PALM BEACH, FLA. – The ankle-brachial index value is directly associated with the prevalence of carotid artery stenosis and with a history of coronary artery disease and cerebrovascular disease, according to analysis of more than 3.6 million records obtained from the private health screening company, Life Line Screening.

But what makes the study interesting is the database itself, and not so much the findings, which have been previously shown, commented Dr. Spence M. Taylor, president of the Greenville (S.C.) Health System Clinical University.

Life Line Screening has mobile units, which travel to various locations and for a fee of more than $100, screen individuals, collecting nearly 300 data points per person. Meanwhile, the ankle-brachial index (ABI) costs less than $30 approximately. Yet, the test hasn’t become widely used, despite the evidence. Not much has changed since the 2001 PARTNERS study, which showed that the primary care physicians’ awareness of PAD diagnosis was "relatively low" (JAMA 2001;286:1317-24).

Results using the Life Line Screening’s large database may show the federal government that ABI can be cost effective, and getting them on board would popularize the screening tool, said Dr. Mark A. Adelman of the New York University Langone Medical Center, who presented his study at the Southern Association for Vascular Surgery annual meeting.

"Life Line is a huge paradox," said Dr. Taylor, senior associate dean of academic affairs at University of South Carolina, Greenville. It’s an operation that "we love to hate and hate to love," he added.

Dr. Adelman, the Frank J. Veith, M.D. Professor of Vascular and Endovascular Surgery and chief of vascular surgery at NYU Langone, and his colleagues analyzed data obtained from Life Line Screening, and found that individuals with an ABI between 0.41 and 0.60 had a 26.4% incidence of carotid artery stenosis (CAS), compared with individuals who had a normal ABI. The incidence increased to 35% for patients with ABI of 0.4 or less.

The majority of the abnormal ABI cases were between 0.81 and 0.90.

The analysis by Dr. Adelman and his colleagues also showed that individuals with PAD were more likely to be aged 70 years or older, male, and have modifiable risk factors, such as a history of smoking, hypertension, diabetes, and hypercholesterolemia, compared with non–PAD persons (P less than .001). (A comparison of Life Line’s database to one from the general population showed that the risk factors such as hypertension, hyperlipidemia, diabetes, and smoking were comparable.)

PAD subjects were also more likely to have CAS, prior stroke, prior transient ischemic attack, prior MI, and prior coronary revascularization, compared with those who didn’t have PAD (P less than .001). There was a significant correlation between decreasing ABI value and an increase in the prevalence of CAS, CAD, and cardiovascular disease (P less than .001).

In a separate study analyzing the same database, Dr. Adelman and his colleagues found that modifiable risk factors, such as hypertension and smoking, are associated with increased prevalence of peripheral vascular disease (J. Vasc. Surg. 2013;58:673-81).

Dr. Adelman said that screening for ABI could trigger other screening and lead to modification of risk factors that could affect better patient outcomes, changes in lifestyle, or changes in pharmacological management.

Dr. Adelman and Dr. Taylor had no disclosures.

[email protected]

On Twitter @naseemsmiller

PALM BEACH, FLA. – The ankle-brachial index value is directly associated with the prevalence of carotid artery stenosis and with a history of coronary artery disease and cerebrovascular disease, according to analysis of more than 3.6 million records obtained from the private health screening company, Life Line Screening.

But what makes the study interesting is the database itself, and not so much the findings, which have been previously shown, commented Dr. Spence M. Taylor, president of the Greenville (S.C.) Health System Clinical University.

Life Line Screening has mobile units, which travel to various locations and for a fee of more than $100, screen individuals, collecting nearly 300 data points per person. Meanwhile, the ankle-brachial index (ABI) costs less than $30 approximately. Yet, the test hasn’t become widely used, despite the evidence. Not much has changed since the 2001 PARTNERS study, which showed that the primary care physicians’ awareness of PAD diagnosis was "relatively low" (JAMA 2001;286:1317-24).

Results using the Life Line Screening’s large database may show the federal government that ABI can be cost effective, and getting them on board would popularize the screening tool, said Dr. Mark A. Adelman of the New York University Langone Medical Center, who presented his study at the Southern Association for Vascular Surgery annual meeting.

"Life Line is a huge paradox," said Dr. Taylor, senior associate dean of academic affairs at University of South Carolina, Greenville. It’s an operation that "we love to hate and hate to love," he added.

Dr. Adelman, the Frank J. Veith, M.D. Professor of Vascular and Endovascular Surgery and chief of vascular surgery at NYU Langone, and his colleagues analyzed data obtained from Life Line Screening, and found that individuals with an ABI between 0.41 and 0.60 had a 26.4% incidence of carotid artery stenosis (CAS), compared with individuals who had a normal ABI. The incidence increased to 35% for patients with ABI of 0.4 or less.

The majority of the abnormal ABI cases were between 0.81 and 0.90.

The analysis by Dr. Adelman and his colleagues also showed that individuals with PAD were more likely to be aged 70 years or older, male, and have modifiable risk factors, such as a history of smoking, hypertension, diabetes, and hypercholesterolemia, compared with non–PAD persons (P less than .001). (A comparison of Life Line’s database to one from the general population showed that the risk factors such as hypertension, hyperlipidemia, diabetes, and smoking were comparable.)

PAD subjects were also more likely to have CAS, prior stroke, prior transient ischemic attack, prior MI, and prior coronary revascularization, compared with those who didn’t have PAD (P less than .001). There was a significant correlation between decreasing ABI value and an increase in the prevalence of CAS, CAD, and cardiovascular disease (P less than .001).

In a separate study analyzing the same database, Dr. Adelman and his colleagues found that modifiable risk factors, such as hypertension and smoking, are associated with increased prevalence of peripheral vascular disease (J. Vasc. Surg. 2013;58:673-81).

Dr. Adelman said that screening for ABI could trigger other screening and lead to modification of risk factors that could affect better patient outcomes, changes in lifestyle, or changes in pharmacological management.

Dr. Adelman and Dr. Taylor had no disclosures.

[email protected]

On Twitter @naseemsmiller

PALM BEACH, FLA. – The ankle-brachial index value is directly associated with the prevalence of carotid artery stenosis and with a history of coronary artery disease and cerebrovascular disease, according to analysis of more than 3.6 million records obtained from the private health screening company, Life Line Screening.

But what makes the study interesting is the database itself, and not so much the findings, which have been previously shown, commented Dr. Spence M. Taylor, president of the Greenville (S.C.) Health System Clinical University.

Life Line Screening has mobile units, which travel to various locations and for a fee of more than $100, screen individuals, collecting nearly 300 data points per person. Meanwhile, the ankle-brachial index (ABI) costs less than $30 approximately. Yet, the test hasn’t become widely used, despite the evidence. Not much has changed since the 2001 PARTNERS study, which showed that the primary care physicians’ awareness of PAD diagnosis was "relatively low" (JAMA 2001;286:1317-24).

Results using the Life Line Screening’s large database may show the federal government that ABI can be cost effective, and getting them on board would popularize the screening tool, said Dr. Mark A. Adelman of the New York University Langone Medical Center, who presented his study at the Southern Association for Vascular Surgery annual meeting.

"Life Line is a huge paradox," said Dr. Taylor, senior associate dean of academic affairs at University of South Carolina, Greenville. It’s an operation that "we love to hate and hate to love," he added.

Dr. Adelman, the Frank J. Veith, M.D. Professor of Vascular and Endovascular Surgery and chief of vascular surgery at NYU Langone, and his colleagues analyzed data obtained from Life Line Screening, and found that individuals with an ABI between 0.41 and 0.60 had a 26.4% incidence of carotid artery stenosis (CAS), compared with individuals who had a normal ABI. The incidence increased to 35% for patients with ABI of 0.4 or less.

The majority of the abnormal ABI cases were between 0.81 and 0.90.

The analysis by Dr. Adelman and his colleagues also showed that individuals with PAD were more likely to be aged 70 years or older, male, and have modifiable risk factors, such as a history of smoking, hypertension, diabetes, and hypercholesterolemia, compared with non–PAD persons (P less than .001). (A comparison of Life Line’s database to one from the general population showed that the risk factors such as hypertension, hyperlipidemia, diabetes, and smoking were comparable.)

PAD subjects were also more likely to have CAS, prior stroke, prior transient ischemic attack, prior MI, and prior coronary revascularization, compared with those who didn’t have PAD (P less than .001). There was a significant correlation between decreasing ABI value and an increase in the prevalence of CAS, CAD, and cardiovascular disease (P less than .001).

In a separate study analyzing the same database, Dr. Adelman and his colleagues found that modifiable risk factors, such as hypertension and smoking, are associated with increased prevalence of peripheral vascular disease (J. Vasc. Surg. 2013;58:673-81).

Dr. Adelman said that screening for ABI could trigger other screening and lead to modification of risk factors that could affect better patient outcomes, changes in lifestyle, or changes in pharmacological management.

Dr. Adelman and Dr. Taylor had no disclosures.

[email protected]

On Twitter @naseemsmiller

Platelets (blue) in a thrombus

Credit: Andre E.X. Brown

New research suggests patients with hereditary hemorrhagic telangiectasia (HHT) have an increased risk of ischemic stroke if they are iron deficient, and this may be due to enhanced platelet aggregation.

In the last few years, several studies have shown that iron deficiency may be a risk factor for ischemic stroke, but exactly how this occurs has been unclear.

Previous research also revealed a possible link between iron deficiency and platelet aggregation, but it has been largely overlooked, until now.

Claire Shovlin, PhD, of Imperial College London in the UK, and her colleagues found that HHT patients who are iron deficient have both an increased risk of stroke and enhanced aggregation of circulating platelets.

The researchers reported these findings in PLOS ONE.

The team had studied 497 HHT patients who had enlarged blood vessels in the lungs known as pulmonary arteriovenous malformations.

Normally, the lungs’ blood vessels act as a filter to remove small clots before blood enters arteries. In patients with pulmonary arteriovenous malformations, blood is able to bypass the filter, so small blood clots can travel to the brain.

