-Ras suppression experienced modest tumor growth after treatment with irinotecan.

“Discovering more about how these different forms of Ras act on one another—including how they control DNA damage repair at Chk1 in combination with chemotherapy—could help us design drugs that greatly stall disease progression,” said study author Elda Grabocka, PhD, also of the New York University School of Medicine.

The researchers are now planning additional experiments on the biological interdependency of Ras proteins and what other chemotherapies might be involved in slowing cancer growth. Their goal is to map the Ras signaling pathways and identify as many therapeutic targets as possible.

Drug release in a cancer cell

Credit: PNAS

New findings suggest drugs can effectively fight K-Ras-mutant cancers—if they have a little help.

Experiments in human cancer cells showed that K-Ras-mutant tumor growth was highly dependent on the cells’ constant need to check and mend their DNA.

However, inhibiting the activity of H-Ras and N-Ras prevented the DNA damage response. And this made the cells more vulnerable to treatment.

“Our finding suggests that K-Ras cancers can be made more susceptible to existing therapies by interfering with their DNA repair mechanisms,” said Dafna Bar-Sagi, PhD, of the New York University School of Medicine.

“What some researchers have described as therapeutic ‘mission impossible’ may now become a ‘mission doable.’”

Dr Bar-Sagi and her colleagues reported this discovery in Cancer Cell.

The group’s research began with experiments to determine how Ras signaling leads to the uncontrolled growth of cancer cells. The team found that downregulation of wild-type H-Ras and N-Ras in mutant K-Ras cells caused the buildup of damaged DNA and slowed cell growth.

In the absence of H-Ras and N-Ras, K-Ras-mutant cancer cells failed to repair their DNA at the G2 phase of cell division. And this defect was caused by failure to properly activate Chk1.

With this in mind, the researchers decided to test the effects of H-Ras or N-Ras knockdown on treatment with DNA-damaging agents.

Knockdown of H-Ras or N-Ras sensitized K-Ras-mutant cancer cells to SN38 and oxaliplatin in vitro. But the same effect did not occur when H-Ras or N-Ras was knocked down in K-Ras-wild-type cancer cells.

K-Ras-mutant cancer cells were also sensitive to treatment with the Chk1/Chk2 inhibitor AZD7726 when H-Ras or N-Ras was knocked down in vitro.

To further support these findings, the researchers conducted experiments in mice with K-Ras-mutant tumors. Mice with H-Ras knockdown experienced tumor growth similar to controls.

But when the mice with H-Ras-suppressed tumors received the chemotherapy drug irinotecan, they experienced tumor regression that lasted up to 18 days post-treatment. On the other hand, mice without H-Ras suppression experienced modest tumor growth after treatment with irinotecan.

“Discovering more about how these different forms of Ras act on one another—including how they control DNA damage repair at Chk1 in combination with chemotherapy—could help us design drugs that greatly stall disease progression,” said study author Elda Grabocka, PhD, also of the New York University School of Medicine.

The researchers are now planning additional experiments on the biological interdependency of Ras proteins and what other chemotherapies might be involved in slowing cancer growth. Their goal is to map the Ras signaling pathways and identify as many therapeutic targets as possible.

Drug release in a cancer cell

Credit: PNAS

New findings suggest drugs can effectively fight K-Ras-mutant cancers—if they have a little help.

Experiments in human cancer cells showed that K-Ras-mutant tumor growth was highly dependent on the cells’ constant need to check and mend their DNA.

However, inhibiting the activity of H-Ras and N-Ras prevented the DNA damage response. And this made the cells more vulnerable to treatment.

“Our finding suggests that K-Ras cancers can be made more susceptible to existing therapies by interfering with their DNA repair mechanisms,” said Dafna Bar-Sagi, PhD, of the New York University School of Medicine.

“What some researchers have described as therapeutic ‘mission impossible’ may now become a ‘mission doable.’”

Dr Bar-Sagi and her colleagues reported this discovery in Cancer Cell.

The group’s research began with experiments to determine how Ras signaling leads to the uncontrolled growth of cancer cells. The team found that downregulation of wild-type H-Ras and N-Ras in mutant K-Ras cells caused the buildup of damaged DNA and slowed cell growth.

In the absence of H-Ras and N-Ras, K-Ras-mutant cancer cells failed to repair their DNA at the G2 phase of cell division. And this defect was caused by failure to properly activate Chk1.

With this in mind, the researchers decided to test the effects of H-Ras or N-Ras knockdown on treatment with DNA-damaging agents.

Knockdown of H-Ras or N-Ras sensitized K-Ras-mutant cancer cells to SN38 and oxaliplatin in vitro. But the same effect did not occur when H-Ras or N-Ras was knocked down in K-Ras-wild-type cancer cells.

K-Ras-mutant cancer cells were also sensitive to treatment with the Chk1/Chk2 inhibitor AZD7726 when H-Ras or N-Ras was knocked down in vitro.

To further support these findings, the researchers conducted experiments in mice with K-Ras-mutant tumors. Mice with H-Ras knockdown experienced tumor growth similar to controls.

