The United States is in the midst of a public health crisis. Every day, 91 Americans die from opioid overdoses.¹ Opioid addiction has a tremendous negative effect on parents and children by destroying lives and breaking up families. When used appropriately, these drugs, such as morphine, hydrocodone, oxycodone, and fentanyl, provide much needed pain relief to patients, especially after a surgical procedure or during treatment for cancer. Unfortunately, opioids also have qualities that make them addictive and prone to overuse and abuse.

Heroin and other opioid drugs are affecting social, health, and economic welfare in communities throughout the United States. Opioid addiction does not discriminate among occupations, socioeconomic statuses, or ethnicities. Once addicted, users find it difficult to fight and overcome the habit. In this context, hospitalists who develop and use opioid policies and tactics are better equipped to deal with the increasing prevalence of opioid addiction and overdoses seen in the medical center environment.

Overview of opioid addiction

Opioids are more prevalent and easily available today in part because of the intense marketing campaigns by pharmaceutical companies. In fact, according to the 2014 National Survey on Drug Use and Health, almost 2 million Americans were dependent on or abused prescription opioids.² Opioids create artificial endorphins in the brain, amplifying positive feelings and euphoria. Once they become dependent, patients feel sick and become depressed when they aren’t using narcotics. They experience uncontrollable cravings, relieved only by increasing opioid use. Personal relationships and finances are severely affected because patients will do whatever they can to acquire more opioids. Some resort to doctor shopping to obtain more opioids, while others will engage in drug trafficking to purchase and sell narcotics. Most new heroin users report that they started with nonmedical use of opioid pain relievers.³

Unfortunately, in 2015, there were more than 20,000 prescription opioid overdose deaths and almost 13,000 overdose deaths related to heroin.⁴ In addition to addiction and death, overuse of narcotics can cause many medical issues, including dizziness, constipation, depression, and immune dysfunction.

As with any addiction, there are many problems related to opiate withdrawal. Some of these include anxiety, rhinorrhea, lacrimation, piloerection, mydriasis, nausea, vomiting, abdominal pain, diarrhea, tachycardia, and hypertension. Methadone, buprenorphine, and extended-release naltrexone typically are used to help alleviate cravings and the symptoms of withdrawal. With more than 1,000 patients treated daily by emergency departments for misuse of prescription opioids, it’s imperative for the medical community to address this health care crisis.⁵
 

Impact on first responders and hospitalists

The impact of this epidemic on the medical community is dramatic. Emergency system resources, already on overload, are further taxed and drained by the increased 911 calls for overdose incidents. This means that instead of responding to heart attacks, strokes, or other emergencies, first responders are spending time stabilizing overdose patients and taking them to hospitals. This resource drain spreads to emergency rooms and hospitals as they treat these patients. Eventually, the epidemic results in higher insurance costs to cover the impact on medical resources.

Strategies for hospitalists

A multifaceted approach is required to combat this crisis, and hospitalists are one component of that solution. Here are strategies hospitalists can employ to combat the growing use and abuse of narcotics:

• Screen for high-risk conditions. Before prescribing opioids, screen patients for conditions that may be exacerbated by opioid use, including sleep apnea, obesity COPD, and heart failure, as well as whether they are using medications that cause sedation and respiratory depression.
• Develop and follow pain management clinical pathway protocols. For example, start with nonopioid analgesics, such as acetaminophen, ibuprofen, and naproxen, for patients with mild pain. If the patient is in moderate pain, or if the mild pain was unrelieved by the first type of medicine, continue with opioid analgesics including codeine, oxycodone, hydrocodone, or morphine. Finally, if the patient is experiencing severe pain, or if the mild to moderate pain was unrelieved by previous medications, prescribe higher doses of morphine, fentanyl, or hydromorphone or use a patient-controlled analgesia delivery of an intravenous opioid.
• Discuss other treatment options. Instead of prescribing narcotics, assess whether other treatment options are viable. These include physical and occupational therapy, steroid shots, massage, local nerve blocks, and muscle relaxers.
• Evaluate the reason(s) for current use of prescribed narcotics. It’s crucial to determine why patients are using opioids. The medical condition for which they were prescribed these medications may have resolved. If patients are using opioids without a medically indicated reason, offer alternative medications, such as methadone or naltrexone, and provide education to help them slowly taper off the drugs. Do not cease opioid use altogether unless the use is contraindicated because of other medical conditions or unstable vital signs (for example, low blood pressure).
• Train nurses on opioid use and addiction. Educate nurses about opioid addiction risk factors and symptoms of addiction. Instruct them on managing the Ramsay Sedation Scale and using an opioid sedation scale with patients receiving IV narcotics.
• Educate families on opioid use and addiction. Counsel patients and their families on the long-term effects of opioid use and about the warning signs of addiction. Teach them about alternatives to narcotics.
• Offer referrals to specialized clinics. Work with social workers, case managers, and local mental health professionals to refer patients to behavioral counseling, patient and family support groups, and monitored detoxification clinics qualified to treat opioid addiction.

Socioeconomic impact

The effects of the opioid epidemic are felt in all areas of the United States, especially in the health care industry. Emergency department visits are mounting while billions of dollars are spent on medical care for those addicted to opioids. Additionally, the socioeconomic effects of this crisis contribute to increasing depression, anxiety, missed days of work or school, unemployment, drop-out rates, and loss of productivity among those addicted to opioids. Also, the epidemic is adversely affecting families, leading to increased divorce rates, single parent families, and child abuse and neglect. By creating strategies and protocols for medical staff, patients, and families affected by opioid use, addiction, or overdose, hospitalists can have a positive influence on patients’ lives and ultimately the opioid epidemic.

Dr. Kasarla is a hospitalist with Apogee Physicians at Parkway Surgical & Cardiovascular Hospital in Fort Worth, Tex. He also works for Texas Health Physicians Group at Texas Health Harris Methodist Hospital and Texas Health Harris Methodist Hospital Southwest in Fort Worth, as well as at Texas Health Harris Methodist Hospital in Azle, Tex.

You can contact him at [email protected] or [email protected].

References

1. Understanding the Epidemic: Drug overdose deaths in the United States continue to increase in 2015. Accessed Sept. 11, 2017.

2. Behavioral health trends in the United States: Results from the 2014 national survey on drug use and health. Accessed Sept. 11, 2017.

3. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132(1-2):95-100.

4. Rudd RA et al. Increases in drug and opioid-involved overdose deaths – United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(50-51):1445-52.

5. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. Accessed Sept. 11, 2017.
 

The United States is in the midst of a public health crisis. Every day, 91 Americans die from opioid overdoses.¹ Opioid addiction has a tremendous negative effect on parents and children by destroying lives and breaking up families. When used appropriately, these drugs, such as morphine, hydrocodone, oxycodone, and fentanyl, provide much needed pain relief to patients, especially after a surgical procedure or during treatment for cancer. Unfortunately, opioids also have qualities that make them addictive and prone to overuse and abuse.

Heroin and other opioid drugs are affecting social, health, and economic welfare in communities throughout the United States. Opioid addiction does not discriminate among occupations, socioeconomic statuses, or ethnicities. Once addicted, users find it difficult to fight and overcome the habit. In this context, hospitalists who develop and use opioid policies and tactics are better equipped to deal with the increasing prevalence of opioid addiction and overdoses seen in the medical center environment.

Overview of opioid addiction

Opioids are more prevalent and easily available today in part because of the intense marketing campaigns by pharmaceutical companies. In fact, according to the 2014 National Survey on Drug Use and Health, almost 2 million Americans were dependent on or abused prescription opioids.² Opioids create artificial endorphins in the brain, amplifying positive feelings and euphoria. Once they become dependent, patients feel sick and become depressed when they aren’t using narcotics. They experience uncontrollable cravings, relieved only by increasing opioid use. Personal relationships and finances are severely affected because patients will do whatever they can to acquire more opioids. Some resort to doctor shopping to obtain more opioids, while others will engage in drug trafficking to purchase and sell narcotics. Most new heroin users report that they started with nonmedical use of opioid pain relievers.³

Unfortunately, in 2015, there were more than 20,000 prescription opioid overdose deaths and almost 13,000 overdose deaths related to heroin.⁴ In addition to addiction and death, overuse of narcotics can cause many medical issues, including dizziness, constipation, depression, and immune dysfunction.

As with any addiction, there are many problems related to opiate withdrawal. Some of these include anxiety, rhinorrhea, lacrimation, piloerection, mydriasis, nausea, vomiting, abdominal pain, diarrhea, tachycardia, and hypertension. Methadone, buprenorphine, and extended-release naltrexone typically are used to help alleviate cravings and the symptoms of withdrawal. With more than 1,000 patients treated daily by emergency departments for misuse of prescription opioids, it’s imperative for the medical community to address this health care crisis.⁵
 

Impact on first responders and hospitalists

The impact of this epidemic on the medical community is dramatic. Emergency system resources, already on overload, are further taxed and drained by the increased 911 calls for overdose incidents. This means that instead of responding to heart attacks, strokes, or other emergencies, first responders are spending time stabilizing overdose patients and taking them to hospitals. This resource drain spreads to emergency rooms and hospitals as they treat these patients. Eventually, the epidemic results in higher insurance costs to cover the impact on medical resources.

