The identification of risk factors associated with recurrent Clostridium difficile infection (rCDI) might allow early recognition of those children at highest risk, said Dr. Maribeth Nicholson of Vanderbilt University, Nashville, Tenn., and her associates.

In a small study, results showed that fecal lactoferrin, calprotectin, and interleukin-8 (IL-8) should be further studied to determine their value in predicting the risk of rCDI in children.

CDC/Jennifer Hulsey

[email protected]

The identification of risk factors associated with recurrent Clostridium difficile infection (rCDI) might allow early recognition of those children at highest risk, said Dr. Maribeth Nicholson of Vanderbilt University, Nashville, Tenn., and her associates.

In a small study, results showed that fecal lactoferrin, calprotectin, and interleukin-8 (IL-8) should be further studied to determine their value in predicting the risk of rCDI in children.

CDC/Jennifer Hulsey

[email protected]

The identification of risk factors associated with recurrent Clostridium difficile infection (rCDI) might allow early recognition of those children at highest risk, said Dr. Maribeth Nicholson of Vanderbilt University, Nashville, Tenn., and her associates.

In a small study, results showed that fecal lactoferrin, calprotectin, and interleukin-8 (IL-8) should be further studied to determine their value in predicting the risk of rCDI in children.

CDC/Jennifer Hulsey

[email protected]

Adverse childhood experiences (ACEs) are the traumatic experiences in a person’s life occurring before the age of 18 years that the person remembers as an adult and that have consequences on a diverse set of outcomes. ACEs include physical abuse, sexual abuse, emotional abuse, mental illness of a household member, problematic drinking or alcoholism of a household member, illegal street or prescription drug use by a household member, divorce or separation of a parent, domestic violence toward a parent, and incarceration of a household member. Each of these experiences before the age of 18 years increases the likelihood of not only adulthood depression, suicide, and substance use disorders, but also a range of nonpsychiatric outcomes such as heart disease and chronic lung disease.

Case summary

Ellie is a 16-year-old girl with a past history of ADHD and oppositionality who arrives on her own in a walk-in clinic to be seen for a sports physical. Ellie has been generally healthy and was previously on a stable medical regimen of methylphenidate but has not been taking it for about 1 year. The oppositionality that she previously experienced in her early school-age years has slowly decreased. She generally does well in school and is in several clubs. In the course of the history, Ellie reveals that her mother’s depression has been worse lately to the point where her mother has resumed her drinking and illegal opiate use. You discuss safety with Ellie, and she reveals that, while she has never been threatened or injured, there has been domestic violence in the home that Ellie felt responsible to try to stop by calling the police. This led to the one and only time that Ellie was physically struck. Her father is now incarcerated, and Ellie feels guilty. After a discussion with Ellie, you report this situation to social services, who already has the case on file. Ellie’s mental status exam, including a thorough examination of symptoms of mood disorders, anxiety, substance use, and PTSD, is within normal limits.

Case discussion

Ellie has suffered a set of ACEs. Specifically, her mother has a mental illness, has a drinking problem, and uses illegal drugs; Ellie has witnessed domestic violence toward her mother, has a family member who is incarcerated, and has suffered from physical abuse. This ACEs score of 6 puts her at markedly increased risk for multiple psychiatric and nonpsychiatric medical outcomes. Individuals with scores of 4 or above on the simple ACEs questionnaire have demonstrated a 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempts. Further, studies have shown a twofold to fourfold increase in smoking, poor self-rated health, increased numbers of sexual partners and sexually transmitted disease, and 1.4- to 1.6-fold increase in physical inactivity and severe obesity (Am J Prev Med. 1998 May;14[4]:245-58). In Ellie’s case, her history of ADHD and family history of substance use puts her at even further increased risk for later substance use disorders.

While there is no pharmacotherapy or psychotherapy specific to the treatment of having suffered adversity, it is critical for the clinician to note her increased risk. Ellie would be an individual for whom health promotion and prevention would be critical. It is excellent that she is exercising and participating in sports, which appear to be protective. Careful counseling and follow-up with regard to her increased risk for psychiatric and nonpsychiatric disorders is paramount.
 

Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at [email protected].

Adverse childhood experiences (ACEs) are the traumatic experiences in a person’s life occurring before the age of 18 years that the person remembers as an adult and that have consequences on a diverse set of outcomes. ACEs include physical abuse, sexual abuse, emotional abuse, mental illness of a household member, problematic drinking or alcoholism of a household member, illegal street or prescription drug use by a household member, divorce or separation of a parent, domestic violence toward a parent, and incarceration of a household member. Each of these experiences before the age of 18 years increases the likelihood of not only adulthood depression, suicide, and substance use disorders, but also a range of nonpsychiatric outcomes such as heart disease and chronic lung disease.

Case summary

Ellie is a 16-year-old girl with a past history of ADHD and oppositionality who arrives on her own in a walk-in clinic to be seen for a sports physical. Ellie has been generally healthy and was previously on a stable medical regimen of methylphenidate but has not been taking it for about 1 year. The oppositionality that she previously experienced in her early school-age years has slowly decreased. She generally does well in school and is in several clubs. In the course of the history, Ellie reveals that her mother’s depression has been worse lately to the point where her mother has resumed her drinking and illegal opiate use. You discuss safety with Ellie, and she reveals that, while she has never been threatened or injured, there has been domestic violence in the home that Ellie felt responsible to try to stop by calling the police. This led to the one and only time that Ellie was physically struck. Her father is now incarcerated, and Ellie feels guilty. After a discussion with Ellie, you report this situation to social services, who already has the case on file. Ellie’s mental status exam, including a thorough examination of symptoms of mood disorders, anxiety, substance use, and PTSD, is within normal limits.

Case discussion

Ellie has suffered a set of ACEs. Specifically, her mother has a mental illness, has a drinking problem, and uses illegal drugs; Ellie has witnessed domestic violence toward her mother, has a family member who is incarcerated, and has suffered from physical abuse. This ACEs score of 6 puts her at markedly increased risk for multiple psychiatric and nonpsychiatric medical outcomes. Individuals with scores of 4 or above on the simple ACEs questionnaire have demonstrated a 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempts. Further, studies have shown a twofold to fourfold increase in smoking, poor self-rated health, increased numbers of sexual partners and sexually transmitted disease, and 1.4- to 1.6-fold increase in physical inactivity and severe obesity (Am J Prev Med. 1998 May;14[4]:245-58). In Ellie’s case, her history of ADHD and family history of substance use puts her at even further increased risk for later substance use disorders.

While there is no pharmacotherapy or psychotherapy specific to the treatment of having suffered adversity, it is critical for the clinician to note her increased risk. Ellie would be an individual for whom health promotion and prevention would be critical. It is excellent that she is exercising and participating in sports, which appear to be protective. Careful counseling and follow-up with regard to her increased risk for psychiatric and nonpsychiatric disorders is paramount.
 

Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at [email protected].