But when the mice with H-Ras-suppressed tumors received the chemotherapy drug irinotecan, they experienced tumor regression that lasted up to 18 days post-treatment. On the other hand, mice without H-Ras suppression experienced modest tumor growth after treatment with irinotecan.

“Discovering more about how these different forms of Ras act on one another—including how they control DNA damage repair at Chk1 in combination with chemotherapy—could help us design drugs that greatly stall disease progression,” said study author Elda Grabocka, PhD, also of the New York University School of Medicine.

The researchers are now planning additional experiments on the biological interdependency of Ras proteins and what other chemotherapies might be involved in slowing cancer growth. Their goal is to map the Ras signaling pathways and identify as many therapeutic targets as possible.

Cancer patient receives therapy

Credit: Rhoda Baer

The first reported outbreak of Tsukamurella species bloodstream infections was due to improper handling of intravenous saline, according to a report published in Infection Control and Hospital Epidemiology.

From September 2011 to May 2012, 15 immunocompromised patients treated at an outpatient oncology clinic in West Virginia developed infections with Tsukamurella, which are gram-positive bacteria that rarely cause disease in humans.

All patients had received a cancer diagnosis and had an indwelling central line, although central line types varied.

A case-control study revealed that the only risk factor for developing Tsukamurella infection was the receipt of a saline flush in September or October 2011, when clinic staff were using a common-source bag of saline.

Investigations by the West Virginia Bureau of Public Health (WVBPH) and the Centers for Disease Control and Prevention (CDC) uncovered several lapses in infection control procedures relating to the care of long-term intravenous catheters and preparation of chemotherapy for patients at the clinic.

However, these investigations also suggested that saline flush syringes were the likely source of infection.

So the WVBPH and the CDC recommended the clinic institute several changes to its infection prevention and control practices, including using pre-packaged, manufactured saline flushes.

After the clinic changed this practice, Tsukamurella bloodstream infections stopped occurring, further supporting the saline flush as the source of infection.

“This outbreak illustrates the need for outpatient clinics to follow proper infection control guidelines and medication preparation practices to minimize the risk of infection for patients with weakened immune systems,” said lead study author Isaac See, MD, of the CDC.

To that end, the CDC has developed a basic infection control plan tailored to outpatient oncology facilities.

The plan outlines policies and procedures needed to meet minimal requirements for patient safety, including the proper use and handling of injectable medications and correct procedures for assessing central lines.

Cancer patient receives therapy

Credit: Rhoda Baer

The first reported outbreak of Tsukamurella species bloodstream infections was due to improper handling of intravenous saline, according to a report published in Infection Control and Hospital Epidemiology.

From September 2011 to May 2012, 15 immunocompromised patients treated at an outpatient oncology clinic in West Virginia developed infections with Tsukamurella, which are gram-positive bacteria that rarely cause disease in humans.

All patients had received a cancer diagnosis and had an indwelling central line, although central line types varied.

A case-control study revealed that the only risk factor for developing Tsukamurella infection was the receipt of a saline flush in September or October 2011, when clinic staff were using a common-source bag of saline.

Investigations by the West Virginia Bureau of Public Health (WVBPH) and the Centers for Disease Control and Prevention (CDC) uncovered several lapses in infection control procedures relating to the care of long-term intravenous catheters and preparation of chemotherapy for patients at the clinic.

However, these investigations also suggested that saline flush syringes were the likely source of infection.

So the WVBPH and the CDC recommended the clinic institute several changes to its infection prevention and control practices, including using pre-packaged, manufactured saline flushes.

After the clinic changed this practice, Tsukamurella bloodstream infections stopped occurring, further supporting the saline flush as the source of infection.

“This outbreak illustrates the need for outpatient clinics to follow proper infection control guidelines and medication preparation practices to minimize the risk of infection for patients with weakened immune systems,” said lead study author Isaac See, MD, of the CDC.

To that end, the CDC has developed a basic infection control plan tailored to outpatient oncology facilities.

The plan outlines policies and procedures needed to meet minimal requirements for patient safety, including the proper use and handling of injectable medications and correct procedures for assessing central lines.

Cancer patient receives therapy

Credit: Rhoda Baer

The first reported outbreak of Tsukamurella species bloodstream infections was due to improper handling of intravenous saline, according to a report published in Infection Control and Hospital Epidemiology.

From September 2011 to May 2012, 15 immunocompromised patients treated at an outpatient oncology clinic in West Virginia developed infections with Tsukamurella, which are gram-positive bacteria that rarely cause disease in humans.

All patients had received a cancer diagnosis and had an indwelling central line, although central line types varied.

A case-control study revealed that the only risk factor for developing Tsukamurella infection was the receipt of a saline flush in September or October 2011, when clinic staff were using a common-source bag of saline.

Investigations by the West Virginia Bureau of Public Health (WVBPH) and the Centers for Disease Control and Prevention (CDC) uncovered several lapses in infection control procedures relating to the care of long-term intravenous catheters and preparation of chemotherapy for patients at the clinic.

