ORLANDO – Port site infiltration during laparoscopic or robot-assisted hysterectomy with extended-release liposomal bupivacaine did not significantly improve most postoperative pain scores, compared with plain 0.25% bupivacaine.

In a randomized trial, the liposomal formulation was associated with 30% less pain on postoperative day 3, a significant difference not seen on postoperative day 1, 2, or 14.

“Liposomal bupivacaine is expected to last about 72 hours but it also comes at a cost,” Kenneth I. Barron, MD, a fellow in advanced minimally invasive gynecologic surgery at Florida Hospital Orlando, said at the meeting sponsored by AAGL. Extended-release bupivacaine costs $280, compared with $1.83 for plain bupivacaine, according to Dr. Barron.

“Based on this study, the routine use of liposomal bupivacaine as a port site local anesthetic in laparoscopic hysterectomy has limited usefulness and is not justified,” he said.

In the blinded study, surgeons at a tertiary-care community hospital performed pre-incision infiltration with undiluted liposomal extended-release bupivacaine for 32 surgery patients and with the short-acting formulation for another 32 surgery patients. All patients underwent either laparoscopic or robot-assisted total hysterectomy for benign indications. They were recruited for the study between July 2015 and January 2016 and there were no significant demographic differences between groups preoperatively.

For the primary outcome measure, investigators called each participant and asked them to rate their average overall pain on postoperative days 1, 2, 3, and 14. They used the Brief Pain Inventory 0-10 scale. There were no significant differences between groups on a composite score of their average and worst pain on days 1, 2, or 14. However, on day 3, the composite score was 3.26 in the extended-release group, compared with 4.83 for those receiving short-acting bupivacaine (P = .009).

“What this shows, if anything, is one method of local anesthetic is probably not enough to make a significant impact,” Dr. Barron said. What is needed instead is “probably more of a global approach to enhance recovery.”

There were no significant differences between groups in the secondary study outcomes: pain scores during the first 24 hours in the hospital, function based on pain interference scores, opioid use, or adverse events.

Dr. Barron reported having no relevant financial disclosures.

ORLANDO – Port site infiltration during laparoscopic or robot-assisted hysterectomy with extended-release liposomal bupivacaine did not significantly improve most postoperative pain scores, compared with plain 0.25% bupivacaine.

In a randomized trial, the liposomal formulation was associated with 30% less pain on postoperative day 3, a significant difference not seen on postoperative day 1, 2, or 14.

“Liposomal bupivacaine is expected to last about 72 hours but it also comes at a cost,” Kenneth I. Barron, MD, a fellow in advanced minimally invasive gynecologic surgery at Florida Hospital Orlando, said at the meeting sponsored by AAGL. Extended-release bupivacaine costs $280, compared with $1.83 for plain bupivacaine, according to Dr. Barron.

“Based on this study, the routine use of liposomal bupivacaine as a port site local anesthetic in laparoscopic hysterectomy has limited usefulness and is not justified,” he said.

In the blinded study, surgeons at a tertiary-care community hospital performed pre-incision infiltration with undiluted liposomal extended-release bupivacaine for 32 surgery patients and with the short-acting formulation for another 32 surgery patients. All patients underwent either laparoscopic or robot-assisted total hysterectomy for benign indications. They were recruited for the study between July 2015 and January 2016 and there were no significant demographic differences between groups preoperatively.

For the primary outcome measure, investigators called each participant and asked them to rate their average overall pain on postoperative days 1, 2, 3, and 14. They used the Brief Pain Inventory 0-10 scale. There were no significant differences between groups on a composite score of their average and worst pain on days 1, 2, or 14. However, on day 3, the composite score was 3.26 in the extended-release group, compared with 4.83 for those receiving short-acting bupivacaine (P = .009).

“What this shows, if anything, is one method of local anesthetic is probably not enough to make a significant impact,” Dr. Barron said. What is needed instead is “probably more of a global approach to enhance recovery.”

There were no significant differences between groups in the secondary study outcomes: pain scores during the first 24 hours in the hospital, function based on pain interference scores, opioid use, or adverse events.

Dr. Barron reported having no relevant financial disclosures.

ORLANDO – Port site infiltration during laparoscopic or robot-assisted hysterectomy with extended-release liposomal bupivacaine did not significantly improve most postoperative pain scores, compared with plain 0.25% bupivacaine.

In a randomized trial, the liposomal formulation was associated with 30% less pain on postoperative day 3, a significant difference not seen on postoperative day 1, 2, or 14.

“Liposomal bupivacaine is expected to last about 72 hours but it also comes at a cost,” Kenneth I. Barron, MD, a fellow in advanced minimally invasive gynecologic surgery at Florida Hospital Orlando, said at the meeting sponsored by AAGL. Extended-release bupivacaine costs $280, compared with $1.83 for plain bupivacaine, according to Dr. Barron.

“Based on this study, the routine use of liposomal bupivacaine as a port site local anesthetic in laparoscopic hysterectomy has limited usefulness and is not justified,” he said.

In the blinded study, surgeons at a tertiary-care community hospital performed pre-incision infiltration with undiluted liposomal extended-release bupivacaine for 32 surgery patients and with the short-acting formulation for another 32 surgery patients. All patients underwent either laparoscopic or robot-assisted total hysterectomy for benign indications. They were recruited for the study between July 2015 and January 2016 and there were no significant demographic differences between groups preoperatively.

For the primary outcome measure, investigators called each participant and asked them to rate their average overall pain on postoperative days 1, 2, 3, and 14. They used the Brief Pain Inventory 0-10 scale. There were no significant differences between groups on a composite score of their average and worst pain on days 1, 2, or 14. However, on day 3, the composite score was 3.26 in the extended-release group, compared with 4.83 for those receiving short-acting bupivacaine (P = .009).

“What this shows, if anything, is one method of local anesthetic is probably not enough to make a significant impact,” Dr. Barron said. What is needed instead is “probably more of a global approach to enhance recovery.”

There were no significant differences between groups in the secondary study outcomes: pain scores during the first 24 hours in the hospital, function based on pain interference scores, opioid use, or adverse events.

Dr. Barron reported having no relevant financial disclosures.

The recent decision by the US Food and Drug Administration to approve ofatumumab in combination with fludarabine and cyclophosphamide in relapsed disease marks a fourth approved indication for this drug in patients with chronic lymphocytic leukemia (CLL). Ofatumumab is a fully human monoclonal antibody that targets the CD20 protein on the surface of B cells, first approved for the treatment of CLL back in 2009.

Click on the PDF icon at the top of this introduction to read the full article.

The recent decision by the US Food and Drug Administration to approve ofatumumab in combination with fludarabine and cyclophosphamide in relapsed disease marks a fourth approved indication for this drug in patients with chronic lymphocytic leukemia (CLL). Ofatumumab is a fully human monoclonal antibody that targets the CD20 protein on the surface of B cells, first approved for the treatment of CLL back in 2009.

Click on the PDF icon at the top of this introduction to read the full article.

The recent decision by the US Food and Drug Administration to approve ofatumumab in combination with fludarabine and cyclophosphamide in relapsed disease marks a fourth approved indication for this drug in patients with chronic lymphocytic leukemia (CLL). Ofatumumab is a fully human monoclonal antibody that targets the CD20 protein on the surface of B cells, first approved for the treatment of CLL back in 2009.

Click on the PDF icon at the top of this introduction to read the full article.