Adverse childhood experiences (ACEs) are the traumatic experiences in a person’s life occurring before the age of 18 years that the person remembers as an adult and that have consequences on a diverse set of outcomes. ACEs include physical abuse, sexual abuse, emotional abuse, mental illness of a household member, problematic drinking or alcoholism of a household member, illegal street or prescription drug use by a household member, divorce or separation of a parent, domestic violence toward a parent, and incarceration of a household member. Each of these experiences before the age of 18 years increases the likelihood of not only adulthood depression, suicide, and substance use disorders, but also a range of nonpsychiatric outcomes such as heart disease and chronic lung disease.

Case summary

Ellie is a 16-year-old girl with a past history of ADHD and oppositionality who arrives on her own in a walk-in clinic to be seen for a sports physical. Ellie has been generally healthy and was previously on a stable medical regimen of methylphenidate but has not been taking it for about 1 year. The oppositionality that she previously experienced in her early school-age years has slowly decreased. She generally does well in school and is in several clubs. In the course of the history, Ellie reveals that her mother’s depression has been worse lately to the point where her mother has resumed her drinking and illegal opiate use. You discuss safety with Ellie, and she reveals that, while she has never been threatened or injured, there has been domestic violence in the home that Ellie felt responsible to try to stop by calling the police. This led to the one and only time that Ellie was physically struck. Her father is now incarcerated, and Ellie feels guilty. After a discussion with Ellie, you report this situation to social services, who already has the case on file. Ellie’s mental status exam, including a thorough examination of symptoms of mood disorders, anxiety, substance use, and PTSD, is within normal limits.

Case discussion

Ellie has suffered a set of ACEs. Specifically, her mother has a mental illness, has a drinking problem, and uses illegal drugs; Ellie has witnessed domestic violence toward her mother, has a family member who is incarcerated, and has suffered from physical abuse. This ACEs score of 6 puts her at markedly increased risk for multiple psychiatric and nonpsychiatric medical outcomes. Individuals with scores of 4 or above on the simple ACEs questionnaire have demonstrated a 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempts. Further, studies have shown a twofold to fourfold increase in smoking, poor self-rated health, increased numbers of sexual partners and sexually transmitted disease, and 1.4- to 1.6-fold increase in physical inactivity and severe obesity (Am J Prev Med. 1998 May;14[4]:245-58). In Ellie’s case, her history of ADHD and family history of substance use puts her at even further increased risk for later substance use disorders.

While there is no pharmacotherapy or psychotherapy specific to the treatment of having suffered adversity, it is critical for the clinician to note her increased risk. Ellie would be an individual for whom health promotion and prevention would be critical. It is excellent that she is exercising and participating in sports, which appear to be protective. Careful counseling and follow-up with regard to her increased risk for psychiatric and nonpsychiatric disorders is paramount.
 

Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at [email protected].

SEATTLE – In patients coinfected with HIV and tuberculosis, addition of prednisone to an antiretroviral therapy (ART)/TB regimen significantly reduced the incidence of tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS).

The study showed a reduction of incidence of TB-IRIS – a worsening of the inflammatory elements of tuberculosis that often occurs within a few weeks of starting ART – in the prednisone group, with no sign of adverse events associated with immunosuppression. That safety profile “gives us the reassurance that this is something that could be scaled up. It’s effective but it’s also safe,” said Graeme Meintjes, MD, PhD, professor of medicine at the University of Cape Town, South Africa.

TB-IRIS occurs in 18% of patients undergoing ART/TB regimens, and 25% of these patients wind up in the hospital (Future Microbiol. 2015;10[6]:1077-99).

Ironically, TB-IRIS is of increasing concern because of improved treatment strategies. Clinical trials have shown that, in patients with low CD4 counts, TB mortality is decreased by about 20% if ART is started within 2 weeks of initiation of TB treatment. But when ART is started so soon after TB therapy, patients with low CD4 counts are at about a twofold increased risk of TB-IRIS (Ann Intern Med. 2015;163[1]:32-9).

“That brought into focus the need for an intervention to prevent this complication,” said Dr. Meintjes, who presented the study at the Conference on Retroviruses & Opportunistic Infections in partnership with the International Antiviral Society.

There were concerns that prednisone could put HIV patients at greater risk of opportunistic infections such as Kaposi’s sarcoma, although Dr. Meintjes noted that those risks were seen in a context of patients who were not taking ART. His team also showed in a previous study (AIDS. 2010;24:2381-90) that prednisone reduced duration of symptoms and hospitalization in TB-IRIS, with no increase in serious infections.

The researchers randomized 240 patients to receive prednisone (40 mg/day for 2 weeks, then 20 mg/day for 2 weeks) within 48 hours of starting ART. All patients started ART within 30 days of starting TB treatment, and had a CD4 count of 100 or fewer cells/microL.

Excluded patients included those with rifampicin resistance, neurobiological tuberculosis, Kaposi’s sarcoma, or hepatitis B, and those who weren’t on the standard first line TB treatment because they couldn’t tolerate it. Patients were also excluded if they had a poor clinical response to TB treatment.

Most endpoints were followed for 12 weeks, but HIV-related cancers were monitored out to 1 year.

Forty-seven percent of patients in the placebo group experienced TB-IRIS within 12 weeks, compared with 33% of patients in the prednisone group (risk ratio, 0.70; 95% confidence interval 0.51-0.96). In an open-label extension study, the researchers noted that 28% of patients who started out in the placebo arm eventually received corticosteroids to treat TB-IRIS, compared with 13% of those who started out in the prednisone arm (RR 0.47, 95% CI 0.27-0.83).

Subjects in the prednisone arm had a lower rate of grade 3 adverse events (29% vs. 45%, P = .01).

There was a similar mortality rate in both arms, and no difference in the incidence of Kaposi’s sarcoma or new-onset AIDS-defining infections.

Dr. Meintjes pointed out that patient selection is important. The trial patients were seen in the clinical setting, not sicker, hospitalized patients, and they had to be improving with TB treatment; significant comorbidities were excluded. “In those patients, prednisone was safe.”

Dr. Meintjes reported having no relevant financial disclosures.

SEATTLE – In patients coinfected with HIV and tuberculosis, addition of prednisone to an antiretroviral therapy (ART)/TB regimen significantly reduced the incidence of tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS).

The study showed a reduction of incidence of TB-IRIS – a worsening of the inflammatory elements of tuberculosis that often occurs within a few weeks of starting ART – in the prednisone group, with no sign of adverse events associated with immunosuppression. That safety profile “gives us the reassurance that this is something that could be scaled up. It’s effective but it’s also safe,” said Graeme Meintjes, MD, PhD, professor of medicine at the University of Cape Town, South Africa.

TB-IRIS occurs in 18% of patients undergoing ART/TB regimens, and 25% of these patients wind up in the hospital (Future Microbiol. 2015;10[6]:1077-99).

Ironically, TB-IRIS is of increasing concern because of improved treatment strategies. Clinical trials have shown that, in patients with low CD4 counts, TB mortality is decreased by about 20% if ART is started within 2 weeks of initiation of TB treatment. But when ART is started so soon after TB therapy, patients with low CD4 counts are at about a twofold increased risk of TB-IRIS (Ann Intern Med. 2015;163[1]:32-9).

“That brought into focus the need for an intervention to prevent this complication,” said Dr. Meintjes, who presented the study at the Conference on Retroviruses & Opportunistic Infections in partnership with the International Antiviral Society.