However, these investigations also suggested that saline flush syringes were the likely source of infection.

So the WVBPH and the CDC recommended the clinic institute several changes to its infection prevention and control practices, including using pre-packaged, manufactured saline flushes.

After the clinic changed this practice, Tsukamurella bloodstream infections stopped occurring, further supporting the saline flush as the source of infection.

“This outbreak illustrates the need for outpatient clinics to follow proper infection control guidelines and medication preparation practices to minimize the risk of infection for patients with weakened immune systems,” said lead study author Isaac See, MD, of the CDC.

To that end, the CDC has developed a basic infection control plan tailored to outpatient oncology facilities.

The plan outlines policies and procedures needed to meet minimal requirements for patient safety, including the proper use and handling of injectable medications and correct procedures for assessing central lines.

Lab mice

Credit: Aaron Logan

Two papers published in Nature Immunology have shed new light on the role of Ikaros in B-cell acute lymphoblastic leukemia (B-ALL).

In one paper, researchers describe experiments in mice that show a defect in Ikaros function can disrupt lymphopoiesis and prevent the development of mature B cells.

The cells stay in an aberrant state, which closely resembles that of cells in human B-ALL.

The other paper provides insight into how pre-B cells transition from a proliferative phase to a differentiation phase.

Investigators found that this process, which is vulnerable to leukemic transformation, is dependent upon Ikaros.

Ikaros defect in mice mimics human B-ALL

In the first sudy, researchers showed that loss of Ikaros function in mice creates an environment that mimics human B-ALL.

“We already know several transcription factors that play a central role in B-cell differentiation,” said study author Meinrad Busslinger, PhD, of the Research Institute of Molecular Pathology in Vienna, Austria.

“Pax5, for example, represents a critical factor which activates the B-cell-specific program in precursor cells and simultaneously suppresses alternative cell fates. For Ikaros, we did not know, until now, what this factor is doing during early B-cell development.”

To find out, he and his colleagues analyzed mice that lacked Ikaros from an early stage of B-cell development on. They found that Ikaros deficiency arrested B-cell development due to a defect in pre-BCR signaling.

The cells remained in an aberrant, pro-B-cell stage and were prevented from further differentiation. They also showed increased cell adhesion and reduced migration compared to normal cells.

The researchers noted that loss of Ikaros function has previously been associated with the development of B-ALL. As in mice with a mutated Ikaros gene, B cells from B-ALL patients are arrested at an early checkpoint of B-cell development.

Loss of Ikaros in pre-B cells

With the second study, investigators provided new insight into pre-B-cell differentiation. They described the cells’ transition from a stroma-adherent proliferative phase to a nonadherent differentiation phase.

The stroma-adherent pre-B cells were highly proliferative and had limited self-renewing potential. But when they transitioned to the nonadherent phase, they exited the cell cycle, lost their capacity for self-renewal, and acquired the expression of genes encoding molecules that support B-cell maturation.

And this transition was dependent upon Ikaros.

“Loss of function in the transcription factor Ikaros appears to create a differentiation block that drives the pre-B cells into an adhesive state, promotes self-renewal, and primes them for malignant potential,” said study author Richard Van Etten, MD, PhD, of the University of California, Irvine.

Furthermore, the survival and proliferation of the Ikaros-deficient pre-B cells appeared to be dependent on cooperation between signaling via integrins and signaling via receptors for growth factors.

The researchers said this discovery points to a new avenue for treating B-ALLs resulting from Ikaros mutations.

Lab mice

Credit: Aaron Logan

Two papers published in Nature Immunology have shed new light on the role of Ikaros in B-cell acute lymphoblastic leukemia (B-ALL).

In one paper, researchers describe experiments in mice that show a defect in Ikaros function can disrupt lymphopoiesis and prevent the development of mature B cells.

The cells stay in an aberrant state, which closely resembles that of cells in human B-ALL.

The other paper provides insight into how pre-B cells transition from a proliferative phase to a differentiation phase.

Investigators found that this process, which is vulnerable to leukemic transformation, is dependent upon Ikaros.

Ikaros defect in mice mimics human B-ALL

In the first sudy, researchers showed that loss of Ikaros function in mice creates an environment that mimics human B-ALL.

“We already know several transcription factors that play a central role in B-cell differentiation,” said study author Meinrad Busslinger, PhD, of the Research Institute of Molecular Pathology in Vienna, Austria.

“Pax5, for example, represents a critical factor which activates the B-cell-specific program in precursor cells and simultaneously suppresses alternative cell fates. For Ikaros, we did not know, until now, what this factor is doing during early B-cell development.”

To find out, he and his colleagues analyzed mice that lacked Ikaros from an early stage of B-cell development on. They found that Ikaros deficiency arrested B-cell development due to a defect in pre-BCR signaling.

The cells remained in an aberrant, pro-B-cell stage and were prevented from further differentiation. They also showed increased cell adhesion and reduced migration compared to normal cells.

The researchers noted that loss of Ikaros function has previously been associated with the development of B-ALL. As in mice with a mutated Ikaros gene, B cells from B-ALL patients are arrested at an early checkpoint of B-cell development.