Intrusive musical imagery (IMI) is characterized by recalling pieces of music,¹ usually repetitions of 15 to 30 seconds,² without pathology of the ear or nervous system.¹ Also known as earworm—ohrwurm in German—or involuntary musical imagery, bits of music can become a constant cause of distress.¹

IMI is prevalent in the general population; in an internet survey >85% of respondents reported experiencing IMI at least weekly.² IMI can be generated by:

• hearing music
• reading song lyrics
• being in contact with an environment or people who are linked to specific song, such as department stores that play holiday music.^2,3

IMI also is associated with stressful situations or neurological insult.¹

Any song or segment of music can be the basis of IMI. The content of IMI change over time (ie, a new song can become a source of IMI).³ The frequency of experiencing IMI is correlated to how much music a person is exposed to and the importance a person places on music.² Most episodes are intermittent; however, continuous musical episodes are known to occur.³ Episodes of IMI with obsessive-compulsive features can be classified as musical obsessions (MO).¹ MO may be part of obsessive-compulsive symptoms, including washing, checking, aggression, sexual obsessions, and religious obsessions or other obsessions.¹

Diagnosing musical obsessions

No current measures are adequate to diagnose MO. The Yale-Brown Obsessive Compulsive Scale does not distinguish MO from other intrusive auditory imagery.¹

It is important to differentiate MO from:

• Musical preoccupations or recollections in which an individual repeatedly listens or recalls a particular song or part of a song, but does not have the urge to listen or recall music in an obsessive-compulsive pattern.¹ These individuals do not display fear and avoidant behaviors that could be seen in patients with MO.¹
• Musical hallucinations lack an input stimulus and the patient believes the music comes from an outside source and interprets it as reality. Misdiagnosing MO as a psychotic symptom is common and can result in improper treatment.¹

Management

Pharmacotherapy. MO responds to the same medications used to treat obsessive-compulsive disorder, such as selective serotonin reuptake inhibitors and clomipramine.¹ Cognitive-behavioral interventions could help patients address dysfunctional beliefs, without trying to suppress them.¹

Distraction. Encourage patients to sing a different song that does not have obsessive quality¹ or engage in a task that uses working memory.³

Exposure and response prevention therapy. Some case reports have reported efficacy in treating MO.¹

Intrusive musical imagery (IMI) is characterized by recalling pieces of music,¹ usually repetitions of 15 to 30 seconds,² without pathology of the ear or nervous system.¹ Also known as earworm—ohrwurm in German—or involuntary musical imagery, bits of music can become a constant cause of distress.¹

IMI is prevalent in the general population; in an internet survey >85% of respondents reported experiencing IMI at least weekly.² IMI can be generated by:

• hearing music
• reading song lyrics
• being in contact with an environment or people who are linked to specific song, such as department stores that play holiday music.^2,3

IMI also is associated with stressful situations or neurological insult.¹

Any song or segment of music can be the basis of IMI. The content of IMI change over time (ie, a new song can become a source of IMI).³ The frequency of experiencing IMI is correlated to how much music a person is exposed to and the importance a person places on music.² Most episodes are intermittent; however, continuous musical episodes are known to occur.³ Episodes of IMI with obsessive-compulsive features can be classified as musical obsessions (MO).¹ MO may be part of obsessive-compulsive symptoms, including washing, checking, aggression, sexual obsessions, and religious obsessions or other obsessions.¹

Diagnosing musical obsessions

No current measures are adequate to diagnose MO. The Yale-Brown Obsessive Compulsive Scale does not distinguish MO from other intrusive auditory imagery.¹

It is important to differentiate MO from:

• Musical preoccupations or recollections in which an individual repeatedly listens or recalls a particular song or part of a song, but does not have the urge to listen or recall music in an obsessive-compulsive pattern.¹ These individuals do not display fear and avoidant behaviors that could be seen in patients with MO.¹
• Musical hallucinations lack an input stimulus and the patient believes the music comes from an outside source and interprets it as reality. Misdiagnosing MO as a psychotic symptom is common and can result in improper treatment.¹

Management

Pharmacotherapy. MO responds to the same medications used to treat obsessive-compulsive disorder, such as selective serotonin reuptake inhibitors and clomipramine.¹ Cognitive-behavioral interventions could help patients address dysfunctional beliefs, without trying to suppress them.¹

Distraction. Encourage patients to sing a different song that does not have obsessive quality¹ or engage in a task that uses working memory.³

Exposure and response prevention therapy. Some case reports have reported efficacy in treating MO.¹

Intrusive musical imagery (IMI) is characterized by recalling pieces of music,¹ usually repetitions of 15 to 30 seconds,² without pathology of the ear or nervous system.¹ Also known as earworm—ohrwurm in German—or involuntary musical imagery, bits of music can become a constant cause of distress.¹

IMI is prevalent in the general population; in an internet survey >85% of respondents reported experiencing IMI at least weekly.² IMI can be generated by:

• hearing music
• reading song lyrics
• being in contact with an environment or people who are linked to specific song, such as department stores that play holiday music.^2,3

IMI also is associated with stressful situations or neurological insult.¹

Any song or segment of music can be the basis of IMI. The content of IMI change over time (ie, a new song can become a source of IMI).³ The frequency of experiencing IMI is correlated to how much music a person is exposed to and the importance a person places on music.² Most episodes are intermittent; however, continuous musical episodes are known to occur.³ Episodes of IMI with obsessive-compulsive features can be classified as musical obsessions (MO).¹ MO may be part of obsessive-compulsive symptoms, including washing, checking, aggression, sexual obsessions, and religious obsessions or other obsessions.¹

Diagnosing musical obsessions

No current measures are adequate to diagnose MO. The Yale-Brown Obsessive Compulsive Scale does not distinguish MO from other intrusive auditory imagery.¹

It is important to differentiate MO from:

• Musical preoccupations or recollections in which an individual repeatedly listens or recalls a particular song or part of a song, but does not have the urge to listen or recall music in an obsessive-compulsive pattern.¹ These individuals do not display fear and avoidant behaviors that could be seen in patients with MO.¹
• Musical hallucinations lack an input stimulus and the patient believes the music comes from an outside source and interprets it as reality. Misdiagnosing MO as a psychotic symptom is common and can result in improper treatment.¹

Management

Pharmacotherapy. MO responds to the same medications used to treat obsessive-compulsive disorder, such as selective serotonin reuptake inhibitors and clomipramine.¹ Cognitive-behavioral interventions could help patients address dysfunctional beliefs, without trying to suppress them.¹

Distraction. Encourage patients to sing a different song that does not have obsessive quality¹ or engage in a task that uses working memory.³

Exposure and response prevention therapy. Some case reports have reported efficacy in treating MO.¹

The business of cancer care is in transition. Driven by the Centers for Medicare & Medicaid Services’ (CMS) Oncology Care Model (OCM) program, practices around the country are working to re-engineer the way they provide services, and the way they charge for those services. The implicit goal of all this is to manage (as in reduce) the overall cost of cancer care. A more frequently stated goal is to improve value, typically defined as outcome (numerator) relative to cost (denominator). Alternative payment models are challenged to assess the value of transformational improvement in cancer care.

Click on the PDF icon at the top of this introduction to read the full article.

The business of cancer care is in transition. Driven by the Centers for Medicare & Medicaid Services’ (CMS) Oncology Care Model (OCM) program, practices around the country are working to re-engineer the way they provide services, and the way they charge for those services. The implicit goal of all this is to manage (as in reduce) the overall cost of cancer care. A more frequently stated goal is to improve value, typically defined as outcome (numerator) relative to cost (denominator). Alternative payment models are challenged to assess the value of transformational improvement in cancer care.

Click on the PDF icon at the top of this introduction to read the full article.

The business of cancer care is in transition. Driven by the Centers for Medicare & Medicaid Services’ (CMS) Oncology Care Model (OCM) program, practices around the country are working to re-engineer the way they provide services, and the way they charge for those services. The implicit goal of all this is to manage (as in reduce) the overall cost of cancer care. A more frequently stated goal is to improve value, typically defined as outcome (numerator) relative to cost (denominator). Alternative payment models are challenged to assess the value of transformational improvement in cancer care.

Click on the PDF icon at the top of this introduction to read the full article.

A fracture occurring after anterior cruciate ligament (ACL) reconstruction is rare, and rarer still when it involves the harvest site of a bone—patellar tendon—bone (BPTB) autograft. The vast majority of fractures described in the literature are patellar, with the weak point along the patellar bone cut. A number of fractures generally also occur through the bone tunnels in both hamstring and BPTB grafts. However, only 2 cases of tibial tubercle fracture after BPTB graft have been published, and we expound on them in this case report.^1,2 The patient provided written informed consent for print and electronic publication of this case report.