Dr Shovlin and her colleagues found that patients with iron deficiency had a greater risk of stroke than patients with normal iron levels. Even moderately low iron levels, around 6 μmol/L, approximately doubled the risk of stroke when compared with levels in the middle of the normal range (7 to 27 μmol/L).

The researchers evaluated platelet activity in 15 patients, dividing them into 2 groups according to serum ferritin. Iron-deficient patients (n=7) had ferritin levels ranging from 2 μg/L to 17 μg/L. Control subjects (n=8) had ferritin levels of 24 μg/L to 98 μg/L. (None of the patients had levels between 17μg/L and 24 μg/L.)

The team found that ADP induced similar, dose-dependent platelet aggregation in iron-deficient patients and control subjects. But iron-deficient patients exhibited enhanced total aggregation to 5HT over a 5-minute period. And the iron-deficient group displayed faster rates of aggregation in response to 5HT.

“Since platelets in the blood stick together more if you are short of iron, we think this may explain why being short of iron can lead to strokes, though much more research will be needed to prove this link,” Dr Shovlin said.

“The next step is to test whether we can reduce high-risk patients’ chances of having a stroke by treating their iron deficiency. We will be able to look at whether their platelets become less sticky.”

“There are many additional steps from a clot blocking a blood vessel to the final stroke developing, so it is still unclear just how important sticky platelets are to the overall process. We would certainly encourage more studies to investigate this link.”

Platelets (blue) in a thrombus

Credit: Andre E.X. Brown

New research suggests patients with hereditary hemorrhagic telangiectasia (HHT) have an increased risk of ischemic stroke if they are iron deficient, and this may be due to enhanced platelet aggregation.

In the last few years, several studies have shown that iron deficiency may be a risk factor for ischemic stroke, but exactly how this occurs has been unclear.

Previous research also revealed a possible link between iron deficiency and platelet aggregation, but it has been largely overlooked, until now.

Claire Shovlin, PhD, of Imperial College London in the UK, and her colleagues found that HHT patients who are iron deficient have both an increased risk of stroke and enhanced aggregation of circulating platelets.

The researchers reported these findings in PLOS ONE.

The team had studied 497 HHT patients who had enlarged blood vessels in the lungs known as pulmonary arteriovenous malformations.

Normally, the lungs’ blood vessels act as a filter to remove small clots before blood enters arteries. In patients with pulmonary arteriovenous malformations, blood is able to bypass the filter, so small blood clots can travel to the brain.

Dr Shovlin and her colleagues found that patients with iron deficiency had a greater risk of stroke than patients with normal iron levels. Even moderately low iron levels, around 6 μmol/L, approximately doubled the risk of stroke when compared with levels in the middle of the normal range (7 to 27 μmol/L).

The researchers evaluated platelet activity in 15 patients, dividing them into 2 groups according to serum ferritin. Iron-deficient patients (n=7) had ferritin levels ranging from 2 μg/L to 17 μg/L. Control subjects (n=8) had ferritin levels of 24 μg/L to 98 μg/L. (None of the patients had levels between 17μg/L and 24 μg/L.)

The team found that ADP induced similar, dose-dependent platelet aggregation in iron-deficient patients and control subjects. But iron-deficient patients exhibited enhanced total aggregation to 5HT over a 5-minute period. And the iron-deficient group displayed faster rates of aggregation in response to 5HT.

“Since platelets in the blood stick together more if you are short of iron, we think this may explain why being short of iron can lead to strokes, though much more research will be needed to prove this link,” Dr Shovlin said.

“The next step is to test whether we can reduce high-risk patients’ chances of having a stroke by treating their iron deficiency. We will be able to look at whether their platelets become less sticky.”

“There are many additional steps from a clot blocking a blood vessel to the final stroke developing, so it is still unclear just how important sticky platelets are to the overall process. We would certainly encourage more studies to investigate this link.”

Platelets (blue) in a thrombus

Credit: Andre E.X. Brown

New research suggests patients with hereditary hemorrhagic telangiectasia (HHT) have an increased risk of ischemic stroke if they are iron deficient, and this may be due to enhanced platelet aggregation.

In the last few years, several studies have shown that iron deficiency may be a risk factor for ischemic stroke, but exactly how this occurs has been unclear.

Previous research also revealed a possible link between iron deficiency and platelet aggregation, but it has been largely overlooked, until now.

Claire Shovlin, PhD, of Imperial College London in the UK, and her colleagues found that HHT patients who are iron deficient have both an increased risk of stroke and enhanced aggregation of circulating platelets.

The researchers reported these findings in PLOS ONE.

The team had studied 497 HHT patients who had enlarged blood vessels in the lungs known as pulmonary arteriovenous malformations.

Normally, the lungs’ blood vessels act as a filter to remove small clots before blood enters arteries. In patients with pulmonary arteriovenous malformations, blood is able to bypass the filter, so small blood clots can travel to the brain.

Dr Shovlin and her colleagues found that patients with iron deficiency had a greater risk of stroke than patients with normal iron levels. Even moderately low iron levels, around 6 μmol/L, approximately doubled the risk of stroke when compared with levels in the middle of the normal range (7 to 27 μmol/L).

The researchers evaluated platelet activity in 15 patients, dividing them into 2 groups according to serum ferritin. Iron-deficient patients (n=7) had ferritin levels ranging from 2 μg/L to 17 μg/L. Control subjects (n=8) had ferritin levels of 24 μg/L to 98 μg/L. (None of the patients had levels between 17μg/L and 24 μg/L.)

The team found that ADP induced similar, dose-dependent platelet aggregation in iron-deficient patients and control subjects. But iron-deficient patients exhibited enhanced total aggregation to 5HT over a 5-minute period. And the iron-deficient group displayed faster rates of aggregation in response to 5HT.

“Since platelets in the blood stick together more if you are short of iron, we think this may explain why being short of iron can lead to strokes, though much more research will be needed to prove this link,” Dr Shovlin said.

“The next step is to test whether we can reduce high-risk patients’ chances of having a stroke by treating their iron deficiency. We will be able to look at whether their platelets become less sticky.”

“There are many additional steps from a clot blocking a blood vessel to the final stroke developing, so it is still unclear just how important sticky platelets are to the overall process. We would certainly encourage more studies to investigate this link.”

Steven Grant, MD

Credit: VCU

The experimental drug dinaciclib could potentially improve the treatment of multiple myeloma (MM) and myeloid leukemias, according to preclinical research published in Molecular Cancer Therapeutics.

The study showed that dinaciclib disrupts a cell survival mechanism known as the unfolded protein response (UPR).

And without the UPR, MM and myeloid leukemia cells were unable to combat damage caused by anticancer agents that induce stress in the endoplasmic reticulum (ER).

“Although dinaciclib has shown promising preclinical activity against a variety of tumor cells and is currently undergoing phase 1/2 clinical trials in several malignancies, the mechanisms responsible for its antitumor activity are not fully understood,” said study author Steven Grant, MD, of the Virginia Commonwealth University Massey Cancer Center.

“Our research highlights a potentially new mechanism of dinaciclib action and raises the possibility that this agent could be a useful addition to current multiple myeloma and myeloid leukemia therapies.”

Dinaciclib is a cyclin-dependent kinase (CDK) inhibitor. CDKs are overactive in many cancers, which results in unregulated proliferation of cancer cells.

Observations from this study suggest that 2 specific CDKs, CDK1 and CDK5, play key roles in regulating the UPR by helping to control the production and accumulation of X-box binding pretein-1 (XBP-1). The spliced form of XBP-1 (XBP-1s) helps regulate the expression of genes critical to cellular stress responses.

External stressors, including certain anticancer agents, can cause misfolded proteins to accumulate in the ER. These stressors can also cause XBP-1s to accumulate in the cell’s nucleus, which promotes the UPR and helps cells withstand the damaging effects of misfolded proteins.

This research showed that dinaciclib, by interfering with UPR activation, caused MM and myeloid leukemia cells to initiate apoptosis when exposed to thapsigargin and tunicamycin—2 agents that induce ER stress.

And single-agent dinaciclib treatment significantly decreased tumor growth in mouse models of MM, when compared to vehicle control.

“These findings build on a long history of work in our laboratory investigating mechanisms by which cancer cells respond to environmental stresses,” Dr Grant said.

“We intend to continue investigating ways in which dinaciclib and other CDK inhibitors might be used to disrupt the UPR and potentially improve the effectiveness of certain agents for the treatment of multiple myeloma or myeloid leukemia.”

Steven Grant, MD

Credit: VCU

The experimental drug dinaciclib could potentially improve the treatment of multiple myeloma (MM) and myeloid leukemias, according to preclinical research published in Molecular Cancer Therapeutics.

The study showed that dinaciclib disrupts a cell survival mechanism known as the unfolded protein response (UPR).

And without the UPR, MM and myeloid leukemia cells were unable to combat damage caused by anticancer agents that induce stress in the endoplasmic reticulum (ER).

“Although dinaciclib has shown promising preclinical activity against a variety of tumor cells and is currently undergoing phase 1/2 clinical trials in several malignancies, the mechanisms responsible for its antitumor activity are not fully understood,” said study author Steven Grant, MD, of the Virginia Commonwealth University Massey Cancer Center.

“Our research highlights a potentially new mechanism of dinaciclib action and raises the possibility that this agent could be a useful addition to current multiple myeloma and myeloid leukemia therapies.”

Dinaciclib is a cyclin-dependent kinase (CDK) inhibitor. CDKs are overactive in many cancers, which results in unregulated proliferation of cancer cells.

Observations from this study suggest that 2 specific CDKs, CDK1 and CDK5, play key roles in regulating the UPR by helping to control the production and accumulation of X-box binding pretein-1 (XBP-1). The spliced form of XBP-1 (XBP-1s) helps regulate the expression of genes critical to cellular stress responses.

External stressors, including certain anticancer agents, can cause misfolded proteins to accumulate in the ER. These stressors can also cause XBP-1s to accumulate in the cell’s nucleus, which promotes the UPR and helps cells withstand the damaging effects of misfolded proteins.