There were concerns that prednisone could put HIV patients at greater risk of opportunistic infections such as Kaposi’s sarcoma, although Dr. Meintjes noted that those risks were seen in a context of patients who were not taking ART. His team also showed in a previous study (AIDS. 2010;24:2381-90) that prednisone reduced duration of symptoms and hospitalization in TB-IRIS, with no increase in serious infections.

The researchers randomized 240 patients to receive prednisone (40 mg/day for 2 weeks, then 20 mg/day for 2 weeks) within 48 hours of starting ART. All patients started ART within 30 days of starting TB treatment, and had a CD4 count of 100 or fewer cells/microL.

Excluded patients included those with rifampicin resistance, neurobiological tuberculosis, Kaposi’s sarcoma, or hepatitis B, and those who weren’t on the standard first line TB treatment because they couldn’t tolerate it. Patients were also excluded if they had a poor clinical response to TB treatment.

Most endpoints were followed for 12 weeks, but HIV-related cancers were monitored out to 1 year.

Forty-seven percent of patients in the placebo group experienced TB-IRIS within 12 weeks, compared with 33% of patients in the prednisone group (risk ratio, 0.70; 95% confidence interval 0.51-0.96). In an open-label extension study, the researchers noted that 28% of patients who started out in the placebo arm eventually received corticosteroids to treat TB-IRIS, compared with 13% of those who started out in the prednisone arm (RR 0.47, 95% CI 0.27-0.83).

Subjects in the prednisone arm had a lower rate of grade 3 adverse events (29% vs. 45%, P = .01).

There was a similar mortality rate in both arms, and no difference in the incidence of Kaposi’s sarcoma or new-onset AIDS-defining infections.

Dr. Meintjes pointed out that patient selection is important. The trial patients were seen in the clinical setting, not sicker, hospitalized patients, and they had to be improving with TB treatment; significant comorbidities were excluded. “In those patients, prednisone was safe.”

Dr. Meintjes reported having no relevant financial disclosures.

SEATTLE – In patients coinfected with HIV and tuberculosis, addition of prednisone to an antiretroviral therapy (ART)/TB regimen significantly reduced the incidence of tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS).

The study showed a reduction of incidence of TB-IRIS – a worsening of the inflammatory elements of tuberculosis that often occurs within a few weeks of starting ART – in the prednisone group, with no sign of adverse events associated with immunosuppression. That safety profile “gives us the reassurance that this is something that could be scaled up. It’s effective but it’s also safe,” said Graeme Meintjes, MD, PhD, professor of medicine at the University of Cape Town, South Africa.

TB-IRIS occurs in 18% of patients undergoing ART/TB regimens, and 25% of these patients wind up in the hospital (Future Microbiol. 2015;10[6]:1077-99).

Ironically, TB-IRIS is of increasing concern because of improved treatment strategies. Clinical trials have shown that, in patients with low CD4 counts, TB mortality is decreased by about 20% if ART is started within 2 weeks of initiation of TB treatment. But when ART is started so soon after TB therapy, patients with low CD4 counts are at about a twofold increased risk of TB-IRIS (Ann Intern Med. 2015;163[1]:32-9).

“That brought into focus the need for an intervention to prevent this complication,” said Dr. Meintjes, who presented the study at the Conference on Retroviruses & Opportunistic Infections in partnership with the International Antiviral Society.

There were concerns that prednisone could put HIV patients at greater risk of opportunistic infections such as Kaposi’s sarcoma, although Dr. Meintjes noted that those risks were seen in a context of patients who were not taking ART. His team also showed in a previous study (AIDS. 2010;24:2381-90) that prednisone reduced duration of symptoms and hospitalization in TB-IRIS, with no increase in serious infections.

The researchers randomized 240 patients to receive prednisone (40 mg/day for 2 weeks, then 20 mg/day for 2 weeks) within 48 hours of starting ART. All patients started ART within 30 days of starting TB treatment, and had a CD4 count of 100 or fewer cells/microL.

Excluded patients included those with rifampicin resistance, neurobiological tuberculosis, Kaposi’s sarcoma, or hepatitis B, and those who weren’t on the standard first line TB treatment because they couldn’t tolerate it. Patients were also excluded if they had a poor clinical response to TB treatment.

Most endpoints were followed for 12 weeks, but HIV-related cancers were monitored out to 1 year.

Forty-seven percent of patients in the placebo group experienced TB-IRIS within 12 weeks, compared with 33% of patients in the prednisone group (risk ratio, 0.70; 95% confidence interval 0.51-0.96). In an open-label extension study, the researchers noted that 28% of patients who started out in the placebo arm eventually received corticosteroids to treat TB-IRIS, compared with 13% of those who started out in the prednisone arm (RR 0.47, 95% CI 0.27-0.83).

Subjects in the prednisone arm had a lower rate of grade 3 adverse events (29% vs. 45%, P = .01).

There was a similar mortality rate in both arms, and no difference in the incidence of Kaposi’s sarcoma or new-onset AIDS-defining infections.

Dr. Meintjes pointed out that patient selection is important. The trial patients were seen in the clinical setting, not sicker, hospitalized patients, and they had to be improving with TB treatment; significant comorbidities were excluded. “In those patients, prednisone was safe.”

Dr. Meintjes reported having no relevant financial disclosures.

Photo courtesy of CDC

A new analysis indicates that cancer survivors may be more likely than the rest of the US population to change their prescription drug use due to financial concerns.

The study showed that cancer survivors were more likely to delay filling prescriptions, skip medication doses, request cheaper medications from their doctors, and engage in other cost-saving behaviors.

However, this was only true for non-elderly individuals.

There was no significant difference in cost-saving behaviors between elderly (age 65 and older) cancer survivors and elderly individuals in the general population.

Ahmedin Jemal, DVM, PhD, of the American Cancer Society in Atlanta, Georgia, and his colleagues reported these findings in Cancer.

The researchers used 2011-2014 data from the National Health Interview Survey, an annual household interview survey conducted by the US Centers for Disease Control and Prevention.

The survey included 8931 cancer survivors and 126,287 individuals without a cancer history.

Among non-elderly adults, 31.6% of those who had been diagnosed with cancer recently and 27.9% of those who had been diagnosed at least 2 years earlier reported a change in prescription drug use for financial reasons, compared with 21.4% of individuals without a history of cancer (P<0.05).

“Specifically, non-elderly cancer survivors were more likely to skip medication, delay filling a prescription, ask their doctor for lower-cost medication, and use alternative therapies for financial reasons compared with non-elderly individuals without a cancer history,” Dr Jemal said.

On the other hand, changes in prescription drug use for financial reasons were generally similar between elderly cancer survivors and elderly individuals without a cancer history.

The proportion of elderly individuals who changed their drug use for financial reasons was 24.9% among those who had been diagnosed with cancer recently, 21.8% among those who had been diagnosed at least 2 years earlier, and 20.4% among those without a history of cancer.

The researchers said these results could be explained by uniform healthcare coverage through Medicare.

The team also said their findings may have significant policy implications.

“Healthcare reforms addressing the financial burden of cancer among survivors, including the escalating cost of prescription drugs, should consider multiple comorbid conditions and high-deductible health plans, and the working poor,” Dr Jemal said.