Case Report

Eight years after undergoing successful left ACL reconstruction with ipsilateral BPTB graft, a 45-year-old man developed a graft rupture and demonstrated recurrent instability. He requested revision reconstruction, again with a BPTB construct. In the operating room, he was prepared and draped in the usual sterile fashion, and left ACL reconstruction was performed with right-knee central-third BPTB graft.

During surgery, the left knee was arthroscopically examined, and residual ACL graft from the initial reconstruction was removed. Notchplasty was performed, and the residual femoral interference screw was removed from the 12:30 position. A transtibial approach was used, with a 10-mm reamer brought through the proximal tibia, the posterior tibial ACL footprint, and the 2:00 distal femoral position, with 30 mm of femoral condyle drilled, leaving 1 mm of posterior femoral cortex.

After the right leg was exsanguinated, a central-third patellar tendon graft was harvested through a longitudinal incision with a 22-mm × 10-mm patellar plug, a 10-mm patellar graft, and a 22-mm × 11-mm tibial plug. The graft was prepared, the left tibia was overreamed, and the graft was passed. The graft was fixed with a 7-mm × 23-mm biointerference screw in the femur, trialed, and fixed with an 8-mm × 23-mm interference screw in the tibia. Excess bone graft was packed in the patellar defect in the right knee. The rent in the patellar tendon was closed. The rest of the incision was closed, and the patient was placed in an immobilizer and a cold therapy device (Polar Care; Breg, Inc).

At 2-week follow-up, the patient reported having slipped on ice and flexed the right knee, causing a pop, pain, and limitation in range of motion (ROM; 0°-70°).

Discussion

Cases of tibial tubercle fracture after BPTB autograft harvest are extremely rare in the published literature. PubMed and Cochrane Review searches revealed only 2—1 in the ipsilateral knee as ACL fixation¹ and 1 in the contralateral knee.² The middle third of the patellar tendon has been used for ACL reconstruction for more than 50 years, which supports the extreme rarity of this complication.³ Tibial tubercle fractures are so rare that they are not even mentioned in reviews of ACL complications.⁴ These fractures are universally treated with ORIF.^1,2

Far more common but still rare, fracture-type complications involve the extensor mechanism and the tibial plateau. Patellar fractures have been documented as occurring in 0.2% to 2.3% of cases.^5-7 One paper reported a fracture in 1.3% of cases at a mean of 57 days, with roughly half caused by trauma and the other half having atraumatic causes.⁸ Lee and colleagues⁹ found a 0.2% complication rate for all BPTB grafts in 1725 consecutive patients. Although some patients were treated nonoperatively, others underwent operative fixation. Time to clinical and radiographic healing was 7 and 10 weeks, respectively.

Tibial plateau fracture after BPTB harvest is a rare complication, with 11 cases reported in the literature.¹⁰ In 4 of those cases, the proposed mechanism of fracture was a stress riser resulting from the synergistic weakness of the tibial harvest site combined with the tibial tunnel reducing proximal tibial bone strength.^11-14 The mechanism of injury varied from traumatic to insufficiency fracture, with fixation varying with fracture displacement.

Tibial tubercle fracture after BPTB harvest is extremely rare, with the present case being only the third published in the literature. Like most reported post-ACL reconstruction extensor mechanism disruptions, our case resulted from a traumatic event at an interval after surgery. All other tibial tubercle fracture post-ACL reconstruction disruptions occurred within 2 weeks after surgery.^1,2 Sudden tension on the extensor mechanism secondary to hyperflexion caused a fracture through a weakened tibial tubercle with avulsion of the remaining tendon in 2 of the 3 cases, with the third being a lower stress popping noise that occurred during a pivot to stand.¹

The residual defect after tibial bone block harvest could represent a weakening of the tubercle by loss of structural bone and by development of stress risers. The previous reports of tibial tubercle fracture after BPTB harvest documented a similar methodology: Use a bone saw and osteotomes to harvest a trapezoidal tibial bone plug 10 mm to 11 mm wide and 22 cm to 35 cm long. As previously documented, we suggest taking care with saw cuts and osteotomes so as not to weaken the proximal tibia or distal patella more than is necessary.^1,2 Before surgery, patients should be warned about the possibility of extensor mechanism injuries with use of BPTB grafts.

Conclusion

Tibial tubercle fracture after BPTB harvest for ACL reconstruction is an extremely rare complication. Treatment is ORIF of the tubercle fragment, with a delay in ACL rehabilitation in cases involving the ipsilateral knee.

Am J Orthop. 2016;45(7):E469-E471. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

A fracture occurring after anterior cruciate ligament (ACL) reconstruction is rare, and rarer still when it involves the harvest site of a bone—patellar tendon—bone (BPTB) autograft. The vast majority of fractures described in the literature are patellar, with the weak point along the patellar bone cut. A number of fractures generally also occur through the bone tunnels in both hamstring and BPTB grafts. However, only 2 cases of tibial tubercle fracture after BPTB graft have been published, and we expound on them in this case report.^1,2 The patient provided written informed consent for print and electronic publication of this case report.

Case Report

Eight years after undergoing successful left ACL reconstruction with ipsilateral BPTB graft, a 45-year-old man developed a graft rupture and demonstrated recurrent instability. He requested revision reconstruction, again with a BPTB construct. In the operating room, he was prepared and draped in the usual sterile fashion, and left ACL reconstruction was performed with right-knee central-third BPTB graft.

During surgery, the left knee was arthroscopically examined, and residual ACL graft from the initial reconstruction was removed. Notchplasty was performed, and the residual femoral interference screw was removed from the 12:30 position. A transtibial approach was used, with a 10-mm reamer brought through the proximal tibia, the posterior tibial ACL footprint, and the 2:00 distal femoral position, with 30 mm of femoral condyle drilled, leaving 1 mm of posterior femoral cortex.

After the right leg was exsanguinated, a central-third patellar tendon graft was harvested through a longitudinal incision with a 22-mm × 10-mm patellar plug, a 10-mm patellar graft, and a 22-mm × 11-mm tibial plug. The graft was prepared, the left tibia was overreamed, and the graft was passed. The graft was fixed with a 7-mm × 23-mm biointerference screw in the femur, trialed, and fixed with an 8-mm × 23-mm interference screw in the tibia. Excess bone graft was packed in the patellar defect in the right knee. The rent in the patellar tendon was closed. The rest of the incision was closed, and the patient was placed in an immobilizer and a cold therapy device (Polar Care; Breg, Inc).

At 2-week follow-up, the patient reported having slipped on ice and flexed the right knee, causing a pop, pain, and limitation in range of motion (ROM; 0°-70°).

Discussion

Cases of tibial tubercle fracture after BPTB autograft harvest are extremely rare in the published literature. PubMed and Cochrane Review searches revealed only 2—1 in the ipsilateral knee as ACL fixation¹ and 1 in the contralateral knee.² The middle third of the patellar tendon has been used for ACL reconstruction for more than 50 years, which supports the extreme rarity of this complication.³ Tibial tubercle fractures are so rare that they are not even mentioned in reviews of ACL complications.⁴ These fractures are universally treated with ORIF.^1,2

Far more common but still rare, fracture-type complications involve the extensor mechanism and the tibial plateau. Patellar fractures have been documented as occurring in 0.2% to 2.3% of cases.^5-7 One paper reported a fracture in 1.3% of cases at a mean of 57 days, with roughly half caused by trauma and the other half having atraumatic causes.⁸ Lee and colleagues⁹ found a 0.2% complication rate for all BPTB grafts in 1725 consecutive patients. Although some patients were treated nonoperatively, others underwent operative fixation. Time to clinical and radiographic healing was 7 and 10 weeks, respectively.

Tibial plateau fracture after BPTB harvest is a rare complication, with 11 cases reported in the literature.¹⁰ In 4 of those cases, the proposed mechanism of fracture was a stress riser resulting from the synergistic weakness of the tibial harvest site combined with the tibial tunnel reducing proximal tibial bone strength.^11-14 The mechanism of injury varied from traumatic to insufficiency fracture, with fixation varying with fracture displacement.

