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Focus on patient experience to cut readmission rates
Incorporate patient-reported quality measures
Hospitalists have focused much attention on reducing 30-day readmission rates, at a time when 15-20% of health care dollars spent on those readmissions is considered potentially preventable.
But until very recently, no study has explored patient perceptions of the likelihood of readmission during index admission. Now, that’s changed.
“Our objective was to examine associations between patient perceptions of care during index hospital admission and 30-day readmission,” says Jocelyn Carter, MD, of Massachusetts General Hospital, Boston, and lead author of November 2017 study in BMJ Quality & Safety.
Enrolled in the study were 846 patients at two inpatient adult medicine units at Massachusetts General, Boston; 201 (23.8%) of these patients were readmitted within 30 days. In multivariable models adjusting for baseline differences, respondents who reported being “very satisfied” with the care received during the index hospitalization were less likely to be readmitted; participants reporting that doctors “always listened to them carefully” also were less likely to be readmitted.
“These findings are important since they suggest that engaging patients in an assessment of communication quality, unmet needs, concerns, and overall experience during admission may help to identify issues that might not be captured in standard postdischarge surveys when the appropriate time for quality improvement interventions has passed,” Dr. Carter said. “Incorporating patient-reported measures during index hospitalizations may improve readmission rates and help predict which patients are more likely to be readmitted.”
Reference
Carter J et al. The association between patient experience factors and likelihood of 30-day readmission: A prospective cohort study. BMJ Qual Saf. 16 Nov 2017. Accessed Feb 2, 2018.
Incorporate patient-reported quality measures
Incorporate patient-reported quality measures
Hospitalists have focused much attention on reducing 30-day readmission rates, at a time when 15-20% of health care dollars spent on those readmissions is considered potentially preventable.
But until very recently, no study has explored patient perceptions of the likelihood of readmission during index admission. Now, that’s changed.
“Our objective was to examine associations between patient perceptions of care during index hospital admission and 30-day readmission,” says Jocelyn Carter, MD, of Massachusetts General Hospital, Boston, and lead author of November 2017 study in BMJ Quality & Safety.
Enrolled in the study were 846 patients at two inpatient adult medicine units at Massachusetts General, Boston; 201 (23.8%) of these patients were readmitted within 30 days. In multivariable models adjusting for baseline differences, respondents who reported being “very satisfied” with the care received during the index hospitalization were less likely to be readmitted; participants reporting that doctors “always listened to them carefully” also were less likely to be readmitted.
“These findings are important since they suggest that engaging patients in an assessment of communication quality, unmet needs, concerns, and overall experience during admission may help to identify issues that might not be captured in standard postdischarge surveys when the appropriate time for quality improvement interventions has passed,” Dr. Carter said. “Incorporating patient-reported measures during index hospitalizations may improve readmission rates and help predict which patients are more likely to be readmitted.”
Reference
Carter J et al. The association between patient experience factors and likelihood of 30-day readmission: A prospective cohort study. BMJ Qual Saf. 16 Nov 2017. Accessed Feb 2, 2018.
Hospitalists have focused much attention on reducing 30-day readmission rates, at a time when 15-20% of health care dollars spent on those readmissions is considered potentially preventable.
But until very recently, no study has explored patient perceptions of the likelihood of readmission during index admission. Now, that’s changed.
“Our objective was to examine associations between patient perceptions of care during index hospital admission and 30-day readmission,” says Jocelyn Carter, MD, of Massachusetts General Hospital, Boston, and lead author of November 2017 study in BMJ Quality & Safety.
Enrolled in the study were 846 patients at two inpatient adult medicine units at Massachusetts General, Boston; 201 (23.8%) of these patients were readmitted within 30 days. In multivariable models adjusting for baseline differences, respondents who reported being “very satisfied” with the care received during the index hospitalization were less likely to be readmitted; participants reporting that doctors “always listened to them carefully” also were less likely to be readmitted.
“These findings are important since they suggest that engaging patients in an assessment of communication quality, unmet needs, concerns, and overall experience during admission may help to identify issues that might not be captured in standard postdischarge surveys when the appropriate time for quality improvement interventions has passed,” Dr. Carter said. “Incorporating patient-reported measures during index hospitalizations may improve readmission rates and help predict which patients are more likely to be readmitted.”
Reference
Carter J et al. The association between patient experience factors and likelihood of 30-day readmission: A prospective cohort study. BMJ Qual Saf. 16 Nov 2017. Accessed Feb 2, 2018.
Pediatric indications appear in one-third of orphan drug approvals
WASHINGTON – Pediatric indications appeared in approximately 36% of orphan drug approvals between 2000 and 2017, according to data from the Food and Drug Administration.
“Given the impact of rare disease on children, it is of particular interest to better understand where new drug approvals and advances are occurring, through the lens of pediatrics,” said Kathleen L. Miller, Ph.D., and Michael Lanthier of the Food and Drug Administration in Silver Spring, Md. They presented their findings in a poster at the NORD Rare Summit, held by the National Organization for Rare Disorders.
Overall, 31% of 314 orphan drug approvals by the FDA between 2000 and 2017 had a pediatric and adult indication, 5% had pediatric-only indications, and 64% had adult-only indications.
For the 112 pediatric indication approvals, 14% were for inherited blood disorders, 14% for inherited metabolic disorders, 13% for rare cancers, 10% for antidotes and medical countermeasures, 9% for infectious diseases, 8% for auto-inflammatory diseases, 7% for neurologic disorders, and 25% for other conditions.
Approximately 63% of the total orphan drug approvals during the study period were for rare cancers or genetic disorders (138 approvals and 59 approvals, respectively). Although 90% of the rare cancer approvals were for adults only, 84% of genetic disorder drug approvals had pediatric indications, Dr. Miller and Mr. Lanthier noted.
When analyzed by submission type, pediatric indications were included in 52% of new orphan formulations, 35% of orphan secondary indication approvals, and 32% of new molecular entity approvals.
Although more research is needed, the results suggest that “pediatric indications represent a sizable proportion of orphan drug approvals in both a range of therapeutic areas and in a range of approval types,” the investigators concluded.
The researchers are employed by the FDA, which sponsored the study. They had no financial conflicts to disclose.
WASHINGTON – Pediatric indications appeared in approximately 36% of orphan drug approvals between 2000 and 2017, according to data from the Food and Drug Administration.
“Given the impact of rare disease on children, it is of particular interest to better understand where new drug approvals and advances are occurring, through the lens of pediatrics,” said Kathleen L. Miller, Ph.D., and Michael Lanthier of the Food and Drug Administration in Silver Spring, Md. They presented their findings in a poster at the NORD Rare Summit, held by the National Organization for Rare Disorders.
Overall, 31% of 314 orphan drug approvals by the FDA between 2000 and 2017 had a pediatric and adult indication, 5% had pediatric-only indications, and 64% had adult-only indications.
For the 112 pediatric indication approvals, 14% were for inherited blood disorders, 14% for inherited metabolic disorders, 13% for rare cancers, 10% for antidotes and medical countermeasures, 9% for infectious diseases, 8% for auto-inflammatory diseases, 7% for neurologic disorders, and 25% for other conditions.
Approximately 63% of the total orphan drug approvals during the study period were for rare cancers or genetic disorders (138 approvals and 59 approvals, respectively). Although 90% of the rare cancer approvals were for adults only, 84% of genetic disorder drug approvals had pediatric indications, Dr. Miller and Mr. Lanthier noted.
When analyzed by submission type, pediatric indications were included in 52% of new orphan formulations, 35% of orphan secondary indication approvals, and 32% of new molecular entity approvals.
Although more research is needed, the results suggest that “pediatric indications represent a sizable proportion of orphan drug approvals in both a range of therapeutic areas and in a range of approval types,” the investigators concluded.
The researchers are employed by the FDA, which sponsored the study. They had no financial conflicts to disclose.
WASHINGTON – Pediatric indications appeared in approximately 36% of orphan drug approvals between 2000 and 2017, according to data from the Food and Drug Administration.
“Given the impact of rare disease on children, it is of particular interest to better understand where new drug approvals and advances are occurring, through the lens of pediatrics,” said Kathleen L. Miller, Ph.D., and Michael Lanthier of the Food and Drug Administration in Silver Spring, Md. They presented their findings in a poster at the NORD Rare Summit, held by the National Organization for Rare Disorders.
Overall, 31% of 314 orphan drug approvals by the FDA between 2000 and 2017 had a pediatric and adult indication, 5% had pediatric-only indications, and 64% had adult-only indications.
For the 112 pediatric indication approvals, 14% were for inherited blood disorders, 14% for inherited metabolic disorders, 13% for rare cancers, 10% for antidotes and medical countermeasures, 9% for infectious diseases, 8% for auto-inflammatory diseases, 7% for neurologic disorders, and 25% for other conditions.
Approximately 63% of the total orphan drug approvals during the study period were for rare cancers or genetic disorders (138 approvals and 59 approvals, respectively). Although 90% of the rare cancer approvals were for adults only, 84% of genetic disorder drug approvals had pediatric indications, Dr. Miller and Mr. Lanthier noted.
When analyzed by submission type, pediatric indications were included in 52% of new orphan formulations, 35% of orphan secondary indication approvals, and 32% of new molecular entity approvals.
Although more research is needed, the results suggest that “pediatric indications represent a sizable proportion of orphan drug approvals in both a range of therapeutic areas and in a range of approval types,” the investigators concluded.
The researchers are employed by the FDA, which sponsored the study. They had no financial conflicts to disclose.
REPORTING FROM NORD SUMMIT 2018
Key clinical point:
Major finding: A total of 112 orphan drug approvals between 2000 and 2017 included a pediatric indication.
Study details: The data come from a review of 314 orphan drug approvals by the FDA between 2000 and 2017.