“Our findings also have implications for doctor and patient communication about the financial burden of cancer when making treatment decisions, especially on the use of certain drugs that cost hundreds of thousands of dollars but with very small benefit compared with alternative and more affordable drugs.”

Photo courtesy of CDC

A new analysis indicates that cancer survivors may be more likely than the rest of the US population to change their prescription drug use due to financial concerns.

The study showed that cancer survivors were more likely to delay filling prescriptions, skip medication doses, request cheaper medications from their doctors, and engage in other cost-saving behaviors.

However, this was only true for non-elderly individuals.

There was no significant difference in cost-saving behaviors between elderly (age 65 and older) cancer survivors and elderly individuals in the general population.

Ahmedin Jemal, DVM, PhD, of the American Cancer Society in Atlanta, Georgia, and his colleagues reported these findings in Cancer.

The researchers used 2011-2014 data from the National Health Interview Survey, an annual household interview survey conducted by the US Centers for Disease Control and Prevention.

The survey included 8931 cancer survivors and 126,287 individuals without a cancer history.

Among non-elderly adults, 31.6% of those who had been diagnosed with cancer recently and 27.9% of those who had been diagnosed at least 2 years earlier reported a change in prescription drug use for financial reasons, compared with 21.4% of individuals without a history of cancer (P<0.05).

“Specifically, non-elderly cancer survivors were more likely to skip medication, delay filling a prescription, ask their doctor for lower-cost medication, and use alternative therapies for financial reasons compared with non-elderly individuals without a cancer history,” Dr Jemal said.

On the other hand, changes in prescription drug use for financial reasons were generally similar between elderly cancer survivors and elderly individuals without a cancer history.

The proportion of elderly individuals who changed their drug use for financial reasons was 24.9% among those who had been diagnosed with cancer recently, 21.8% among those who had been diagnosed at least 2 years earlier, and 20.4% among those without a history of cancer.

The researchers said these results could be explained by uniform healthcare coverage through Medicare.

The team also said their findings may have significant policy implications.

“Healthcare reforms addressing the financial burden of cancer among survivors, including the escalating cost of prescription drugs, should consider multiple comorbid conditions and high-deductible health plans, and the working poor,” Dr Jemal said.

“Our findings also have implications for doctor and patient communication about the financial burden of cancer when making treatment decisions, especially on the use of certain drugs that cost hundreds of thousands of dollars but with very small benefit compared with alternative and more affordable drugs.”

Photo courtesy of CDC

A new analysis indicates that cancer survivors may be more likely than the rest of the US population to change their prescription drug use due to financial concerns.

The study showed that cancer survivors were more likely to delay filling prescriptions, skip medication doses, request cheaper medications from their doctors, and engage in other cost-saving behaviors.

However, this was only true for non-elderly individuals.

There was no significant difference in cost-saving behaviors between elderly (age 65 and older) cancer survivors and elderly individuals in the general population.

Ahmedin Jemal, DVM, PhD, of the American Cancer Society in Atlanta, Georgia, and his colleagues reported these findings in Cancer.

The researchers used 2011-2014 data from the National Health Interview Survey, an annual household interview survey conducted by the US Centers for Disease Control and Prevention.

The survey included 8931 cancer survivors and 126,287 individuals without a cancer history.

Among non-elderly adults, 31.6% of those who had been diagnosed with cancer recently and 27.9% of those who had been diagnosed at least 2 years earlier reported a change in prescription drug use for financial reasons, compared with 21.4% of individuals without a history of cancer (P<0.05).

“Specifically, non-elderly cancer survivors were more likely to skip medication, delay filling a prescription, ask their doctor for lower-cost medication, and use alternative therapies for financial reasons compared with non-elderly individuals without a cancer history,” Dr Jemal said.

On the other hand, changes in prescription drug use for financial reasons were generally similar between elderly cancer survivors and elderly individuals without a cancer history.

The proportion of elderly individuals who changed their drug use for financial reasons was 24.9% among those who had been diagnosed with cancer recently, 21.8% among those who had been diagnosed at least 2 years earlier, and 20.4% among those without a history of cancer.

The researchers said these results could be explained by uniform healthcare coverage through Medicare.

The team also said their findings may have significant policy implications.

“Healthcare reforms addressing the financial burden of cancer among survivors, including the escalating cost of prescription drugs, should consider multiple comorbid conditions and high-deductible health plans, and the working poor,” Dr Jemal said.

“Our findings also have implications for doctor and patient communication about the financial burden of cancer when making treatment decisions, especially on the use of certain drugs that cost hundreds of thousands of dollars but with very small benefit compared with alternative and more affordable drugs.”

B-cell precursor ALL

The US Food and Drug Administration (FDA) has granted priority review for inotuzumab ozogamicin as a treatment for adults with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL).

The FDA grants priority review to applications for products that may provide significant improvements in the treatment, diagnosis, or prevention of serious conditions.

The agency’s goal is to take action on a priority review application within 6 months of receiving it, rather than the standard 10-month period.

The Prescription Drug User Fee Act goal date for inotuzumab ozogamicin is August 2017.

About inotuzumab ozogamicin

Inotuzumab ozogamicin is an antibody-drug conjugate that consists of a monoclonal antibody targeting CD22 and a cytotoxic agent known as calicheamicin.

The product originates from a collaboration between Pfizer and Celltech (now UCB), but Pfizer has sole responsibility for all manufacturing and clinical development activities.

The application for inotuzumab ozogamicin is supported by results from a phase 3 trial, which were published in NEJM in June 2016.

The trial enrolled 326 adult patients with relapsed or refractory B-cell ALL and compared inotuzumab ozogamicin to standard of care chemotherapy.

The rate of complete remission, including incomplete hematologic recovery, was 80.7% in the inotuzumab arm and 29.4% in the chemotherapy arm (P<0.001). The median duration of remission was 4.6 months and 3.1 months, respectively (P=0.03).

Forty-one percent of patients treated with inotuzumab and 11% of those who received chemotherapy proceeded to stem cell transplant directly after treatment (P<0.001).

The median progression-free survival was 5.0 months in the inotuzumab arm and 1.8 months in the chemotherapy arm (P<0.001).

The median overall survival was 7.7 months and 6.7 months, respectively (P=0.04). This did not meet the prespecified boundary of significance (P=0.0208).

Liver-related adverse events were more common in the inotuzumab arm than the chemotherapy arm. The most frequent of these were increased aspartate aminotransferase level (20% vs 10%), hyperbilirubinemia (15% vs 10%), and increased alanine aminotransferase level (14% vs 11%).

Veno-occlusive liver disease occurred in 11% of patients in the inotuzumab arm and 1% in the chemotherapy arm.

There were 17 deaths during treatment in the inotuzumab arm and 11 in the chemotherapy arm. Four deaths were considered related to inotuzumab, and 2 were thought to be related to chemotherapy.

B-cell precursor ALL

The US Food and Drug Administration (FDA) has granted priority review for inotuzumab ozogamicin as a treatment for adults with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL).

The FDA grants priority review to applications for products that may provide significant improvements in the treatment, diagnosis, or prevention of serious conditions.

The agency’s goal is to take action on a priority review application within 6 months of receiving it, rather than the standard 10-month period.