This research showed that dinaciclib, by interfering with UPR activation, caused MM and myeloid leukemia cells to initiate apoptosis when exposed to thapsigargin and tunicamycin—2 agents that induce ER stress.

And single-agent dinaciclib treatment significantly decreased tumor growth in mouse models of MM, when compared to vehicle control.

“These findings build on a long history of work in our laboratory investigating mechanisms by which cancer cells respond to environmental stresses,” Dr Grant said.

“We intend to continue investigating ways in which dinaciclib and other CDK inhibitors might be used to disrupt the UPR and potentially improve the effectiveness of certain agents for the treatment of multiple myeloma or myeloid leukemia.”

Steven Grant, MD

Credit: VCU

The experimental drug dinaciclib could potentially improve the treatment of multiple myeloma (MM) and myeloid leukemias, according to preclinical research published in Molecular Cancer Therapeutics.

The study showed that dinaciclib disrupts a cell survival mechanism known as the unfolded protein response (UPR).

And without the UPR, MM and myeloid leukemia cells were unable to combat damage caused by anticancer agents that induce stress in the endoplasmic reticulum (ER).

“Although dinaciclib has shown promising preclinical activity against a variety of tumor cells and is currently undergoing phase 1/2 clinical trials in several malignancies, the mechanisms responsible for its antitumor activity are not fully understood,” said study author Steven Grant, MD, of the Virginia Commonwealth University Massey Cancer Center.

“Our research highlights a potentially new mechanism of dinaciclib action and raises the possibility that this agent could be a useful addition to current multiple myeloma and myeloid leukemia therapies.”

Dinaciclib is a cyclin-dependent kinase (CDK) inhibitor. CDKs are overactive in many cancers, which results in unregulated proliferation of cancer cells.

Observations from this study suggest that 2 specific CDKs, CDK1 and CDK5, play key roles in regulating the UPR by helping to control the production and accumulation of X-box binding pretein-1 (XBP-1). The spliced form of XBP-1 (XBP-1s) helps regulate the expression of genes critical to cellular stress responses.

External stressors, including certain anticancer agents, can cause misfolded proteins to accumulate in the ER. These stressors can also cause XBP-1s to accumulate in the cell’s nucleus, which promotes the UPR and helps cells withstand the damaging effects of misfolded proteins.

This research showed that dinaciclib, by interfering with UPR activation, caused MM and myeloid leukemia cells to initiate apoptosis when exposed to thapsigargin and tunicamycin—2 agents that induce ER stress.

And single-agent dinaciclib treatment significantly decreased tumor growth in mouse models of MM, when compared to vehicle control.

“These findings build on a long history of work in our laboratory investigating mechanisms by which cancer cells respond to environmental stresses,” Dr Grant said.

“We intend to continue investigating ways in which dinaciclib and other CDK inhibitors might be used to disrupt the UPR and potentially improve the effectiveness of certain agents for the treatment of multiple myeloma or myeloid leukemia.”

Prescription medications

Credit: Steven Harbour

The US Food and Drug Administration (FDA) has launched a program that allows certain companies to expedite the importation of drugs and drug ingredients.

Thirteen companies have been selected to take part in this 2-year program, called the Secure Supply Chain Pilot Program.

As the companies meet certain criteria, they are eligible to receive expedited entry for up to 5 drug products. These products can enter the US after electronic screening without undergoing human examination.

The FDA said its goal with this program is to allow the agency to focus its imports surveillance resources on preventing the entry of drugs that are most likely to compromise the quality and safety of the US drug supply.

The companies that have been accepted into the program are:

• AbbVie Inc.
• Allergan, Inc.
• Astellas U.S. Technologies, Inc.
• Bristol-Myers Squibb Company
• Celgene Corporation
• GE Healthcare Inc.
• GlaxoSmithKline LLC
• Merck Sharp & Dohme Corporation
• Mylan Pharmaceuticals Inc.
• Novartis Pharmaceuticals Corporation
• Pfizer, Inc.
• Teva Pharmaceutcials USA, Inc.
• Watson Laboratories, Inc.

Each of these companies met the participation conditions, including:

• Committing to comply with requirements of the Food, Drug, and Cosmetics Act (FDCA)
• Having a validated, secure supply chain protocol per the US Customs and Border Protection’s Customs-Trade Partnership Against Terrorism (C-TPAT) program
• Having a plan in place to quickly correct potential problems the FDA identifies regarding importation of specific products
• Having effective recall and corrective action plans in place
• Maintaining control over their drugs from the time of manufacture abroad through entry into the US.

Over the next 2 years, the FDA will evaluate whether this program enhances imported drug compliance with FDA regulations and the security of the drug supply chain. If the FDA deems the program effective, a more permanent program may be established and possibly extended to additional companies.

For more information, see the FDA’s notice about the program, published in the Federal Register last August.

Prescription medications

Credit: Steven Harbour

The US Food and Drug Administration (FDA) has launched a program that allows certain companies to expedite the importation of drugs and drug ingredients.

Thirteen companies have been selected to take part in this 2-year program, called the Secure Supply Chain Pilot Program.

As the companies meet certain criteria, they are eligible to receive expedited entry for up to 5 drug products. These products can enter the US after electronic screening without undergoing human examination.

The FDA said its goal with this program is to allow the agency to focus its imports surveillance resources on preventing the entry of drugs that are most likely to compromise the quality and safety of the US drug supply.

The companies that have been accepted into the program are:

• AbbVie Inc.
• Allergan, Inc.
• Astellas U.S. Technologies, Inc.
• Bristol-Myers Squibb Company
• Celgene Corporation
• GE Healthcare Inc.
• GlaxoSmithKline LLC
• Merck Sharp & Dohme Corporation
• Mylan Pharmaceuticals Inc.
• Novartis Pharmaceuticals Corporation
• Pfizer, Inc.
• Teva Pharmaceutcials USA, Inc.
• Watson Laboratories, Inc.

Each of these companies met the participation conditions, including:

• Committing to comply with requirements of the Food, Drug, and Cosmetics Act (FDCA)
• Having a validated, secure supply chain protocol per the US Customs and Border Protection’s Customs-Trade Partnership Against Terrorism (C-TPAT) program
• Having a plan in place to quickly correct potential problems the FDA identifies regarding importation of specific products
• Having effective recall and corrective action plans in place
• Maintaining control over their drugs from the time of manufacture abroad through entry into the US.

Over the next 2 years, the FDA will evaluate whether this program enhances imported drug compliance with FDA regulations and the security of the drug supply chain. If the FDA deems the program effective, a more permanent program may be established and possibly extended to additional companies.

For more information, see the FDA’s notice about the program, published in the Federal Register last August.

Prescription medications

Credit: Steven Harbour

The US Food and Drug Administration (FDA) has launched a program that allows certain companies to expedite the importation of drugs and drug ingredients.

Thirteen companies have been selected to take part in this 2-year program, called the Secure Supply Chain Pilot Program.

As the companies meet certain criteria, they are eligible to receive expedited entry for up to 5 drug products. These products can enter the US after electronic screening without undergoing human examination.

The FDA said its goal with this program is to allow the agency to focus its imports surveillance resources on preventing the entry of drugs that are most likely to compromise the quality and safety of the US drug supply.

The companies that have been accepted into the program are:

• AbbVie Inc.
• Allergan, Inc.
• Astellas U.S. Technologies, Inc.
• Bristol-Myers Squibb Company
• Celgene Corporation
• GE Healthcare Inc.
• GlaxoSmithKline LLC
• Merck Sharp & Dohme Corporation
• Mylan Pharmaceuticals Inc.
• Novartis Pharmaceuticals Corporation
• Pfizer, Inc.
• Teva Pharmaceutcials USA, Inc.
• Watson Laboratories, Inc.

Each of these companies met the participation conditions, including:

• Committing to comply with requirements of the Food, Drug, and Cosmetics Act (FDCA)
• Having a validated, secure supply chain protocol per the US Customs and Border Protection’s Customs-Trade Partnership Against Terrorism (C-TPAT) program
• Having a plan in place to quickly correct potential problems the FDA identifies regarding importation of specific products
• Having effective recall and corrective action plans in place
• Maintaining control over their drugs from the time of manufacture abroad through entry into the US.

Over the next 2 years, the FDA will evaluate whether this program enhances imported drug compliance with FDA regulations and the security of the drug supply chain. If the FDA deems the program effective, a more permanent program may be established and possibly extended to additional companies.

For more information, see the FDA’s notice about the program, published in the Federal Register last August.

Michel Sadelain, MD, PhD

Credit: MSKCC

Several studies have shown that infusions of T cells modified with chimeric antigen receptors (CARs) can elicit complete responses in leukemia patients who have run out of treatment options.

However, the therapy also puts patients at risk of developing cytokine release syndrome (CRS).

With updated research, investigators have again shown that CAR T cells can produce complete responses in patients with relapsed or refractory B-cell acute lymphoblastic leukemia (B-ALL), thereby allowing them to receive allogeneic stem cell transplant (allo-SCT).

But the researchers have also used this group of patients to define diagnostic criteria for severe CRS. And the team has discovered that measuring C-reactive protein levels can help predict the severity of CRS.

Michel Sadelain, MD, PhD, of Memorial Sloan-Kettering Cancer Center in New York, and his colleagues described these findings in Science Translational Medicine.

Response, bridge to allo-SCT

Dr Sadelain and his colleagues previously reported results in 5 patients with relapsed/refractory B-ALL who received autologous T cells expressing a CD19-specific, CD28/CD3z CAR called 19-28z.

After receiving salvage chemotherapy and CAR T cells, all 5 patients were negative for minimal residual disease. And 4 of the patients went on to receive allo-SCT.

Now, the investigators have expanded upon these findings, reporting results in a total of 16 patients with relapsed/refractory B-ALL who received the 19-28z CAR T cells.