Strategies for hospitalists

A multifaceted approach is required to combat this crisis, and hospitalists are one component of that solution. Here are strategies hospitalists can employ to combat the growing use and abuse of narcotics:

• Screen for high-risk conditions. Before prescribing opioids, screen patients for conditions that may be exacerbated by opioid use, including sleep apnea, obesity COPD, and heart failure, as well as whether they are using medications that cause sedation and respiratory depression.
• Develop and follow pain management clinical pathway protocols. For example, start with nonopioid analgesics, such as acetaminophen, ibuprofen, and naproxen, for patients with mild pain. If the patient is in moderate pain, or if the mild pain was unrelieved by the first type of medicine, continue with opioid analgesics including codeine, oxycodone, hydrocodone, or morphine. Finally, if the patient is experiencing severe pain, or if the mild to moderate pain was unrelieved by previous medications, prescribe higher doses of morphine, fentanyl, or hydromorphone or use a patient-controlled analgesia delivery of an intravenous opioid.
• Discuss other treatment options. Instead of prescribing narcotics, assess whether other treatment options are viable. These include physical and occupational therapy, steroid shots, massage, local nerve blocks, and muscle relaxers.
• Evaluate the reason(s) for current use of prescribed narcotics. It’s crucial to determine why patients are using opioids. The medical condition for which they were prescribed these medications may have resolved. If patients are using opioids without a medically indicated reason, offer alternative medications, such as methadone or naltrexone, and provide education to help them slowly taper off the drugs. Do not cease opioid use altogether unless the use is contraindicated because of other medical conditions or unstable vital signs (for example, low blood pressure).
• Train nurses on opioid use and addiction. Educate nurses about opioid addiction risk factors and symptoms of addiction. Instruct them on managing the Ramsay Sedation Scale and using an opioid sedation scale with patients receiving IV narcotics.
• Educate families on opioid use and addiction. Counsel patients and their families on the long-term effects of opioid use and about the warning signs of addiction. Teach them about alternatives to narcotics.
• Offer referrals to specialized clinics. Work with social workers, case managers, and local mental health professionals to refer patients to behavioral counseling, patient and family support groups, and monitored detoxification clinics qualified to treat opioid addiction.

Socioeconomic impact

The effects of the opioid epidemic are felt in all areas of the United States, especially in the health care industry. Emergency department visits are mounting while billions of dollars are spent on medical care for those addicted to opioids. Additionally, the socioeconomic effects of this crisis contribute to increasing depression, anxiety, missed days of work or school, unemployment, drop-out rates, and loss of productivity among those addicted to opioids. Also, the epidemic is adversely affecting families, leading to increased divorce rates, single parent families, and child abuse and neglect. By creating strategies and protocols for medical staff, patients, and families affected by opioid use, addiction, or overdose, hospitalists can have a positive influence on patients’ lives and ultimately the opioid epidemic.

Dr. Kasarla is a hospitalist with Apogee Physicians at Parkway Surgical & Cardiovascular Hospital in Fort Worth, Tex. He also works for Texas Health Physicians Group at Texas Health Harris Methodist Hospital and Texas Health Harris Methodist Hospital Southwest in Fort Worth, as well as at Texas Health Harris Methodist Hospital in Azle, Tex.

You can contact him at [email protected] or [email protected].

References

1. Understanding the Epidemic: Drug overdose deaths in the United States continue to increase in 2015. Accessed Sept. 11, 2017.

2. Behavioral health trends in the United States: Results from the 2014 national survey on drug use and health. Accessed Sept. 11, 2017.

3. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132(1-2):95-100.

4. Rudd RA et al. Increases in drug and opioid-involved overdose deaths – United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(50-51):1445-52.

5. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. Accessed Sept. 11, 2017.
 

The United States is in the midst of a public health crisis. Every day, 91 Americans die from opioid overdoses.¹ Opioid addiction has a tremendous negative effect on parents and children by destroying lives and breaking up families. When used appropriately, these drugs, such as morphine, hydrocodone, oxycodone, and fentanyl, provide much needed pain relief to patients, especially after a surgical procedure or during treatment for cancer. Unfortunately, opioids also have qualities that make them addictive and prone to overuse and abuse.

Heroin and other opioid drugs are affecting social, health, and economic welfare in communities throughout the United States. Opioid addiction does not discriminate among occupations, socioeconomic statuses, or ethnicities. Once addicted, users find it difficult to fight and overcome the habit. In this context, hospitalists who develop and use opioid policies and tactics are better equipped to deal with the increasing prevalence of opioid addiction and overdoses seen in the medical center environment.

Overview of opioid addiction

Opioids are more prevalent and easily available today in part because of the intense marketing campaigns by pharmaceutical companies. In fact, according to the 2014 National Survey on Drug Use and Health, almost 2 million Americans were dependent on or abused prescription opioids.² Opioids create artificial endorphins in the brain, amplifying positive feelings and euphoria. Once they become dependent, patients feel sick and become depressed when they aren’t using narcotics. They experience uncontrollable cravings, relieved only by increasing opioid use. Personal relationships and finances are severely affected because patients will do whatever they can to acquire more opioids. Some resort to doctor shopping to obtain more opioids, while others will engage in drug trafficking to purchase and sell narcotics. Most new heroin users report that they started with nonmedical use of opioid pain relievers.³

Unfortunately, in 2015, there were more than 20,000 prescription opioid overdose deaths and almost 13,000 overdose deaths related to heroin.⁴ In addition to addiction and death, overuse of narcotics can cause many medical issues, including dizziness, constipation, depression, and immune dysfunction.

As with any addiction, there are many problems related to opiate withdrawal. Some of these include anxiety, rhinorrhea, lacrimation, piloerection, mydriasis, nausea, vomiting, abdominal pain, diarrhea, tachycardia, and hypertension. Methadone, buprenorphine, and extended-release naltrexone typically are used to help alleviate cravings and the symptoms of withdrawal. With more than 1,000 patients treated daily by emergency departments for misuse of prescription opioids, it’s imperative for the medical community to address this health care crisis.⁵
 

Impact on first responders and hospitalists

The impact of this epidemic on the medical community is dramatic. Emergency system resources, already on overload, are further taxed and drained by the increased 911 calls for overdose incidents. This means that instead of responding to heart attacks, strokes, or other emergencies, first responders are spending time stabilizing overdose patients and taking them to hospitals. This resource drain spreads to emergency rooms and hospitals as they treat these patients. Eventually, the epidemic results in higher insurance costs to cover the impact on medical resources.

Strategies for hospitalists

A multifaceted approach is required to combat this crisis, and hospitalists are one component of that solution. Here are strategies hospitalists can employ to combat the growing use and abuse of narcotics:

• Screen for high-risk conditions. Before prescribing opioids, screen patients for conditions that may be exacerbated by opioid use, including sleep apnea, obesity COPD, and heart failure, as well as whether they are using medications that cause sedation and respiratory depression.
• Develop and follow pain management clinical pathway protocols. For example, start with nonopioid analgesics, such as acetaminophen, ibuprofen, and naproxen, for patients with mild pain. If the patient is in moderate pain, or if the mild pain was unrelieved by the first type of medicine, continue with opioid analgesics including codeine, oxycodone, hydrocodone, or morphine. Finally, if the patient is experiencing severe pain, or if the mild to moderate pain was unrelieved by previous medications, prescribe higher doses of morphine, fentanyl, or hydromorphone or use a patient-controlled analgesia delivery of an intravenous opioid.
• Discuss other treatment options. Instead of prescribing narcotics, assess whether other treatment options are viable. These include physical and occupational therapy, steroid shots, massage, local nerve blocks, and muscle relaxers.
• Evaluate the reason(s) for current use of prescribed narcotics. It’s crucial to determine why patients are using opioids. The medical condition for which they were prescribed these medications may have resolved. If patients are using opioids without a medically indicated reason, offer alternative medications, such as methadone or naltrexone, and provide education to help them slowly taper off the drugs. Do not cease opioid use altogether unless the use is contraindicated because of other medical conditions or unstable vital signs (for example, low blood pressure).
• Train nurses on opioid use and addiction. Educate nurses about opioid addiction risk factors and symptoms of addiction. Instruct them on managing the Ramsay Sedation Scale and using an opioid sedation scale with patients receiving IV narcotics.
• Educate families on opioid use and addiction. Counsel patients and their families on the long-term effects of opioid use and about the warning signs of addiction. Teach them about alternatives to narcotics.
• Offer referrals to specialized clinics. Work with social workers, case managers, and local mental health professionals to refer patients to behavioral counseling, patient and family support groups, and monitored detoxification clinics qualified to treat opioid addiction.