Disclosures: The researchers are employed by the Food and Drug Administration, which sponsored the study. They had no financial conflicts to disclose.
Funding for NIH BRAIN Initiative reaches new heights
The National Institutes of Health’s Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative will finish 2018 with its largest round of grant funding ever, giving $220 million to more than 200 research awards, and bringing this year’s total to more than $400 million, according to an announcement from the agency.
The BRAIN Initiative began in 2013 with the objective of revolutionizing our understanding of the human brain by accelerating the development and application of innovative technologies that will allow researchers to show how individual cells and complex neural circuits interact in both time and space and thereby seek new ways to treat, cure, and prevent brain disorders.
In the current round of funding that was authorized by Congress through the regular appropriations process and the 21st Century Cures Act, new projects include the creation of a wireless optical tomography cap for scanning human brain activity; the development of a noninvasive brain-computer interface system for improving the lives of paralysis patients; and the testing of noninvasive brain stimulation devices for treating schizophrenia, attention deficit disorders, and other brain diseases; the development of self-growing biological electrodes for recording brain activity; and the creation of an indestructible hydrogel system to help map neural circuits, according to the announcement.
Not all of the research involves technological advancement. In fact, one line of funding involves neuroethics. For instance, for epilepsy syndromes in the latest round of funding for 2018, researchers aim to explore ethical issues confronting families and clinicians when considering new treatment options for drug-resistant epilepsy in children.
The NIH is also leveraging some of the BRAIN Initiative funding toward finding new, nonaddictive pain treatments as part of the its HEAL (Helping to End Addiction Long-term) Initiative, such as support for research on the fundamental neurobiology of endogenous opioid systems.
The National Institutes of Health’s Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative will finish 2018 with its largest round of grant funding ever, giving $220 million to more than 200 research awards, and bringing this year’s total to more than $400 million, according to an announcement from the agency.
The BRAIN Initiative began in 2013 with the objective of revolutionizing our understanding of the human brain by accelerating the development and application of innovative technologies that will allow researchers to show how individual cells and complex neural circuits interact in both time and space and thereby seek new ways to treat, cure, and prevent brain disorders.
In the current round of funding that was authorized by Congress through the regular appropriations process and the 21st Century Cures Act, new projects include the creation of a wireless optical tomography cap for scanning human brain activity; the development of a noninvasive brain-computer interface system for improving the lives of paralysis patients; and the testing of noninvasive brain stimulation devices for treating schizophrenia, attention deficit disorders, and other brain diseases; the development of self-growing biological electrodes for recording brain activity; and the creation of an indestructible hydrogel system to help map neural circuits, according to the announcement.
Not all of the research involves technological advancement. In fact, one line of funding involves neuroethics. For instance, for epilepsy syndromes in the latest round of funding for 2018, researchers aim to explore ethical issues confronting families and clinicians when considering new treatment options for drug-resistant epilepsy in children.
The NIH is also leveraging some of the BRAIN Initiative funding toward finding new, nonaddictive pain treatments as part of the its HEAL (Helping to End Addiction Long-term) Initiative, such as support for research on the fundamental neurobiology of endogenous opioid systems.
The National Institutes of Health’s Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative will finish 2018 with its largest round of grant funding ever, giving $220 million to more than 200 research awards, and bringing this year’s total to more than $400 million, according to an announcement from the agency.
The BRAIN Initiative began in 2013 with the objective of revolutionizing our understanding of the human brain by accelerating the development and application of innovative technologies that will allow researchers to show how individual cells and complex neural circuits interact in both time and space and thereby seek new ways to treat, cure, and prevent brain disorders.
In the current round of funding that was authorized by Congress through the regular appropriations process and the 21st Century Cures Act, new projects include the creation of a wireless optical tomography cap for scanning human brain activity; the development of a noninvasive brain-computer interface system for improving the lives of paralysis patients; and the testing of noninvasive brain stimulation devices for treating schizophrenia, attention deficit disorders, and other brain diseases; the development of self-growing biological electrodes for recording brain activity; and the creation of an indestructible hydrogel system to help map neural circuits, according to the announcement.
Not all of the research involves technological advancement. In fact, one line of funding involves neuroethics. For instance, for epilepsy syndromes in the latest round of funding for 2018, researchers aim to explore ethical issues confronting families and clinicians when considering new treatment options for drug-resistant epilepsy in children.
The NIH is also leveraging some of the BRAIN Initiative funding toward finding new, nonaddictive pain treatments as part of the its HEAL (Helping to End Addiction Long-term) Initiative, such as support for research on the fundamental neurobiology of endogenous opioid systems.
The election’s impact on health care: Some bellwether races to watch
Voters this year have told pollsters in no uncertain terms that health care is important to them. In particular, maintaining insurance protections for preexisting conditions is the top issue to many.
But the results of the midterm elections are likely to have a major impact on a broad array of other health issues that touch every single American. And how those issues are addressed will depend in large part on which party controls the U.S. House and Senate, governors’ mansions, and state legislatures around the country.
All politics is local, and no single race is likely to determine national or even state action. But some key contests can provide something of a barometer of what’s likely to happen – or not happen – over the next 2 years.
For example, keep an eye on Kansas. The razor-tight race for governor could determine whether the state expands Medicaid to all people with low incomes, as allowed under the Affordable Care Act. The legislature in that deep-red state passed a bill to accept expansion in 2017, but it could not override the veto of then-Gov. Sam Brownback. Of the candidates running for governor in 2018, Democrat Laura Kelly supports expansion, while Republican Kris Kobach does not.
Here are three big health issues that could be dramatically affected by Tuesday’s vote.
1. The Affordable Care Act
Protections for preexisting conditions are only a small part of the ACA. The law also made big changes to Medicare and Medicaid, employer-provided health plans, and the generic drug approval process, among other things.
Republicans ran hard on promises to get rid of the law in every election since it passed in 2010. But when the GOP finally got control of the House, the Senate, and the White House in 2017, Republicans found they could not reach agreement on how to “repeal and replace” the law.
This year has Democrats on the attack over the votes Republicans took on various proposals to remake the health law. Probably the most endangered Democrat in the Senate, Heidi Heitkamp of North Dakota, has hammered her Republican opponent, U.S. Rep. Kevin Cramer, over his votes in the House for the unsuccessful repeal-and-replace bills. Rep. Cramer said that despite his votes he supports protections for preexisting conditions, but he has not said what he would do or get behind that could have that effect.
Polls suggest Rep. Cramer has a healthy lead in that race, but if Sen. Heitkamp pulled off a surprise win, health care might well get some of the credit.
And in New Jersey, Rep. Tom MacArthur, the moderate Republican who wrote the language that got the GOP health bill passed in the House in 2017, is in a heated race with Democrat Andy Kim, who has never held elective office. The overriding issue in that race, too, is health care.
It is not just congressional action that has Republicans playing defense on the ACA. In February, 18 GOP attorneys general and 2 GOP governors filed a lawsuit seeking a judgment that the law is now unconstitutional because Congress in the 2017 tax bill repealed the penalty for not having insurance. Two of those attorneys general – Missouri’s Josh Hawley and West Virginia’s Patrick Morrisey – are running for the Senate. Both states overwhelmingly supported President Donald Trump in 2016.
The attorneys general are running against Democratic incumbents – Claire McCaskill of Missouri and Joe Manchin of West Virginia. And both Republicans are being hotly criticized by their opponents for their participation in the lawsuit.
Although Sen. Manchin appears to have taken a lead, the Hawley-McCaskill race is rated a toss-up by political analysts.
But in the end the fate of the ACA depends less on an individual race than on which party winds up in control of Congress.
“If Democrats take the House ... then any attempt at repeal-and-replace will be kaput,” said John McDonough, a former Democratic Senate aide who helped write the ACA and now teaches at the Harvard School of Public Health, Boston.
Conservative health care strategist Chris Jacobs, who worked for Republicans on Capitol Hill, said a new repeal-and-replace effort might not happen even if Republicans are successful Tuesday.
“Republicans, if they maintain the majority in the House, will have a margin of a half-dozen seats – if they are lucky,” he said. That likely would not allow the party to push through another controversial effort to change the law. Currently there are 42 more Republicans than Democrats in the House. Even so, the GOP barely got its health bill passed out of the House in 2017.
And political strategists say that, when the dust clears after voting, the numbers in the Senate may not be much different so change could be hard there too. Republicans, even with a small majority last year, could not pass a repeal bill there.
2. Medicaid expansion
The Supreme Court in 2012 made optional the ACA’s expansion of Medicaid to cover all low-income Americans up to 138% of the poverty line ($16,753 for an individual in 2018). Most states have now expanded, particularly since the federal government is paying the vast majority of the cost: 94% in 2018, gradually dropping to 90% in 2020.
Still, 17 states, all with GOP governors or state legislatures (or both), have yet to expand Medicaid.
Mr. McDonough is confident that’s about to change. “I’m wondering if we’re on the cusp of a Medicaid wave,” he said.
Four states – Idaho, Montana, Nebraska, and Utah – have Medicaid expansion questions on their ballots. All but Montana have yet to expand the program. Montana’s question would eliminate the 2019 sunset date included in its expansion in 2016. But it will be interesting to watch results because the measure has run into big-pocketed opposition: the tobacco industry. The initiative would increase taxes on cigarettes and other tobacco products to fund the state’s increased Medicaid costs.
In Idaho, the ballot measure is being embraced by a number of Republican leaders. GOP Gov. Butch Otter, who is retiring after three terms, endorsed it Oct. 30.
But the issue is in play in other states, too. Several nonexpansion states have close or closer-than-expected races for governor where the Democrat has made Medicaid expansion a priority.
In Florida, one of the largest states not to have expanded Medicaid, the Republican candidate for governor, former U.S. Rep. Ron DeSantis, opposes expansion. His Democratic opponent, Tallahassee Mayor Andrew Gillum, supports it.