Forty-four percent of patients (n=7) had a complete response to the salvage chemotherapy, and 88% (n=14) had a complete response after CAR T-cell therapy (alghough some had incomplete count recovery). Sixty-three percent of patients (n=10) achieved a complete remission.

Of the 10 patients who were eligible for allo-SCT, 7 underwent the procedure, and all 7 remain free of relapse.

“These extraordinary results demonstrate that cell therapy is a powerful treatment for patients who have exhausted all conventional therapies,” Dr Sadelain said. “Our initial findings have held up in a larger cohort of patients, and we are already looking at new clinical studies to advance this novel therapeutic approach in fighting cancer.”

CRS diagnosis, stratification

In their analysis of 5 B-ALL patients, Dr Sadelain and his colleagues observed a correlation between cytokine elevation and tumor burden at the time of CAR T-cell administration. The team confirmed this correlation in the larger cohort of 16 patients and identified 7 cytokines whose elevation was correlated with pretreatment tumor burden and severe CRS.

Patients with CRS that required intensive medical intervention had a 75-fold increase over baseline levels in 2 of the 7 cytokines, which included IFN-γ, IL-5, IL-6, IL-10, Flt-3L, Fracktalkine, and GM-CSF. These patients also had at least 1 of the following: hypoxia, hypotension, and neurologic changes (such as delirium and seizure-like activity).

Taking these findings together, the researchers concluded that patients had severe CRS if they had persistent fevers (38°C) for more than 3 days, selected cytokine elevations, and additional clinical evidence of toxicity.

The investigators stressed that these patients should be closely monitored. Patients with severe CRS are more likely to need medical intervention than patients with mild CRS, which is characterized by low-grade fever and mild cytokine increases, or absent CRS, which is defined as no fevers and/or no significant cytokine elevations.

Finally, the researchers found that measuring C-reactive protein in serum samples could predict the severity of CRS. Only those patients who met the criteria for severe CRS had a C-reactive protein level of 20 mg/dL or higher.

Patients who had received high-dose steroids were excluded from this analysis, due to the inverse correlation between high-dose steroid treatment and serum C-reactive protein.

Incidentally, the investigators confirmed prior findings that the monoclonal antibody tocilizumab can ameliorate severe CRS as effectively as steroid treatment, without inhibiting the expansion of CAR T cells.

Michel Sadelain, MD, PhD

Credit: MSKCC

Several studies have shown that infusions of T cells modified with chimeric antigen receptors (CARs) can elicit complete responses in leukemia patients who have run out of treatment options.

However, the therapy also puts patients at risk of developing cytokine release syndrome (CRS).

With updated research, investigators have again shown that CAR T cells can produce complete responses in patients with relapsed or refractory B-cell acute lymphoblastic leukemia (B-ALL), thereby allowing them to receive allogeneic stem cell transplant (allo-SCT).

But the researchers have also used this group of patients to define diagnostic criteria for severe CRS. And the team has discovered that measuring C-reactive protein levels can help predict the severity of CRS.

Michel Sadelain, MD, PhD, of Memorial Sloan-Kettering Cancer Center in New York, and his colleagues described these findings in Science Translational Medicine.

Response, bridge to allo-SCT

Dr Sadelain and his colleagues previously reported results in 5 patients with relapsed/refractory B-ALL who received autologous T cells expressing a CD19-specific, CD28/CD3z CAR called 19-28z.

After receiving salvage chemotherapy and CAR T cells, all 5 patients were negative for minimal residual disease. And 4 of the patients went on to receive allo-SCT.

Now, the investigators have expanded upon these findings, reporting results in a total of 16 patients with relapsed/refractory B-ALL who received the 19-28z CAR T cells.

Forty-four percent of patients (n=7) had a complete response to the salvage chemotherapy, and 88% (n=14) had a complete response after CAR T-cell therapy (alghough some had incomplete count recovery). Sixty-three percent of patients (n=10) achieved a complete remission.

Of the 10 patients who were eligible for allo-SCT, 7 underwent the procedure, and all 7 remain free of relapse.

“These extraordinary results demonstrate that cell therapy is a powerful treatment for patients who have exhausted all conventional therapies,” Dr Sadelain said. “Our initial findings have held up in a larger cohort of patients, and we are already looking at new clinical studies to advance this novel therapeutic approach in fighting cancer.”

CRS diagnosis, stratification

In their analysis of 5 B-ALL patients, Dr Sadelain and his colleagues observed a correlation between cytokine elevation and tumor burden at the time of CAR T-cell administration. The team confirmed this correlation in the larger cohort of 16 patients and identified 7 cytokines whose elevation was correlated with pretreatment tumor burden and severe CRS.

Patients with CRS that required intensive medical intervention had a 75-fold increase over baseline levels in 2 of the 7 cytokines, which included IFN-γ, IL-5, IL-6, IL-10, Flt-3L, Fracktalkine, and GM-CSF. These patients also had at least 1 of the following: hypoxia, hypotension, and neurologic changes (such as delirium and seizure-like activity).

Taking these findings together, the researchers concluded that patients had severe CRS if they had persistent fevers (38°C) for more than 3 days, selected cytokine elevations, and additional clinical evidence of toxicity.

The investigators stressed that these patients should be closely monitored. Patients with severe CRS are more likely to need medical intervention than patients with mild CRS, which is characterized by low-grade fever and mild cytokine increases, or absent CRS, which is defined as no fevers and/or no significant cytokine elevations.

Finally, the researchers found that measuring C-reactive protein in serum samples could predict the severity of CRS. Only those patients who met the criteria for severe CRS had a C-reactive protein level of 20 mg/dL or higher.

Patients who had received high-dose steroids were excluded from this analysis, due to the inverse correlation between high-dose steroid treatment and serum C-reactive protein.

Incidentally, the investigators confirmed prior findings that the monoclonal antibody tocilizumab can ameliorate severe CRS as effectively as steroid treatment, without inhibiting the expansion of CAR T cells.

Michel Sadelain, MD, PhD

Credit: MSKCC

Several studies have shown that infusions of T cells modified with chimeric antigen receptors (CARs) can elicit complete responses in leukemia patients who have run out of treatment options.

However, the therapy also puts patients at risk of developing cytokine release syndrome (CRS).

With updated research, investigators have again shown that CAR T cells can produce complete responses in patients with relapsed or refractory B-cell acute lymphoblastic leukemia (B-ALL), thereby allowing them to receive allogeneic stem cell transplant (allo-SCT).

But the researchers have also used this group of patients to define diagnostic criteria for severe CRS. And the team has discovered that measuring C-reactive protein levels can help predict the severity of CRS.

Michel Sadelain, MD, PhD, of Memorial Sloan-Kettering Cancer Center in New York, and his colleagues described these findings in Science Translational Medicine.

Response, bridge to allo-SCT

Dr Sadelain and his colleagues previously reported results in 5 patients with relapsed/refractory B-ALL who received autologous T cells expressing a CD19-specific, CD28/CD3z CAR called 19-28z.

After receiving salvage chemotherapy and CAR T cells, all 5 patients were negative for minimal residual disease. And 4 of the patients went on to receive allo-SCT.

Now, the investigators have expanded upon these findings, reporting results in a total of 16 patients with relapsed/refractory B-ALL who received the 19-28z CAR T cells.

Forty-four percent of patients (n=7) had a complete response to the salvage chemotherapy, and 88% (n=14) had a complete response after CAR T-cell therapy (alghough some had incomplete count recovery). Sixty-three percent of patients (n=10) achieved a complete remission.

Of the 10 patients who were eligible for allo-SCT, 7 underwent the procedure, and all 7 remain free of relapse.

“These extraordinary results demonstrate that cell therapy is a powerful treatment for patients who have exhausted all conventional therapies,” Dr Sadelain said. “Our initial findings have held up in a larger cohort of patients, and we are already looking at new clinical studies to advance this novel therapeutic approach in fighting cancer.”

CRS diagnosis, stratification

In their analysis of 5 B-ALL patients, Dr Sadelain and his colleagues observed a correlation between cytokine elevation and tumor burden at the time of CAR T-cell administration. The team confirmed this correlation in the larger cohort of 16 patients and identified 7 cytokines whose elevation was correlated with pretreatment tumor burden and severe CRS.

Patients with CRS that required intensive medical intervention had a 75-fold increase over baseline levels in 2 of the 7 cytokines, which included IFN-γ, IL-5, IL-6, IL-10, Flt-3L, Fracktalkine, and GM-CSF. These patients also had at least 1 of the following: hypoxia, hypotension, and neurologic changes (such as delirium and seizure-like activity).

Taking these findings together, the researchers concluded that patients had severe CRS if they had persistent fevers (38°C) for more than 3 days, selected cytokine elevations, and additional clinical evidence of toxicity.

The investigators stressed that these patients should be closely monitored. Patients with severe CRS are more likely to need medical intervention than patients with mild CRS, which is characterized by low-grade fever and mild cytokine increases, or absent CRS, which is defined as no fevers and/or no significant cytokine elevations.

Finally, the researchers found that measuring C-reactive protein in serum samples could predict the severity of CRS. Only those patients who met the criteria for severe CRS had a C-reactive protein level of 20 mg/dL or higher.

Patients who had received high-dose steroids were excluded from this analysis, due to the inverse correlation between high-dose steroid treatment and serum C-reactive protein.

Incidentally, the investigators confirmed prior findings that the monoclonal antibody tocilizumab can ameliorate severe CRS as effectively as steroid treatment, without inhibiting the expansion of CAR T cells.

Clinical question: What antibiotic-resistant bacteria are the greatest threats for the next 10 years?

Background: Two million people suffer antibiotic-resistant infections yearly, and 23,000 die each year as a result. Most of these infections occur in the community, but deaths usually occur in healthcare settings. Cost estimates vary but may be as high as $20 billion in excess direct healthcare costs.

Study design: The CDC used several different surveys and databanks, including the National Antimicrobial Resistance Monitoring System, to collect data. The threat level for antibiotic-resistant bacteria was determined using several factors: clinical impact, economic impact, incidence, 10-year projection of incidence, transmissibility, availability of effective antibiotics, and barriers to prevention.