Socioeconomic impact

The effects of the opioid epidemic are felt in all areas of the United States, especially in the health care industry. Emergency department visits are mounting while billions of dollars are spent on medical care for those addicted to opioids. Additionally, the socioeconomic effects of this crisis contribute to increasing depression, anxiety, missed days of work or school, unemployment, drop-out rates, and loss of productivity among those addicted to opioids. Also, the epidemic is adversely affecting families, leading to increased divorce rates, single parent families, and child abuse and neglect. By creating strategies and protocols for medical staff, patients, and families affected by opioid use, addiction, or overdose, hospitalists can have a positive influence on patients’ lives and ultimately the opioid epidemic.

Dr. Kasarla is a hospitalist with Apogee Physicians at Parkway Surgical & Cardiovascular Hospital in Fort Worth, Tex. He also works for Texas Health Physicians Group at Texas Health Harris Methodist Hospital and Texas Health Harris Methodist Hospital Southwest in Fort Worth, as well as at Texas Health Harris Methodist Hospital in Azle, Tex.

You can contact him at [email protected] or [email protected].

References

1. Understanding the Epidemic: Drug overdose deaths in the United States continue to increase in 2015. Accessed Sept. 11, 2017.

2. Behavioral health trends in the United States: Results from the 2014 national survey on drug use and health. Accessed Sept. 11, 2017.

3. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132(1-2):95-100.

4. Rudd RA et al. Increases in drug and opioid-involved overdose deaths – United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(50-51):1445-52.

5. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. Accessed Sept. 11, 2017.
 

The suicide rate in the United States rose over 19% from 2001 to 2015, with an increasing gap separating rural areas from those with large urban populations, according to the Centers for Disease Control and Prevention.

Suicide rates in nonmetropolitan/rural counties for those aged 10 years and older have been consistently higher, and increased more, than those in large metropolitan counties, the CDC said.

[email protected]

The suicide rate in the United States rose over 19% from 2001 to 2015, with an increasing gap separating rural areas from those with large urban populations, according to the Centers for Disease Control and Prevention.

Suicide rates in nonmetropolitan/rural counties for those aged 10 years and older have been consistently higher, and increased more, than those in large metropolitan counties, the CDC said.

[email protected]

The suicide rate in the United States rose over 19% from 2001 to 2015, with an increasing gap separating rural areas from those with large urban populations, according to the Centers for Disease Control and Prevention.

Suicide rates in nonmetropolitan/rural counties for those aged 10 years and older have been consistently higher, and increased more, than those in large metropolitan counties, the CDC said.

[email protected]

A patient with Merkel cell carcinoma (MCC) came to Sir Charles Gairdner Hospital in Perth, Australia, after 2 weeks of dyspnea. He was diagnosed with cardiac tamponade and received urgent pericardiocentesis. An echocardiogram and computer tomography scan showed a large infiltrating mass in the heart. Immunohistochemistry of the pericardial fluid revealed MCC. The MCC had metastasized to his heart—the tenth such reported case, and the second case reported of MCC causing cardiac tamponade.

The clinicians report on several “important illustrative aspects” that appeared while they were unraveling the clues to the patient’s condition. One aspect was the challenge of the histopathologic diagnosis itself. The majority of patients with MCC present with localized disease, they note. Only 4% of patients have distant metastases, usually to lymph nodes, lung, central nervous system, and bone. MCC metastases to the heart are extremely rare. Most commonly, a cancer that spreads to the heart has started in the lungs, esophagus, or breast, or has begun as lymphoma, melanoma, or leukemia.  

However, it’s “exponentially more likely,” the clinicians say, for a cardiac tumor to be a metastasis than a primary cardiac tumor, and it is uncommon for the heart to be the only site of metastatic disease from a noncardiac malignancy. Thus, the patient represented a unique case: apart from an internal mammary lymph node, the heart was the only site of distant metastatic spread.  

This patient’s case highlights the importance of early and accurate diagnosis of MCC with aggressive surgical treatment for localized disease, the clinicians say. New cardiac symptoms in the setting of malignancy should raise suspicion of cardiac metastasis.

Source:
Di Loreto M, Francis R. BMJ Case Rep. 2017. pii: bcr-2017-221311.
doi: 10.1136/bcr-2017-221311.

A patient with Merkel cell carcinoma (MCC) came to Sir Charles Gairdner Hospital in Perth, Australia, after 2 weeks of dyspnea. He was diagnosed with cardiac tamponade and received urgent pericardiocentesis. An echocardiogram and computer tomography scan showed a large infiltrating mass in the heart. Immunohistochemistry of the pericardial fluid revealed MCC. The MCC had metastasized to his heart—the tenth such reported case, and the second case reported of MCC causing cardiac tamponade.

The clinicians report on several “important illustrative aspects” that appeared while they were unraveling the clues to the patient’s condition. One aspect was the challenge of the histopathologic diagnosis itself. The majority of patients with MCC present with localized disease, they note. Only 4% of patients have distant metastases, usually to lymph nodes, lung, central nervous system, and bone. MCC metastases to the heart are extremely rare. Most commonly, a cancer that spreads to the heart has started in the lungs, esophagus, or breast, or has begun as lymphoma, melanoma, or leukemia.  

However, it’s “exponentially more likely,” the clinicians say, for a cardiac tumor to be a metastasis than a primary cardiac tumor, and it is uncommon for the heart to be the only site of metastatic disease from a noncardiac malignancy. Thus, the patient represented a unique case: apart from an internal mammary lymph node, the heart was the only site of distant metastatic spread.  

This patient’s case highlights the importance of early and accurate diagnosis of MCC with aggressive surgical treatment for localized disease, the clinicians say. New cardiac symptoms in the setting of malignancy should raise suspicion of cardiac metastasis.

Source:
Di Loreto M, Francis R. BMJ Case Rep. 2017. pii: bcr-2017-221311.
doi: 10.1136/bcr-2017-221311.

A patient with Merkel cell carcinoma (MCC) came to Sir Charles Gairdner Hospital in Perth, Australia, after 2 weeks of dyspnea. He was diagnosed with cardiac tamponade and received urgent pericardiocentesis. An echocardiogram and computer tomography scan showed a large infiltrating mass in the heart. Immunohistochemistry of the pericardial fluid revealed MCC. The MCC had metastasized to his heart—the tenth such reported case, and the second case reported of MCC causing cardiac tamponade.

The clinicians report on several “important illustrative aspects” that appeared while they were unraveling the clues to the patient’s condition. One aspect was the challenge of the histopathologic diagnosis itself. The majority of patients with MCC present with localized disease, they note. Only 4% of patients have distant metastases, usually to lymph nodes, lung, central nervous system, and bone. MCC metastases to the heart are extremely rare. Most commonly, a cancer that spreads to the heart has started in the lungs, esophagus, or breast, or has begun as lymphoma, melanoma, or leukemia.  

However, it’s “exponentially more likely,” the clinicians say, for a cardiac tumor to be a metastasis than a primary cardiac tumor, and it is uncommon for the heart to be the only site of metastatic disease from a noncardiac malignancy. Thus, the patient represented a unique case: apart from an internal mammary lymph node, the heart was the only site of distant metastatic spread.  

This patient’s case highlights the importance of early and accurate diagnosis of MCC with aggressive surgical treatment for localized disease, the clinicians say. New cardiac symptoms in the setting of malignancy should raise suspicion of cardiac metastasis.

Source:
Di Loreto M, Francis R. BMJ Case Rep. 2017. pii: bcr-2017-221311.
doi: 10.1136/bcr-2017-221311.

Photo by Rhoda Baer

New research indicates that hospitalized patients with advanced cancer have a high burden of physical and psychological symptoms, and this burden is linked to longer hospital stays and a greater risk for unplanned hospital readmissions and death.

Researchers said these findings highlight the need to develop and test interventions to lessen patients’ symptoms.

Ryan Nipp, MD, of Massachusetts General Hospital in Boston, and his colleagues reported the findings in Cancer.

The researchers noted that patients with advanced cancer often experience frequent and prolonged hospitalizations for reasons that have not been fully explored.

To investigate, the team collected information from 1036 patients with advanced cancer as they were being admitted for an unplanned hospitalization.

The Edmonton Symptom Assessment System (ESAS) was used to assess patients’ physical symptoms, and the Patient Health Questionnaire 4 (PHQ-4) was used to assess their psychological symptoms.

The researchers examined the relationship between patients’ symptom burden and the duration of their hospital stay, risk of readmission, and death.

Many patients reported moderate or severe fatigue (86.7%), poor well-being (74.2%), drowsiness (71.7%), pain (67.7%), and lack of appetite (67.3%). Nearly 30% of patients had clinically significant symptoms of depression (28.8%) and anxiety (28.0%).

The patients’ mean hospital stay was 6.3 days, the readmission rate within 90 days of discharge was 43.1%, and the 90-day mortality rate was 41.6%.