In Georgia, the gubernatorial candidates, Democrat Stacey Abrams and Republican Brian Kemp, are also on opposite sides of the Medicaid expansion debate.
However, the legislatures in both states have opposed the expansion, and it’s not clear if they would be swayed by arguments from a new governor.
3. Medicare
Until recently, Republicans have remained relatively quiet about efforts to change the popular Medicare program for seniors and people with disabilities.
Their new talking point is that proposals to expand the program – such as the often-touted “Medicare-for-all,” which an increasing number of Democrats are embracing – could threaten the existing program.
“Medicare is at significant risk of being cut if Democrats take over the House,” Rep. Greg Gianforte (R-Mont.) told the Lee Montana Newspapers. “Medicare-for-all is Medicare for none. It will gut Medicare, end the VA [Department of Veterans Affairs] as we know it, and force Montana seniors to the back of the line.”
Gianforte’s Democratic opponent, Kathleen Williams, is proposing another idea popular with Democrats: allowing people aged 55 years and over to “buy into” Medicare coverage. That race, too, is very tight.
Meanwhile, back in Washington, congressional Republicans are more concerned with how Medicare and other large government social programs are threatening the budget.
“Sooner or later we are going to run out of other people’s money,” said Mr. Jacobs.
Senate Majority Leader Mitch McConnell (R-Ky.) suggested in an Oct. 16 interview with Bloomberg News that entitlement programs like Medicare are “the real driver of the debt by any objective standard,” but that bipartisan cooperation will be needed to address that problem
Republican Mr. Jacobs and Democrat Mr. McDonough think that’s unlikely any time soon.
“Why would Democrats give that up as an issue heading into 2020?” asked Mr. McDonough, especially because Republicans in recent years have been proposing deep cuts to the Medicare program.
Agreed Mr. Jacobs, “Trump may not want that to be the centerpiece of a reelection campaign.”
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
Voters this year have told pollsters in no uncertain terms that health care is important to them. In particular, maintaining insurance protections for preexisting conditions is the top issue to many.
But the results of the midterm elections are likely to have a major impact on a broad array of other health issues that touch every single American. And how those issues are addressed will depend in large part on which party controls the U.S. House and Senate, governors’ mansions, and state legislatures around the country.
All politics is local, and no single race is likely to determine national or even state action. But some key contests can provide something of a barometer of what’s likely to happen – or not happen – over the next 2 years.
For example, keep an eye on Kansas. The razor-tight race for governor could determine whether the state expands Medicaid to all people with low incomes, as allowed under the Affordable Care Act. The legislature in that deep-red state passed a bill to accept expansion in 2017, but it could not override the veto of then-Gov. Sam Brownback. Of the candidates running for governor in 2018, Democrat Laura Kelly supports expansion, while Republican Kris Kobach does not.
Here are three big health issues that could be dramatically affected by Tuesday’s vote.
1. The Affordable Care Act
Protections for preexisting conditions are only a small part of the ACA. The law also made big changes to Medicare and Medicaid, employer-provided health plans, and the generic drug approval process, among other things.
Republicans ran hard on promises to get rid of the law in every election since it passed in 2010. But when the GOP finally got control of the House, the Senate, and the White House in 2017, Republicans found they could not reach agreement on how to “repeal and replace” the law.
This year has Democrats on the attack over the votes Republicans took on various proposals to remake the health law. Probably the most endangered Democrat in the Senate, Heidi Heitkamp of North Dakota, has hammered her Republican opponent, U.S. Rep. Kevin Cramer, over his votes in the House for the unsuccessful repeal-and-replace bills. Rep. Cramer said that despite his votes he supports protections for preexisting conditions, but he has not said what he would do or get behind that could have that effect.
Polls suggest Rep. Cramer has a healthy lead in that race, but if Sen. Heitkamp pulled off a surprise win, health care might well get some of the credit.
And in New Jersey, Rep. Tom MacArthur, the moderate Republican who wrote the language that got the GOP health bill passed in the House in 2017, is in a heated race with Democrat Andy Kim, who has never held elective office. The overriding issue in that race, too, is health care.
It is not just congressional action that has Republicans playing defense on the ACA. In February, 18 GOP attorneys general and 2 GOP governors filed a lawsuit seeking a judgment that the law is now unconstitutional because Congress in the 2017 tax bill repealed the penalty for not having insurance. Two of those attorneys general – Missouri’s Josh Hawley and West Virginia’s Patrick Morrisey – are running for the Senate. Both states overwhelmingly supported President Donald Trump in 2016.
The attorneys general are running against Democratic incumbents – Claire McCaskill of Missouri and Joe Manchin of West Virginia. And both Republicans are being hotly criticized by their opponents for their participation in the lawsuit.
Although Sen. Manchin appears to have taken a lead, the Hawley-McCaskill race is rated a toss-up by political analysts.
But in the end the fate of the ACA depends less on an individual race than on which party winds up in control of Congress.
“If Democrats take the House ... then any attempt at repeal-and-replace will be kaput,” said John McDonough, a former Democratic Senate aide who helped write the ACA and now teaches at the Harvard School of Public Health, Boston.
Conservative health care strategist Chris Jacobs, who worked for Republicans on Capitol Hill, said a new repeal-and-replace effort might not happen even if Republicans are successful Tuesday.
“Republicans, if they maintain the majority in the House, will have a margin of a half-dozen seats – if they are lucky,” he said. That likely would not allow the party to push through another controversial effort to change the law. Currently there are 42 more Republicans than Democrats in the House. Even so, the GOP barely got its health bill passed out of the House in 2017.
And political strategists say that, when the dust clears after voting, the numbers in the Senate may not be much different so change could be hard there too. Republicans, even with a small majority last year, could not pass a repeal bill there.
2. Medicaid expansion
The Supreme Court in 2012 made optional the ACA’s expansion of Medicaid to cover all low-income Americans up to 138% of the poverty line ($16,753 for an individual in 2018). Most states have now expanded, particularly since the federal government is paying the vast majority of the cost: 94% in 2018, gradually dropping to 90% in 2020.
Still, 17 states, all with GOP governors or state legislatures (or both), have yet to expand Medicaid.
Mr. McDonough is confident that’s about to change. “I’m wondering if we’re on the cusp of a Medicaid wave,” he said.
Four states – Idaho, Montana, Nebraska, and Utah – have Medicaid expansion questions on their ballots. All but Montana have yet to expand the program. Montana’s question would eliminate the 2019 sunset date included in its expansion in 2016. But it will be interesting to watch results because the measure has run into big-pocketed opposition: the tobacco industry. The initiative would increase taxes on cigarettes and other tobacco products to fund the state’s increased Medicaid costs.
In Idaho, the ballot measure is being embraced by a number of Republican leaders. GOP Gov. Butch Otter, who is retiring after three terms, endorsed it Oct. 30.
But the issue is in play in other states, too. Several nonexpansion states have close or closer-than-expected races for governor where the Democrat has made Medicaid expansion a priority.
In Florida, one of the largest states not to have expanded Medicaid, the Republican candidate for governor, former U.S. Rep. Ron DeSantis, opposes expansion. His Democratic opponent, Tallahassee Mayor Andrew Gillum, supports it.
In Georgia, the gubernatorial candidates, Democrat Stacey Abrams and Republican Brian Kemp, are also on opposite sides of the Medicaid expansion debate.
However, the legislatures in both states have opposed the expansion, and it’s not clear if they would be swayed by arguments from a new governor.
3. Medicare
Until recently, Republicans have remained relatively quiet about efforts to change the popular Medicare program for seniors and people with disabilities.
Their new talking point is that proposals to expand the program – such as the often-touted “Medicare-for-all,” which an increasing number of Democrats are embracing – could threaten the existing program.
“Medicare is at significant risk of being cut if Democrats take over the House,” Rep. Greg Gianforte (R-Mont.) told the Lee Montana Newspapers. “Medicare-for-all is Medicare for none. It will gut Medicare, end the VA [Department of Veterans Affairs] as we know it, and force Montana seniors to the back of the line.”
Gianforte’s Democratic opponent, Kathleen Williams, is proposing another idea popular with Democrats: allowing people aged 55 years and over to “buy into” Medicare coverage. That race, too, is very tight.
Meanwhile, back in Washington, congressional Republicans are more concerned with how Medicare and other large government social programs are threatening the budget.
“Sooner or later we are going to run out of other people’s money,” said Mr. Jacobs.
Senate Majority Leader Mitch McConnell (R-Ky.) suggested in an Oct. 16 interview with Bloomberg News that entitlement programs like Medicare are “the real driver of the debt by any objective standard,” but that bipartisan cooperation will be needed to address that problem
Republican Mr. Jacobs and Democrat Mr. McDonough think that’s unlikely any time soon.
“Why would Democrats give that up as an issue heading into 2020?” asked Mr. McDonough, especially because Republicans in recent years have been proposing deep cuts to the Medicare program.
Agreed Mr. Jacobs, “Trump may not want that to be the centerpiece of a reelection campaign.”
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
Voters this year have told pollsters in no uncertain terms that health care is important to them. In particular, maintaining insurance protections for preexisting conditions is the top issue to many.
But the results of the midterm elections are likely to have a major impact on a broad array of other health issues that touch every single American. And how those issues are addressed will depend in large part on which party controls the U.S. House and Senate, governors’ mansions, and state legislatures around the country.
All politics is local, and no single race is likely to determine national or even state action. But some key contests can provide something of a barometer of what’s likely to happen – or not happen – over the next 2 years.
For example, keep an eye on Kansas. The razor-tight race for governor could determine whether the state expands Medicaid to all people with low incomes, as allowed under the Affordable Care Act. The legislature in that deep-red state passed a bill to accept expansion in 2017, but it could not override the veto of then-Gov. Sam Brownback. Of the candidates running for governor in 2018, Democrat Laura Kelly supports expansion, while Republican Kris Kobach does not.