Setting: United States.

Synopsis: The CDC has three classifications of antibiotic-resistant bacteria: urgent, serious, and concerning. Urgent threats are high-consequence, antibiotic-resistant threats because of significant risks identified across several criteria. These threats might not currently be widespread but have the potential to become so and require urgent public health attention to identify infections and to limit transmission. They include carbapenem-resistant Enterobacteriaceae, drug-resistant Neisseria gonorrhoeae, and Clostridium difficile (does not have true resistance, but is a consequence of antibiotic overuse).

Serious threats are significant antibiotic-resistant threats. These threats will worsen, and might become urgent without ongoing public health monitoring and prevention activities. They include multidrug-resistant Acinetobacter, drug-resistant Campylobacter, fluconazole-resistant Candida (a fungus), extended-spectrum ß-lactamase-producing Enterobacteriaceae, vancomycin-resistant Enterococcus, multidrug-resistant Pseudomonas aeruginosa, drug-resistant non-typhoidal Salmonella, drug-resistant Salmonella Typhimurium, drug-resistant Shigella, methicillin-resistant Staphylococcus aureus, drug-resistant Streptococcus pneumonia, and drug-resistant tuberculosis.

Concerning threats are bacteria for which the threat of antibiotic resistance is low, and/or there are multiple therapeutic options for resistant infections. These bacterial pathogens cause severe illness.

Threats in this category require monitoring and, in some cases, rapid incident or outbreak response. These include vancomycin-resistant Staphylococcus aureus, erythromycin-resistant Group A Streptococcus, and clindamycin-resistant Group B Streptococcus.

Research has shown patients with resistant infections have significantly longer hospital stays, delayed recuperation, long-term disability, and higher mortality. As resistance to current antibiotics occurs, providers are forced to use antibiotics that are more toxic, more expensive, and less effective.

The CDC recommends four core actions to fight antibiotic resistance:

• Preventing infections from occurring and preventing resistant bacteria from spreading (immunization, infection control, screening, treatment, and education);
• Tracking resistant bacteria;
• Improving the use of antibiotics (antibiotic stewardship); and
• Promoting the development of new antibiotics and new diagnostic tests for resistant bacteria.

Bottom line: Antibiotics are a limited resource. The more antibiotics are used today, the less likely they will continue to be effective in the future. The CDC lists 18 antibiotic-resistant organisms as urgent, serious, or concerning and recommends actions to combat the spread of current organisms and emergence of new antibiotic organisms.

Citation: Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. CDC website. September 16, 2013. Available at: www.cdc.gov/drugresistance/threat-report-2013. Accessed Nov. 30, 2013.

Clinical question: What antibiotic-resistant bacteria are the greatest threats for the next 10 years?

Background: Two million people suffer antibiotic-resistant infections yearly, and 23,000 die each year as a result. Most of these infections occur in the community, but deaths usually occur in healthcare settings. Cost estimates vary but may be as high as $20 billion in excess direct healthcare costs.

Study design: The CDC used several different surveys and databanks, including the National Antimicrobial Resistance Monitoring System, to collect data. The threat level for antibiotic-resistant bacteria was determined using several factors: clinical impact, economic impact, incidence, 10-year projection of incidence, transmissibility, availability of effective antibiotics, and barriers to prevention.

Setting: United States.

Synopsis: The CDC has three classifications of antibiotic-resistant bacteria: urgent, serious, and concerning. Urgent threats are high-consequence, antibiotic-resistant threats because of significant risks identified across several criteria. These threats might not currently be widespread but have the potential to become so and require urgent public health attention to identify infections and to limit transmission. They include carbapenem-resistant Enterobacteriaceae, drug-resistant Neisseria gonorrhoeae, and Clostridium difficile (does not have true resistance, but is a consequence of antibiotic overuse).

Serious threats are significant antibiotic-resistant threats. These threats will worsen, and might become urgent without ongoing public health monitoring and prevention activities. They include multidrug-resistant Acinetobacter, drug-resistant Campylobacter, fluconazole-resistant Candida (a fungus), extended-spectrum ß-lactamase-producing Enterobacteriaceae, vancomycin-resistant Enterococcus, multidrug-resistant Pseudomonas aeruginosa, drug-resistant non-typhoidal Salmonella, drug-resistant Salmonella Typhimurium, drug-resistant Shigella, methicillin-resistant Staphylococcus aureus, drug-resistant Streptococcus pneumonia, and drug-resistant tuberculosis.

Concerning threats are bacteria for which the threat of antibiotic resistance is low, and/or there are multiple therapeutic options for resistant infections. These bacterial pathogens cause severe illness.

Threats in this category require monitoring and, in some cases, rapid incident or outbreak response. These include vancomycin-resistant Staphylococcus aureus, erythromycin-resistant Group A Streptococcus, and clindamycin-resistant Group B Streptococcus.

Research has shown patients with resistant infections have significantly longer hospital stays, delayed recuperation, long-term disability, and higher mortality. As resistance to current antibiotics occurs, providers are forced to use antibiotics that are more toxic, more expensive, and less effective.

The CDC recommends four core actions to fight antibiotic resistance:

• Preventing infections from occurring and preventing resistant bacteria from spreading (immunization, infection control, screening, treatment, and education);
• Tracking resistant bacteria;
• Improving the use of antibiotics (antibiotic stewardship); and
• Promoting the development of new antibiotics and new diagnostic tests for resistant bacteria.

Bottom line: Antibiotics are a limited resource. The more antibiotics are used today, the less likely they will continue to be effective in the future. The CDC lists 18 antibiotic-resistant organisms as urgent, serious, or concerning and recommends actions to combat the spread of current organisms and emergence of new antibiotic organisms.

Citation: Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. CDC website. September 16, 2013. Available at: www.cdc.gov/drugresistance/threat-report-2013. Accessed Nov. 30, 2013.

Clinical question: What antibiotic-resistant bacteria are the greatest threats for the next 10 years?

Background: Two million people suffer antibiotic-resistant infections yearly, and 23,000 die each year as a result. Most of these infections occur in the community, but deaths usually occur in healthcare settings. Cost estimates vary but may be as high as $20 billion in excess direct healthcare costs.

Study design: The CDC used several different surveys and databanks, including the National Antimicrobial Resistance Monitoring System, to collect data. The threat level for antibiotic-resistant bacteria was determined using several factors: clinical impact, economic impact, incidence, 10-year projection of incidence, transmissibility, availability of effective antibiotics, and barriers to prevention.

Setting: United States.

Synopsis: The CDC has three classifications of antibiotic-resistant bacteria: urgent, serious, and concerning. Urgent threats are high-consequence, antibiotic-resistant threats because of significant risks identified across several criteria. These threats might not currently be widespread but have the potential to become so and require urgent public health attention to identify infections and to limit transmission. They include carbapenem-resistant Enterobacteriaceae, drug-resistant Neisseria gonorrhoeae, and Clostridium difficile (does not have true resistance, but is a consequence of antibiotic overuse).

Serious threats are significant antibiotic-resistant threats. These threats will worsen, and might become urgent without ongoing public health monitoring and prevention activities. They include multidrug-resistant Acinetobacter, drug-resistant Campylobacter, fluconazole-resistant Candida (a fungus), extended-spectrum ß-lactamase-producing Enterobacteriaceae, vancomycin-resistant Enterococcus, multidrug-resistant Pseudomonas aeruginosa, drug-resistant non-typhoidal Salmonella, drug-resistant Salmonella Typhimurium, drug-resistant Shigella, methicillin-resistant Staphylococcus aureus, drug-resistant Streptococcus pneumonia, and drug-resistant tuberculosis.

Concerning threats are bacteria for which the threat of antibiotic resistance is low, and/or there are multiple therapeutic options for resistant infections. These bacterial pathogens cause severe illness.

Threats in this category require monitoring and, in some cases, rapid incident or outbreak response. These include vancomycin-resistant Staphylococcus aureus, erythromycin-resistant Group A Streptococcus, and clindamycin-resistant Group B Streptococcus.

Research has shown patients with resistant infections have significantly longer hospital stays, delayed recuperation, long-term disability, and higher mortality. As resistance to current antibiotics occurs, providers are forced to use antibiotics that are more toxic, more expensive, and less effective.

The CDC recommends four core actions to fight antibiotic resistance:

• Preventing infections from occurring and preventing resistant bacteria from spreading (immunization, infection control, screening, treatment, and education);
• Tracking resistant bacteria;
• Improving the use of antibiotics (antibiotic stewardship); and
• Promoting the development of new antibiotics and new diagnostic tests for resistant bacteria.

Bottom line: Antibiotics are a limited resource. The more antibiotics are used today, the less likely they will continue to be effective in the future. The CDC lists 18 antibiotic-resistant organisms as urgent, serious, or concerning and recommends actions to combat the spread of current organisms and emergence of new antibiotic organisms.

Citation: Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. CDC website. September 16, 2013. Available at: www.cdc.gov/drugresistance/threat-report-2013. Accessed Nov. 30, 2013.

A care model in which physicians and nurses do bedside rounds as a team can reduce average length of stay (LOS) and in-hospital mortality, according to a recent Harvard Business Review blog post written by a group healthcare providers from Emory Healthcare in Atlanta.

In September 2010, members of a quality-improvement program at Emory University Hospital in Atlanta reorganized a 24-bed medical unit where six hospital medicine teams had seen patients into an Accountable Care Unit (ACU). They designed the ACU to have four key features: unit-based physician teams; structured interdisciplinary bedside rounds [PDF]; unit-level performance reports; and unit co-management by nurse and physician directors.

Physicians were assigned to units so more than 90% of their patients could be located on the same floor, which allows scheduling of a permanent daily start time for bedside rounds. This consistent schedule allows the entire health care team to round together. It also makes it easier for family members to know when rounds are happening so they can ask questions and learn about the care plan.