Physical symptoms (P<0.001), total ESAS score (P<0.001), total PHQ-4 score (P=0.040), and depression symptoms (P=0.017) were significantly associated with longer hospital stays, but anxiety symptoms were not (P=0.190).

Physical symptoms (P<0.001), total ESAS score (P<0.001), total PHQ-4 score (P=0.072), and anxiety symptoms (P=0.045) were significantly associated with a higher likelihood of readmission within 90 days, but depression symptoms were not (P=0.219).

Physical symptoms (P<0.001), total ESAS score (P<0.001), total PHQ-4 score (P<0.001), depression symptoms (P<0.001), and anxiety symptoms (P=0.012) were all significantly associated with a higher likelihood of death or readmission within 90 days.

“We demonstrated that many hospitalized patients with advanced cancer experience an immense physical and psychological symptom burden,” Dr Nipp said.

“Interventions to identify and treat symptomatic patients hold great potential for improving patients’ experience with their illness, enhancing their quality of life, and reducing their healthcare utilization.”

Photo by Rhoda Baer

New research indicates that hospitalized patients with advanced cancer have a high burden of physical and psychological symptoms, and this burden is linked to longer hospital stays and a greater risk for unplanned hospital readmissions and death.

Researchers said these findings highlight the need to develop and test interventions to lessen patients’ symptoms.

Ryan Nipp, MD, of Massachusetts General Hospital in Boston, and his colleagues reported the findings in Cancer.

The researchers noted that patients with advanced cancer often experience frequent and prolonged hospitalizations for reasons that have not been fully explored.

To investigate, the team collected information from 1036 patients with advanced cancer as they were being admitted for an unplanned hospitalization.

The Edmonton Symptom Assessment System (ESAS) was used to assess patients’ physical symptoms, and the Patient Health Questionnaire 4 (PHQ-4) was used to assess their psychological symptoms.

The researchers examined the relationship between patients’ symptom burden and the duration of their hospital stay, risk of readmission, and death.

Many patients reported moderate or severe fatigue (86.7%), poor well-being (74.2%), drowsiness (71.7%), pain (67.7%), and lack of appetite (67.3%). Nearly 30% of patients had clinically significant symptoms of depression (28.8%) and anxiety (28.0%).

The patients’ mean hospital stay was 6.3 days, the readmission rate within 90 days of discharge was 43.1%, and the 90-day mortality rate was 41.6%.

Physical symptoms (P<0.001), total ESAS score (P<0.001), total PHQ-4 score (P=0.040), and depression symptoms (P=0.017) were significantly associated with longer hospital stays, but anxiety symptoms were not (P=0.190).

Physical symptoms (P<0.001), total ESAS score (P<0.001), total PHQ-4 score (P=0.072), and anxiety symptoms (P=0.045) were significantly associated with a higher likelihood of readmission within 90 days, but depression symptoms were not (P=0.219).

Physical symptoms (P<0.001), total ESAS score (P<0.001), total PHQ-4 score (P<0.001), depression symptoms (P<0.001), and anxiety symptoms (P=0.012) were all significantly associated with a higher likelihood of death or readmission within 90 days.

“We demonstrated that many hospitalized patients with advanced cancer experience an immense physical and psychological symptom burden,” Dr Nipp said.

“Interventions to identify and treat symptomatic patients hold great potential for improving patients’ experience with their illness, enhancing their quality of life, and reducing their healthcare utilization.”

Photo by Rhoda Baer

New research indicates that hospitalized patients with advanced cancer have a high burden of physical and psychological symptoms, and this burden is linked to longer hospital stays and a greater risk for unplanned hospital readmissions and death.

Researchers said these findings highlight the need to develop and test interventions to lessen patients’ symptoms.

Ryan Nipp, MD, of Massachusetts General Hospital in Boston, and his colleagues reported the findings in Cancer.

The researchers noted that patients with advanced cancer often experience frequent and prolonged hospitalizations for reasons that have not been fully explored.

To investigate, the team collected information from 1036 patients with advanced cancer as they were being admitted for an unplanned hospitalization.

The Edmonton Symptom Assessment System (ESAS) was used to assess patients’ physical symptoms, and the Patient Health Questionnaire 4 (PHQ-4) was used to assess their psychological symptoms.

The researchers examined the relationship between patients’ symptom burden and the duration of their hospital stay, risk of readmission, and death.

Many patients reported moderate or severe fatigue (86.7%), poor well-being (74.2%), drowsiness (71.7%), pain (67.7%), and lack of appetite (67.3%). Nearly 30% of patients had clinically significant symptoms of depression (28.8%) and anxiety (28.0%).

The patients’ mean hospital stay was 6.3 days, the readmission rate within 90 days of discharge was 43.1%, and the 90-day mortality rate was 41.6%.

Physical symptoms (P<0.001), total ESAS score (P<0.001), total PHQ-4 score (P=0.040), and depression symptoms (P=0.017) were significantly associated with longer hospital stays, but anxiety symptoms were not (P=0.190).

Physical symptoms (P<0.001), total ESAS score (P<0.001), total PHQ-4 score (P=0.072), and anxiety symptoms (P=0.045) were significantly associated with a higher likelihood of readmission within 90 days, but depression symptoms were not (P=0.219).

Physical symptoms (P<0.001), total ESAS score (P<0.001), total PHQ-4 score (P<0.001), depression symptoms (P<0.001), and anxiety symptoms (P=0.012) were all significantly associated with a higher likelihood of death or readmission within 90 days.

“We demonstrated that many hospitalized patients with advanced cancer experience an immense physical and psychological symptom burden,” Dr Nipp said.

“Interventions to identify and treat symptomatic patients hold great potential for improving patients’ experience with their illness, enhancing their quality of life, and reducing their healthcare utilization.”

Photo by Chad McNeeley

GRANADA, SPAIN—A monoclonal antibody can resolve co-existing hematopoietic stem cell transplant-associated thrombotic microangiopathy (HSCT-TMA) and graft-versus-host disease (GVHD), according to a case study.

The antibody is OMS721, and it targets MASP-2, a pro-inflammatory protein target involved in activation of the complement system.

The case of OMS721 ameliorating HSCT-TMA and GVHD was presented at the European Society for Blood and Marrow Transplantation Crash Course on Diagnosis and Treatment of Noninfectious Complications after HCT.

The patient was a participant in an ongoing phase 2 trial of thrombotic microangiopathies, including HSCT-TMA. The trial is sponsored by Omeros Corporation, the company developing OMS721.

The patient was an adult male with post-transplant TMA persisting at least 2 weeks following calcineurin inhibitor modification.

The patient had undergone HSCT for T-cell acute lymphoblastic leukemia. His post-transplant course was complicated by multiple episodes of steroid-refractory grade 4 GVHD, cytomegalovirus infection, and HSCT-TMA.

After 2 prior episodes of GVHD, the patient presented with bloody diarrhea. Intestinal biopsy demonstrated both HSCT-TMA and GVHD. No infections were identified.

The patient also had new-onset neurological symptoms of paresthesias, tetraparesis, and a neurogenic bladder, which have been reported as neurological manifestations of GVHD and TMA.

The patient was unable to walk due to the tetraparesis and required blood transfusions at least once daily. Hematological markers demonstrated HSCT-TMA with thrombocytopenia, elevated lactate dehydrogenase, and schistocytes.

Two weeks prior to starting OMS721, the patient’s immunosuppression (cyclosporine) had been decreased, and, given his history of steroid-refractory GVHD, he was receiving only low-dose corticosteroids. He received no other GVHD treatment.

After 2 OMS721 doses, the patient’s bloody diarrhea resolved, and his hematological markers improved. After 4 OMS721 doses, he was able to walk with help.

The patient completed 8 weeks of OMS721 treatment and has been doing well at home. All signs and symptoms of HSCT-TMA and all clinical symptoms of GVHD have resolved. His neurological symptoms have continued to improve.

“This patient’s marked response to OMS721 treatment was very gratifying,” said Anna Grassi, MD, of Azienda Ospedaliera Papa Giovanni XXIII in Bergamo, Italy.

“The cause of his neurological symptoms is not clear but may be a manifestation of GVHD or other endothelial injury. Prior to OMS721 treatment, this patient was deteriorating and at high risk for early death. The improvement of GVHD, H[S]CT-TMA, and the neurological symptoms following OMS721 treatment is promising.”

Photo by Chad McNeeley

GRANADA, SPAIN—A monoclonal antibody can resolve co-existing hematopoietic stem cell transplant-associated thrombotic microangiopathy (HSCT-TMA) and graft-versus-host disease (GVHD), according to a case study.

The antibody is OMS721, and it targets MASP-2, a pro-inflammatory protein target involved in activation of the complement system.

The case of OMS721 ameliorating HSCT-TMA and GVHD was presented at the European Society for Blood and Marrow Transplantation Crash Course on Diagnosis and Treatment of Noninfectious Complications after HCT.

The patient was a participant in an ongoing phase 2 trial of thrombotic microangiopathies, including HSCT-TMA. The trial is sponsored by Omeros Corporation, the company developing OMS721.