Here are three big health issues that could be dramatically affected by Tuesday’s vote.
1. The Affordable Care Act
Protections for preexisting conditions are only a small part of the ACA. The law also made big changes to Medicare and Medicaid, employer-provided health plans, and the generic drug approval process, among other things.
Republicans ran hard on promises to get rid of the law in every election since it passed in 2010. But when the GOP finally got control of the House, the Senate, and the White House in 2017, Republicans found they could not reach agreement on how to “repeal and replace” the law.
This year has Democrats on the attack over the votes Republicans took on various proposals to remake the health law. Probably the most endangered Democrat in the Senate, Heidi Heitkamp of North Dakota, has hammered her Republican opponent, U.S. Rep. Kevin Cramer, over his votes in the House for the unsuccessful repeal-and-replace bills. Rep. Cramer said that despite his votes he supports protections for preexisting conditions, but he has not said what he would do or get behind that could have that effect.
Polls suggest Rep. Cramer has a healthy lead in that race, but if Sen. Heitkamp pulled off a surprise win, health care might well get some of the credit.
And in New Jersey, Rep. Tom MacArthur, the moderate Republican who wrote the language that got the GOP health bill passed in the House in 2017, is in a heated race with Democrat Andy Kim, who has never held elective office. The overriding issue in that race, too, is health care.
It is not just congressional action that has Republicans playing defense on the ACA. In February, 18 GOP attorneys general and 2 GOP governors filed a lawsuit seeking a judgment that the law is now unconstitutional because Congress in the 2017 tax bill repealed the penalty for not having insurance. Two of those attorneys general – Missouri’s Josh Hawley and West Virginia’s Patrick Morrisey – are running for the Senate. Both states overwhelmingly supported President Donald Trump in 2016.
The attorneys general are running against Democratic incumbents – Claire McCaskill of Missouri and Joe Manchin of West Virginia. And both Republicans are being hotly criticized by their opponents for their participation in the lawsuit.
Although Sen. Manchin appears to have taken a lead, the Hawley-McCaskill race is rated a toss-up by political analysts.
But in the end the fate of the ACA depends less on an individual race than on which party winds up in control of Congress.
“If Democrats take the House ... then any attempt at repeal-and-replace will be kaput,” said John McDonough, a former Democratic Senate aide who helped write the ACA and now teaches at the Harvard School of Public Health, Boston.
Conservative health care strategist Chris Jacobs, who worked for Republicans on Capitol Hill, said a new repeal-and-replace effort might not happen even if Republicans are successful Tuesday.
“Republicans, if they maintain the majority in the House, will have a margin of a half-dozen seats – if they are lucky,” he said. That likely would not allow the party to push through another controversial effort to change the law. Currently there are 42 more Republicans than Democrats in the House. Even so, the GOP barely got its health bill passed out of the House in 2017.
And political strategists say that, when the dust clears after voting, the numbers in the Senate may not be much different so change could be hard there too. Republicans, even with a small majority last year, could not pass a repeal bill there.
2. Medicaid expansion
The Supreme Court in 2012 made optional the ACA’s expansion of Medicaid to cover all low-income Americans up to 138% of the poverty line ($16,753 for an individual in 2018). Most states have now expanded, particularly since the federal government is paying the vast majority of the cost: 94% in 2018, gradually dropping to 90% in 2020.
Still, 17 states, all with GOP governors or state legislatures (or both), have yet to expand Medicaid.
Mr. McDonough is confident that’s about to change. “I’m wondering if we’re on the cusp of a Medicaid wave,” he said.
Four states – Idaho, Montana, Nebraska, and Utah – have Medicaid expansion questions on their ballots. All but Montana have yet to expand the program. Montana’s question would eliminate the 2019 sunset date included in its expansion in 2016. But it will be interesting to watch results because the measure has run into big-pocketed opposition: the tobacco industry. The initiative would increase taxes on cigarettes and other tobacco products to fund the state’s increased Medicaid costs.
In Idaho, the ballot measure is being embraced by a number of Republican leaders. GOP Gov. Butch Otter, who is retiring after three terms, endorsed it Oct. 30.
But the issue is in play in other states, too. Several nonexpansion states have close or closer-than-expected races for governor where the Democrat has made Medicaid expansion a priority.
In Florida, one of the largest states not to have expanded Medicaid, the Republican candidate for governor, former U.S. Rep. Ron DeSantis, opposes expansion. His Democratic opponent, Tallahassee Mayor Andrew Gillum, supports it.
In Georgia, the gubernatorial candidates, Democrat Stacey Abrams and Republican Brian Kemp, are also on opposite sides of the Medicaid expansion debate.
However, the legislatures in both states have opposed the expansion, and it’s not clear if they would be swayed by arguments from a new governor.
3. Medicare
Until recently, Republicans have remained relatively quiet about efforts to change the popular Medicare program for seniors and people with disabilities.
Their new talking point is that proposals to expand the program – such as the often-touted “Medicare-for-all,” which an increasing number of Democrats are embracing – could threaten the existing program.
“Medicare is at significant risk of being cut if Democrats take over the House,” Rep. Greg Gianforte (R-Mont.) told the Lee Montana Newspapers. “Medicare-for-all is Medicare for none. It will gut Medicare, end the VA [Department of Veterans Affairs] as we know it, and force Montana seniors to the back of the line.”
Gianforte’s Democratic opponent, Kathleen Williams, is proposing another idea popular with Democrats: allowing people aged 55 years and over to “buy into” Medicare coverage. That race, too, is very tight.
Meanwhile, back in Washington, congressional Republicans are more concerned with how Medicare and other large government social programs are threatening the budget.
“Sooner or later we are going to run out of other people’s money,” said Mr. Jacobs.
Senate Majority Leader Mitch McConnell (R-Ky.) suggested in an Oct. 16 interview with Bloomberg News that entitlement programs like Medicare are “the real driver of the debt by any objective standard,” but that bipartisan cooperation will be needed to address that problem
Republican Mr. Jacobs and Democrat Mr. McDonough think that’s unlikely any time soon.
“Why would Democrats give that up as an issue heading into 2020?” asked Mr. McDonough, especially because Republicans in recent years have been proposing deep cuts to the Medicare program.
Agreed Mr. Jacobs, “Trump may not want that to be the centerpiece of a reelection campaign.”
Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.
Samuel Shem: House of God
Newsweek named the House of God the second best satirical piece of fiction of all time behind Don Quixote. In this conversation, Shem tells me about his motivation for the House of God and reveals that there will be a sequel in 2019 on the current state of medicine.
Newsweek named the House of God the second best satirical piece of fiction of all time behind Don Quixote. In this conversation, Shem tells me about his motivation for the House of God and reveals that there will be a sequel in 2019 on the current state of medicine.
Newsweek named the House of God the second best satirical piece of fiction of all time behind Don Quixote. In this conversation, Shem tells me about his motivation for the House of God and reveals that there will be a sequel in 2019 on the current state of medicine.
Think barrier repair for acne patients
LAS VEGAS – It’s time to start thinking about barrier repair in acne patients, Hilary E. Baldwin, MD, asserts.
“We think about barrier repair with our psoriasis patients, with our dermatitis patients, and our rosacea patients, but we don’t talk about it much with our acne patients,” Dr. Baldwin said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. “Now there is increasing evidence that acne pathophysiology may include a barrier defect.”
Both topical and systemic medications exacerbate the problem, because they are so drying, added Dr. Baldwin, medical director of the Acne Treatment & Research Center in Morristown, N.J. Benzoyl peroxide has been shown to increase transepidermal water loss (TEWL) and deplete tocopherol levels in the stratum corneum, while topical retinoids thin the stratum corneum, increase epidermal fragility, and increase TEWL.
The barrier defect may actually decrease medication use – patients are irritated and they stop taking their medication. “,” she said.
She described the results of an Internet-based survey of 200 acne patients aged 15-40 years who had been prescribed clindamycin/benzoyl peroxide 5% within the last 6 months (J Drugs Dermatol. 2011 Jun;10[6]:605-8). The researchers found that side effects lead to suboptimal use of the topical medication, as patients reported spot application, use only in flares, infrequent use, and discontinuation.
Further, 31% of patients complained to their doctors’ offices about dryness, 23% said their doctors did not understand the potential side effects, 21% lost confidence in their doctors, 11% said they were less likely to see their doctors again, and 41% reported using moisturizer to combat dryness and erythema.
“No acne visit is complete without a discussion of skin care,” Dr. Baldwin said. Quality moisturization is a must for acne patients and has been shown to improve TEWL, normalize ceramides, and repair the microbiome.
“I recommend moisturizers with ceramides, hyaluronic acid, and certainly moisturizers that have been shown to be noncomedogenic,” Dr. Baldwin said. “Most acne patients aren’t willing to use a cream moisturizer during the day – they just feel too greasy – so I have them use a cream in the evening when they are home and a lotion in the morning.”
While there has been one very specific study of using a moisturizer before topical medications, there is no good data for this practice, Dr. Baldwin said. “Clearly, though, using a moisturizer reduces irritation, so I prefer to have my patients put on the moisturizer at a different time, but if that doesn’t work, I have them put it on before the medication.”
Dr. Baldwin indicated that she is on the speakers bureau for LaRoche Posay, Galderma, and Valeant, and had received grant and/or contracted research support from Dermira and Valeant.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – It’s time to start thinking about barrier repair in acne patients, Hilary E. Baldwin, MD, asserts.
“We think about barrier repair with our psoriasis patients, with our dermatitis patients, and our rosacea patients, but we don’t talk about it much with our acne patients,” Dr. Baldwin said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. “Now there is increasing evidence that acne pathophysiology may include a barrier defect.”