"Rather than having six different hospital medicine teams rounding on eight different units every day, we thought it would make more sense to have those teams round on a single unit each day where all their patients were cohorted together," says hospitalist Jason Stein, MD, SFHM, and lead author of the HBR blog post. Dr. Stein is director for quality in the division of hospital medicine at the Emory University School of Medicine and an innovation advisor to the Center for Medicare and Medicaid Innovation, a unit within the Centers for Medicare and Medicaid Services.

According to the blog post, in the first year that the ACU model was implemented, the average LOS for hospitalized patients decreased from 5 days to 4.5 days and in-hospital mortality declined from 2.3 deaths per 100 encounters to 1.1 deaths per 100 encounters. The ACU model was recognized as the top innovation the 2012 SHM Annual Meeting.

Dr. Stein and fellow blog authors noted two challenges in the ACU model—namely, that creating unit teams required assigning attending physicians to a home unit, and that the structure led physicians and staff to follow a patient- and family-based approach to care-planning activities. Dr. Stein says the group behind the creation of the ACU model is in the process of submitting its data for publication.

Visit our website for more information about improving inpatient care coordination.

A care model in which physicians and nurses do bedside rounds as a team can reduce average length of stay (LOS) and in-hospital mortality, according to a recent Harvard Business Review blog post written by a group healthcare providers from Emory Healthcare in Atlanta.

In September 2010, members of a quality-improvement program at Emory University Hospital in Atlanta reorganized a 24-bed medical unit where six hospital medicine teams had seen patients into an Accountable Care Unit (ACU). They designed the ACU to have four key features: unit-based physician teams; structured interdisciplinary bedside rounds [PDF]; unit-level performance reports; and unit co-management by nurse and physician directors.

Physicians were assigned to units so more than 90% of their patients could be located on the same floor, which allows scheduling of a permanent daily start time for bedside rounds. This consistent schedule allows the entire health care team to round together. It also makes it easier for family members to know when rounds are happening so they can ask questions and learn about the care plan.

"Rather than having six different hospital medicine teams rounding on eight different units every day, we thought it would make more sense to have those teams round on a single unit each day where all their patients were cohorted together," says hospitalist Jason Stein, MD, SFHM, and lead author of the HBR blog post. Dr. Stein is director for quality in the division of hospital medicine at the Emory University School of Medicine and an innovation advisor to the Center for Medicare and Medicaid Innovation, a unit within the Centers for Medicare and Medicaid Services.

According to the blog post, in the first year that the ACU model was implemented, the average LOS for hospitalized patients decreased from 5 days to 4.5 days and in-hospital mortality declined from 2.3 deaths per 100 encounters to 1.1 deaths per 100 encounters. The ACU model was recognized as the top innovation the 2012 SHM Annual Meeting.

Dr. Stein and fellow blog authors noted two challenges in the ACU model—namely, that creating unit teams required assigning attending physicians to a home unit, and that the structure led physicians and staff to follow a patient- and family-based approach to care-planning activities. Dr. Stein says the group behind the creation of the ACU model is in the process of submitting its data for publication.

Visit our website for more information about improving inpatient care coordination.

A care model in which physicians and nurses do bedside rounds as a team can reduce average length of stay (LOS) and in-hospital mortality, according to a recent Harvard Business Review blog post written by a group healthcare providers from Emory Healthcare in Atlanta.

In September 2010, members of a quality-improvement program at Emory University Hospital in Atlanta reorganized a 24-bed medical unit where six hospital medicine teams had seen patients into an Accountable Care Unit (ACU). They designed the ACU to have four key features: unit-based physician teams; structured interdisciplinary bedside rounds [PDF]; unit-level performance reports; and unit co-management by nurse and physician directors.

Physicians were assigned to units so more than 90% of their patients could be located on the same floor, which allows scheduling of a permanent daily start time for bedside rounds. This consistent schedule allows the entire health care team to round together. It also makes it easier for family members to know when rounds are happening so they can ask questions and learn about the care plan.

"Rather than having six different hospital medicine teams rounding on eight different units every day, we thought it would make more sense to have those teams round on a single unit each day where all their patients were cohorted together," says hospitalist Jason Stein, MD, SFHM, and lead author of the HBR blog post. Dr. Stein is director for quality in the division of hospital medicine at the Emory University School of Medicine and an innovation advisor to the Center for Medicare and Medicaid Innovation, a unit within the Centers for Medicare and Medicaid Services.

According to the blog post, in the first year that the ACU model was implemented, the average LOS for hospitalized patients decreased from 5 days to 4.5 days and in-hospital mortality declined from 2.3 deaths per 100 encounters to 1.1 deaths per 100 encounters. The ACU model was recognized as the top innovation the 2012 SHM Annual Meeting.

Dr. Stein and fellow blog authors noted two challenges in the ACU model—namely, that creating unit teams required assigning attending physicians to a home unit, and that the structure led physicians and staff to follow a patient- and family-based approach to care-planning activities. Dr. Stein says the group behind the creation of the ACU model is in the process of submitting its data for publication.

Visit our website for more information about improving inpatient care coordination.

The addition of bevacizumab to standard treatment did not improve survival in patients with newly diagnosed glioblastoma, and in some cases, worsened quality of life and led to cognitive decline.

Bevacizumab (Avastin) added to frontline radiation and temozolomide therapy extended progression-free survival, but did not improve overall survival in the Radiation Therapy Oncology Group (RTOG) 0825 study, a double-blind, placebo-controlled phase III trial, Dr. Mark R. Gilbert of the University of Texas M.D. Anderson Cancer Center, Houston, and his associates reported Feb. 19 in the New England Journal of Medicine.

Among 637 patients with centrally confirmed glioblastoma who were randomized, median overall survival reached 16.1 months in those assigned to radiation, temozolomide, and placebo, compared with 15.7 months in patients assigned to radiation, temozolomide, and bevacizumab. (N. Engl. J. Med. 2014; 370:699-708.)

Median overall survival data were virtually identical in a second similarly designed study, also reported Feb. 19 in the New England Journal of Medicine.

Median survival in Avaglio, which ran parallel to RTOG 0825, was 16.8 months in 458 patients in its radiation, temozolomide, and bevacizumab arm, vs. 16.7 months in 463 patients in its radiation, temozolomide, and placebo arm, Dr. Olivier L. Chinot of Aix-Marseille University, Marseille, France, and his associates reported (N. Engl. J. Med. 2014; 370:709-22).

Median progression-free survival in Avaglio reached 10.6 months in the bevacizumab arm vs. 6.2 months in the placebo arm, and the difference was significant (hazard ratio, 0.64; P less than .0001).

The Avaglio trial showed a benefit or maintenance of quality of life measures, but did not look at neurocognitive outcomes. More patients in the bevacizumab group than in the placebo group had grade 3 or higher adverse events (66.8% vs. 51.3%) and grade 3 or higher adverse events often associated with bevacizumab (32.5% vs. 15.8%), reported Dr. Chinot and his associates.

Both studies were presented last year at the annual meeting of the American Society of Clinical Oncology.

The RTOG 0285 study was supported by the National Cancer Institute, with additional support from Genentech. Avaglio was supported by Roche. Dr. Gilbert disclosed consulting for, and receiving honoraria and research support from, Genentech. Dr. Chinot disclosed receiving financial and nonfinancial support from Roche.

[email protected]

On Twitter @NikolaidesLaura

The addition of bevacizumab to standard treatment did not improve survival in patients with newly diagnosed glioblastoma, and in some cases, worsened quality of life and led to cognitive decline.

Bevacizumab (Avastin) added to frontline radiation and temozolomide therapy extended progression-free survival, but did not improve overall survival in the Radiation Therapy Oncology Group (RTOG) 0825 study, a double-blind, placebo-controlled phase III trial, Dr. Mark R. Gilbert of the University of Texas M.D. Anderson Cancer Center, Houston, and his associates reported Feb. 19 in the New England Journal of Medicine.

Among 637 patients with centrally confirmed glioblastoma who were randomized, median overall survival reached 16.1 months in those assigned to radiation, temozolomide, and placebo, compared with 15.7 months in patients assigned to radiation, temozolomide, and bevacizumab. (N. Engl. J. Med. 2014; 370:699-708.)

Median overall survival data were virtually identical in a second similarly designed study, also reported Feb. 19 in the New England Journal of Medicine.

Median survival in Avaglio, which ran parallel to RTOG 0825, was 16.8 months in 458 patients in its radiation, temozolomide, and bevacizumab arm, vs. 16.7 months in 463 patients in its radiation, temozolomide, and placebo arm, Dr. Olivier L. Chinot of Aix-Marseille University, Marseille, France, and his associates reported (N. Engl. J. Med. 2014; 370:709-22).

Median progression-free survival in Avaglio reached 10.6 months in the bevacizumab arm vs. 6.2 months in the placebo arm, and the difference was significant (hazard ratio, 0.64; P less than .0001).

The Avaglio trial showed a benefit or maintenance of quality of life measures, but did not look at neurocognitive outcomes. More patients in the bevacizumab group than in the placebo group had grade 3 or higher adverse events (66.8% vs. 51.3%) and grade 3 or higher adverse events often associated with bevacizumab (32.5% vs. 15.8%), reported Dr. Chinot and his associates.

Both studies were presented last year at the annual meeting of the American Society of Clinical Oncology.

The RTOG 0285 study was supported by the National Cancer Institute, with additional support from Genentech. Avaglio was supported by Roche. Dr. Gilbert disclosed consulting for, and receiving honoraria and research support from, Genentech. Dr. Chinot disclosed receiving financial and nonfinancial support from Roche.

[email protected]

On Twitter @NikolaidesLaura

The addition of bevacizumab to standard treatment did not improve survival in patients with newly diagnosed glioblastoma, and in some cases, worsened quality of life and led to cognitive decline.

Bevacizumab (Avastin) added to frontline radiation and temozolomide therapy extended progression-free survival, but did not improve overall survival in the Radiation Therapy Oncology Group (RTOG) 0825 study, a double-blind, placebo-controlled phase III trial, Dr. Mark R. Gilbert of the University of Texas M.D. Anderson Cancer Center, Houston, and his associates reported Feb. 19 in the New England Journal of Medicine.