The patient was an adult male with post-transplant TMA persisting at least 2 weeks following calcineurin inhibitor modification.

The patient had undergone HSCT for T-cell acute lymphoblastic leukemia. His post-transplant course was complicated by multiple episodes of steroid-refractory grade 4 GVHD, cytomegalovirus infection, and HSCT-TMA.

After 2 prior episodes of GVHD, the patient presented with bloody diarrhea. Intestinal biopsy demonstrated both HSCT-TMA and GVHD. No infections were identified.

The patient also had new-onset neurological symptoms of paresthesias, tetraparesis, and a neurogenic bladder, which have been reported as neurological manifestations of GVHD and TMA.

The patient was unable to walk due to the tetraparesis and required blood transfusions at least once daily. Hematological markers demonstrated HSCT-TMA with thrombocytopenia, elevated lactate dehydrogenase, and schistocytes.

Two weeks prior to starting OMS721, the patient’s immunosuppression (cyclosporine) had been decreased, and, given his history of steroid-refractory GVHD, he was receiving only low-dose corticosteroids. He received no other GVHD treatment.

After 2 OMS721 doses, the patient’s bloody diarrhea resolved, and his hematological markers improved. After 4 OMS721 doses, he was able to walk with help.

The patient completed 8 weeks of OMS721 treatment and has been doing well at home. All signs and symptoms of HSCT-TMA and all clinical symptoms of GVHD have resolved. His neurological symptoms have continued to improve.

“This patient’s marked response to OMS721 treatment was very gratifying,” said Anna Grassi, MD, of Azienda Ospedaliera Papa Giovanni XXIII in Bergamo, Italy.

“The cause of his neurological symptoms is not clear but may be a manifestation of GVHD or other endothelial injury. Prior to OMS721 treatment, this patient was deteriorating and at high risk for early death. The improvement of GVHD, H[S]CT-TMA, and the neurological symptoms following OMS721 treatment is promising.”

Photo by Chad McNeeley

GRANADA, SPAIN—A monoclonal antibody can resolve co-existing hematopoietic stem cell transplant-associated thrombotic microangiopathy (HSCT-TMA) and graft-versus-host disease (GVHD), according to a case study.

The antibody is OMS721, and it targets MASP-2, a pro-inflammatory protein target involved in activation of the complement system.

The case of OMS721 ameliorating HSCT-TMA and GVHD was presented at the European Society for Blood and Marrow Transplantation Crash Course on Diagnosis and Treatment of Noninfectious Complications after HCT.

The patient was a participant in an ongoing phase 2 trial of thrombotic microangiopathies, including HSCT-TMA. The trial is sponsored by Omeros Corporation, the company developing OMS721.

The patient was an adult male with post-transplant TMA persisting at least 2 weeks following calcineurin inhibitor modification.

The patient had undergone HSCT for T-cell acute lymphoblastic leukemia. His post-transplant course was complicated by multiple episodes of steroid-refractory grade 4 GVHD, cytomegalovirus infection, and HSCT-TMA.

After 2 prior episodes of GVHD, the patient presented with bloody diarrhea. Intestinal biopsy demonstrated both HSCT-TMA and GVHD. No infections were identified.

The patient also had new-onset neurological symptoms of paresthesias, tetraparesis, and a neurogenic bladder, which have been reported as neurological manifestations of GVHD and TMA.

The patient was unable to walk due to the tetraparesis and required blood transfusions at least once daily. Hematological markers demonstrated HSCT-TMA with thrombocytopenia, elevated lactate dehydrogenase, and schistocytes.

Two weeks prior to starting OMS721, the patient’s immunosuppression (cyclosporine) had been decreased, and, given his history of steroid-refractory GVHD, he was receiving only low-dose corticosteroids. He received no other GVHD treatment.

After 2 OMS721 doses, the patient’s bloody diarrhea resolved, and his hematological markers improved. After 4 OMS721 doses, he was able to walk with help.

The patient completed 8 weeks of OMS721 treatment and has been doing well at home. All signs and symptoms of HSCT-TMA and all clinical symptoms of GVHD have resolved. His neurological symptoms have continued to improve.

“This patient’s marked response to OMS721 treatment was very gratifying,” said Anna Grassi, MD, of Azienda Ospedaliera Papa Giovanni XXIII in Bergamo, Italy.

“The cause of his neurological symptoms is not clear but may be a manifestation of GVHD or other endothelial injury. Prior to OMS721 treatment, this patient was deteriorating and at high risk for early death. The improvement of GVHD, H[S]CT-TMA, and the neurological symptoms following OMS721 treatment is promising.”

follicular lymphoma

The European Medicines Agency’s (EMA’s) Committee for Orphan Medicinal Products has recommended orphan designation for G100 for the treatment of follicular lymphoma (FL).

G100 contains the synthetic small molecule toll-like receptor-4 agonist glucopyranosyl lipid A.

G100 works by activating innate and adaptive immunity in the tumor microenvironment to generate an immune response against the tumor’s pre-existing antigens.

Clinical and preclinical data have demonstrated G100’s ability to activate tumor-infiltrating lymphocytes, macrophages, and dendritic cells, and promote antigen-presentation and the recruitment of T cells to the tumor.

The induction of local and systemic immune responses has been shown in preclinical studies to result in local and abscopal tumor control.

Immune Design, the company developing G100, is currently evaluating G100 plus local radiation, with or without pembrolizumab, in a phase 1/2 trial of FL patients.

Results from this trial were presented at the 2017 ASCO Annual Meeting (abstract 7537). Nine patients who received G100 (3 patients each at the 5, 10, or 20 μg dose) with radiation (but not pembrolizumab) were evaluable for safety and efficacy.

The overall response rate was 44%, and all of these were partial responses (n=4). Thirty-three percent of patients had stable disease (n=3).

Among the responders, tumor regression ranged from 58% to 89%, which included up to 56% shrinkage of abscopal sites. Tumor biopsies showed increased inflammatory responses and T-cell infiltrates in abscopal tumors.

An additional 13 patients treated at the 10 μg dose were evaluable for safety.  There were no dose-limiting toxicities, serious adverse events (AEs), or grade 3/4 AEs observed.

Common AEs included injection site disorders, abdominal pain/discomfort, nausea, pruritus, and decrease in lymphocytes.

Immune Design said that, if this trial produces a sufficiently robust clinical benefit for patients, the company may pursue FL as the first indication for regulatory approval of G100.

About orphan designation

Orphan designation provides regulatory and financial incentives for companies to develop and market therapies that treat life-threatening or chronically debilitating conditions affecting no more than 5 in 10,000 people in the European Union, and where no satisfactory treatment is available.

Orphan designation provides a 10-year period of marketing exclusivity if the drug receives regulatory approval.

The designation also provides incentives for companies seeking protocol assistance from the EMA during the product development phase and direct access to the centralized authorization procedure.

The EMA’s Committee for Orphan Medicinal Products adopts an opinion on the granting of orphan drug designation, and that opinion is submitted to the European Commission for a final decision. The commission typically makes a decision within 30 days of the submission. 

follicular lymphoma

The European Medicines Agency’s (EMA’s) Committee for Orphan Medicinal Products has recommended orphan designation for G100 for the treatment of follicular lymphoma (FL).

G100 contains the synthetic small molecule toll-like receptor-4 agonist glucopyranosyl lipid A.

G100 works by activating innate and adaptive immunity in the tumor microenvironment to generate an immune response against the tumor’s pre-existing antigens.

Clinical and preclinical data have demonstrated G100’s ability to activate tumor-infiltrating lymphocytes, macrophages, and dendritic cells, and promote antigen-presentation and the recruitment of T cells to the tumor.

The induction of local and systemic immune responses has been shown in preclinical studies to result in local and abscopal tumor control.

Immune Design, the company developing G100, is currently evaluating G100 plus local radiation, with or without pembrolizumab, in a phase 1/2 trial of FL patients.

Results from this trial were presented at the 2017 ASCO Annual Meeting (abstract 7537). Nine patients who received G100 (3 patients each at the 5, 10, or 20 μg dose) with radiation (but not pembrolizumab) were evaluable for safety and efficacy.

The overall response rate was 44%, and all of these were partial responses (n=4). Thirty-three percent of patients had stable disease (n=3).

Among the responders, tumor regression ranged from 58% to 89%, which included up to 56% shrinkage of abscopal sites. Tumor biopsies showed increased inflammatory responses and T-cell infiltrates in abscopal tumors.

An additional 13 patients treated at the 10 μg dose were evaluable for safety.  There were no dose-limiting toxicities, serious adverse events (AEs), or grade 3/4 AEs observed.

Common AEs included injection site disorders, abdominal pain/discomfort, nausea, pruritus, and decrease in lymphocytes.

Immune Design said that, if this trial produces a sufficiently robust clinical benefit for patients, the company may pursue FL as the first indication for regulatory approval of G100.