Loss of Ikaros in pre-B cells

With the second study, investigators provided new insight into pre-B-cell differentiation. They described the cells’ transition from a stroma-adherent proliferative phase to a nonadherent differentiation phase.

The stroma-adherent pre-B cells were highly proliferative and had limited self-renewing potential. But when they transitioned to the nonadherent phase, they exited the cell cycle, lost their capacity for self-renewal, and acquired the expression of genes encoding molecules that support B-cell maturation.

And this transition was dependent upon Ikaros.

“Loss of function in the transcription factor Ikaros appears to create a differentiation block that drives the pre-B cells into an adhesive state, promotes self-renewal, and primes them for malignant potential,” said study author Richard Van Etten, MD, PhD, of the University of California, Irvine.

Furthermore, the survival and proliferation of the Ikaros-deficient pre-B cells appeared to be dependent on cooperation between signaling via integrins and signaling via receptors for growth factors.

The researchers said this discovery points to a new avenue for treating B-ALLs resulting from Ikaros mutations.

Lab mice

Credit: Aaron Logan

Two papers published in Nature Immunology have shed new light on the role of Ikaros in B-cell acute lymphoblastic leukemia (B-ALL).

In one paper, researchers describe experiments in mice that show a defect in Ikaros function can disrupt lymphopoiesis and prevent the development of mature B cells.

The cells stay in an aberrant state, which closely resembles that of cells in human B-ALL.

The other paper provides insight into how pre-B cells transition from a proliferative phase to a differentiation phase.

Investigators found that this process, which is vulnerable to leukemic transformation, is dependent upon Ikaros.

Ikaros defect in mice mimics human B-ALL

In the first sudy, researchers showed that loss of Ikaros function in mice creates an environment that mimics human B-ALL.

“We already know several transcription factors that play a central role in B-cell differentiation,” said study author Meinrad Busslinger, PhD, of the Research Institute of Molecular Pathology in Vienna, Austria.

“Pax5, for example, represents a critical factor which activates the B-cell-specific program in precursor cells and simultaneously suppresses alternative cell fates. For Ikaros, we did not know, until now, what this factor is doing during early B-cell development.”

To find out, he and his colleagues analyzed mice that lacked Ikaros from an early stage of B-cell development on. They found that Ikaros deficiency arrested B-cell development due to a defect in pre-BCR signaling.

The cells remained in an aberrant, pro-B-cell stage and were prevented from further differentiation. They also showed increased cell adhesion and reduced migration compared to normal cells.

The researchers noted that loss of Ikaros function has previously been associated with the development of B-ALL. As in mice with a mutated Ikaros gene, B cells from B-ALL patients are arrested at an early checkpoint of B-cell development.

Loss of Ikaros in pre-B cells

With the second study, investigators provided new insight into pre-B-cell differentiation. They described the cells’ transition from a stroma-adherent proliferative phase to a nonadherent differentiation phase.

The stroma-adherent pre-B cells were highly proliferative and had limited self-renewing potential. But when they transitioned to the nonadherent phase, they exited the cell cycle, lost their capacity for self-renewal, and acquired the expression of genes encoding molecules that support B-cell maturation.

And this transition was dependent upon Ikaros.

“Loss of function in the transcription factor Ikaros appears to create a differentiation block that drives the pre-B cells into an adhesive state, promotes self-renewal, and primes them for malignant potential,” said study author Richard Van Etten, MD, PhD, of the University of California, Irvine.

Furthermore, the survival and proliferation of the Ikaros-deficient pre-B cells appeared to be dependent on cooperation between signaling via integrins and signaling via receptors for growth factors.

The researchers said this discovery points to a new avenue for treating B-ALLs resulting from Ikaros mutations.

In nearly every facet of our lives, our mobile devices have taken over. Managing our calendars, organizing our contacts, and planning our driving directions -- our devices have become invaluable and ubiquitously present. While the ease of use of smartphones and tablets puts the power of portable computing in the hands of everyone, mobile software seems to be particularly appreciated by young professionals, who seek the convenience of on-the-go functionality and feel comfortable with computing in the palms of their hands. Throughout the world of education and a breadth of academic fields, advanced software programs have gained momentum, recognized for their ability to provide up-to-date, on-the-ground information.

In recent years, there has been an explosion of new software programs applicable to the field of cardiothoracic surgery, and these applications have been well received by modern trainees.

"Mobile apps are incredibly convenient because they provide a means of accessing information while on the go," states Jonathan Spicer, a thoracic trainee at M.D. Anderson Cancer Center in Houston.

He continues, "Having the capacity to look up helpful information from my phone while in the operating room, on the ward, or in transit is particularly helpful."