Among 637 patients with centrally confirmed glioblastoma who were randomized, median overall survival reached 16.1 months in those assigned to radiation, temozolomide, and placebo, compared with 15.7 months in patients assigned to radiation, temozolomide, and bevacizumab. (N. Engl. J. Med. 2014; 370:699-708.)

Median overall survival data were virtually identical in a second similarly designed study, also reported Feb. 19 in the New England Journal of Medicine.

Median survival in Avaglio, which ran parallel to RTOG 0825, was 16.8 months in 458 patients in its radiation, temozolomide, and bevacizumab arm, vs. 16.7 months in 463 patients in its radiation, temozolomide, and placebo arm, Dr. Olivier L. Chinot of Aix-Marseille University, Marseille, France, and his associates reported (N. Engl. J. Med. 2014; 370:709-22).

Median progression-free survival in Avaglio reached 10.6 months in the bevacizumab arm vs. 6.2 months in the placebo arm, and the difference was significant (hazard ratio, 0.64; P less than .0001).

The Avaglio trial showed a benefit or maintenance of quality of life measures, but did not look at neurocognitive outcomes. More patients in the bevacizumab group than in the placebo group had grade 3 or higher adverse events (66.8% vs. 51.3%) and grade 3 or higher adverse events often associated with bevacizumab (32.5% vs. 15.8%), reported Dr. Chinot and his associates.

Both studies were presented last year at the annual meeting of the American Society of Clinical Oncology.

The RTOG 0285 study was supported by the National Cancer Institute, with additional support from Genentech. Avaglio was supported by Roche. Dr. Gilbert disclosed consulting for, and receiving honoraria and research support from, Genentech. Dr. Chinot disclosed receiving financial and nonfinancial support from Roche.

[email protected]

On Twitter @NikolaidesLaura

Female pattern hair loss, which affects over 21 million women in the United States, is a nonscarring hair loss primarily involving the frontal and vertex scalp. FPHS causes women significant emotional and psychological distress. We see, and will continue to see, a lot of these cases in primary care. If left untreated or unaddressed, FPHL results in a slow, progressive decline in the density of scalp hair.

FPHL is characterized by the production of shorter and finer hairs and shortening of the growth phase of hair follicles. One may find it important to rule out secondary causes of hair loss, such as hyperandrogenism. So after excluding secondary causes, what are the best treatment options for treatment?

Researchers conducted a systematic review (Cochrane Database Syst. Rev. 2012 May, CD007628 [doi:10.1002/14651858.CD007628.pub3]) assessing the effectiveness of interventions for female pattern hair loss. Studies were included if they compared any type of monotherapy or combination therapy to treat FPHL. Studies evaluating treatments in women with increased circulating androgens (such as polycystic ovarian syndrome) were included. Primary outcomes included self-reported hair regrowth, quality of life, and adverse effects.

The Cochrane review included 22 studies that enrolled a total of 2,349 subjects. Ten studies evaluated minoxidil, four evaluated finasteride, two cyproterone acetate, and two flutamide. A variety of other exotic interventions was evaluated, including topical melatonin-alcohol solution, adenosine lotion, and pulsed electrostatic field.

The best data continue to exist for minoxidil. "Pooled data from 4 studies indicated that a greater proportion of participants (121/488) treated with minoxidil reported a moderate increase in their hair regrowth when compared with placebo (64/476) (risk ratio, 1.86; 95% confidence interval [CI], 1.42 to 2.43). In 7 studies, there was an important increase of 13.28 in total hair count per cm² in the minoxidil group compared to the placebo group (95% CI, 10.89 to 15.68). There was no difference in the number of adverse events in the twice daily minoxidil and placebo intervention groups, with the exception of a reported increase of adverse events (additional hair growth on areas other than the scalp) with minoxidil (5%) twice daily," according to the Cochrane report.

Other promising agents might be octyl nicotinate (0.5%), myristyl nicotinate (5%), and flutamide. Fulvestrant, adenosine, pulsed electrostatic field, and estradiol valerate are ineffective.

Minoxidil it is. It may be important to remind patients that 2% twice daily may be as effective and safe as 5% once a day.

Dr. Ebbert is professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

Female pattern hair loss, which affects over 21 million women in the United States, is a nonscarring hair loss primarily involving the frontal and vertex scalp. FPHS causes women significant emotional and psychological distress. We see, and will continue to see, a lot of these cases in primary care. If left untreated or unaddressed, FPHL results in a slow, progressive decline in the density of scalp hair.

FPHL is characterized by the production of shorter and finer hairs and shortening of the growth phase of hair follicles. One may find it important to rule out secondary causes of hair loss, such as hyperandrogenism. So after excluding secondary causes, what are the best treatment options for treatment?

Researchers conducted a systematic review (Cochrane Database Syst. Rev. 2012 May, CD007628 [doi:10.1002/14651858.CD007628.pub3]) assessing the effectiveness of interventions for female pattern hair loss. Studies were included if they compared any type of monotherapy or combination therapy to treat FPHL. Studies evaluating treatments in women with increased circulating androgens (such as polycystic ovarian syndrome) were included. Primary outcomes included self-reported hair regrowth, quality of life, and adverse effects.

The Cochrane review included 22 studies that enrolled a total of 2,349 subjects. Ten studies evaluated minoxidil, four evaluated finasteride, two cyproterone acetate, and two flutamide. A variety of other exotic interventions was evaluated, including topical melatonin-alcohol solution, adenosine lotion, and pulsed electrostatic field.

The best data continue to exist for minoxidil. "Pooled data from 4 studies indicated that a greater proportion of participants (121/488) treated with minoxidil reported a moderate increase in their hair regrowth when compared with placebo (64/476) (risk ratio, 1.86; 95% confidence interval [CI], 1.42 to 2.43). In 7 studies, there was an important increase of 13.28 in total hair count per cm² in the minoxidil group compared to the placebo group (95% CI, 10.89 to 15.68). There was no difference in the number of adverse events in the twice daily minoxidil and placebo intervention groups, with the exception of a reported increase of adverse events (additional hair growth on areas other than the scalp) with minoxidil (5%) twice daily," according to the Cochrane report.

Other promising agents might be octyl nicotinate (0.5%), myristyl nicotinate (5%), and flutamide. Fulvestrant, adenosine, pulsed electrostatic field, and estradiol valerate are ineffective.

Minoxidil it is. It may be important to remind patients that 2% twice daily may be as effective and safe as 5% once a day.

Dr. Ebbert is professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

Female pattern hair loss, which affects over 21 million women in the United States, is a nonscarring hair loss primarily involving the frontal and vertex scalp. FPHS causes women significant emotional and psychological distress. We see, and will continue to see, a lot of these cases in primary care. If left untreated or unaddressed, FPHL results in a slow, progressive decline in the density of scalp hair.

FPHL is characterized by the production of shorter and finer hairs and shortening of the growth phase of hair follicles. One may find it important to rule out secondary causes of hair loss, such as hyperandrogenism. So after excluding secondary causes, what are the best treatment options for treatment?

Researchers conducted a systematic review (Cochrane Database Syst. Rev. 2012 May, CD007628 [doi:10.1002/14651858.CD007628.pub3]) assessing the effectiveness of interventions for female pattern hair loss. Studies were included if they compared any type of monotherapy or combination therapy to treat FPHL. Studies evaluating treatments in women with increased circulating androgens (such as polycystic ovarian syndrome) were included. Primary outcomes included self-reported hair regrowth, quality of life, and adverse effects.

The Cochrane review included 22 studies that enrolled a total of 2,349 subjects. Ten studies evaluated minoxidil, four evaluated finasteride, two cyproterone acetate, and two flutamide. A variety of other exotic interventions was evaluated, including topical melatonin-alcohol solution, adenosine lotion, and pulsed electrostatic field.

The best data continue to exist for minoxidil. "Pooled data from 4 studies indicated that a greater proportion of participants (121/488) treated with minoxidil reported a moderate increase in their hair regrowth when compared with placebo (64/476) (risk ratio, 1.86; 95% confidence interval [CI], 1.42 to 2.43). In 7 studies, there was an important increase of 13.28 in total hair count per cm² in the minoxidil group compared to the placebo group (95% CI, 10.89 to 15.68). There was no difference in the number of adverse events in the twice daily minoxidil and placebo intervention groups, with the exception of a reported increase of adverse events (additional hair growth on areas other than the scalp) with minoxidil (5%) twice daily," according to the Cochrane report.

Other promising agents might be octyl nicotinate (0.5%), myristyl nicotinate (5%), and flutamide. Fulvestrant, adenosine, pulsed electrostatic field, and estradiol valerate are ineffective.

Minoxidil it is. It may be important to remind patients that 2% twice daily may be as effective and safe as 5% once a day.

Dr. Ebbert is professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. He reports no conflicts of interest.

"You should always consider three differential diagnoses for each patient." This was sound advice from my dermatology residency director, but advice I often neglect to take. What about you?

If you are like most of us, then your brain in clinic is on autopilot. It instantly selects the diagnosis and moves on. But when pushed by a confusing rash or a disease unresponsive to our standard treatment, we quickly encounter the limits of the human brain.

When stumped, we all do the same thing: Recruit more eyeballs (and brains). We find a colleague nearby and pull him into the room. "So, what do you think this is? What would you do?" Although often helpful, this method is inefficient and fails to capitalize on the most important of all medical tools: the computer.

Unlike our brains, computers in the form of clinical decision support (CDS) tools, are not prone to cognitive errors. Good CDS tools aren’t subject to top-of-mind biases. Their ability to generate differential diagnoses exceeds even the masters among us. Fortunately, there is such a CDS for skin disease: VisualDx.

VisualDx is a CDS tool focused on dermatologic conditions. It covers common and rare skin conditions and has more than 25,000 professional images.