Tibial tubercle fracture after BPTB harvest is extremely rare, with the present case being only the third published in the literature. Like most reported post-ACL reconstruction extensor mechanism disruptions, our case resulted from a traumatic event at an interval after surgery. All other tibial tubercle fracture post-ACL reconstruction disruptions occurred within 2 weeks after surgery.^1,2 Sudden tension on the extensor mechanism secondary to hyperflexion caused a fracture through a weakened tibial tubercle with avulsion of the remaining tendon in 2 of the 3 cases, with the third being a lower stress popping noise that occurred during a pivot to stand.¹

The residual defect after tibial bone block harvest could represent a weakening of the tubercle by loss of structural bone and by development of stress risers. The previous reports of tibial tubercle fracture after BPTB harvest documented a similar methodology: Use a bone saw and osteotomes to harvest a trapezoidal tibial bone plug 10 mm to 11 mm wide and 22 cm to 35 cm long. As previously documented, we suggest taking care with saw cuts and osteotomes so as not to weaken the proximal tibia or distal patella more than is necessary.^1,2 Before surgery, patients should be warned about the possibility of extensor mechanism injuries with use of BPTB grafts.

Conclusion

Tibial tubercle fracture after BPTB harvest for ACL reconstruction is an extremely rare complication. Treatment is ORIF of the tubercle fragment, with a delay in ACL rehabilitation in cases involving the ipsilateral knee.

Am J Orthop. 2016;45(7):E469-E471. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

A fracture occurring after anterior cruciate ligament (ACL) reconstruction is rare, and rarer still when it involves the harvest site of a bone—patellar tendon—bone (BPTB) autograft. The vast majority of fractures described in the literature are patellar, with the weak point along the patellar bone cut. A number of fractures generally also occur through the bone tunnels in both hamstring and BPTB grafts. However, only 2 cases of tibial tubercle fracture after BPTB graft have been published, and we expound on them in this case report.^1,2 The patient provided written informed consent for print and electronic publication of this case report.

Case Report

Eight years after undergoing successful left ACL reconstruction with ipsilateral BPTB graft, a 45-year-old man developed a graft rupture and demonstrated recurrent instability. He requested revision reconstruction, again with a BPTB construct. In the operating room, he was prepared and draped in the usual sterile fashion, and left ACL reconstruction was performed with right-knee central-third BPTB graft.

During surgery, the left knee was arthroscopically examined, and residual ACL graft from the initial reconstruction was removed. Notchplasty was performed, and the residual femoral interference screw was removed from the 12:30 position. A transtibial approach was used, with a 10-mm reamer brought through the proximal tibia, the posterior tibial ACL footprint, and the 2:00 distal femoral position, with 30 mm of femoral condyle drilled, leaving 1 mm of posterior femoral cortex.

After the right leg was exsanguinated, a central-third patellar tendon graft was harvested through a longitudinal incision with a 22-mm × 10-mm patellar plug, a 10-mm patellar graft, and a 22-mm × 11-mm tibial plug. The graft was prepared, the left tibia was overreamed, and the graft was passed. The graft was fixed with a 7-mm × 23-mm biointerference screw in the femur, trialed, and fixed with an 8-mm × 23-mm interference screw in the tibia. Excess bone graft was packed in the patellar defect in the right knee. The rent in the patellar tendon was closed. The rest of the incision was closed, and the patient was placed in an immobilizer and a cold therapy device (Polar Care; Breg, Inc).

At 2-week follow-up, the patient reported having slipped on ice and flexed the right knee, causing a pop, pain, and limitation in range of motion (ROM; 0°-70°).

Discussion

Cases of tibial tubercle fracture after BPTB autograft harvest are extremely rare in the published literature. PubMed and Cochrane Review searches revealed only 2—1 in the ipsilateral knee as ACL fixation¹ and 1 in the contralateral knee.² The middle third of the patellar tendon has been used for ACL reconstruction for more than 50 years, which supports the extreme rarity of this complication.³ Tibial tubercle fractures are so rare that they are not even mentioned in reviews of ACL complications.⁴ These fractures are universally treated with ORIF.^1,2

Far more common but still rare, fracture-type complications involve the extensor mechanism and the tibial plateau. Patellar fractures have been documented as occurring in 0.2% to 2.3% of cases.^5-7 One paper reported a fracture in 1.3% of cases at a mean of 57 days, with roughly half caused by trauma and the other half having atraumatic causes.⁸ Lee and colleagues⁹ found a 0.2% complication rate for all BPTB grafts in 1725 consecutive patients. Although some patients were treated nonoperatively, others underwent operative fixation. Time to clinical and radiographic healing was 7 and 10 weeks, respectively.

Tibial plateau fracture after BPTB harvest is a rare complication, with 11 cases reported in the literature.¹⁰ In 4 of those cases, the proposed mechanism of fracture was a stress riser resulting from the synergistic weakness of the tibial harvest site combined with the tibial tunnel reducing proximal tibial bone strength.^11-14 The mechanism of injury varied from traumatic to insufficiency fracture, with fixation varying with fracture displacement.

Tibial tubercle fracture after BPTB harvest is extremely rare, with the present case being only the third published in the literature. Like most reported post-ACL reconstruction extensor mechanism disruptions, our case resulted from a traumatic event at an interval after surgery. All other tibial tubercle fracture post-ACL reconstruction disruptions occurred within 2 weeks after surgery.^1,2 Sudden tension on the extensor mechanism secondary to hyperflexion caused a fracture through a weakened tibial tubercle with avulsion of the remaining tendon in 2 of the 3 cases, with the third being a lower stress popping noise that occurred during a pivot to stand.¹

The residual defect after tibial bone block harvest could represent a weakening of the tubercle by loss of structural bone and by development of stress risers. The previous reports of tibial tubercle fracture after BPTB harvest documented a similar methodology: Use a bone saw and osteotomes to harvest a trapezoidal tibial bone plug 10 mm to 11 mm wide and 22 cm to 35 cm long. As previously documented, we suggest taking care with saw cuts and osteotomes so as not to weaken the proximal tibia or distal patella more than is necessary.^1,2 Before surgery, patients should be warned about the possibility of extensor mechanism injuries with use of BPTB grafts.

Conclusion

Tibial tubercle fracture after BPTB harvest for ACL reconstruction is an extremely rare complication. Treatment is ORIF of the tubercle fragment, with a delay in ACL rehabilitation in cases involving the ipsilateral knee.

Am J Orthop. 2016;45(7):E469-E471. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

Primary and emergency care providers must step up prevention efforts and the use of state-of-the-art medicine when treating patients with addiction, according to the first-ever U.S. Surgeon General’s report on alcohol, drugs, and health.

In the report, “Facing Addiction in America,” Surgeon General Vivek H. Murthy, MD, called on health care providers to increase access to care and approach addiction and substance use disorders as they would any other chronic health condition.

“We must help everyone see that addiction is not a character flaw – it is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer,” Dr. Murthy explained.

In addition to offering an action plan to address substance use of all kinds, the surgeon general’s report updates the public on the state of the art of addiction science, and includes chapters on neurobiology, prevention, treatment, recovery, health systems integration, and recommendations for the future.

Data from 2015 show that more than 27 million people in the United States used illicit drugs or misuse prescription medications, while a quarter of the entire adult and adolescent population reported binge drinking in the past month. However, only 10% of those with a substance use disorder received relevant specialty care.

For the more than 40% of those with substance use disorders who have a comorbid mental health condition, less than half were treated for either, according to the federal Substance Abuse and Mental Health Services Administration.

That treatment gap is the direct result of lack of access to affordable care, shame, discrimination, and the lack of screening for substance misuse and substance use disorders in the primary care setting, Dr. Murthy wrote.

To address the gap, the surgeon general laid out a plan that starts with increasing community-wide substance use prevention efforts, such as enforcement of underage drinking laws and DUI laws, and offering needle exchange programs.

Dr. Murthy also called for a coordinated public health response to addiction, including an overhaul of criminal justice where substance use is concerned, and an emphasis on preventing known risk factors for substance misuse.

The report underscores the need for a better trained and integrated health care workforce equipped to treat addiction as a chronic disease in the general health care setting, enforcement of addiction and mental health parity laws, and the delivery of services based on the latest research into the psychosocial and biological underpinnings of substance use.