The Prescription Drug User Fee Act goal date for inotuzumab ozogamicin is August 2017.

About inotuzumab ozogamicin

Inotuzumab ozogamicin is an antibody-drug conjugate that consists of a monoclonal antibody targeting CD22 and a cytotoxic agent known as calicheamicin.

The product originates from a collaboration between Pfizer and Celltech (now UCB), but Pfizer has sole responsibility for all manufacturing and clinical development activities.

The application for inotuzumab ozogamicin is supported by results from a phase 3 trial, which were published in NEJM in June 2016.

The trial enrolled 326 adult patients with relapsed or refractory B-cell ALL and compared inotuzumab ozogamicin to standard of care chemotherapy.

The rate of complete remission, including incomplete hematologic recovery, was 80.7% in the inotuzumab arm and 29.4% in the chemotherapy arm (P<0.001). The median duration of remission was 4.6 months and 3.1 months, respectively (P=0.03).

Forty-one percent of patients treated with inotuzumab and 11% of those who received chemotherapy proceeded to stem cell transplant directly after treatment (P<0.001).

The median progression-free survival was 5.0 months in the inotuzumab arm and 1.8 months in the chemotherapy arm (P<0.001).

The median overall survival was 7.7 months and 6.7 months, respectively (P=0.04). This did not meet the prespecified boundary of significance (P=0.0208).

Liver-related adverse events were more common in the inotuzumab arm than the chemotherapy arm. The most frequent of these were increased aspartate aminotransferase level (20% vs 10%), hyperbilirubinemia (15% vs 10%), and increased alanine aminotransferase level (14% vs 11%).

Veno-occlusive liver disease occurred in 11% of patients in the inotuzumab arm and 1% in the chemotherapy arm.

There were 17 deaths during treatment in the inotuzumab arm and 11 in the chemotherapy arm. Four deaths were considered related to inotuzumab, and 2 were thought to be related to chemotherapy.

B-cell precursor ALL

The US Food and Drug Administration (FDA) has granted priority review for inotuzumab ozogamicin as a treatment for adults with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL).

The FDA grants priority review to applications for products that may provide significant improvements in the treatment, diagnosis, or prevention of serious conditions.

The agency’s goal is to take action on a priority review application within 6 months of receiving it, rather than the standard 10-month period.

The Prescription Drug User Fee Act goal date for inotuzumab ozogamicin is August 2017.

About inotuzumab ozogamicin

Inotuzumab ozogamicin is an antibody-drug conjugate that consists of a monoclonal antibody targeting CD22 and a cytotoxic agent known as calicheamicin.

The product originates from a collaboration between Pfizer and Celltech (now UCB), but Pfizer has sole responsibility for all manufacturing and clinical development activities.

The application for inotuzumab ozogamicin is supported by results from a phase 3 trial, which were published in NEJM in June 2016.

The trial enrolled 326 adult patients with relapsed or refractory B-cell ALL and compared inotuzumab ozogamicin to standard of care chemotherapy.

The rate of complete remission, including incomplete hematologic recovery, was 80.7% in the inotuzumab arm and 29.4% in the chemotherapy arm (P<0.001). The median duration of remission was 4.6 months and 3.1 months, respectively (P=0.03).

Forty-one percent of patients treated with inotuzumab and 11% of those who received chemotherapy proceeded to stem cell transplant directly after treatment (P<0.001).

The median progression-free survival was 5.0 months in the inotuzumab arm and 1.8 months in the chemotherapy arm (P<0.001).

The median overall survival was 7.7 months and 6.7 months, respectively (P=0.04). This did not meet the prespecified boundary of significance (P=0.0208).

Liver-related adverse events were more common in the inotuzumab arm than the chemotherapy arm. The most frequent of these were increased aspartate aminotransferase level (20% vs 10%), hyperbilirubinemia (15% vs 10%), and increased alanine aminotransferase level (14% vs 11%).

Veno-occlusive liver disease occurred in 11% of patients in the inotuzumab arm and 1% in the chemotherapy arm.

There were 17 deaths during treatment in the inotuzumab arm and 11 in the chemotherapy arm. Four deaths were considered related to inotuzumab, and 2 were thought to be related to chemotherapy.

AML cells

New research indicates that RUNX1, a known tumor suppressor, actually cooperates with internal tandem duplications in the FLT3 receptor tyrosine kinase (FLT3-ITD) to induce acute myeloid leukemia (AML).

Investigators say this discovery suggests that blocking RUNX1 activity will “greatly enhance” current therapeutic approaches using FLT3 inhibitors.

The discovery was published in The Journal of Experimental Medicine.

The research began when investigators noticed that many AML patients with FLT3-ITD also showed increased levels of RUNX1.

“This was unexpected because up to 20% of AML patients carry mutations that inactivate RUNX1, which is generally considered to be a tumor suppressor that prevents the formation of leukemias,” said study author Carol Stocking, PhD, of Heinrich-Pette-Institute-Leibniz Institute for Experimental Virology in Hamburg, Germany.

To investigate this finding, she and her colleagues injected mice with human AML cells expressing FLT3-ITD. The team found that reducing RUNX1 levels attenuated the cells’ ability to form tumors, but elevated RUNX1 levels worked with FLT3-ITD to induce AML.

Mouse hematopoietic stem cells expressing FLT3-ITD were highly proliferative, and co-expression of RUNX1 blocked their differentiation, allowing them to give rise to AML.

Mutant FLT3 appears to stabilize and activate RUNX1 by promoting the transcription factor’s phosphorylation. Active RUNX1 then blocks differentiation, at least in part, by upregulation of another transcription factor, Hhex.

The investigators found that hematopoietic stem cells expressing both Hhex and FLT3-ITD gave rise to AML.

RUNX1 may therefore suppress the initiation of AML but, after being activated by mutant FLT3, block differentiation and promote tumor development.

“Therapies that can reverse this differentiation block may offer significant therapeutic efficacy in AML patients with FLT3 mutations,” Dr Stocking said. “Ablating RUNX1 is toxic to leukemic cells but not to normal hematopoietic stem cells, so inhibiting RUNX1 may be a promising target in combination with FLT3 inhibitors.”

AML cells

New research indicates that RUNX1, a known tumor suppressor, actually cooperates with internal tandem duplications in the FLT3 receptor tyrosine kinase (FLT3-ITD) to induce acute myeloid leukemia (AML).

Investigators say this discovery suggests that blocking RUNX1 activity will “greatly enhance” current therapeutic approaches using FLT3 inhibitors.

The discovery was published in The Journal of Experimental Medicine.

The research began when investigators noticed that many AML patients with FLT3-ITD also showed increased levels of RUNX1.

“This was unexpected because up to 20% of AML patients carry mutations that inactivate RUNX1, which is generally considered to be a tumor suppressor that prevents the formation of leukemias,” said study author Carol Stocking, PhD, of Heinrich-Pette-Institute-Leibniz Institute for Experimental Virology in Hamburg, Germany.

To investigate this finding, she and her colleagues injected mice with human AML cells expressing FLT3-ITD. The team found that reducing RUNX1 levels attenuated the cells’ ability to form tumors, but elevated RUNX1 levels worked with FLT3-ITD to induce AML.