What’s unique here is that VisualDx is more than a database of images. "It is truly a diagnostic decision support tool that allows you to search by multiple factors at once – symptoms, diagnoses, medications, medical history, travel, skin color, etc.," said Dr. Noah Craft, practicing dermatologist and chief medical officer of VisualDx.

In contrast to textbooks and other medical knowledge databases, this system is designed for easy, point-of-care use – it makes a dermatologist’s or even a primary care physician’s work easier. By quickly reviewing photos and diagnostic pearls, our brains are supercharged with deep differentials and management ideas.

For example, I recently had a patient who presented with papulosquamous eruptions that involved his body and hands. Among other diagnoses was secondary syphilis. Yes, I had thought of that, but a quick scan through VisualDx prompted me to ask about other symptoms, including vision changes (which he had). The patient also had HIV. Quick, which test is the best for me to order? Too slow, it’s already there in front of me on my screen.

In addition to improving quality, tools such as these also can improve access. Studies from the company show that the average user saves between 15 and 26 minutes per day using their product. For the working dermatologist, that means being able to see two additional patients a day.

VisualDx also educates and empowers patients. Don’t believe those bumps you have are molluscum? You can see here that these photos look exactly like the bumps you have. Rather than explain conditions through difficult doctor-speak, physicians can show complex knowledge to patients visually. As Dr. Craft notes and many of us have experienced: "For many patients, seeing is believing."

Whether it’s corroborating a diagnosis or exploring treatment options, having the doctor and patient share the same screen is an effective way to increase comprehension and build trust. No matter how good our drawings on the back of a prescription pad may be, they are not as accurate or helpful as curated digital photos. Our screen-savvy patients will soon expect this type of technology with every visit.

Good digital medicine tools also will help remedy one of medicine’s oldest and most glaring defects: We don’t account for the fact that the vast majority of health care happens in between doctor visits. Now patient education doesn’t stop at the culmination of the visit. Physicians can either print or e-mail images and information to patients so that they can have an accurate record at home to share with family members and caregivers.

VisualDx is a leading technology in what will be the future of medicine: Digital tools that serve doctors with everything they need to diagnose and treat patients with a click or flick of the screen. Having ten thousand treatment options instantly in your pocket – try that with any lab coat reference book.

Oftentimes, technology is more sparkle than substance. Not so with VisualDx. Have you used it in your practice? Let us know what you think about it.

For more information and to learn how to subscribe, visit www.visualdx.com. VisualDx is a paid subscription service.

Dr. Benabio is a practicing dermatologist and physician director of health care transformation at Kaiser Permanente in San Diego. Dr. Benabio said he has no financial interest in VisualDx, but he has had complimentary access. Connect with him on Twitter @Dermdoc or drop him a line at [email protected].

"You should always consider three differential diagnoses for each patient." This was sound advice from my dermatology residency director, but advice I often neglect to take. What about you?

If you are like most of us, then your brain in clinic is on autopilot. It instantly selects the diagnosis and moves on. But when pushed by a confusing rash or a disease unresponsive to our standard treatment, we quickly encounter the limits of the human brain.

When stumped, we all do the same thing: Recruit more eyeballs (and brains). We find a colleague nearby and pull him into the room. "So, what do you think this is? What would you do?" Although often helpful, this method is inefficient and fails to capitalize on the most important of all medical tools: the computer.

Unlike our brains, computers in the form of clinical decision support (CDS) tools, are not prone to cognitive errors. Good CDS tools aren’t subject to top-of-mind biases. Their ability to generate differential diagnoses exceeds even the masters among us. Fortunately, there is such a CDS for skin disease: VisualDx.

VisualDx is a CDS tool focused on dermatologic conditions. It covers common and rare skin conditions and has more than 25,000 professional images.

What’s unique here is that VisualDx is more than a database of images. "It is truly a diagnostic decision support tool that allows you to search by multiple factors at once – symptoms, diagnoses, medications, medical history, travel, skin color, etc.," said Dr. Noah Craft, practicing dermatologist and chief medical officer of VisualDx.

In contrast to textbooks and other medical knowledge databases, this system is designed for easy, point-of-care use – it makes a dermatologist’s or even a primary care physician’s work easier. By quickly reviewing photos and diagnostic pearls, our brains are supercharged with deep differentials and management ideas.

For example, I recently had a patient who presented with papulosquamous eruptions that involved his body and hands. Among other diagnoses was secondary syphilis. Yes, I had thought of that, but a quick scan through VisualDx prompted me to ask about other symptoms, including vision changes (which he had). The patient also had HIV. Quick, which test is the best for me to order? Too slow, it’s already there in front of me on my screen.

In addition to improving quality, tools such as these also can improve access. Studies from the company show that the average user saves between 15 and 26 minutes per day using their product. For the working dermatologist, that means being able to see two additional patients a day.

VisualDx also educates and empowers patients. Don’t believe those bumps you have are molluscum? You can see here that these photos look exactly like the bumps you have. Rather than explain conditions through difficult doctor-speak, physicians can show complex knowledge to patients visually. As Dr. Craft notes and many of us have experienced: "For many patients, seeing is believing."

Whether it’s corroborating a diagnosis or exploring treatment options, having the doctor and patient share the same screen is an effective way to increase comprehension and build trust. No matter how good our drawings on the back of a prescription pad may be, they are not as accurate or helpful as curated digital photos. Our screen-savvy patients will soon expect this type of technology with every visit.

Good digital medicine tools also will help remedy one of medicine’s oldest and most glaring defects: We don’t account for the fact that the vast majority of health care happens in between doctor visits. Now patient education doesn’t stop at the culmination of the visit. Physicians can either print or e-mail images and information to patients so that they can have an accurate record at home to share with family members and caregivers.

VisualDx is a leading technology in what will be the future of medicine: Digital tools that serve doctors with everything they need to diagnose and treat patients with a click or flick of the screen. Having ten thousand treatment options instantly in your pocket – try that with any lab coat reference book.

Oftentimes, technology is more sparkle than substance. Not so with VisualDx. Have you used it in your practice? Let us know what you think about it.

For more information and to learn how to subscribe, visit www.visualdx.com. VisualDx is a paid subscription service.

Dr. Benabio is a practicing dermatologist and physician director of health care transformation at Kaiser Permanente in San Diego. Dr. Benabio said he has no financial interest in VisualDx, but he has had complimentary access. Connect with him on Twitter @Dermdoc or drop him a line at [email protected].

"You should always consider three differential diagnoses for each patient." This was sound advice from my dermatology residency director, but advice I often neglect to take. What about you?

If you are like most of us, then your brain in clinic is on autopilot. It instantly selects the diagnosis and moves on. But when pushed by a confusing rash or a disease unresponsive to our standard treatment, we quickly encounter the limits of the human brain.

When stumped, we all do the same thing: Recruit more eyeballs (and brains). We find a colleague nearby and pull him into the room. "So, what do you think this is? What would you do?" Although often helpful, this method is inefficient and fails to capitalize on the most important of all medical tools: the computer.

Unlike our brains, computers in the form of clinical decision support (CDS) tools, are not prone to cognitive errors. Good CDS tools aren’t subject to top-of-mind biases. Their ability to generate differential diagnoses exceeds even the masters among us. Fortunately, there is such a CDS for skin disease: VisualDx.

VisualDx is a CDS tool focused on dermatologic conditions. It covers common and rare skin conditions and has more than 25,000 professional images.

What’s unique here is that VisualDx is more than a database of images. "It is truly a diagnostic decision support tool that allows you to search by multiple factors at once – symptoms, diagnoses, medications, medical history, travel, skin color, etc.," said Dr. Noah Craft, practicing dermatologist and chief medical officer of VisualDx.

In contrast to textbooks and other medical knowledge databases, this system is designed for easy, point-of-care use – it makes a dermatologist’s or even a primary care physician’s work easier. By quickly reviewing photos and diagnostic pearls, our brains are supercharged with deep differentials and management ideas.

For example, I recently had a patient who presented with papulosquamous eruptions that involved his body and hands. Among other diagnoses was secondary syphilis. Yes, I had thought of that, but a quick scan through VisualDx prompted me to ask about other symptoms, including vision changes (which he had). The patient also had HIV. Quick, which test is the best for me to order? Too slow, it’s already there in front of me on my screen.

In addition to improving quality, tools such as these also can improve access. Studies from the company show that the average user saves between 15 and 26 minutes per day using their product. For the working dermatologist, that means being able to see two additional patients a day.

VisualDx also educates and empowers patients. Don’t believe those bumps you have are molluscum? You can see here that these photos look exactly like the bumps you have. Rather than explain conditions through difficult doctor-speak, physicians can show complex knowledge to patients visually. As Dr. Craft notes and many of us have experienced: "For many patients, seeing is believing."

Whether it’s corroborating a diagnosis or exploring treatment options, having the doctor and patient share the same screen is an effective way to increase comprehension and build trust. No matter how good our drawings on the back of a prescription pad may be, they are not as accurate or helpful as curated digital photos. Our screen-savvy patients will soon expect this type of technology with every visit.

Good digital medicine tools also will help remedy one of medicine’s oldest and most glaring defects: We don’t account for the fact that the vast majority of health care happens in between doctor visits. Now patient education doesn’t stop at the culmination of the visit. Physicians can either print or e-mail images and information to patients so that they can have an accurate record at home to share with family members and caregivers.

VisualDx is a leading technology in what will be the future of medicine: Digital tools that serve doctors with everything they need to diagnose and treat patients with a click or flick of the screen. Having ten thousand treatment options instantly in your pocket – try that with any lab coat reference book.

Oftentimes, technology is more sparkle than substance. Not so with VisualDx. Have you used it in your practice? Let us know what you think about it.

For more information and to learn how to subscribe, visit www.visualdx.com. VisualDx is a paid subscription service.

Dr. Benabio is a practicing dermatologist and physician director of health care transformation at Kaiser Permanente in San Diego. Dr. Benabio said he has no financial interest in VisualDx, but he has had complimentary access. Connect with him on Twitter @Dermdoc or drop him a line at [email protected].