Surgeon General Murthy also used the report to urge professional medical associations to advocate for more access to medication-assisted treatment and prescription drug monitoring programs, and to create evidence-based guidelines for integrating substance use disorder treatment.

The American Medical Association responded positively to the report. In a statement, AMA President Andrew W. Gurman, MD, called it a “crucial starting point” and praised its “important guidance for the nation to see that addiction is a chronic disease and must be treated as such.”

While also supporting the report, others in the addiction medicine field pointed out that such starting points had come and gone before.

“As a profession, we saw what was happening 10 years ago, but there was no strong [push] to respond, for a variety of factors,” Ako Jacintho, MD, director of addiction medicine for HealthRIGHT 360, a California community health network, said in an interview.

[email protected]

On Twitter @whitneymcknight

Primary and emergency care providers must step up prevention efforts and the use of state-of-the-art medicine when treating patients with addiction, according to the first-ever U.S. Surgeon General’s report on alcohol, drugs, and health.

In the report, “Facing Addiction in America,” Surgeon General Vivek H. Murthy, MD, called on health care providers to increase access to care and approach addiction and substance use disorders as they would any other chronic health condition.

“We must help everyone see that addiction is not a character flaw – it is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer,” Dr. Murthy explained.

In addition to offering an action plan to address substance use of all kinds, the surgeon general’s report updates the public on the state of the art of addiction science, and includes chapters on neurobiology, prevention, treatment, recovery, health systems integration, and recommendations for the future.

Data from 2015 show that more than 27 million people in the United States used illicit drugs or misuse prescription medications, while a quarter of the entire adult and adolescent population reported binge drinking in the past month. However, only 10% of those with a substance use disorder received relevant specialty care.

For the more than 40% of those with substance use disorders who have a comorbid mental health condition, less than half were treated for either, according to the federal Substance Abuse and Mental Health Services Administration.

That treatment gap is the direct result of lack of access to affordable care, shame, discrimination, and the lack of screening for substance misuse and substance use disorders in the primary care setting, Dr. Murthy wrote.

To address the gap, the surgeon general laid out a plan that starts with increasing community-wide substance use prevention efforts, such as enforcement of underage drinking laws and DUI laws, and offering needle exchange programs.

Dr. Murthy also called for a coordinated public health response to addiction, including an overhaul of criminal justice where substance use is concerned, and an emphasis on preventing known risk factors for substance misuse.

The report underscores the need for a better trained and integrated health care workforce equipped to treat addiction as a chronic disease in the general health care setting, enforcement of addiction and mental health parity laws, and the delivery of services based on the latest research into the psychosocial and biological underpinnings of substance use.

Surgeon General Murthy also used the report to urge professional medical associations to advocate for more access to medication-assisted treatment and prescription drug monitoring programs, and to create evidence-based guidelines for integrating substance use disorder treatment.

The American Medical Association responded positively to the report. In a statement, AMA President Andrew W. Gurman, MD, called it a “crucial starting point” and praised its “important guidance for the nation to see that addiction is a chronic disease and must be treated as such.”

While also supporting the report, others in the addiction medicine field pointed out that such starting points had come and gone before.

“As a profession, we saw what was happening 10 years ago, but there was no strong [push] to respond, for a variety of factors,” Ako Jacintho, MD, director of addiction medicine for HealthRIGHT 360, a California community health network, said in an interview.

[email protected]

On Twitter @whitneymcknight

Primary and emergency care providers must step up prevention efforts and the use of state-of-the-art medicine when treating patients with addiction, according to the first-ever U.S. Surgeon General’s report on alcohol, drugs, and health.

In the report, “Facing Addiction in America,” Surgeon General Vivek H. Murthy, MD, called on health care providers to increase access to care and approach addiction and substance use disorders as they would any other chronic health condition.

“We must help everyone see that addiction is not a character flaw – it is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer,” Dr. Murthy explained.

In addition to offering an action plan to address substance use of all kinds, the surgeon general’s report updates the public on the state of the art of addiction science, and includes chapters on neurobiology, prevention, treatment, recovery, health systems integration, and recommendations for the future.

Data from 2015 show that more than 27 million people in the United States used illicit drugs or misuse prescription medications, while a quarter of the entire adult and adolescent population reported binge drinking in the past month. However, only 10% of those with a substance use disorder received relevant specialty care.

For the more than 40% of those with substance use disorders who have a comorbid mental health condition, less than half were treated for either, according to the federal Substance Abuse and Mental Health Services Administration.

That treatment gap is the direct result of lack of access to affordable care, shame, discrimination, and the lack of screening for substance misuse and substance use disorders in the primary care setting, Dr. Murthy wrote.

To address the gap, the surgeon general laid out a plan that starts with increasing community-wide substance use prevention efforts, such as enforcement of underage drinking laws and DUI laws, and offering needle exchange programs.

Dr. Murthy also called for a coordinated public health response to addiction, including an overhaul of criminal justice where substance use is concerned, and an emphasis on preventing known risk factors for substance misuse.

The report underscores the need for a better trained and integrated health care workforce equipped to treat addiction as a chronic disease in the general health care setting, enforcement of addiction and mental health parity laws, and the delivery of services based on the latest research into the psychosocial and biological underpinnings of substance use.

Surgeon General Murthy also used the report to urge professional medical associations to advocate for more access to medication-assisted treatment and prescription drug monitoring programs, and to create evidence-based guidelines for integrating substance use disorder treatment.

The American Medical Association responded positively to the report. In a statement, AMA President Andrew W. Gurman, MD, called it a “crucial starting point” and praised its “important guidance for the nation to see that addiction is a chronic disease and must be treated as such.”

While also supporting the report, others in the addiction medicine field pointed out that such starting points had come and gone before.

“As a profession, we saw what was happening 10 years ago, but there was no strong [push] to respond, for a variety of factors,” Ako Jacintho, MD, director of addiction medicine for HealthRIGHT 360, a California community health network, said in an interview.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Prolonged dosing with canakinumab, an anti-interleukin-1beta monoclonal antibody, confirmed its efficacy in controlling flares in three rare autoinflammatory diseases grouped as periodic fever syndromes: familial Mediterranean fever, hyperimmunoglobulin D syndrome/mevalonate kinase deficiency, and TNF receptor–associated periodic syndrome.

“Colchicine is effective in the majority of patients with FMF [familial Mediterranean fever]. However, patients with resistance to colchicine and patients with HIDS/MKD [hyperimmunoglobulin D syndrome/mevalonate kinase deficiency] or TRAPS [TNF receptor–associated periodic syndrome] have no available therapy until now. The diseases have different mechanisms and different genetic causes, but overlapping and different clinical features and a common mediator. They are all characterized by recurrent fever, joint pain, and involvement of various organs. In addition to greatly affecting the quality of life, the major complication is amyloidosis. Clinical studies and animal studies suggested that IL-1beta was involved in the pathogenesis of these diseases, and canakinumab [Ilaris] targets IL-1beta,” explained Fabrizio De Benedetti, MD, a pediatric rheumatologist at Bambino Gesu Children’s Hospital in Rome.

Alice Goodman/Frontline Medical News

WASHINGTON – Prolonged dosing with canakinumab, an anti-interleukin-1beta monoclonal antibody, confirmed its efficacy in controlling flares in three rare autoinflammatory diseases grouped as periodic fever syndromes: familial Mediterranean fever, hyperimmunoglobulin D syndrome/mevalonate kinase deficiency, and TNF receptor–associated periodic syndrome.

“Colchicine is effective in the majority of patients with FMF [familial Mediterranean fever]. However, patients with resistance to colchicine and patients with HIDS/MKD [hyperimmunoglobulin D syndrome/mevalonate kinase deficiency] or TRAPS [TNF receptor–associated periodic syndrome] have no available therapy until now. The diseases have different mechanisms and different genetic causes, but overlapping and different clinical features and a common mediator. They are all characterized by recurrent fever, joint pain, and involvement of various organs. In addition to greatly affecting the quality of life, the major complication is amyloidosis. Clinical studies and animal studies suggested that IL-1beta was involved in the pathogenesis of these diseases, and canakinumab [Ilaris] targets IL-1beta,” explained Fabrizio De Benedetti, MD, a pediatric rheumatologist at Bambino Gesu Children’s Hospital in Rome.