Both topical and systemic medications exacerbate the problem, because they are so drying, added Dr. Baldwin, medical director of the Acne Treatment & Research Center in Morristown, N.J. Benzoyl peroxide has been shown to increase transepidermal water loss (TEWL) and deplete tocopherol levels in the stratum corneum, while topical retinoids thin the stratum corneum, increase epidermal fragility, and increase TEWL.
The barrier defect may actually decrease medication use – patients are irritated and they stop taking their medication. “,” she said.
She described the results of an Internet-based survey of 200 acne patients aged 15-40 years who had been prescribed clindamycin/benzoyl peroxide 5% within the last 6 months (J Drugs Dermatol. 2011 Jun;10[6]:605-8). The researchers found that side effects lead to suboptimal use of the topical medication, as patients reported spot application, use only in flares, infrequent use, and discontinuation.
Further, 31% of patients complained to their doctors’ offices about dryness, 23% said their doctors did not understand the potential side effects, 21% lost confidence in their doctors, 11% said they were less likely to see their doctors again, and 41% reported using moisturizer to combat dryness and erythema.
“No acne visit is complete without a discussion of skin care,” Dr. Baldwin said. Quality moisturization is a must for acne patients and has been shown to improve TEWL, normalize ceramides, and repair the microbiome.
“I recommend moisturizers with ceramides, hyaluronic acid, and certainly moisturizers that have been shown to be noncomedogenic,” Dr. Baldwin said. “Most acne patients aren’t willing to use a cream moisturizer during the day – they just feel too greasy – so I have them use a cream in the evening when they are home and a lotion in the morning.”
While there has been one very specific study of using a moisturizer before topical medications, there is no good data for this practice, Dr. Baldwin said. “Clearly, though, using a moisturizer reduces irritation, so I prefer to have my patients put on the moisturizer at a different time, but if that doesn’t work, I have them put it on before the medication.”
Dr. Baldwin indicated that she is on the speakers bureau for LaRoche Posay, Galderma, and Valeant, and had received grant and/or contracted research support from Dermira and Valeant.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – It’s time to start thinking about barrier repair in acne patients, Hilary E. Baldwin, MD, asserts.
“We think about barrier repair with our psoriasis patients, with our dermatitis patients, and our rosacea patients, but we don’t talk about it much with our acne patients,” Dr. Baldwin said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. “Now there is increasing evidence that acne pathophysiology may include a barrier defect.”
Both topical and systemic medications exacerbate the problem, because they are so drying, added Dr. Baldwin, medical director of the Acne Treatment & Research Center in Morristown, N.J. Benzoyl peroxide has been shown to increase transepidermal water loss (TEWL) and deplete tocopherol levels in the stratum corneum, while topical retinoids thin the stratum corneum, increase epidermal fragility, and increase TEWL.
The barrier defect may actually decrease medication use – patients are irritated and they stop taking their medication. “,” she said.
She described the results of an Internet-based survey of 200 acne patients aged 15-40 years who had been prescribed clindamycin/benzoyl peroxide 5% within the last 6 months (J Drugs Dermatol. 2011 Jun;10[6]:605-8). The researchers found that side effects lead to suboptimal use of the topical medication, as patients reported spot application, use only in flares, infrequent use, and discontinuation.
Further, 31% of patients complained to their doctors’ offices about dryness, 23% said their doctors did not understand the potential side effects, 21% lost confidence in their doctors, 11% said they were less likely to see their doctors again, and 41% reported using moisturizer to combat dryness and erythema.
“No acne visit is complete without a discussion of skin care,” Dr. Baldwin said. Quality moisturization is a must for acne patients and has been shown to improve TEWL, normalize ceramides, and repair the microbiome.
“I recommend moisturizers with ceramides, hyaluronic acid, and certainly moisturizers that have been shown to be noncomedogenic,” Dr. Baldwin said. “Most acne patients aren’t willing to use a cream moisturizer during the day – they just feel too greasy – so I have them use a cream in the evening when they are home and a lotion in the morning.”
While there has been one very specific study of using a moisturizer before topical medications, there is no good data for this practice, Dr. Baldwin said. “Clearly, though, using a moisturizer reduces irritation, so I prefer to have my patients put on the moisturizer at a different time, but if that doesn’t work, I have them put it on before the medication.”
Dr. Baldwin indicated that she is on the speakers bureau for LaRoche Posay, Galderma, and Valeant, and had received grant and/or contracted research support from Dermira and Valeant.
SDEF and this news organization are owned by the same parent company.
REPORTING FROM SDEF LAS VEGAS DERMATOLOGY SEMINAR
Four predictors confirmed for treatment-resistant depression
BARCELONA – Four potent clinical predictors of treatment-resistant depression have been confirmed in a validation study that showed the four factors collectively have a predictive accuracy of 87%, Alexander Kautzky, MD, reported at the annual congress of the European College of Neuropsychopharmacology.
The four predictors – all easily assessed – are symptom severity, which was independently associated with a 3.3-fold increased likelihood of treatment-resistant depression (TRD) in a study of 916 patients with major depression at 10 referral centers in eight European countries; suicidal risk, with a 1.74-fold increased risk; comorbid anxiety disorder, with a 1.68-fold increased risk; and the lifetime number of major depressive episodes, for which the associated TRD risk climbs by 15% per prior episode, according to Dr. Kautzky of the Medical University of Vienna.
When these four predictors were put to the test in an independent validation cohort of 314 patients with major depression, the four clinical markers of TRD exhibited a sensitivity of 86%, a specificity of 88%, and an overall predictive accuracy of 87%.
In these studies, Response was defined as at least a 50% drop in MADRS score to below 22 points.
The validation of these clinical predictors of TRD is a welcome development in psychiatry. The World Health Organization ranks major depressive disorder as the No. 4 cause of disease burden worldwide, and an impressive number of antidepressant medications are available, but up to 60% of patients do not respond sufficiently to their first round of antidepressant therapy. And there is a notable absence of biological markers to aid in selecting the best initial antidepressant for a given individual, Dr. Kautzky observed.
The validation study was supported by an unrestricted research grant from Lundbeck to a European research consortium known as the Group for the Study of Resistant Depression. Dr. Kautzky reported having no financial conflicts of interest.
BARCELONA – Four potent clinical predictors of treatment-resistant depression have been confirmed in a validation study that showed the four factors collectively have a predictive accuracy of 87%, Alexander Kautzky, MD, reported at the annual congress of the European College of Neuropsychopharmacology.
The four predictors – all easily assessed – are symptom severity, which was independently associated with a 3.3-fold increased likelihood of treatment-resistant depression (TRD) in a study of 916 patients with major depression at 10 referral centers in eight European countries; suicidal risk, with a 1.74-fold increased risk; comorbid anxiety disorder, with a 1.68-fold increased risk; and the lifetime number of major depressive episodes, for which the associated TRD risk climbs by 15% per prior episode, according to Dr. Kautzky of the Medical University of Vienna.
When these four predictors were put to the test in an independent validation cohort of 314 patients with major depression, the four clinical markers of TRD exhibited a sensitivity of 86%, a specificity of 88%, and an overall predictive accuracy of 87%.
In these studies, Response was defined as at least a 50% drop in MADRS score to below 22 points.
The validation of these clinical predictors of TRD is a welcome development in psychiatry. The World Health Organization ranks major depressive disorder as the No. 4 cause of disease burden worldwide, and an impressive number of antidepressant medications are available, but up to 60% of patients do not respond sufficiently to their first round of antidepressant therapy. And there is a notable absence of biological markers to aid in selecting the best initial antidepressant for a given individual, Dr. Kautzky observed.
The validation study was supported by an unrestricted research grant from Lundbeck to a European research consortium known as the Group for the Study of Resistant Depression. Dr. Kautzky reported having no financial conflicts of interest.
BARCELONA – Four potent clinical predictors of treatment-resistant depression have been confirmed in a validation study that showed the four factors collectively have a predictive accuracy of 87%, Alexander Kautzky, MD, reported at the annual congress of the European College of Neuropsychopharmacology.
The four predictors – all easily assessed – are symptom severity, which was independently associated with a 3.3-fold increased likelihood of treatment-resistant depression (TRD) in a study of 916 patients with major depression at 10 referral centers in eight European countries; suicidal risk, with a 1.74-fold increased risk; comorbid anxiety disorder, with a 1.68-fold increased risk; and the lifetime number of major depressive episodes, for which the associated TRD risk climbs by 15% per prior episode, according to Dr. Kautzky of the Medical University of Vienna.
When these four predictors were put to the test in an independent validation cohort of 314 patients with major depression, the four clinical markers of TRD exhibited a sensitivity of 86%, a specificity of 88%, and an overall predictive accuracy of 87%.
In these studies, Response was defined as at least a 50% drop in MADRS score to below 22 points.
The validation of these clinical predictors of TRD is a welcome development in psychiatry. The World Health Organization ranks major depressive disorder as the No. 4 cause of disease burden worldwide, and an impressive number of antidepressant medications are available, but up to 60% of patients do not respond sufficiently to their first round of antidepressant therapy. And there is a notable absence of biological markers to aid in selecting the best initial antidepressant for a given individual, Dr. Kautzky observed.
The validation study was supported by an unrestricted research grant from Lundbeck to a European research consortium known as the Group for the Study of Resistant Depression. Dr. Kautzky reported having no financial conflicts of interest.
REPORTING FROM THE ECNP CONGRESS
Key clinical point: Patients with major depressive disorder at high risk for treatment-resistant depression are now readily identifiable.
Major finding: Four easily collected clinical variables predict treatment-resistant depression with 87% accuracy.
Study details: This project identified clinical predictors of treatment-resistant depression in a cohort of 916 patients with major depressive disorder then validated the predictors in a separate cohort of 314 patients.
Disclosures: The presenter reported having no financial conflicts regarding this study, which was supported by an unrestricted research grant from Lundbeck.