Mouse hematopoietic stem cells expressing FLT3-ITD were highly proliferative, and co-expression of RUNX1 blocked their differentiation, allowing them to give rise to AML.

Mutant FLT3 appears to stabilize and activate RUNX1 by promoting the transcription factor’s phosphorylation. Active RUNX1 then blocks differentiation, at least in part, by upregulation of another transcription factor, Hhex.

The investigators found that hematopoietic stem cells expressing both Hhex and FLT3-ITD gave rise to AML.

RUNX1 may therefore suppress the initiation of AML but, after being activated by mutant FLT3, block differentiation and promote tumor development.

“Therapies that can reverse this differentiation block may offer significant therapeutic efficacy in AML patients with FLT3 mutations,” Dr Stocking said. “Ablating RUNX1 is toxic to leukemic cells but not to normal hematopoietic stem cells, so inhibiting RUNX1 may be a promising target in combination with FLT3 inhibitors.”

AML cells

New research indicates that RUNX1, a known tumor suppressor, actually cooperates with internal tandem duplications in the FLT3 receptor tyrosine kinase (FLT3-ITD) to induce acute myeloid leukemia (AML).

Investigators say this discovery suggests that blocking RUNX1 activity will “greatly enhance” current therapeutic approaches using FLT3 inhibitors.

The discovery was published in The Journal of Experimental Medicine.

The research began when investigators noticed that many AML patients with FLT3-ITD also showed increased levels of RUNX1.

“This was unexpected because up to 20% of AML patients carry mutations that inactivate RUNX1, which is generally considered to be a tumor suppressor that prevents the formation of leukemias,” said study author Carol Stocking, PhD, of Heinrich-Pette-Institute-Leibniz Institute for Experimental Virology in Hamburg, Germany.

To investigate this finding, she and her colleagues injected mice with human AML cells expressing FLT3-ITD. The team found that reducing RUNX1 levels attenuated the cells’ ability to form tumors, but elevated RUNX1 levels worked with FLT3-ITD to induce AML.

Mouse hematopoietic stem cells expressing FLT3-ITD were highly proliferative, and co-expression of RUNX1 blocked their differentiation, allowing them to give rise to AML.

Mutant FLT3 appears to stabilize and activate RUNX1 by promoting the transcription factor’s phosphorylation. Active RUNX1 then blocks differentiation, at least in part, by upregulation of another transcription factor, Hhex.

The investigators found that hematopoietic stem cells expressing both Hhex and FLT3-ITD gave rise to AML.

RUNX1 may therefore suppress the initiation of AML but, after being activated by mutant FLT3, block differentiation and promote tumor development.

“Therapies that can reverse this differentiation block may offer significant therapeutic efficacy in AML patients with FLT3 mutations,” Dr Stocking said. “Ablating RUNX1 is toxic to leukemic cells but not to normal hematopoietic stem cells, so inhibiting RUNX1 may be a promising target in combination with FLT3 inhibitors.”

Benjamin Chaigne-Delalande

The US Food and Drug Administration (FDA) has granted fast track designation to CMD-003 (baltaleucel-T) for patients with relapsed/refractory lymphoma and post-transplant lymphoproliferative disease associated with Epstein-Barr virus (EBV).

CMD-003 consists of patient-derived T cells that have been activated to kill malignant cells expressing antigens associated with EBV.

The T cells specifically target 4 EBV epitopes—LMP1, LMP2, EBNA, and BARF1.

CMD-003 is being developed by Cell Medica and the Baylor College of Medicine with funding provided, in part, by the Cancer Prevention and Research Institute of Texas.

About fast track designation

The FDA’s fast track program is designed to facilitate the development and expedite the review of products intended to treat or prevent serious or life-threatening conditions and address unmet medical need.

Through the FDA’s fast track program, a product may be eligible for priority review. In addition, the company developing the product may be allowed to submit sections of the biologic license application or new drug application on a rolling basis as data become available.

Fast track designation also provides the company with opportunities for more frequent meetings and written communications with the FDA.

CMD-003-related research

CMD-003 is currently under investigation in the phase 2 CITADEL trial for patients with extranodal natural killer T-cell lymphoma and the phase 2 CIVIC trial for patients with EBV-associated diffuse large B-cell lymphoma, Hodgkin lymphoma, and post-transplant lymphoproliferative disease.

Researchers have not published results from any trials of CMD-003, but they have published results with EBV-specific T-cell products related to CMD-003.

In one study, published in the Journal of Clinical Oncology in 2014, researchers administered cytotoxic T lymphocytes (CTLs) in 50 patients with EBV-associated Hodgkin or non-Hodgkin lymphoma.

Twenty-nine of the patients were in remission when they received CTL infusions, but they were at a high risk of relapse. The remaining 21 patients had relapsed or refractory disease at the time of CTL infusion.

Twenty-seven of the patients who received CTLs as an adjuvant treatment remained in remission at 3.1 years after treatment.

Their 2-year event-free survival rate was 82%. None of the patients died of lymphoma, but 9 died from complications associated with the chemotherapy and radiation they had received.

Of the 21 patients with relapsed or refractory disease, 13 responded to CTL infusions, and 11 patients achieved a complete response. In this group, the 2-year event-free survival rate was about 50%.

The researchers said there were no toxicities that were definitively related to CTL infusion.

One patient had central nervous system deterioration 2 weeks after infusion. This was attributed to disease progression but could possibly have been treatment-related.

Another patient developed respiratory complications about 4 weeks after a second CTL infusion that may have been treatment-related. However, the researchers attributed it to an intercurrent infection, and the patient made a complete recovery.

Benjamin Chaigne-Delalande

The US Food and Drug Administration (FDA) has granted fast track designation to CMD-003 (baltaleucel-T) for patients with relapsed/refractory lymphoma and post-transplant lymphoproliferative disease associated with Epstein-Barr virus (EBV).

CMD-003 consists of patient-derived T cells that have been activated to kill malignant cells expressing antigens associated with EBV.

The T cells specifically target 4 EBV epitopes—LMP1, LMP2, EBNA, and BARF1.

CMD-003 is being developed by Cell Medica and the Baylor College of Medicine with funding provided, in part, by the Cancer Prevention and Research Institute of Texas.

About fast track designation

The FDA’s fast track program is designed to facilitate the development and expedite the review of products intended to treat or prevent serious or life-threatening conditions and address unmet medical need.

Through the FDA’s fast track program, a product may be eligible for priority review. In addition, the company developing the product may be allowed to submit sections of the biologic license application or new drug application on a rolling basis as data become available.

Fast track designation also provides the company with opportunities for more frequent meetings and written communications with the FDA.

CMD-003-related research

CMD-003 is currently under investigation in the phase 2 CITADEL trial for patients with extranodal natural killer T-cell lymphoma and the phase 2 CIVIC trial for patients with EBV-associated diffuse large B-cell lymphoma, Hodgkin lymphoma, and post-transplant lymphoproliferative disease.

Researchers have not published results from any trials of CMD-003, but they have published results with EBV-specific T-cell products related to CMD-003.

In one study, published in the Journal of Clinical Oncology in 2014, researchers administered cytotoxic T lymphocytes (CTLs) in 50 patients with EBV-associated Hodgkin or non-Hodgkin lymphoma.