Alice Goodman/Frontline Medical News

WASHINGTON – Prolonged dosing with canakinumab, an anti-interleukin-1beta monoclonal antibody, confirmed its efficacy in controlling flares in three rare autoinflammatory diseases grouped as periodic fever syndromes: familial Mediterranean fever, hyperimmunoglobulin D syndrome/mevalonate kinase deficiency, and TNF receptor–associated periodic syndrome.

“Colchicine is effective in the majority of patients with FMF [familial Mediterranean fever]. However, patients with resistance to colchicine and patients with HIDS/MKD [hyperimmunoglobulin D syndrome/mevalonate kinase deficiency] or TRAPS [TNF receptor–associated periodic syndrome] have no available therapy until now. The diseases have different mechanisms and different genetic causes, but overlapping and different clinical features and a common mediator. They are all characterized by recurrent fever, joint pain, and involvement of various organs. In addition to greatly affecting the quality of life, the major complication is amyloidosis. Clinical studies and animal studies suggested that IL-1beta was involved in the pathogenesis of these diseases, and canakinumab [Ilaris] targets IL-1beta,” explained Fabrizio De Benedetti, MD, a pediatric rheumatologist at Bambino Gesu Children’s Hospital in Rome.

Alice Goodman/Frontline Medical News

Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/getinvolved for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.

This month, The Hospitalist spotlights Scott Kaatz, DO, MSc, FACP, SFHM, a hospitalist at Henry Ford Hospital in Detroit. In addition to being an active SHM member, he is immediate past president of SHM’s Michigan Chapter and has been involved in multiple mentored implementation (MI) programs offered by SHM’s Center for Hospital Innovation and Improvement.

Question: What inspired you to begin working in hospital medicine and later join and become so involved with SHM?

Answer: For most of my career, I’ve been at Henry Ford Hospital in Detroit, including during my internal medicine residency. After residency, I was a primary-care physician there, and I rounded three to four months out of the year in the hospital with traditional house staff model. Four years ago, I transitioned to another role as a chief quality officer at Hurley Medical Center in Flint, Mich. While in Flint, I didn’t have a clinic and was strictly a hospitalist, spending about four months a year rounding.

When my career path led me to mostly inpatient work in the hospital, I became more involved not only with hospital medicine but with SHM. As of this past June, I went back home to Henry Ford as a full-time hospitalist. I now focus my attention on hospital medicine for eight months of the year, with some protected time for faculty development and scholarly activities for residents and junior faculty in the division of hospital medicine.

Q: How has your involvement with SHM’s mentored implementation programs impacted your practice and led to improved patient care?

A: After participating in the venous thromboembolism (VTE) mentored implementation program, I became a participant as a mentee site for I-PASS, a program focused on improving communication between providers during patient handoffs. During my time with the I-PASS team, I could sense the commitment and energy to improving handoffs not only at my site but at other participant sites nationwide during our regular check-in calls. Mentored implementation programs are brilliant because they go beyond providing sites with data, a few research papers, and some written recommendations. They really dig down into the true spirit of mentoring with a team.

At Hurley Medical Center, we went “all in” with our pediatric residency. What was most encouraging was that by the end of the year, the I-PASS recommendations and processes were standard practice and fully integrated into the culture and workflow of the care teams.

I applaud these programs tremendously. That’s really how you impact change, and it’s the spark, energy, and momentum from both mentors and mentees that keeps the team on track.

Q: You are the immediate past president of the Michigan Chapter of SHM. What have been some of the biggest benefits of being involved with an SHM chapter?

A: When I first became involved with SHM, there had been a Northern Michigan Chapter, but since SHM seeks to have regional chapters that cater to local audiences, I and some of my colleagues set out to develop a Southern Michigan Chapter. We developed our chapter and designed our meetings with support from SHM’s Chapter Support Committee.

At a typical meeting, we typically host an hour of cocktails with some hors d’oeuvres to provide an opportunity for networking and fellowship. The personal connections are at the heart of these meetings. From the content side, we always have a speaker to talk about issues germane to hospitalists. These are not just run-of-the-mill grand rounds discussions but rather information on clinical updates or the business and policy side of hospital medicine.

In our chapter, we also cycle leadership each year, using a “see one, do one, teach one” approach with our vice president-elect, president, and immediate past president to ensure proper development and continuity.

Moving forward, we are trying to reach out to medical students on a more regular basis. If you’re in your third year of medical school, it’s beneficial to start talking informally to hospitalists from multiple organizations in the state and get a feel for what a career in hospital medicine is like. How amazing would it be to walk in and interview for residency with a person you had dinner with a few months ago?

Q: SHM’s Board of Directors recently approved a Chapter Development Fund to support innovative initiatives that drive engagement on a local level. Explain the potential impact you see this having on chapters and, more broadly, SHM’s membership and hospital medicine.

A: Since our chapter’s inception, we have been able to expand our reach and stream our content to other parts of the state on the Internet. Part of the reason we have been able to do this is due to support from a Chapter Development Fund recently approved by SHM’s Board of Directors. As a result, we have turned our Southern Michigan Chapter into a statewide chapter with virtual sites. At the last meeting, we had over 75 attendees between our physical site and our “satellite site” in Michigan.

Our next project is to apply for funding to provide first- and second-year residents with free membership for a year through our chapter to expose them to the resources SHM has available to them and get their foot in the door with the organization. At a recent co-sponsored statewide meeting with the American College of Physicians, we were able to sign up 20 residents as new members of SHM, and our chapter paid their dues as an investment into our specialty.

Q: Any closing thoughts?

A: If there’s one thing I haven’t yet shared that I feel quite passionately about, it’s that SHM has such a robust library of educational resources that all hospitalists should be aware of, especially SHM’s annual meeting. It’s extraordinarily clinical and features a sizeable amount of content for grassroots clinicians and hospital leaders, including the best speakers in the field. On top of the educational components, the networking possibilities with hospitalists across the country make the annual meeting a prime example of the value SHM offers.

I’ve also been fortunate to have been involved with developing enduring materials on SHM’s Learning Portal, some of which are available without cost due to grant funding. The fact that SHM has pursued this funding and made some of these resources available to hospitalists outside of SHM’s membership embodies the organization’s mission of not only teaching doctors how to take better care of patients but helping patients get better—one of many reasons I am proud to be an active member. TH

Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/getinvolved for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.

This month, The Hospitalist spotlights Scott Kaatz, DO, MSc, FACP, SFHM, a hospitalist at Henry Ford Hospital in Detroit. In addition to being an active SHM member, he is immediate past president of SHM’s Michigan Chapter and has been involved in multiple mentored implementation (MI) programs offered by SHM’s Center for Hospital Innovation and Improvement.

Question: What inspired you to begin working in hospital medicine and later join and become so involved with SHM?

Answer: For most of my career, I’ve been at Henry Ford Hospital in Detroit, including during my internal medicine residency. After residency, I was a primary-care physician there, and I rounded three to four months out of the year in the hospital with traditional house staff model. Four years ago, I transitioned to another role as a chief quality officer at Hurley Medical Center in Flint, Mich. While in Flint, I didn’t have a clinic and was strictly a hospitalist, spending about four months a year rounding.

When my career path led me to mostly inpatient work in the hospital, I became more involved not only with hospital medicine but with SHM. As of this past June, I went back home to Henry Ford as a full-time hospitalist. I now focus my attention on hospital medicine for eight months of the year, with some protected time for faculty development and scholarly activities for residents and junior faculty in the division of hospital medicine.

Q: How has your involvement with SHM’s mentored implementation programs impacted your practice and led to improved patient care?

A: After participating in the venous thromboembolism (VTE) mentored implementation program, I became a participant as a mentee site for I-PASS, a program focused on improving communication between providers during patient handoffs. During my time with the I-PASS team, I could sense the commitment and energy to improving handoffs not only at my site but at other participant sites nationwide during our regular check-in calls. Mentored implementation programs are brilliant because they go beyond providing sites with data, a few research papers, and some written recommendations. They really dig down into the true spirit of mentoring with a team.