Vascular ultrasound reasonable for first-line imaging of large-vessel GCA
CHICAGO – Vascular ultrasound showed high sensitivity and specificity for diagnosing large-vessel giant-cell arteritis (LV-GCA) in a prospective study of patients with suspected new-onset disease.
The findings highlight the value of vascular ultrasound – in the hands of experienced sonographers – as a first-line imaging test in this setting, Berit Dalsgaard Nielsen, MD, reported at the annual meeting of the American College of Rheumatology.
Of 41 control subjects without LV-GCA, none had a positive ultrasound, whereas 36 of 45 LV-GCA patients had a positive ultrasound, which gives the test a specificity of 100% and sensitivity of 80%, Dr. Nielsen of Aarhus (Denmark) University Hospital said during a press briefing at the meeting.
Ultrasound was performed on the carotid artery in the neck and axillary arteries under the arm, which are easily accessible by ultrasound.
“These patients also had temporal arteries evaluated, and if we included this evaluation in the diagnostic performance, it showed a sensitivity of 91%,” she noted, explaining that temporal artery ultrasound alone conferred 71% sensitivity. “So it actually helped us identify more GCA patients.”
The study subjects were adults with suspected GCA. Inclusion criteria included age of at least 50 years, C-reactive protein of more than 15 mg/L or erythrocyte sedimentation rate of more than 40 mm, and either cranial symptoms, new-onset limb claudication, protracted constitutional symptoms, or polymyalgia rheumatica (PMR) symptoms. Patients were excluded if they had recent or ongoing glucocorticoid or disease-modifying antirheumatic drug treatment, a previous GCA or PMR diagnosis, or a large vessel inflammation that mimicked LV-GCA.
Clinical evaluations and imaging tests were performed prior to treatment initiation. The reference diagnosis was a clinical diagnosis of GCA and a positive 18F-FDG PET/CT scan, Dr Nielsen said, adding that ultrasound examinations were performed by experienced sonographers who were blinded to the PET/CT results.
Of the 86 patients included, 45 had LV-GCA with or without concomitant cranial GCA, 10 had isolated cranial GCA, 21 had PMR, and 10 were diagnosed with other diseases. The patients found to not have LV-GCA were considered control subjects.
The findings are notable because, while PET is considered the gold standard, it is very expensive and not always readily available, Dr. Nielsen said.
Additionally, while cranial-GCA patients generally present with symptoms such as headache, jaw claudication, and visual disturbances that are considered typical for GCA, LV-GCA patients rarely present with these symptoms.
Rather, these LV-GCA patients tend to present with constitutional symptoms mimicking infection or cancer, and they undergo extensive examination programs before the diagnosis is established. For this reason, diagnosis is often delayed for several months in LV-GCA patients until late in the disease course.
“During this time they often experience a decline in physical ability,” she said. “So in this disease subset of patients with GCA, there’s an unmet need for earlier recognition and earlier diagnosis.”
New recommendations from the European League Against Rheumatism call for early diagnostic imaging in all cases of suspected GCA, she added, noting that, for cranial-GCA symptoms, temporal artery ultrasound is recommended first line, but for those who present without cranial symptoms, no particular imaging modality is recommended because of a lack of comparative and diagnostic accuracy data in LV-GCA.
Biopsy has traditionally been used in these cases, but now imaging can be substituted – and vascular ultrasound is an attractive first-line option given its affordability and availability.
Indeed, the current findings support its use in this setting, she said.
“We think that these results indicate that ultrasound should not only be the first-line imaging test in patients presenting with cranial symptoms, but also in patients suspected of GCA presenting with constitutional symptoms, and if this examination is included in the standard examinations in fast-track clinics, it may overcome the delay in diagnosis and the patients can be treated earlier. It may also spare the unneeded examinations performed in these patients,” she concluded.
Dr. Nielsen disclosed a relationship with Roche.
SOURCE: Nielsen B et al. Arthritis Rheumatol. 2018;70(Suppl 10): Abstract 2905.
CHICAGO – Vascular ultrasound showed high sensitivity and specificity for diagnosing large-vessel giant-cell arteritis (LV-GCA) in a prospective study of patients with suspected new-onset disease.
The findings highlight the value of vascular ultrasound – in the hands of experienced sonographers – as a first-line imaging test in this setting, Berit Dalsgaard Nielsen, MD, reported at the annual meeting of the American College of Rheumatology.
Of 41 control subjects without LV-GCA, none had a positive ultrasound, whereas 36 of 45 LV-GCA patients had a positive ultrasound, which gives the test a specificity of 100% and sensitivity of 80%, Dr. Nielsen of Aarhus (Denmark) University Hospital said during a press briefing at the meeting.
Ultrasound was performed on the carotid artery in the neck and axillary arteries under the arm, which are easily accessible by ultrasound.
“These patients also had temporal arteries evaluated, and if we included this evaluation in the diagnostic performance, it showed a sensitivity of 91%,” she noted, explaining that temporal artery ultrasound alone conferred 71% sensitivity. “So it actually helped us identify more GCA patients.”
The study subjects were adults with suspected GCA. Inclusion criteria included age of at least 50 years, C-reactive protein of more than 15 mg/L or erythrocyte sedimentation rate of more than 40 mm, and either cranial symptoms, new-onset limb claudication, protracted constitutional symptoms, or polymyalgia rheumatica (PMR) symptoms. Patients were excluded if they had recent or ongoing glucocorticoid or disease-modifying antirheumatic drug treatment, a previous GCA or PMR diagnosis, or a large vessel inflammation that mimicked LV-GCA.
Clinical evaluations and imaging tests were performed prior to treatment initiation. The reference diagnosis was a clinical diagnosis of GCA and a positive 18F-FDG PET/CT scan, Dr Nielsen said, adding that ultrasound examinations were performed by experienced sonographers who were blinded to the PET/CT results.
Of the 86 patients included, 45 had LV-GCA with or without concomitant cranial GCA, 10 had isolated cranial GCA, 21 had PMR, and 10 were diagnosed with other diseases. The patients found to not have LV-GCA were considered control subjects.
The findings are notable because, while PET is considered the gold standard, it is very expensive and not always readily available, Dr. Nielsen said.
Additionally, while cranial-GCA patients generally present with symptoms such as headache, jaw claudication, and visual disturbances that are considered typical for GCA, LV-GCA patients rarely present with these symptoms.
Rather, these LV-GCA patients tend to present with constitutional symptoms mimicking infection or cancer, and they undergo extensive examination programs before the diagnosis is established. For this reason, diagnosis is often delayed for several months in LV-GCA patients until late in the disease course.
“During this time they often experience a decline in physical ability,” she said. “So in this disease subset of patients with GCA, there’s an unmet need for earlier recognition and earlier diagnosis.”
New recommendations from the European League Against Rheumatism call for early diagnostic imaging in all cases of suspected GCA, she added, noting that, for cranial-GCA symptoms, temporal artery ultrasound is recommended first line, but for those who present without cranial symptoms, no particular imaging modality is recommended because of a lack of comparative and diagnostic accuracy data in LV-GCA.
Biopsy has traditionally been used in these cases, but now imaging can be substituted – and vascular ultrasound is an attractive first-line option given its affordability and availability.
Indeed, the current findings support its use in this setting, she said.
“We think that these results indicate that ultrasound should not only be the first-line imaging test in patients presenting with cranial symptoms, but also in patients suspected of GCA presenting with constitutional symptoms, and if this examination is included in the standard examinations in fast-track clinics, it may overcome the delay in diagnosis and the patients can be treated earlier. It may also spare the unneeded examinations performed in these patients,” she concluded.
Dr. Nielsen disclosed a relationship with Roche.
SOURCE: Nielsen B et al. Arthritis Rheumatol. 2018;70(Suppl 10): Abstract 2905.
CHICAGO – Vascular ultrasound showed high sensitivity and specificity for diagnosing large-vessel giant-cell arteritis (LV-GCA) in a prospective study of patients with suspected new-onset disease.
The findings highlight the value of vascular ultrasound – in the hands of experienced sonographers – as a first-line imaging test in this setting, Berit Dalsgaard Nielsen, MD, reported at the annual meeting of the American College of Rheumatology.
Of 41 control subjects without LV-GCA, none had a positive ultrasound, whereas 36 of 45 LV-GCA patients had a positive ultrasound, which gives the test a specificity of 100% and sensitivity of 80%, Dr. Nielsen of Aarhus (Denmark) University Hospital said during a press briefing at the meeting.
Ultrasound was performed on the carotid artery in the neck and axillary arteries under the arm, which are easily accessible by ultrasound.
“These patients also had temporal arteries evaluated, and if we included this evaluation in the diagnostic performance, it showed a sensitivity of 91%,” she noted, explaining that temporal artery ultrasound alone conferred 71% sensitivity. “So it actually helped us identify more GCA patients.”
The study subjects were adults with suspected GCA. Inclusion criteria included age of at least 50 years, C-reactive protein of more than 15 mg/L or erythrocyte sedimentation rate of more than 40 mm, and either cranial symptoms, new-onset limb claudication, protracted constitutional symptoms, or polymyalgia rheumatica (PMR) symptoms. Patients were excluded if they had recent or ongoing glucocorticoid or disease-modifying antirheumatic drug treatment, a previous GCA or PMR diagnosis, or a large vessel inflammation that mimicked LV-GCA.
Clinical evaluations and imaging tests were performed prior to treatment initiation. The reference diagnosis was a clinical diagnosis of GCA and a positive 18F-FDG PET/CT scan, Dr Nielsen said, adding that ultrasound examinations were performed by experienced sonographers who were blinded to the PET/CT results.
Of the 86 patients included, 45 had LV-GCA with or without concomitant cranial GCA, 10 had isolated cranial GCA, 21 had PMR, and 10 were diagnosed with other diseases. The patients found to not have LV-GCA were considered control subjects.