In this article, we aim to highlight some of the more exciting and innovative mobile software programs available today for those interested in expanding their knowledge in cardiothoracic surgery or looking for an easy-to-access resource.

iBronch (Edward Bender), $0.99: iBronch is one of the many outstanding thoracic surgical apps developed by Ed Bender. This program aims to guide learners through the basic anatomy of the trachea and bronchial tree, with correlation of simultaneous images from a fiberoptic bronchoscope and along an anatomic airway diagram. Branches of the pulmonary tree are labeled on the schematic and the bronchoscopy images. This app is particularly useful for those trainees gaining comfort with bronchoscopic procedures; however, its utility may be less significant for more advanced learners. Regardless, this is a great program, quite helpful for the intended audience.

Thoracic Lymph Node Map (RADIOLOGiQ, LLC), Free: This app provides a color-coded lymph node map, associated with computed tomography images and adapted from the International Association for the Study of Lung Cancer (IASLC) lung cancer project. This program provides excellent illustrations of the anatomic definitions for each of the intrathoracic lymph node stations. This is helpful both in examining imaging studies of actual patients and in the operating room.

CT Journals (Edward Bender), Free: This software program serves as a scholarly journal aggregator for the field of cardiothoracic surgery. The app displays feeds for journals of interest, with inclusion of those relevant periodicals with the most readership and highest impact factors. Not only can one access the articles while online, abstracts can be saved for future use offline. This is a great resource, but users should be aware that access to the full articles is available only for those who have active accounts providing them access to the specific journals.

CTSNetWiki (Edward Bender), Free: Cardiothoracic Surgery Notes is an online review developed and maintained by residents in thoracic surgical training. This resource is a tremendous repository of information, compiling graphics, text, and other multimedia content on a breadth of topics. This app allows general review of a wide variety of cardiothoracic surgical problems and is appropriate for both the novice learner and as a review for those who are further along in their training.

SESATS IX (Edward Bender), Free: Perhaps the most valuable mobile software application out there, the Self Education Self Assessment in Thoracic Surgery (SESATS) IX application contains actual questions from previous versions of the SESATS. The mobile app even includes the associated images, videos, and CT scans that correspond with the questions. Although the program does not contain the latest version of SESATS, the utility of this app cannot be overestimated. This program is enormously helpful for self-testing, on-the-go topic-specific learning, and exam preparation. This is a real gem of a find, and it comes with a strong recommendation to all trainees for its download and use.

TSRA Primer of Cardiothoracic Surgery (Thoracic Surgery Residents' Association), $4.99: Produced by CT residents for CT residents, this is probably the most useful resource for the intern, junior resident, or new fellow who needs to brush up on the basics before rounds, in between consults, and before assisting in the OR. It's not comprehensive, but it is full of clinical pearls covering all the major divisions of cardiothoracic surgery. Many cardiac residents, especially younger integrated residents, have been waiting for a straightforward, practical tutorial like this for years. Beautiful and often interactive illustrations and videos really make this iBook memorable.

NCCN Guidelines (TIP Medical Communications), Free: Available for Android and iOS, this compendium of NCCN guidelines for 56 cancers and cancer-related topics is indispensible for trainees. The utility of having up-to-date, in-depth guidelines for diagnosis and staging of all commonly encountered malignancies cannot be overstated. Additional topics ranging from management of cancer-related emesis to lung cancer screening guidelines polish it off. A must have for anyone who treats cancer, not just thoracic surgeons.

CathSource (ECGSource, LLC), $3.99: Available for Android and iOS, CathSource is a mobile app that aims to teach cardiovascular medicine fellows about coronary anatomy, angiogram projections, and catheter-based hemodynamic measurements. Luckily, CT trainees stand to benefit from the app as well. It seems to be most helpful for learning coronary anatomy on the different projections, but it also has exhaustive hemodynamic formulae and tracings for more detailed review. The app has over 30 videos of normal and abnormal findings.

EchoSource (ECGSource, LLC), $4.99:It's the same idea as above, but -- you guessed it -- for echocardiography. Both are good tools, especially for residents who teach. Both apps take simple, conceptual drawings to start and expand them with real imaging. Residents who have spent a good deal of time in learning cath and echo may find these apps less useful.

Pocket Heart (PocketAnatomy), $9.99: This is an interactive, 3D heart model with a fairly detailed presentation of cardiac anatomy and added features such as pinning quizzes and case studies. While cardiothoracic residents ought to have the anatomy down, the app can be used to teach patients and families about various anatomical aspects of cardiac disease. The graphics leave a little to be desired, but anyone who teaches medical students or patients frequently will enjoy having this easy-to-understand tool handy.

This list of cardiothoracic-specific mobile applications is by no means exhaustive. Each physician's needs will be different, and the options are countless. Countless risk calculators, mnemonic databases, formula compendiums, and pharmacologic formularies clutter the app store. Note-taking suites such as OneNote and Evernote (personal favorite of both of the authors) can help turn the most hare-brained resident into a paragon of organizational excellence. Journal citation managers such as EndNote, Dropbox, Mendeley, and Yep can help organize and manage that virtual pile of unread but probably important journal articles that keeps building up in your inbox. Even the humble iBooks app can be used to read and mark up pdf files on the fly, all while syncing with your library on your home computer. Many hospital EMRs have mobile platforms with various levels of functionality for tablets and smartphones.