Twenty-nine of the patients were in remission when they received CTL infusions, but they were at a high risk of relapse. The remaining 21 patients had relapsed or refractory disease at the time of CTL infusion.

Twenty-seven of the patients who received CTLs as an adjuvant treatment remained in remission at 3.1 years after treatment.

Their 2-year event-free survival rate was 82%. None of the patients died of lymphoma, but 9 died from complications associated with the chemotherapy and radiation they had received.

Of the 21 patients with relapsed or refractory disease, 13 responded to CTL infusions, and 11 patients achieved a complete response. In this group, the 2-year event-free survival rate was about 50%.

The researchers said there were no toxicities that were definitively related to CTL infusion.

One patient had central nervous system deterioration 2 weeks after infusion. This was attributed to disease progression but could possibly have been treatment-related.

Another patient developed respiratory complications about 4 weeks after a second CTL infusion that may have been treatment-related. However, the researchers attributed it to an intercurrent infection, and the patient made a complete recovery.

Benjamin Chaigne-Delalande

The US Food and Drug Administration (FDA) has granted fast track designation to CMD-003 (baltaleucel-T) for patients with relapsed/refractory lymphoma and post-transplant lymphoproliferative disease associated with Epstein-Barr virus (EBV).

CMD-003 consists of patient-derived T cells that have been activated to kill malignant cells expressing antigens associated with EBV.

The T cells specifically target 4 EBV epitopes—LMP1, LMP2, EBNA, and BARF1.

CMD-003 is being developed by Cell Medica and the Baylor College of Medicine with funding provided, in part, by the Cancer Prevention and Research Institute of Texas.

About fast track designation

The FDA’s fast track program is designed to facilitate the development and expedite the review of products intended to treat or prevent serious or life-threatening conditions and address unmet medical need.

Through the FDA’s fast track program, a product may be eligible for priority review. In addition, the company developing the product may be allowed to submit sections of the biologic license application or new drug application on a rolling basis as data become available.

Fast track designation also provides the company with opportunities for more frequent meetings and written communications with the FDA.

CMD-003-related research

CMD-003 is currently under investigation in the phase 2 CITADEL trial for patients with extranodal natural killer T-cell lymphoma and the phase 2 CIVIC trial for patients with EBV-associated diffuse large B-cell lymphoma, Hodgkin lymphoma, and post-transplant lymphoproliferative disease.

Researchers have not published results from any trials of CMD-003, but they have published results with EBV-specific T-cell products related to CMD-003.

In one study, published in the Journal of Clinical Oncology in 2014, researchers administered cytotoxic T lymphocytes (CTLs) in 50 patients with EBV-associated Hodgkin or non-Hodgkin lymphoma.

Twenty-nine of the patients were in remission when they received CTL infusions, but they were at a high risk of relapse. The remaining 21 patients had relapsed or refractory disease at the time of CTL infusion.

Twenty-seven of the patients who received CTLs as an adjuvant treatment remained in remission at 3.1 years after treatment.

Their 2-year event-free survival rate was 82%. None of the patients died of lymphoma, but 9 died from complications associated with the chemotherapy and radiation they had received.

Of the 21 patients with relapsed or refractory disease, 13 responded to CTL infusions, and 11 patients achieved a complete response. In this group, the 2-year event-free survival rate was about 50%.

The researchers said there were no toxicities that were definitively related to CTL infusion.

One patient had central nervous system deterioration 2 weeks after infusion. This was attributed to disease progression but could possibly have been treatment-related.

Another patient developed respiratory complications about 4 weeks after a second CTL infusion that may have been treatment-related. However, the researchers attributed it to an intercurrent infection, and the patient made a complete recovery.

LAS VEGAS – A triad of signs – elevated serum calcium, elevated parathyroid hormone, and a history of kidney stones – can predict hypercalcemic crisis among patients with hyperparathyroidism, a study showed.

Patients who present with the trifecta should be considered for expedited parathyroidectomy, Andrew Lowell said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
 

• 91% of those with a serum calcium higher than 13.25 mg/dL and 6% of those with a lower serum calcium level.

• 60% of those with a PTH of 394 pg/mL or higher and 19% of those with a PTH less than 394 pg/mL.

• 31% of those with a history of kidney stones and 14% of those without such a history.

The investigators created a decision tree that begins with a calcium level greater than 13.25 mg/dL, a PTH level higher than 394 pg/mL, and a Charlson comorbidity index of 4 or greater. The model carried an overall predictive accuracy of 90% and a positive predictive value of 76%, Mr. Lowell said.

Session moderator Benjamin Poulose, MD, of Vanderbilt University, Nashville, Tenn., said the model looks very good on paper, but might be challenging to implement when assessing emergent patients.

Mr. Lowell suggested that it would be better employed in an outpatient setting.

“I think this would be more useful in the situation of a physician who knows that patient’s comorbidities, in the context of counseling, to determine” the need for and timing of surgery, he said.

He had no relevant financial disclosures.
 

[email protected]

On Twitter @Alz_Gal

LAS VEGAS – A triad of signs – elevated serum calcium, elevated parathyroid hormone, and a history of kidney stones – can predict hypercalcemic crisis among patients with hyperparathyroidism, a study showed.

Patients who present with the trifecta should be considered for expedited parathyroidectomy, Andrew Lowell said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
 

• 91% of those with a serum calcium higher than 13.25 mg/dL and 6% of those with a lower serum calcium level.

• 60% of those with a PTH of 394 pg/mL or higher and 19% of those with a PTH less than 394 pg/mL.

• 31% of those with a history of kidney stones and 14% of those without such a history.

The investigators created a decision tree that begins with a calcium level greater than 13.25 mg/dL, a PTH level higher than 394 pg/mL, and a Charlson comorbidity index of 4 or greater. The model carried an overall predictive accuracy of 90% and a positive predictive value of 76%, Mr. Lowell said.

Session moderator Benjamin Poulose, MD, of Vanderbilt University, Nashville, Tenn., said the model looks very good on paper, but might be challenging to implement when assessing emergent patients.

Mr. Lowell suggested that it would be better employed in an outpatient setting.

“I think this would be more useful in the situation of a physician who knows that patient’s comorbidities, in the context of counseling, to determine” the need for and timing of surgery, he said.

He had no relevant financial disclosures.
 

[email protected]

On Twitter @Alz_Gal

LAS VEGAS – A triad of signs – elevated serum calcium, elevated parathyroid hormone, and a history of kidney stones – can predict hypercalcemic crisis among patients with hyperparathyroidism, a study showed.

Patients who present with the trifecta should be considered for expedited parathyroidectomy, Andrew Lowell said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
 

• 91% of those with a serum calcium higher than 13.25 mg/dL and 6% of those with a lower serum calcium level.

• 60% of those with a PTH of 394 pg/mL or higher and 19% of those with a PTH less than 394 pg/mL.

• 31% of those with a history of kidney stones and 14% of those without such a history.

The investigators created a decision tree that begins with a calcium level greater than 13.25 mg/dL, a PTH level higher than 394 pg/mL, and a Charlson comorbidity index of 4 or greater. The model carried an overall predictive accuracy of 90% and a positive predictive value of 76%, Mr. Lowell said.