The findings are notable because, while PET is considered the gold standard, it is very expensive and not always readily available, Dr. Nielsen said.
Additionally, while cranial-GCA patients generally present with symptoms such as headache, jaw claudication, and visual disturbances that are considered typical for GCA, LV-GCA patients rarely present with these symptoms.
Rather, these LV-GCA patients tend to present with constitutional symptoms mimicking infection or cancer, and they undergo extensive examination programs before the diagnosis is established. For this reason, diagnosis is often delayed for several months in LV-GCA patients until late in the disease course.
“During this time they often experience a decline in physical ability,” she said. “So in this disease subset of patients with GCA, there’s an unmet need for earlier recognition and earlier diagnosis.”
New recommendations from the European League Against Rheumatism call for early diagnostic imaging in all cases of suspected GCA, she added, noting that, for cranial-GCA symptoms, temporal artery ultrasound is recommended first line, but for those who present without cranial symptoms, no particular imaging modality is recommended because of a lack of comparative and diagnostic accuracy data in LV-GCA.
Biopsy has traditionally been used in these cases, but now imaging can be substituted – and vascular ultrasound is an attractive first-line option given its affordability and availability.
Indeed, the current findings support its use in this setting, she said.
“We think that these results indicate that ultrasound should not only be the first-line imaging test in patients presenting with cranial symptoms, but also in patients suspected of GCA presenting with constitutional symptoms, and if this examination is included in the standard examinations in fast-track clinics, it may overcome the delay in diagnosis and the patients can be treated earlier. It may also spare the unneeded examinations performed in these patients,” she concluded.
Dr. Nielsen disclosed a relationship with Roche.
SOURCE: Nielsen B et al. Arthritis Rheumatol. 2018;70(Suppl 10): Abstract 2905.
REPORTING FROM THE ACR ANNUAL MEETING
Key clinical point: Vascular ultrasound is reasonable for first-line maging of suspected LV-GCA.
Major finding: Vascular ultrasound had 100% specificity and 80% sensitivity.
Study details: A prospective study of 86 patients.
Disclosures: Dr. Nielsen disclosed a relationship with Roche.
Source: Nielsen BD et al. Arthritis Rheumatol. 2018;70(Suppl 10): Abstract 2905.
MRI Measure Distinguishes MS From Migraine
Gray matter–white matter contrast ratio may be lowest in progressive MS, compared with other MS phenotypes.
BERLIN—Gray matter–white matter (GM/WM) contrast ratio on T1 magnetization prepared rapid gradient echo (MPRAGE) is sensitive to multiple sclerosis (MS), but not to migraine pathology, according to research presented at ECTRIMS 2018. The diagnostic and prognostic value of this MRI marker could be subjects for future investigations, said the study authors.
Researchers have suggested that MRI brain T1 GM/WM contrast may be a marker of neurodegeneration in Alzheimer’s disease. Whether this contrast has diagnostic value in MS remains unknown, however. Tina Mitrovic, a research assistant at the University of Basel in Switzerland, and colleagues conducted a study to compare the T1 GM/WM contrast in patients with MS, migraineurs, and healthy controls. They also investigated whether the contrast was associated with disability outcomes in MS.
Ms. Mitrovic and colleagues analyzed precontrast 3D MPRAGE data from two independent cohorts. Cohort A was examined with 1.5-T MRI and included 124 patients with MS (65% relapsing-remitting MS; 66% female; mean disease duration, 13 years; median Expanded Disability Status Scale [EDSS] score, 2.5) and 20 healthy controls. Cohort B was examined with 3-T MRI and included 43 patients with relapsing-remitting MS (56% female; mean disease duration, three years; median EDSS score, 1.5), 19 migraineurs (47% with aura and 54% with WM abnormalities on T2-weighted scans), and 37 healthy controls.
WM lesions were segmented manually on T1- and T2-weighted images. GM and WM were segmented using Statistical Parametric Mapping 12. The researchers calculated GM and WM fractions and thresholded GM and WM masks by 95%. T1 GM/WM contrast ratio was calculated as [mean T1 intensity of WM minus mean T1 intensity of GM] divided by [mean T1 intensity of WM plus mean T1 intensity of GM]. Clinical outcomes included EDSS and Multiple Sclerosis Functional Composite (MSFC) scores. Associations between variables were investigated using univariate and multivariate general linear models. Results were bootstrapped.
Mean T1 GM/WM contrast ratio was lower in patients with MS than healthy controls in both cohorts. Furthermore, T1 GM/WM contrast ratio was lower in patients with MS than migraineurs, but the researchers observed no difference between migraine and healthy controls. Mean T1 GM/WM contrast was lowest in patients with progressive MS (11.7%), followed by those with relapsing-remitting MS or clinically isolated syndrome (12.2%) and healthy controls (12.8%). In MS, T1 GM/WM contrast was associated with WM lesion volume, disease duration, EDSS, and MSFC. A multivariable analysis with T1 GM/WM contrast as a dependent variable and age, disease duration, T1 and T2 WM lesion volume, and GM and WM fraction as independent variables indicated that GM fraction and T2 lesion volume were independently associated with T1 GM/WM contrast ratio.
Gray matter–white matter contrast ratio may be lowest in progressive MS, compared with other MS phenotypes.
Gray matter–white matter contrast ratio may be lowest in progressive MS, compared with other MS phenotypes.
BERLIN—Gray matter–white matter (GM/WM) contrast ratio on T1 magnetization prepared rapid gradient echo (MPRAGE) is sensitive to multiple sclerosis (MS), but not to migraine pathology, according to research presented at ECTRIMS 2018. The diagnostic and prognostic value of this MRI marker could be subjects for future investigations, said the study authors.
Researchers have suggested that MRI brain T1 GM/WM contrast may be a marker of neurodegeneration in Alzheimer’s disease. Whether this contrast has diagnostic value in MS remains unknown, however. Tina Mitrovic, a research assistant at the University of Basel in Switzerland, and colleagues conducted a study to compare the T1 GM/WM contrast in patients with MS, migraineurs, and healthy controls. They also investigated whether the contrast was associated with disability outcomes in MS.
Ms. Mitrovic and colleagues analyzed precontrast 3D MPRAGE data from two independent cohorts. Cohort A was examined with 1.5-T MRI and included 124 patients with MS (65% relapsing-remitting MS; 66% female; mean disease duration, 13 years; median Expanded Disability Status Scale [EDSS] score, 2.5) and 20 healthy controls. Cohort B was examined with 3-T MRI and included 43 patients with relapsing-remitting MS (56% female; mean disease duration, three years; median EDSS score, 1.5), 19 migraineurs (47% with aura and 54% with WM abnormalities on T2-weighted scans), and 37 healthy controls.
WM lesions were segmented manually on T1- and T2-weighted images. GM and WM were segmented using Statistical Parametric Mapping 12. The researchers calculated GM and WM fractions and thresholded GM and WM masks by 95%. T1 GM/WM contrast ratio was calculated as [mean T1 intensity of WM minus mean T1 intensity of GM] divided by [mean T1 intensity of WM plus mean T1 intensity of GM]. Clinical outcomes included EDSS and Multiple Sclerosis Functional Composite (MSFC) scores. Associations between variables were investigated using univariate and multivariate general linear models. Results were bootstrapped.
Mean T1 GM/WM contrast ratio was lower in patients with MS than healthy controls in both cohorts. Furthermore, T1 GM/WM contrast ratio was lower in patients with MS than migraineurs, but the researchers observed no difference between migraine and healthy controls. Mean T1 GM/WM contrast was lowest in patients with progressive MS (11.7%), followed by those with relapsing-remitting MS or clinically isolated syndrome (12.2%) and healthy controls (12.8%). In MS, T1 GM/WM contrast was associated with WM lesion volume, disease duration, EDSS, and MSFC. A multivariable analysis with T1 GM/WM contrast as a dependent variable and age, disease duration, T1 and T2 WM lesion volume, and GM and WM fraction as independent variables indicated that GM fraction and T2 lesion volume were independently associated with T1 GM/WM contrast ratio.
BERLIN—Gray matter–white matter (GM/WM) contrast ratio on T1 magnetization prepared rapid gradient echo (MPRAGE) is sensitive to multiple sclerosis (MS), but not to migraine pathology, according to research presented at ECTRIMS 2018. The diagnostic and prognostic value of this MRI marker could be subjects for future investigations, said the study authors.
Researchers have suggested that MRI brain T1 GM/WM contrast may be a marker of neurodegeneration in Alzheimer’s disease. Whether this contrast has diagnostic value in MS remains unknown, however. Tina Mitrovic, a research assistant at the University of Basel in Switzerland, and colleagues conducted a study to compare the T1 GM/WM contrast in patients with MS, migraineurs, and healthy controls. They also investigated whether the contrast was associated with disability outcomes in MS.
Ms. Mitrovic and colleagues analyzed precontrast 3D MPRAGE data from two independent cohorts. Cohort A was examined with 1.5-T MRI and included 124 patients with MS (65% relapsing-remitting MS; 66% female; mean disease duration, 13 years; median Expanded Disability Status Scale [EDSS] score, 2.5) and 20 healthy controls. Cohort B was examined with 3-T MRI and included 43 patients with relapsing-remitting MS (56% female; mean disease duration, three years; median EDSS score, 1.5), 19 migraineurs (47% with aura and 54% with WM abnormalities on T2-weighted scans), and 37 healthy controls.
WM lesions were segmented manually on T1- and T2-weighted images. GM and WM were segmented using Statistical Parametric Mapping 12. The researchers calculated GM and WM fractions and thresholded GM and WM masks by 95%. T1 GM/WM contrast ratio was calculated as [mean T1 intensity of WM minus mean T1 intensity of GM] divided by [mean T1 intensity of WM plus mean T1 intensity of GM]. Clinical outcomes included EDSS and Multiple Sclerosis Functional Composite (MSFC) scores. Associations between variables were investigated using univariate and multivariate general linear models. Results were bootstrapped.