What is obvious is that mobile computing technology is rapidly changing medicine and surgery in many ways. Although each one of us strives to be a complete physician, utterly self-reliant and assured of one's clinical knowledge, we all must learn the basics first. Whether at the bus stop, in a resident lounge, or in the operating room, these mobile technologies help us to learn more efficiently while on the go.

If there are any gems we have forgotten to highlight, please send an e-mail to Thoracic Surgery News and we will try to present them in the future. We hope that the residents reading this column can find a new app they didn't know they needed, one that will energize them and push their learning to a new height. Just don't forget to look up once in a while.

Dr. Antonoff is a 2nd-year, Thoracic-track trainee at Washington University in St Louis. Dr. Zeigler is a 3rd-year, integrated Cardiothoracic Surgery trainee at Stanford (Calif.) University. They reported no relevant financial conflicts.

In nearly every facet of our lives, our mobile devices have taken over. Managing our calendars, organizing our contacts, and planning our driving directions -- our devices have become invaluable and ubiquitously present. While the ease of use of smartphones and tablets puts the power of portable computing in the hands of everyone, mobile software seems to be particularly appreciated by young professionals, who seek the convenience of on-the-go functionality and feel comfortable with computing in the palms of their hands. Throughout the world of education and a breadth of academic fields, advanced software programs have gained momentum, recognized for their ability to provide up-to-date, on-the-ground information.

In recent years, there has been an explosion of new software programs applicable to the field of cardiothoracic surgery, and these applications have been well received by modern trainees.

"Mobile apps are incredibly convenient because they provide a means of accessing information while on the go," states Jonathan Spicer, a thoracic trainee at M.D. Anderson Cancer Center in Houston.

He continues, "Having the capacity to look up helpful information from my phone while in the operating room, on the ward, or in transit is particularly helpful."

In this article, we aim to highlight some of the more exciting and innovative mobile software programs available today for those interested in expanding their knowledge in cardiothoracic surgery or looking for an easy-to-access resource.

iBronch (Edward Bender), $0.99: iBronch is one of the many outstanding thoracic surgical apps developed by Ed Bender. This program aims to guide learners through the basic anatomy of the trachea and bronchial tree, with correlation of simultaneous images from a fiberoptic bronchoscope and along an anatomic airway diagram. Branches of the pulmonary tree are labeled on the schematic and the bronchoscopy images. This app is particularly useful for those trainees gaining comfort with bronchoscopic procedures; however, its utility may be less significant for more advanced learners. Regardless, this is a great program, quite helpful for the intended audience.

Thoracic Lymph Node Map (RADIOLOGiQ, LLC), Free: This app provides a color-coded lymph node map, associated with computed tomography images and adapted from the International Association for the Study of Lung Cancer (IASLC) lung cancer project. This program provides excellent illustrations of the anatomic definitions for each of the intrathoracic lymph node stations. This is helpful both in examining imaging studies of actual patients and in the operating room.

CT Journals (Edward Bender), Free: This software program serves as a scholarly journal aggregator for the field of cardiothoracic surgery. The app displays feeds for journals of interest, with inclusion of those relevant periodicals with the most readership and highest impact factors. Not only can one access the articles while online, abstracts can be saved for future use offline. This is a great resource, but users should be aware that access to the full articles is available only for those who have active accounts providing them access to the specific journals.

CTSNetWiki (Edward Bender), Free: Cardiothoracic Surgery Notes is an online review developed and maintained by residents in thoracic surgical training. This resource is a tremendous repository of information, compiling graphics, text, and other multimedia content on a breadth of topics. This app allows general review of a wide variety of cardiothoracic surgical problems and is appropriate for both the novice learner and as a review for those who are further along in their training.

SESATS IX (Edward Bender), Free: Perhaps the most valuable mobile software application out there, the Self Education Self Assessment in Thoracic Surgery (SESATS) IX application contains actual questions from previous versions of the SESATS. The mobile app even includes the associated images, videos, and CT scans that correspond with the questions. Although the program does not contain the latest version of SESATS, the utility of this app cannot be overestimated. This program is enormously helpful for self-testing, on-the-go topic-specific learning, and exam preparation. This is a real gem of a find, and it comes with a strong recommendation to all trainees for its download and use.

TSRA Primer of Cardiothoracic Surgery (Thoracic Surgery Residents' Association), $4.99: Produced by CT residents for CT residents, this is probably the most useful resource for the intern, junior resident, or new fellow who needs to brush up on the basics before rounds, in between consults, and before assisting in the OR. It's not comprehensive, but it is full of clinical pearls covering all the major divisions of cardiothoracic surgery. Many cardiac residents, especially younger integrated residents, have been waiting for a straightforward, practical tutorial like this for years. Beautiful and often interactive illustrations and videos really make this iBook memorable.

NCCN Guidelines (TIP Medical Communications), Free: Available for Android and iOS, this compendium of NCCN guidelines for 56 cancers and cancer-related topics is indispensible for trainees. The utility of having up-to-date, in-depth guidelines for diagnosis and staging of all commonly encountered malignancies cannot be overstated. Additional topics ranging from management of cancer-related emesis to lung cancer screening guidelines polish it off. A must have for anyone who treats cancer, not just thoracic surgeons.