About orphan designation

Orphan designation provides regulatory and financial incentives for companies to develop and market therapies that treat life-threatening or chronically debilitating conditions affecting no more than 5 in 10,000 people in the European Union, and where no satisfactory treatment is available.

Orphan designation provides a 10-year period of marketing exclusivity if the drug receives regulatory approval.

The designation also provides incentives for companies seeking protocol assistance from the EMA during the product development phase and direct access to the centralized authorization procedure.

The EMA’s Committee for Orphan Medicinal Products adopts an opinion on the granting of orphan drug designation, and that opinion is submitted to the European Commission for a final decision. The commission typically makes a decision within 30 days of the submission. 

follicular lymphoma

The European Medicines Agency’s (EMA’s) Committee for Orphan Medicinal Products has recommended orphan designation for G100 for the treatment of follicular lymphoma (FL).

G100 contains the synthetic small molecule toll-like receptor-4 agonist glucopyranosyl lipid A.

G100 works by activating innate and adaptive immunity in the tumor microenvironment to generate an immune response against the tumor’s pre-existing antigens.

Clinical and preclinical data have demonstrated G100’s ability to activate tumor-infiltrating lymphocytes, macrophages, and dendritic cells, and promote antigen-presentation and the recruitment of T cells to the tumor.

The induction of local and systemic immune responses has been shown in preclinical studies to result in local and abscopal tumor control.

Immune Design, the company developing G100, is currently evaluating G100 plus local radiation, with or without pembrolizumab, in a phase 1/2 trial of FL patients.

Results from this trial were presented at the 2017 ASCO Annual Meeting (abstract 7537). Nine patients who received G100 (3 patients each at the 5, 10, or 20 μg dose) with radiation (but not pembrolizumab) were evaluable for safety and efficacy.

The overall response rate was 44%, and all of these were partial responses (n=4). Thirty-three percent of patients had stable disease (n=3).

Among the responders, tumor regression ranged from 58% to 89%, which included up to 56% shrinkage of abscopal sites. Tumor biopsies showed increased inflammatory responses and T-cell infiltrates in abscopal tumors.

An additional 13 patients treated at the 10 μg dose were evaluable for safety.  There were no dose-limiting toxicities, serious adverse events (AEs), or grade 3/4 AEs observed.

Common AEs included injection site disorders, abdominal pain/discomfort, nausea, pruritus, and decrease in lymphocytes.

Immune Design said that, if this trial produces a sufficiently robust clinical benefit for patients, the company may pursue FL as the first indication for regulatory approval of G100.

About orphan designation

Orphan designation provides regulatory and financial incentives for companies to develop and market therapies that treat life-threatening or chronically debilitating conditions affecting no more than 5 in 10,000 people in the European Union, and where no satisfactory treatment is available.

Orphan designation provides a 10-year period of marketing exclusivity if the drug receives regulatory approval.

The designation also provides incentives for companies seeking protocol assistance from the EMA during the product development phase and direct access to the centralized authorization procedure.

The EMA’s Committee for Orphan Medicinal Products adopts an opinion on the granting of orphan drug designation, and that opinion is submitted to the European Commission for a final decision. The commission typically makes a decision within 30 days of the submission. 

Infants with congenital cytomegalovirus (cCMV) who were asymptomatic at birth with normal hearing by age 2 years were not at higher risk of intellectual impairment or low academic achievement, compared with controls, but patients with sensorineural hearing loss may experience more difficulty, according to a longitudinal study.

Full-scale intelligence, language, and academic achievement was evaluated in 78 adolescents with cCMV and normal hearing, 11 with cCMV and sensorineural hearing loss (SNHL) by age 2 years, and 40 controls. Mean full-scale intelligence scores did not vary among the patients with normal hearing and the controls, said Adriana S. Lopez of the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, and her coauthors. Each group scored a mean 108 (95% confidence interval, 105-110 and 104-111, respectively) at age 5 years and 111 (95% CI, 108-114 and 107-104, respectively) at age 18 years (P = .96). The scores of the patients with SNHL, however, were 7 points lower at both times (P less than .05).

CDC/Craig Lyerla

[email protected]

Infants with congenital cytomegalovirus (cCMV) who were asymptomatic at birth with normal hearing by age 2 years were not at higher risk of intellectual impairment or low academic achievement, compared with controls, but patients with sensorineural hearing loss may experience more difficulty, according to a longitudinal study.

Full-scale intelligence, language, and academic achievement was evaluated in 78 adolescents with cCMV and normal hearing, 11 with cCMV and sensorineural hearing loss (SNHL) by age 2 years, and 40 controls. Mean full-scale intelligence scores did not vary among the patients with normal hearing and the controls, said Adriana S. Lopez of the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, and her coauthors. Each group scored a mean 108 (95% confidence interval, 105-110 and 104-111, respectively) at age 5 years and 111 (95% CI, 108-114 and 107-104, respectively) at age 18 years (P = .96). The scores of the patients with SNHL, however, were 7 points lower at both times (P less than .05).

CDC/Craig Lyerla

[email protected]

Infants with congenital cytomegalovirus (cCMV) who were asymptomatic at birth with normal hearing by age 2 years were not at higher risk of intellectual impairment or low academic achievement, compared with controls, but patients with sensorineural hearing loss may experience more difficulty, according to a longitudinal study.

Full-scale intelligence, language, and academic achievement was evaluated in 78 adolescents with cCMV and normal hearing, 11 with cCMV and sensorineural hearing loss (SNHL) by age 2 years, and 40 controls. Mean full-scale intelligence scores did not vary among the patients with normal hearing and the controls, said Adriana S. Lopez of the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, and her coauthors. Each group scored a mean 108 (95% confidence interval, 105-110 and 104-111, respectively) at age 5 years and 111 (95% CI, 108-114 and 107-104, respectively) at age 18 years (P = .96). The scores of the patients with SNHL, however, were 7 points lower at both times (P less than .05).

CDC/Craig Lyerla

[email protected]

During AGA’s annual Joint Committee weekend, 55 AGA members collectively attended 79 meetings with staff from the offices of their House representatives and senators, lobbying for the top concerns of gastroenterologists across the country, including:

• Continued coverage of patients through either the Affordable Care Act or another bill that has the patient’s best interests in mind. More specifically, one that provides coverage for those with pre-existing conditions and for children under their parents’ plan until 26 years of age, among many other important provisions.
• Changes in health care language that label a colonoscopy for cancer screening as “therapeutic,” which renders a large copay for patients.
• Increased funding for the NIH.

Participants shared experiences from their time on Capitol Hill in the AGA Community forum, and encouraged others to get involved. Here are some of their reasons why.

• Your voice matters: You are constituents – which translates to votes in the minds of representatives and senators – and providing face-to-face conversation with their staffers shows them that you care about your patients and their needs, explains Siddharth Singh, MD.
• Being consistent gets your foot in the door: Some staffers recognized and remembered previous Advocacy Day participants, like Peter Liang, MD, MPH. Personally connecting could lead to follow-up communication and advocacy efforts, says Sarah Streett, MD, AGAF.
• You’re indirectly (and sometimes directly) connecting with decision makers: Staff members from these offices work closely with the legislators who evaluate which policies to support or oppose. “So it’s important to come to Washington, build relationships, and make the case for our science, our specialty, and our patients,” says Kim Barrett, PhD, AGAF.
• Others could be advocating against you on the same issues: “I very strongly believe that it is important to keep letting our legislators know how we feel and what we believe in,” shares Deborah Proctor, MD, AGAF.
• It’s a rewarding experience: “Voice [your] concerns to your representatives who embrace the stories of how their decisions and policies affect your patients, practice, research, and institution,” explains Susan Ramdhaney, MD, AGAF.
• It’s a critical time to take action: With the current health care environment, gastroenterologists need to express the needs of their patients and profession, Dr. Streett explains.

View the full discussion and read updates from colleagues who visited with legislative staffers from California, New York, North Carolina, and Oregon in the forum, community.gastro.org.

Please contact [email protected].
 

[email protected]

During AGA’s annual Joint Committee weekend, 55 AGA members collectively attended 79 meetings with staff from the offices of their House representatives and senators, lobbying for the top concerns of gastroenterologists across the country, including:

• Continued coverage of patients through either the Affordable Care Act or another bill that has the patient’s best interests in mind. More specifically, one that provides coverage for those with pre-existing conditions and for children under their parents’ plan until 26 years of age, among many other important provisions.
• Changes in health care language that label a colonoscopy for cancer screening as “therapeutic,” which renders a large copay for patients.
• Increased funding for the NIH.

Participants shared experiences from their time on Capitol Hill in the AGA Community forum, and encouraged others to get involved. Here are some of their reasons why.