Session moderator Benjamin Poulose, MD, of Vanderbilt University, Nashville, Tenn., said the model looks very good on paper, but might be challenging to implement when assessing emergent patients.

Mr. Lowell suggested that it would be better employed in an outpatient setting.

“I think this would be more useful in the situation of a physician who knows that patient’s comorbidities, in the context of counseling, to determine” the need for and timing of surgery, he said.

He had no relevant financial disclosures.
 

[email protected]

On Twitter @Alz_Gal

Oral methotrexate prolonged and slightly boosted the efficacy of intra-articular corticosteroid injections in children with oligoarticular juvenile idiopathic arthritis without causing serious adverse effects, based on the results of a first-in-kind multicenter, randomized, open-label trial.

“This combination could be considered as reference treatment in everyday clinical practice for pediatricians, particularly in children with higher erythrocyte sedimentation rate,” Angelo Ravelli, MD, of Istituto Giannini Gaslini, Genoa, Italy, and his associates wrote in The Lancet. The regimen also could take center stage in treat-to-target strategies for children with chronic arthritis, they said (Lancet. 2017 Feb 2. doi: 10.1016/S0140-6736[17]30065-X).

Oral methotrexate prolonged and slightly boosted the efficacy of intra-articular corticosteroid injections in children with oligoarticular juvenile idiopathic arthritis without causing serious adverse effects, based on the results of a first-in-kind multicenter, randomized, open-label trial.

“This combination could be considered as reference treatment in everyday clinical practice for pediatricians, particularly in children with higher erythrocyte sedimentation rate,” Angelo Ravelli, MD, of Istituto Giannini Gaslini, Genoa, Italy, and his associates wrote in The Lancet. The regimen also could take center stage in treat-to-target strategies for children with chronic arthritis, they said (Lancet. 2017 Feb 2. doi: 10.1016/S0140-6736[17]30065-X).

Oral methotrexate prolonged and slightly boosted the efficacy of intra-articular corticosteroid injections in children with oligoarticular juvenile idiopathic arthritis without causing serious adverse effects, based on the results of a first-in-kind multicenter, randomized, open-label trial.

“This combination could be considered as reference treatment in everyday clinical practice for pediatricians, particularly in children with higher erythrocyte sedimentation rate,” Angelo Ravelli, MD, of Istituto Giannini Gaslini, Genoa, Italy, and his associates wrote in The Lancet. The regimen also could take center stage in treat-to-target strategies for children with chronic arthritis, they said (Lancet. 2017 Feb 2. doi: 10.1016/S0140-6736[17]30065-X).

In the course of researching our book, “Committed: The Battle Over Involuntary Psychiatric Care,” I came to a few very important conclusions. Involuntary commitment can be traumatizing to patients, and it should be done as a last resort when patients are dangerous (generally to themselves, but sometimes toward others) or tormented, and when they can’t be persuaded to get voluntary care. That may sound obvious, but in practice, it doesn’t always work that way. Furthermore, if there is no choice but to hold people against their will, there should be no use of physical force unless it is absolutely necessary to maintain safety, and patients should be treated with kindness and respect. It’s what we’d all want if we were the patient, and it’s not what all patients get.

Knowing that, you can imagine my shock when I saw reporter Mike Anderson’s article “Jail cells await mentally ill in Rapid City” in the Feb. 8, 2017, edition of the Rapid City Journal. Mr. Anderson noted that the Rapid City Regional Hospital was changing its policy on psychiatric admissions. The South Dakota city of 60,000 has a 44-bed psychiatric hospital located 1.5 miles from the main hospital. It is the only inpatient facility for at least 250 miles and serves a total population of approximately 250,000 people. If the unit is full – either because all beds are full or because staffing and acuity issues limit capacity – its policy always has been to admit overflow psychiatric patients to medical beds.

My thanks to Mr. Anderson of the Rapid City Journal, Dr. Manlove, and Sheriff Thom for their help with this article.

Dr. Miller wrote “Committed: The Battle Over Involuntary Psychiatric Care” with Annette Hanson, MD (Baltimore: Johns Hopkins University Press, 2016).

In the course of researching our book, “Committed: The Battle Over Involuntary Psychiatric Care,” I came to a few very important conclusions. Involuntary commitment can be traumatizing to patients, and it should be done as a last resort when patients are dangerous (generally to themselves, but sometimes toward others) or tormented, and when they can’t be persuaded to get voluntary care. That may sound obvious, but in practice, it doesn’t always work that way. Furthermore, if there is no choice but to hold people against their will, there should be no use of physical force unless it is absolutely necessary to maintain safety, and patients should be treated with kindness and respect. It’s what we’d all want if we were the patient, and it’s not what all patients get.

Knowing that, you can imagine my shock when I saw reporter Mike Anderson’s article “Jail cells await mentally ill in Rapid City” in the Feb. 8, 2017, edition of the Rapid City Journal. Mr. Anderson noted that the Rapid City Regional Hospital was changing its policy on psychiatric admissions. The South Dakota city of 60,000 has a 44-bed psychiatric hospital located 1.5 miles from the main hospital. It is the only inpatient facility for at least 250 miles and serves a total population of approximately 250,000 people. If the unit is full – either because all beds are full or because staffing and acuity issues limit capacity – its policy always has been to admit overflow psychiatric patients to medical beds.

My thanks to Mr. Anderson of the Rapid City Journal, Dr. Manlove, and Sheriff Thom for their help with this article.

Dr. Miller wrote “Committed: The Battle Over Involuntary Psychiatric Care” with Annette Hanson, MD (Baltimore: Johns Hopkins University Press, 2016).

In the course of researching our book, “Committed: The Battle Over Involuntary Psychiatric Care,” I came to a few very important conclusions. Involuntary commitment can be traumatizing to patients, and it should be done as a last resort when patients are dangerous (generally to themselves, but sometimes toward others) or tormented, and when they can’t be persuaded to get voluntary care. That may sound obvious, but in practice, it doesn’t always work that way. Furthermore, if there is no choice but to hold people against their will, there should be no use of physical force unless it is absolutely necessary to maintain safety, and patients should be treated with kindness and respect. It’s what we’d all want if we were the patient, and it’s not what all patients get.

Knowing that, you can imagine my shock when I saw reporter Mike Anderson’s article “Jail cells await mentally ill in Rapid City” in the Feb. 8, 2017, edition of the Rapid City Journal. Mr. Anderson noted that the Rapid City Regional Hospital was changing its policy on psychiatric admissions. The South Dakota city of 60,000 has a 44-bed psychiatric hospital located 1.5 miles from the main hospital. It is the only inpatient facility for at least 250 miles and serves a total population of approximately 250,000 people. If the unit is full – either because all beds are full or because staffing and acuity issues limit capacity – its policy always has been to admit overflow psychiatric patients to medical beds.

My thanks to Mr. Anderson of the Rapid City Journal, Dr. Manlove, and Sheriff Thom for their help with this article.

Dr. Miller wrote “Committed: The Battle Over Involuntary Psychiatric Care” with Annette Hanson, MD (Baltimore: Johns Hopkins University Press, 2016).