CathSource (ECGSource, LLC), $3.99: Available for Android and iOS, CathSource is a mobile app that aims to teach cardiovascular medicine fellows about coronary anatomy, angiogram projections, and catheter-based hemodynamic measurements. Luckily, CT trainees stand to benefit from the app as well. It seems to be most helpful for learning coronary anatomy on the different projections, but it also has exhaustive hemodynamic formulae and tracings for more detailed review. The app has over 30 videos of normal and abnormal findings.

EchoSource (ECGSource, LLC), $4.99:It's the same idea as above, but -- you guessed it -- for echocardiography. Both are good tools, especially for residents who teach. Both apps take simple, conceptual drawings to start and expand them with real imaging. Residents who have spent a good deal of time in learning cath and echo may find these apps less useful.

Pocket Heart (PocketAnatomy), $9.99: This is an interactive, 3D heart model with a fairly detailed presentation of cardiac anatomy and added features such as pinning quizzes and case studies. While cardiothoracic residents ought to have the anatomy down, the app can be used to teach patients and families about various anatomical aspects of cardiac disease. The graphics leave a little to be desired, but anyone who teaches medical students or patients frequently will enjoy having this easy-to-understand tool handy.

This list of cardiothoracic-specific mobile applications is by no means exhaustive. Each physician's needs will be different, and the options are countless. Countless risk calculators, mnemonic databases, formula compendiums, and pharmacologic formularies clutter the app store. Note-taking suites such as OneNote and Evernote (personal favorite of both of the authors) can help turn the most hare-brained resident into a paragon of organizational excellence. Journal citation managers such as EndNote, Dropbox, Mendeley, and Yep can help organize and manage that virtual pile of unread but probably important journal articles that keeps building up in your inbox. Even the humble iBooks app can be used to read and mark up pdf files on the fly, all while syncing with your library on your home computer. Many hospital EMRs have mobile platforms with various levels of functionality for tablets and smartphones.

What is obvious is that mobile computing technology is rapidly changing medicine and surgery in many ways. Although each one of us strives to be a complete physician, utterly self-reliant and assured of one's clinical knowledge, we all must learn the basics first. Whether at the bus stop, in a resident lounge, or in the operating room, these mobile technologies help us to learn more efficiently while on the go.

If there are any gems we have forgotten to highlight, please send an e-mail to Thoracic Surgery News and we will try to present them in the future. We hope that the residents reading this column can find a new app they didn't know they needed, one that will energize them and push their learning to a new height. Just don't forget to look up once in a while.

Dr. Antonoff is a 2nd-year, Thoracic-track trainee at Washington University in St Louis. Dr. Zeigler is a 3rd-year, integrated Cardiothoracic Surgery trainee at Stanford (Calif.) University. They reported no relevant financial conflicts.

In nearly every facet of our lives, our mobile devices have taken over. Managing our calendars, organizing our contacts, and planning our driving directions -- our devices have become invaluable and ubiquitously present. While the ease of use of smartphones and tablets puts the power of portable computing in the hands of everyone, mobile software seems to be particularly appreciated by young professionals, who seek the convenience of on-the-go functionality and feel comfortable with computing in the palms of their hands. Throughout the world of education and a breadth of academic fields, advanced software programs have gained momentum, recognized for their ability to provide up-to-date, on-the-ground information.

In recent years, there has been an explosion of new software programs applicable to the field of cardiothoracic surgery, and these applications have been well received by modern trainees.

"Mobile apps are incredibly convenient because they provide a means of accessing information while on the go," states Jonathan Spicer, a thoracic trainee at M.D. Anderson Cancer Center in Houston.

He continues, "Having the capacity to look up helpful information from my phone while in the operating room, on the ward, or in transit is particularly helpful."

In this article, we aim to highlight some of the more exciting and innovative mobile software programs available today for those interested in expanding their knowledge in cardiothoracic surgery or looking for an easy-to-access resource.

iBronch (Edward Bender), $0.99: iBronch is one of the many outstanding thoracic surgical apps developed by Ed Bender. This program aims to guide learners through the basic anatomy of the trachea and bronchial tree, with correlation of simultaneous images from a fiberoptic bronchoscope and along an anatomic airway diagram. Branches of the pulmonary tree are labeled on the schematic and the bronchoscopy images. This app is particularly useful for those trainees gaining comfort with bronchoscopic procedures; however, its utility may be less significant for more advanced learners. Regardless, this is a great program, quite helpful for the intended audience.

Thoracic Lymph Node Map (RADIOLOGiQ, LLC), Free: This app provides a color-coded lymph node map, associated with computed tomography images and adapted from the International Association for the Study of Lung Cancer (IASLC) lung cancer project. This program provides excellent illustrations of the anatomic definitions for each of the intrathoracic lymph node stations. This is helpful both in examining imaging studies of actual patients and in the operating room.