• Your voice matters: You are constituents – which translates to votes in the minds of representatives and senators – and providing face-to-face conversation with their staffers shows them that you care about your patients and their needs, explains Siddharth Singh, MD.
• Being consistent gets your foot in the door: Some staffers recognized and remembered previous Advocacy Day participants, like Peter Liang, MD, MPH. Personally connecting could lead to follow-up communication and advocacy efforts, says Sarah Streett, MD, AGAF.
• You’re indirectly (and sometimes directly) connecting with decision makers: Staff members from these offices work closely with the legislators who evaluate which policies to support or oppose. “So it’s important to come to Washington, build relationships, and make the case for our science, our specialty, and our patients,” says Kim Barrett, PhD, AGAF.
• Others could be advocating against you on the same issues: “I very strongly believe that it is important to keep letting our legislators know how we feel and what we believe in,” shares Deborah Proctor, MD, AGAF.
• It’s a rewarding experience: “Voice [your] concerns to your representatives who embrace the stories of how their decisions and policies affect your patients, practice, research, and institution,” explains Susan Ramdhaney, MD, AGAF.
• It’s a critical time to take action: With the current health care environment, gastroenterologists need to express the needs of their patients and profession, Dr. Streett explains.

View the full discussion and read updates from colleagues who visited with legislative staffers from California, New York, North Carolina, and Oregon in the forum, community.gastro.org.

Please contact [email protected].
 

[email protected]

During AGA’s annual Joint Committee weekend, 55 AGA members collectively attended 79 meetings with staff from the offices of their House representatives and senators, lobbying for the top concerns of gastroenterologists across the country, including:

• Continued coverage of patients through either the Affordable Care Act or another bill that has the patient’s best interests in mind. More specifically, one that provides coverage for those with pre-existing conditions and for children under their parents’ plan until 26 years of age, among many other important provisions.
• Changes in health care language that label a colonoscopy for cancer screening as “therapeutic,” which renders a large copay for patients.
• Increased funding for the NIH.

Participants shared experiences from their time on Capitol Hill in the AGA Community forum, and encouraged others to get involved. Here are some of their reasons why.

• Your voice matters: You are constituents – which translates to votes in the minds of representatives and senators – and providing face-to-face conversation with their staffers shows them that you care about your patients and their needs, explains Siddharth Singh, MD.
• Being consistent gets your foot in the door: Some staffers recognized and remembered previous Advocacy Day participants, like Peter Liang, MD, MPH. Personally connecting could lead to follow-up communication and advocacy efforts, says Sarah Streett, MD, AGAF.
• You’re indirectly (and sometimes directly) connecting with decision makers: Staff members from these offices work closely with the legislators who evaluate which policies to support or oppose. “So it’s important to come to Washington, build relationships, and make the case for our science, our specialty, and our patients,” says Kim Barrett, PhD, AGAF.
• Others could be advocating against you on the same issues: “I very strongly believe that it is important to keep letting our legislators know how we feel and what we believe in,” shares Deborah Proctor, MD, AGAF.
• It’s a rewarding experience: “Voice [your] concerns to your representatives who embrace the stories of how their decisions and policies affect your patients, practice, research, and institution,” explains Susan Ramdhaney, MD, AGAF.
• It’s a critical time to take action: With the current health care environment, gastroenterologists need to express the needs of their patients and profession, Dr. Streett explains.

View the full discussion and read updates from colleagues who visited with legislative staffers from California, New York, North Carolina, and Oregon in the forum, community.gastro.org.

Please contact [email protected].
 

[email protected]

CHICAGO – Nearly half of all children have wheezing in their first year of life, and one in five have recurrent wheezing episodes, but that doesn’t mean they have asthma, explained Erik Hysinger, MD, MS, of the division of pulmonary medicine at Cincinnati Children’s Hospital.

Localized wheezing is not consistent with asthmatic or viral wheezing, which is typically diffuse and polyphonic, Dr. Hysinger emphasized at the annual meeting of the American Academy of Pediatrics.

“Localized wheezing is less common than diffuse wheezing and typically has a homophonous sound,” Dr. Hysinger said. It also usually arises from a central airway pathology. “High flow rates create loud amplitude sounds.”

iStock/Thinkstock

Airway occlusion diagnoses

Four potential causes of an airway blockage are a foreign body, a bronchial cast, mucous plugs, or airway tumors.

A foreign body typically occurs with a cough, wheezing, stridor, and respiratory distress. It is most common in children under age 4 years, usually in those without a history of aspiration, yet providers initially misdiagnose more than 20% of patients with a foreign body. The foreign object – often coins, food, or batteries – frequently ends up in the right main bronchus and may go undetected up to a month, potentially leading to pneumonia, abscess, atelectasis, bronchiectasis, or airway erosion.

Airway narrowing diagnoses

Two possible diagnoses for an intrinsic airway narrowing include bronchomalacia, occurring in only 1 of 2,100 children, and bronchial stenosis.

In bronchomalacia – diagnosed primarily with bronchoscopy – the airway collapses from weakening of the cartilage and posterior membrane. Bronchomalacia sounds like homophonous wheezing with a barky or brassy cough, and it’s frequently accompanied by recurrent bronchitis and/or pneumonia. Intervention is rarely necessary when occurring on its own, but severe cases may require endobronchial stents. Dr. Hysinger also recommended considering ipratroprium instead of albuterol.

Bronchial stenosis involves a fixed narrowing of the bronchi and can be congenital – typically occurring with heart disease – or acquired after an intubation and suction trauma or bronchiolitis obliterans (“popcorn lung”). A chest x-ray and bronchoscopy again are standard, but MRI may be necessary as well. Aside from helping the patient clear the airway, bronchial stenosis typically needs limited management unless the patient is symptomatic. In that case, options include balloon dilation, endobronchial stents, or a slide bronchoplasty.

Airway compression diagnoses

An extrinsic airway compression could have a vascular cause or could result from pressure by an extrinsic mass or the axial skeleton.

Vascular compression usually occurs due to abnormal vasculature development, particularly with vascular stents, Dr. Hysinger said. The wheezing presents with stridor, feeding intolerance, recurrent infections, and cyanotic episodes. The work-up should include a chest x-ray, bronchoscopy, and a chest CT and/or MRI. A variety of interventions may be necessary to treat it, including an aortopexy, pulmonary artery trunk–pexy, arterioplasty, vessel implantation, or endobronchial stent. Residual malacia may remain after treatment, however.

The most common reasons for airway compression by some kind of mass is a reactive lymphadenopathy, a tumor, or an infection, including tuberculosis or histoplasmosis. Severe narrowing of the airway can lead to respiratory failure, but because the compression can develop slowly, the wheezing can be mistaken for asthma. In addition to a chest CT and bronchoscopy, a patient will need other work-ups depending on the cause. Possibilities include a biopsy, a gastric aspirate (for tuberculosis), a bronchoalveolar lavage, or antibody titers.

Similarly, because therapeutic intervention requires treating the underlying infection, specific treatments will vary. Tumors typically will need resection, chemotherapy, and/or radiation – and, until the airway is fully cleared, the patient may need chronic mechanical ventilation.

Children with severe scoliosis or kyphosis are those most likely to experience airway compression resulting from pressure by the axial skeleton, in which the spine’s curvature directly presses on the airway. In addition to the wheeze, these patients may have respiratory distress or recurrent focal pneumonia, Dr. Hysinger said. The standard work-up involves a chest x-ray, chest CT, spinal MRI, and bronchoscopy.

Consider using spinal rods, but they can both help the condition or potentially exacerbate the compression, Dr. Hysinger said. Either way, children also will need help with airway clearance and coughing.

Dr. Hysinger concluded by reviewing what you may consider changing in your current practice, including the initial trial of bronchodilators, a chest x-ray, and a subspecialist referral.

No funding was used for this presentation, and Dr. Hysinger reported having no relevant financial disclosures.

[email protected]

CHICAGO – Nearly half of all children have wheezing in their first year of life, and one in five have recurrent wheezing episodes, but that doesn’t mean they have asthma, explained Erik Hysinger, MD, MS, of the division of pulmonary medicine at Cincinnati Children’s Hospital.

Localized wheezing is not consistent with asthmatic or viral wheezing, which is typically diffuse and polyphonic, Dr. Hysinger emphasized at the annual meeting of the American Academy of Pediatrics.

“Localized wheezing is less common than diffuse wheezing and typically has a homophonous sound,” Dr. Hysinger said. It also usually arises from a central airway pathology. “High flow rates create loud amplitude sounds.”

iStock/Thinkstock

Airway occlusion diagnoses

Four potential causes of an airway blockage are a foreign body, a bronchial cast, mucous plugs, or airway tumors.

A foreign body typically occurs with a cough, wheezing, stridor, and respiratory distress. It is most common in children under age 4 years, usually in those without a history of aspiration, yet providers initially misdiagnose more than 20% of patients with a foreign body. The foreign object – often coins, food, or batteries – frequently ends up in the right main bronchus and may go undetected up to a month, potentially leading to pneumonia, abscess, atelectasis, bronchiectasis, or airway erosion.

Airway narrowing diagnoses

Two possible diagnoses for an intrinsic airway narrowing include bronchomalacia, occurring in only 1 of 2,100 children, and bronchial stenosis.