At Hurley Medical Center, we went “all in” with our pediatric residency. What was most encouraging was that by the end of the year, the I-PASS recommendations and processes were standard practice and fully integrated into the culture and workflow of the care teams.

I applaud these programs tremendously. That’s really how you impact change, and it’s the spark, energy, and momentum from both mentors and mentees that keeps the team on track.

Q: You are the immediate past president of the Michigan Chapter of SHM. What have been some of the biggest benefits of being involved with an SHM chapter?

A: When I first became involved with SHM, there had been a Northern Michigan Chapter, but since SHM seeks to have regional chapters that cater to local audiences, I and some of my colleagues set out to develop a Southern Michigan Chapter. We developed our chapter and designed our meetings with support from SHM’s Chapter Support Committee.

At a typical meeting, we typically host an hour of cocktails with some hors d’oeuvres to provide an opportunity for networking and fellowship. The personal connections are at the heart of these meetings. From the content side, we always have a speaker to talk about issues germane to hospitalists. These are not just run-of-the-mill grand rounds discussions but rather information on clinical updates or the business and policy side of hospital medicine.

In our chapter, we also cycle leadership each year, using a “see one, do one, teach one” approach with our vice president-elect, president, and immediate past president to ensure proper development and continuity.

Moving forward, we are trying to reach out to medical students on a more regular basis. If you’re in your third year of medical school, it’s beneficial to start talking informally to hospitalists from multiple organizations in the state and get a feel for what a career in hospital medicine is like. How amazing would it be to walk in and interview for residency with a person you had dinner with a few months ago?

Q: SHM’s Board of Directors recently approved a Chapter Development Fund to support innovative initiatives that drive engagement on a local level. Explain the potential impact you see this having on chapters and, more broadly, SHM’s membership and hospital medicine.

A: Since our chapter’s inception, we have been able to expand our reach and stream our content to other parts of the state on the Internet. Part of the reason we have been able to do this is due to support from a Chapter Development Fund recently approved by SHM’s Board of Directors. As a result, we have turned our Southern Michigan Chapter into a statewide chapter with virtual sites. At the last meeting, we had over 75 attendees between our physical site and our “satellite site” in Michigan.

Our next project is to apply for funding to provide first- and second-year residents with free membership for a year through our chapter to expose them to the resources SHM has available to them and get their foot in the door with the organization. At a recent co-sponsored statewide meeting with the American College of Physicians, we were able to sign up 20 residents as new members of SHM, and our chapter paid their dues as an investment into our specialty.

Q: Any closing thoughts?

A: If there’s one thing I haven’t yet shared that I feel quite passionately about, it’s that SHM has such a robust library of educational resources that all hospitalists should be aware of, especially SHM’s annual meeting. It’s extraordinarily clinical and features a sizeable amount of content for grassroots clinicians and hospital leaders, including the best speakers in the field. On top of the educational components, the networking possibilities with hospitalists across the country make the annual meeting a prime example of the value SHM offers.

I’ve also been fortunate to have been involved with developing enduring materials on SHM’s Learning Portal, some of which are available without cost due to grant funding. The fact that SHM has pursued this funding and made some of these resources available to hospitalists outside of SHM’s membership embodies the organization’s mission of not only teaching doctors how to take better care of patients but helping patients get better—one of many reasons I am proud to be an active member. TH

Editor’s note: Each month, SHM puts the spotlight on some of our most active members who are making substantial contributions to hospital medicine. Log on to www.hospitalmedicine.org/getinvolved for more information on how you can lend your expertise to help SHM improve the care of hospitalized patients.

This month, The Hospitalist spotlights Scott Kaatz, DO, MSc, FACP, SFHM, a hospitalist at Henry Ford Hospital in Detroit. In addition to being an active SHM member, he is immediate past president of SHM’s Michigan Chapter and has been involved in multiple mentored implementation (MI) programs offered by SHM’s Center for Hospital Innovation and Improvement.

Question: What inspired you to begin working in hospital medicine and later join and become so involved with SHM?

Answer: For most of my career, I’ve been at Henry Ford Hospital in Detroit, including during my internal medicine residency. After residency, I was a primary-care physician there, and I rounded three to four months out of the year in the hospital with traditional house staff model. Four years ago, I transitioned to another role as a chief quality officer at Hurley Medical Center in Flint, Mich. While in Flint, I didn’t have a clinic and was strictly a hospitalist, spending about four months a year rounding.

When my career path led me to mostly inpatient work in the hospital, I became more involved not only with hospital medicine but with SHM. As of this past June, I went back home to Henry Ford as a full-time hospitalist. I now focus my attention on hospital medicine for eight months of the year, with some protected time for faculty development and scholarly activities for residents and junior faculty in the division of hospital medicine.

Q: How has your involvement with SHM’s mentored implementation programs impacted your practice and led to improved patient care?

A: After participating in the venous thromboembolism (VTE) mentored implementation program, I became a participant as a mentee site for I-PASS, a program focused on improving communication between providers during patient handoffs. During my time with the I-PASS team, I could sense the commitment and energy to improving handoffs not only at my site but at other participant sites nationwide during our regular check-in calls. Mentored implementation programs are brilliant because they go beyond providing sites with data, a few research papers, and some written recommendations. They really dig down into the true spirit of mentoring with a team.

At Hurley Medical Center, we went “all in” with our pediatric residency. What was most encouraging was that by the end of the year, the I-PASS recommendations and processes were standard practice and fully integrated into the culture and workflow of the care teams.

I applaud these programs tremendously. That’s really how you impact change, and it’s the spark, energy, and momentum from both mentors and mentees that keeps the team on track.

Q: You are the immediate past president of the Michigan Chapter of SHM. What have been some of the biggest benefits of being involved with an SHM chapter?

A: When I first became involved with SHM, there had been a Northern Michigan Chapter, but since SHM seeks to have regional chapters that cater to local audiences, I and some of my colleagues set out to develop a Southern Michigan Chapter. We developed our chapter and designed our meetings with support from SHM’s Chapter Support Committee.

At a typical meeting, we typically host an hour of cocktails with some hors d’oeuvres to provide an opportunity for networking and fellowship. The personal connections are at the heart of these meetings. From the content side, we always have a speaker to talk about issues germane to hospitalists. These are not just run-of-the-mill grand rounds discussions but rather information on clinical updates or the business and policy side of hospital medicine.

In our chapter, we also cycle leadership each year, using a “see one, do one, teach one” approach with our vice president-elect, president, and immediate past president to ensure proper development and continuity.

Moving forward, we are trying to reach out to medical students on a more regular basis. If you’re in your third year of medical school, it’s beneficial to start talking informally to hospitalists from multiple organizations in the state and get a feel for what a career in hospital medicine is like. How amazing would it be to walk in and interview for residency with a person you had dinner with a few months ago?

Q: SHM’s Board of Directors recently approved a Chapter Development Fund to support innovative initiatives that drive engagement on a local level. Explain the potential impact you see this having on chapters and, more broadly, SHM’s membership and hospital medicine.

A: Since our chapter’s inception, we have been able to expand our reach and stream our content to other parts of the state on the Internet. Part of the reason we have been able to do this is due to support from a Chapter Development Fund recently approved by SHM’s Board of Directors. As a result, we have turned our Southern Michigan Chapter into a statewide chapter with virtual sites. At the last meeting, we had over 75 attendees between our physical site and our “satellite site” in Michigan.

Our next project is to apply for funding to provide first- and second-year residents with free membership for a year through our chapter to expose them to the resources SHM has available to them and get their foot in the door with the organization. At a recent co-sponsored statewide meeting with the American College of Physicians, we were able to sign up 20 residents as new members of SHM, and our chapter paid their dues as an investment into our specialty.

Q: Any closing thoughts?

A: If there’s one thing I haven’t yet shared that I feel quite passionately about, it’s that SHM has such a robust library of educational resources that all hospitalists should be aware of, especially SHM’s annual meeting. It’s extraordinarily clinical and features a sizeable amount of content for grassroots clinicians and hospital leaders, including the best speakers in the field. On top of the educational components, the networking possibilities with hospitalists across the country make the annual meeting a prime example of the value SHM offers.