CT Journals (Edward Bender), Free: This software program serves as a scholarly journal aggregator for the field of cardiothoracic surgery. The app displays feeds for journals of interest, with inclusion of those relevant periodicals with the most readership and highest impact factors. Not only can one access the articles while online, abstracts can be saved for future use offline. This is a great resource, but users should be aware that access to the full articles is available only for those who have active accounts providing them access to the specific journals.

CTSNetWiki (Edward Bender), Free: Cardiothoracic Surgery Notes is an online review developed and maintained by residents in thoracic surgical training. This resource is a tremendous repository of information, compiling graphics, text, and other multimedia content on a breadth of topics. This app allows general review of a wide variety of cardiothoracic surgical problems and is appropriate for both the novice learner and as a review for those who are further along in their training.

SESATS IX (Edward Bender), Free: Perhaps the most valuable mobile software application out there, the Self Education Self Assessment in Thoracic Surgery (SESATS) IX application contains actual questions from previous versions of the SESATS. The mobile app even includes the associated images, videos, and CT scans that correspond with the questions. Although the program does not contain the latest version of SESATS, the utility of this app cannot be overestimated. This program is enormously helpful for self-testing, on-the-go topic-specific learning, and exam preparation. This is a real gem of a find, and it comes with a strong recommendation to all trainees for its download and use.

TSRA Primer of Cardiothoracic Surgery (Thoracic Surgery Residents' Association), $4.99: Produced by CT residents for CT residents, this is probably the most useful resource for the intern, junior resident, or new fellow who needs to brush up on the basics before rounds, in between consults, and before assisting in the OR. It's not comprehensive, but it is full of clinical pearls covering all the major divisions of cardiothoracic surgery. Many cardiac residents, especially younger integrated residents, have been waiting for a straightforward, practical tutorial like this for years. Beautiful and often interactive illustrations and videos really make this iBook memorable.

NCCN Guidelines (TIP Medical Communications), Free: Available for Android and iOS, this compendium of NCCN guidelines for 56 cancers and cancer-related topics is indispensible for trainees. The utility of having up-to-date, in-depth guidelines for diagnosis and staging of all commonly encountered malignancies cannot be overstated. Additional topics ranging from management of cancer-related emesis to lung cancer screening guidelines polish it off. A must have for anyone who treats cancer, not just thoracic surgeons.

CathSource (ECGSource, LLC), $3.99: Available for Android and iOS, CathSource is a mobile app that aims to teach cardiovascular medicine fellows about coronary anatomy, angiogram projections, and catheter-based hemodynamic measurements. Luckily, CT trainees stand to benefit from the app as well. It seems to be most helpful for learning coronary anatomy on the different projections, but it also has exhaustive hemodynamic formulae and tracings for more detailed review. The app has over 30 videos of normal and abnormal findings.

EchoSource (ECGSource, LLC), $4.99:It's the same idea as above, but -- you guessed it -- for echocardiography. Both are good tools, especially for residents who teach. Both apps take simple, conceptual drawings to start and expand them with real imaging. Residents who have spent a good deal of time in learning cath and echo may find these apps less useful.

Pocket Heart (PocketAnatomy), $9.99: This is an interactive, 3D heart model with a fairly detailed presentation of cardiac anatomy and added features such as pinning quizzes and case studies. While cardiothoracic residents ought to have the anatomy down, the app can be used to teach patients and families about various anatomical aspects of cardiac disease. The graphics leave a little to be desired, but anyone who teaches medical students or patients frequently will enjoy having this easy-to-understand tool handy.

This list of cardiothoracic-specific mobile applications is by no means exhaustive. Each physician's needs will be different, and the options are countless. Countless risk calculators, mnemonic databases, formula compendiums, and pharmacologic formularies clutter the app store. Note-taking suites such as OneNote and Evernote (personal favorite of both of the authors) can help turn the most hare-brained resident into a paragon of organizational excellence. Journal citation managers such as EndNote, Dropbox, Mendeley, and Yep can help organize and manage that virtual pile of unread but probably important journal articles that keeps building up in your inbox. Even the humble iBooks app can be used to read and mark up pdf files on the fly, all while syncing with your library on your home computer. Many hospital EMRs have mobile platforms with various levels of functionality for tablets and smartphones.

What is obvious is that mobile computing technology is rapidly changing medicine and surgery in many ways. Although each one of us strives to be a complete physician, utterly self-reliant and assured of one's clinical knowledge, we all must learn the basics first. Whether at the bus stop, in a resident lounge, or in the operating room, these mobile technologies help us to learn more efficiently while on the go.

If there are any gems we have forgotten to highlight, please send an e-mail to Thoracic Surgery News and we will try to present them in the future. We hope that the residents reading this column can find a new app they didn't know they needed, one that will energize them and push their learning to a new height. Just don't forget to look up once in a while.

Dr. Antonoff is a 2nd-year, Thoracic-track trainee at Washington University in St Louis. Dr. Zeigler is a 3rd-year, integrated Cardiothoracic Surgery trainee at Stanford (Calif.) University. They reported no relevant financial conflicts.