In bronchomalacia – diagnosed primarily with bronchoscopy – the airway collapses from weakening of the cartilage and posterior membrane. Bronchomalacia sounds like homophonous wheezing with a barky or brassy cough, and it’s frequently accompanied by recurrent bronchitis and/or pneumonia. Intervention is rarely necessary when occurring on its own, but severe cases may require endobronchial stents. Dr. Hysinger also recommended considering ipratroprium instead of albuterol.

Bronchial stenosis involves a fixed narrowing of the bronchi and can be congenital – typically occurring with heart disease – or acquired after an intubation and suction trauma or bronchiolitis obliterans (“popcorn lung”). A chest x-ray and bronchoscopy again are standard, but MRI may be necessary as well. Aside from helping the patient clear the airway, bronchial stenosis typically needs limited management unless the patient is symptomatic. In that case, options include balloon dilation, endobronchial stents, or a slide bronchoplasty.

Airway compression diagnoses

An extrinsic airway compression could have a vascular cause or could result from pressure by an extrinsic mass or the axial skeleton.

Vascular compression usually occurs due to abnormal vasculature development, particularly with vascular stents, Dr. Hysinger said. The wheezing presents with stridor, feeding intolerance, recurrent infections, and cyanotic episodes. The work-up should include a chest x-ray, bronchoscopy, and a chest CT and/or MRI. A variety of interventions may be necessary to treat it, including an aortopexy, pulmonary artery trunk–pexy, arterioplasty, vessel implantation, or endobronchial stent. Residual malacia may remain after treatment, however.

The most common reasons for airway compression by some kind of mass is a reactive lymphadenopathy, a tumor, or an infection, including tuberculosis or histoplasmosis. Severe narrowing of the airway can lead to respiratory failure, but because the compression can develop slowly, the wheezing can be mistaken for asthma. In addition to a chest CT and bronchoscopy, a patient will need other work-ups depending on the cause. Possibilities include a biopsy, a gastric aspirate (for tuberculosis), a bronchoalveolar lavage, or antibody titers.

Similarly, because therapeutic intervention requires treating the underlying infection, specific treatments will vary. Tumors typically will need resection, chemotherapy, and/or radiation – and, until the airway is fully cleared, the patient may need chronic mechanical ventilation.

Children with severe scoliosis or kyphosis are those most likely to experience airway compression resulting from pressure by the axial skeleton, in which the spine’s curvature directly presses on the airway. In addition to the wheeze, these patients may have respiratory distress or recurrent focal pneumonia, Dr. Hysinger said. The standard work-up involves a chest x-ray, chest CT, spinal MRI, and bronchoscopy.

Consider using spinal rods, but they can both help the condition or potentially exacerbate the compression, Dr. Hysinger said. Either way, children also will need help with airway clearance and coughing.

Dr. Hysinger concluded by reviewing what you may consider changing in your current practice, including the initial trial of bronchodilators, a chest x-ray, and a subspecialist referral.

No funding was used for this presentation, and Dr. Hysinger reported having no relevant financial disclosures.

[email protected]

CHICAGO – Nearly half of all children have wheezing in their first year of life, and one in five have recurrent wheezing episodes, but that doesn’t mean they have asthma, explained Erik Hysinger, MD, MS, of the division of pulmonary medicine at Cincinnati Children’s Hospital.

Localized wheezing is not consistent with asthmatic or viral wheezing, which is typically diffuse and polyphonic, Dr. Hysinger emphasized at the annual meeting of the American Academy of Pediatrics.

“Localized wheezing is less common than diffuse wheezing and typically has a homophonous sound,” Dr. Hysinger said. It also usually arises from a central airway pathology. “High flow rates create loud amplitude sounds.”

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Airway occlusion diagnoses

Four potential causes of an airway blockage are a foreign body, a bronchial cast, mucous plugs, or airway tumors.

A foreign body typically occurs with a cough, wheezing, stridor, and respiratory distress. It is most common in children under age 4 years, usually in those without a history of aspiration, yet providers initially misdiagnose more than 20% of patients with a foreign body. The foreign object – often coins, food, or batteries – frequently ends up in the right main bronchus and may go undetected up to a month, potentially leading to pneumonia, abscess, atelectasis, bronchiectasis, or airway erosion.

Airway narrowing diagnoses

Two possible diagnoses for an intrinsic airway narrowing include bronchomalacia, occurring in only 1 of 2,100 children, and bronchial stenosis.

In bronchomalacia – diagnosed primarily with bronchoscopy – the airway collapses from weakening of the cartilage and posterior membrane. Bronchomalacia sounds like homophonous wheezing with a barky or brassy cough, and it’s frequently accompanied by recurrent bronchitis and/or pneumonia. Intervention is rarely necessary when occurring on its own, but severe cases may require endobronchial stents. Dr. Hysinger also recommended considering ipratroprium instead of albuterol.

Bronchial stenosis involves a fixed narrowing of the bronchi and can be congenital – typically occurring with heart disease – or acquired after an intubation and suction trauma or bronchiolitis obliterans (“popcorn lung”). A chest x-ray and bronchoscopy again are standard, but MRI may be necessary as well. Aside from helping the patient clear the airway, bronchial stenosis typically needs limited management unless the patient is symptomatic. In that case, options include balloon dilation, endobronchial stents, or a slide bronchoplasty.

Airway compression diagnoses

An extrinsic airway compression could have a vascular cause or could result from pressure by an extrinsic mass or the axial skeleton.

Vascular compression usually occurs due to abnormal vasculature development, particularly with vascular stents, Dr. Hysinger said. The wheezing presents with stridor, feeding intolerance, recurrent infections, and cyanotic episodes. The work-up should include a chest x-ray, bronchoscopy, and a chest CT and/or MRI. A variety of interventions may be necessary to treat it, including an aortopexy, pulmonary artery trunk–pexy, arterioplasty, vessel implantation, or endobronchial stent. Residual malacia may remain after treatment, however.

The most common reasons for airway compression by some kind of mass is a reactive lymphadenopathy, a tumor, or an infection, including tuberculosis or histoplasmosis. Severe narrowing of the airway can lead to respiratory failure, but because the compression can develop slowly, the wheezing can be mistaken for asthma. In addition to a chest CT and bronchoscopy, a patient will need other work-ups depending on the cause. Possibilities include a biopsy, a gastric aspirate (for tuberculosis), a bronchoalveolar lavage, or antibody titers.

Similarly, because therapeutic intervention requires treating the underlying infection, specific treatments will vary. Tumors typically will need resection, chemotherapy, and/or radiation – and, until the airway is fully cleared, the patient may need chronic mechanical ventilation.

Children with severe scoliosis or kyphosis are those most likely to experience airway compression resulting from pressure by the axial skeleton, in which the spine’s curvature directly presses on the airway. In addition to the wheeze, these patients may have respiratory distress or recurrent focal pneumonia, Dr. Hysinger said. The standard work-up involves a chest x-ray, chest CT, spinal MRI, and bronchoscopy.

Consider using spinal rods, but they can both help the condition or potentially exacerbate the compression, Dr. Hysinger said. Either way, children also will need help with airway clearance and coughing.

Dr. Hysinger concluded by reviewing what you may consider changing in your current practice, including the initial trial of bronchodilators, a chest x-ray, and a subspecialist referral.

No funding was used for this presentation, and Dr. Hysinger reported having no relevant financial disclosures.

[email protected]

The progression of Parkinson’s disease over 2 years takes a toll on the driving skills of even drivers who initially perform as well as healthy age-matched drivers, according to a longitudinal cohort study conducted by Urgun Uc, MD, and associates.

While some patients with Parkinson’s disease who took part in a test of driving skills on a standardized driving course performed significantly worse at a baseline assessment than did healthy control patients, the patients who performed at a similar level as the control group made a significantly higher number of driving mistakes 2 years later on a follow-up evaluation.

Michael Shake/Fotolia.com

[email protected]

The progression of Parkinson’s disease over 2 years takes a toll on the driving skills of even drivers who initially perform as well as healthy age-matched drivers, according to a longitudinal cohort study conducted by Urgun Uc, MD, and associates.

While some patients with Parkinson’s disease who took part in a test of driving skills on a standardized driving course performed significantly worse at a baseline assessment than did healthy control patients, the patients who performed at a similar level as the control group made a significantly higher number of driving mistakes 2 years later on a follow-up evaluation.

Michael Shake/Fotolia.com

[email protected]

The progression of Parkinson’s disease over 2 years takes a toll on the driving skills of even drivers who initially perform as well as healthy age-matched drivers, according to a longitudinal cohort study conducted by Urgun Uc, MD, and associates.

While some patients with Parkinson’s disease who took part in a test of driving skills on a standardized driving course performed significantly worse at a baseline assessment than did healthy control patients, the patients who performed at a similar level as the control group made a significantly higher number of driving mistakes 2 years later on a follow-up evaluation.

Michael Shake/Fotolia.com

[email protected]