Mean T1 GM/WM contrast ratio was lower in patients with MS than healthy controls in both cohorts. Furthermore, T1 GM/WM contrast ratio was lower in patients with MS than migraineurs, but the researchers observed no difference between migraine and healthy controls. Mean T1 GM/WM contrast was lowest in patients with progressive MS (11.7%), followed by those with relapsing-remitting MS or clinically isolated syndrome (12.2%) and healthy controls (12.8%). In MS, T1 GM/WM contrast was associated with WM lesion volume, disease duration, EDSS, and MSFC. A multivariable analysis with T1 GM/WM contrast as a dependent variable and age, disease duration, T1 and T2 WM lesion volume, and GM and WM fraction as independent variables indicated that GM fraction and T2 lesion volume were independently associated with T1 GM/WM contrast ratio.
KPNA2 is “novel prognostic factor” in RCC
High expression of karyopherin alpha 2 (KPNA2), a carrier protein that helps shuttle cancer-associated proteins from the nucleus to the cytoplasm, is an adverse prognostic factor in patients with clear cell or papillary renal cell carcinoma (RCC), according to a retrospective cohort study.
Senior author Glen Kristiansen, MD, director of the Institute of Pathology at the University Hospital Bonn (Germany), and his colleagues assessed tumor levels of KPNA2 protein by immunohistochemistry in 240 clinic patients with RCC (217 with clear cell histology, 23 with papillary histology). They also assessed tumor levels of KPNA2 mRNA in 771 patients with RCC (481 with clear cell histology, 290 with papillary cell histology) using publicly available gene expression data from the Cancer Genome Atlas (CGA).
Overall, 19% of the clinic patients’ tumors showed high expression of KPNA2 protein, according to results reported in Clinical Genitourinary Cancer. In addition, 26% of the CGA patients’ tumors showed high expression of KPNA2 mRNA.
Among patients with clear cell RCC, those with high tumor levels of KPNA2 protein survived roughly half as long as counterparts with low levels or none (74 months vs. 171 months); the difference was significant in univariate analysis (P = .012) but not in multivariate analysis that included well-known prognostic factors (HR, 1.491; P = .237). On the other hand, those with high tumor levels of KPNA2 mRNA had an elevated risk of death in both univariate analysis (HR, 2.31; P less than .001) and multivariate analysis (HR, 1.45; P = .035).
Among patients with papillary RCC, tumor levels of KPNA2 protein were not significantly associated with survival. However, those with high tumor levels of KPNA2 mRNA had a sharply elevated risk of death in both univariate analysis (HR, 9.7; P less than .001) and multivariate analysis (HR, 6.2; P = .004).
KPNA2 expression “represents a novel prognostic factor in these subtypes of RCC,” concluded Dr. Kristiansen and his coinvestigators. Therefore, this biomarker “could be used to stratify risk groups within RCC.” Collectively, the study’s findings suggest that KPNA2 is involved in both the pathogenesis and the progression of RCC. Given evidence that it helps transport p53 and fibroblast growth factor 2 at least in tumors with clear cell histology, “investigation of the nucleocytoplasmic transport through KPNA2 in [clear cell] RCC is an important task for future studies to better understand the link between elevated KPNA2 expression and altered biological processes like proliferation, cell growth, migration, invasion and tumor formation in RCC. In addition, examination of other members of [the] karyopherin-alpha family could elucidate the role of the nucleocytoplasmic transport system in pathogenesis of RCC.”
The authors reported that they had no conflict of interests.
SOURCE: Kristiansen G et al. Clin Genitourin Cancer. 2018 Oct 22. doi: 10.1016/j.clgc.2018.10.008.
High expression of karyopherin alpha 2 (KPNA2), a carrier protein that helps shuttle cancer-associated proteins from the nucleus to the cytoplasm, is an adverse prognostic factor in patients with clear cell or papillary renal cell carcinoma (RCC), according to a retrospective cohort study.
Senior author Glen Kristiansen, MD, director of the Institute of Pathology at the University Hospital Bonn (Germany), and his colleagues assessed tumor levels of KPNA2 protein by immunohistochemistry in 240 clinic patients with RCC (217 with clear cell histology, 23 with papillary histology). They also assessed tumor levels of KPNA2 mRNA in 771 patients with RCC (481 with clear cell histology, 290 with papillary cell histology) using publicly available gene expression data from the Cancer Genome Atlas (CGA).
Overall, 19% of the clinic patients’ tumors showed high expression of KPNA2 protein, according to results reported in Clinical Genitourinary Cancer. In addition, 26% of the CGA patients’ tumors showed high expression of KPNA2 mRNA.
Among patients with clear cell RCC, those with high tumor levels of KPNA2 protein survived roughly half as long as counterparts with low levels or none (74 months vs. 171 months); the difference was significant in univariate analysis (P = .012) but not in multivariate analysis that included well-known prognostic factors (HR, 1.491; P = .237). On the other hand, those with high tumor levels of KPNA2 mRNA had an elevated risk of death in both univariate analysis (HR, 2.31; P less than .001) and multivariate analysis (HR, 1.45; P = .035).
Among patients with papillary RCC, tumor levels of KPNA2 protein were not significantly associated with survival. However, those with high tumor levels of KPNA2 mRNA had a sharply elevated risk of death in both univariate analysis (HR, 9.7; P less than .001) and multivariate analysis (HR, 6.2; P = .004).
KPNA2 expression “represents a novel prognostic factor in these subtypes of RCC,” concluded Dr. Kristiansen and his coinvestigators. Therefore, this biomarker “could be used to stratify risk groups within RCC.” Collectively, the study’s findings suggest that KPNA2 is involved in both the pathogenesis and the progression of RCC. Given evidence that it helps transport p53 and fibroblast growth factor 2 at least in tumors with clear cell histology, “investigation of the nucleocytoplasmic transport through KPNA2 in [clear cell] RCC is an important task for future studies to better understand the link between elevated KPNA2 expression and altered biological processes like proliferation, cell growth, migration, invasion and tumor formation in RCC. In addition, examination of other members of [the] karyopherin-alpha family could elucidate the role of the nucleocytoplasmic transport system in pathogenesis of RCC.”
The authors reported that they had no conflict of interests.
SOURCE: Kristiansen G et al. Clin Genitourin Cancer. 2018 Oct 22. doi: 10.1016/j.clgc.2018.10.008.
High expression of karyopherin alpha 2 (KPNA2), a carrier protein that helps shuttle cancer-associated proteins from the nucleus to the cytoplasm, is an adverse prognostic factor in patients with clear cell or papillary renal cell carcinoma (RCC), according to a retrospective cohort study.
Senior author Glen Kristiansen, MD, director of the Institute of Pathology at the University Hospital Bonn (Germany), and his colleagues assessed tumor levels of KPNA2 protein by immunohistochemistry in 240 clinic patients with RCC (217 with clear cell histology, 23 with papillary histology). They also assessed tumor levels of KPNA2 mRNA in 771 patients with RCC (481 with clear cell histology, 290 with papillary cell histology) using publicly available gene expression data from the Cancer Genome Atlas (CGA).
Overall, 19% of the clinic patients’ tumors showed high expression of KPNA2 protein, according to results reported in Clinical Genitourinary Cancer. In addition, 26% of the CGA patients’ tumors showed high expression of KPNA2 mRNA.
Among patients with clear cell RCC, those with high tumor levels of KPNA2 protein survived roughly half as long as counterparts with low levels or none (74 months vs. 171 months); the difference was significant in univariate analysis (P = .012) but not in multivariate analysis that included well-known prognostic factors (HR, 1.491; P = .237). On the other hand, those with high tumor levels of KPNA2 mRNA had an elevated risk of death in both univariate analysis (HR, 2.31; P less than .001) and multivariate analysis (HR, 1.45; P = .035).
Among patients with papillary RCC, tumor levels of KPNA2 protein were not significantly associated with survival. However, those with high tumor levels of KPNA2 mRNA had a sharply elevated risk of death in both univariate analysis (HR, 9.7; P less than .001) and multivariate analysis (HR, 6.2; P = .004).
KPNA2 expression “represents a novel prognostic factor in these subtypes of RCC,” concluded Dr. Kristiansen and his coinvestigators. Therefore, this biomarker “could be used to stratify risk groups within RCC.” Collectively, the study’s findings suggest that KPNA2 is involved in both the pathogenesis and the progression of RCC. Given evidence that it helps transport p53 and fibroblast growth factor 2 at least in tumors with clear cell histology, “investigation of the nucleocytoplasmic transport through KPNA2 in [clear cell] RCC is an important task for future studies to better understand the link between elevated KPNA2 expression and altered biological processes like proliferation, cell growth, migration, invasion and tumor formation in RCC. In addition, examination of other members of [the] karyopherin-alpha family could elucidate the role of the nucleocytoplasmic transport system in pathogenesis of RCC.”
The authors reported that they had no conflict of interests.
SOURCE: Kristiansen G et al. Clin Genitourin Cancer. 2018 Oct 22. doi: 10.1016/j.clgc.2018.10.008.
FROM CLINICAL GENITOURINARY CANCER
Key clinical point:
Major finding: Survival was poorer for patients with clear cell RCC having high KPNA2 protein levels (74 vs. 171 months) or mRNA levels (hazard ratio for death, 1.45) and for patients with papillary RCC having high KPNA2 mRNA levels (HR, 6.2).
Study details: A retrospective dual cohort study of 240 clinic patients and 771 Cancer Genome Atlas patients.
Disclosures: The authors reported that they had no conflict of interests.
Source: Kristiansen G et al. Clin Genitourin Cancer. 2018 Oct 22. doi: 10.1016/j.clgc.2018.10.008.