I’ve also been fortunate to have been involved with developing enduring materials on SHM’s Learning Portal, some of which are available without cost due to grant funding. The fact that SHM has pursued this funding and made some of these resources available to hospitalists outside of SHM’s membership embodies the organization’s mission of not only teaching doctors how to take better care of patients but helping patients get better—one of many reasons I am proud to be an active member. TH

Daratumumab (Darzalex)

Photo courtesy of Janssen

The US Food and Drug Administration (FDA) has approved new indications for the monoclonal antibody daratumumab (Darzalex®).

The drug is now approved for use in combination with lenalidomide and dexamethasone or bortezomib and dexamethasone to treat patients with multiple myeloma (MM) who have received at least 1 prior therapy.

This approval comes 3 months after a supplemental biologics license application was submitted to the FDA.

The application was granted priority review last month, and the FDA granted daratumumab breakthrough therapy designation in July.

Daratumumab is the first CD38-directed cytolytic antibody approved anywhere in the world.

The drug received accelerated approval from the FDA in November of last year for use as monotherapy in MM patients who have received at least 3 prior lines of therapy, including a proteasome inhibitor and an immunomodulatory agent, or MM patients who are double refractory to a proteasome inhibitor and immunomodulatory agent.

Daratumumab is being developed by Janssen Biotech, Inc. under an exclusive worldwide license from Genmab. For the full prescribing information, visit www.DARZALEX.com.

Phase 3 trials

The FDA’s latest approval of daratumumab was based on data from the phase 3 POLLUX and CASTOR trials.

In the POLLUX trial, researchers compared treatment with lenalidomide and dexamethasone to treatment with daratumumab, lenalidomide, and dexamethasone in patients with relapsed or refractory MM.

Patients who received daratumumab in combination had a significantly higher response rate and longer progression-free survival than patients who received the 2-drug combination.

However, treatment with daratumumab was associated with infusion-related reactions and a higher incidence of neutropenia.

Results from this trial were published in NEJM in October.

In the CASTOR trial, researchers compared treatment with bortezomib and dexamethasone to treatment with daratumumab, bortezomib, and dexamethasone in patients with previously treated MM.

Patients who received the 3-drug combination had a higher response rate, longer progression-free survival, and a higher incidence of grade 3/4 adverse events than those who received the 2-drug combination.

Results from this trial were published in NEJM in August.

Daratumumab (Darzalex)

Photo courtesy of Janssen

The US Food and Drug Administration (FDA) has approved new indications for the monoclonal antibody daratumumab (Darzalex®).

The drug is now approved for use in combination with lenalidomide and dexamethasone or bortezomib and dexamethasone to treat patients with multiple myeloma (MM) who have received at least 1 prior therapy.

This approval comes 3 months after a supplemental biologics license application was submitted to the FDA.

The application was granted priority review last month, and the FDA granted daratumumab breakthrough therapy designation in July.

Daratumumab is the first CD38-directed cytolytic antibody approved anywhere in the world.

The drug received accelerated approval from the FDA in November of last year for use as monotherapy in MM patients who have received at least 3 prior lines of therapy, including a proteasome inhibitor and an immunomodulatory agent, or MM patients who are double refractory to a proteasome inhibitor and immunomodulatory agent.

Daratumumab is being developed by Janssen Biotech, Inc. under an exclusive worldwide license from Genmab. For the full prescribing information, visit www.DARZALEX.com.

Phase 3 trials

The FDA’s latest approval of daratumumab was based on data from the phase 3 POLLUX and CASTOR trials.

In the POLLUX trial, researchers compared treatment with lenalidomide and dexamethasone to treatment with daratumumab, lenalidomide, and dexamethasone in patients with relapsed or refractory MM.

Patients who received daratumumab in combination had a significantly higher response rate and longer progression-free survival than patients who received the 2-drug combination.

However, treatment with daratumumab was associated with infusion-related reactions and a higher incidence of neutropenia.

Results from this trial were published in NEJM in October.

In the CASTOR trial, researchers compared treatment with bortezomib and dexamethasone to treatment with daratumumab, bortezomib, and dexamethasone in patients with previously treated MM.

Patients who received the 3-drug combination had a higher response rate, longer progression-free survival, and a higher incidence of grade 3/4 adverse events than those who received the 2-drug combination.

Results from this trial were published in NEJM in August.

Daratumumab (Darzalex)

Photo courtesy of Janssen

The US Food and Drug Administration (FDA) has approved new indications for the monoclonal antibody daratumumab (Darzalex®).

The drug is now approved for use in combination with lenalidomide and dexamethasone or bortezomib and dexamethasone to treat patients with multiple myeloma (MM) who have received at least 1 prior therapy.

This approval comes 3 months after a supplemental biologics license application was submitted to the FDA.

The application was granted priority review last month, and the FDA granted daratumumab breakthrough therapy designation in July.

Daratumumab is the first CD38-directed cytolytic antibody approved anywhere in the world.

The drug received accelerated approval from the FDA in November of last year for use as monotherapy in MM patients who have received at least 3 prior lines of therapy, including a proteasome inhibitor and an immunomodulatory agent, or MM patients who are double refractory to a proteasome inhibitor and immunomodulatory agent.

Daratumumab is being developed by Janssen Biotech, Inc. under an exclusive worldwide license from Genmab. For the full prescribing information, visit www.DARZALEX.com.

Phase 3 trials

The FDA’s latest approval of daratumumab was based on data from the phase 3 POLLUX and CASTOR trials.

In the POLLUX trial, researchers compared treatment with lenalidomide and dexamethasone to treatment with daratumumab, lenalidomide, and dexamethasone in patients with relapsed or refractory MM.

Patients who received daratumumab in combination had a significantly higher response rate and longer progression-free survival than patients who received the 2-drug combination.

However, treatment with daratumumab was associated with infusion-related reactions and a higher incidence of neutropenia.

Results from this trial were published in NEJM in October.

In the CASTOR trial, researchers compared treatment with bortezomib and dexamethasone to treatment with daratumumab, bortezomib, and dexamethasone in patients with previously treated MM.

Patients who received the 3-drug combination had a higher response rate, longer progression-free survival, and a higher incidence of grade 3/4 adverse events than those who received the 2-drug combination.

Results from this trial were published in NEJM in August.

Charles Mullighan, MD, MBBS

Photo courtesy of St. Jude

Children’s Research Hospital

Researchers have found evidence to suggest that a high-risk subtype of acute lymphoblastic leukemia (ALL) is “highly prevalent” in adults with ALL.

In a study of nearly 800 adults with ALL, roughly a quarter of the patients had Philadelphia chromosome-like (Ph-like) ALL.

Patients with Ph-like ALL had inferior overall survival (OS) and event-free survival (EFS), but most of them also had kinase-activating alterations that suggest they might respond well to tyrosine kinase inhibitors.

The researchers reported these findings in the Journal of Clinical Oncology.

“This study establishes that a large percentage of adults with ALL have this high-risk subtype,” said study author Charles Mullighan, MD, MBBS, of St. Jude Children’s Research Hospital in Memphis, Tennessee.

“The finding provides a compelling reason to identify those with Ph-like ALL and move forward with clinical trials of these targeted therapies in combination with current chemotherapeutic regimens.”

This study builds on previous research, which suggested that Ph-like ALL becomes more common with age, is associated with poor prognosis, and is characterized by genomic alterations that appear to make patients responsive to treatment with tyrosine kinase inhibitors.

“Our 2014 findings that the prevalence of Ph-like ALL increased with age and was particularly common in young adults generated tremendous interest because adult ALL is difficult to treat,” Dr Mullighan said. “In this study, we determined that the prevalence remains high across the age spectrum of adults with ALL.”

Prevalence and outcomes

The study included 798 adults who were between the ages of 21 and 86 when diagnosed with ALL. A total of 194 patients (24%) had Ph-like ALL.

The incidence of Ph-like ALL was 27.9% among young adults (ages 21 to 39), 20.4% in adults (ages 40 to 59), and 24.0% in older adults (ages 60 to 86).

Patients with Ph-like ALL had significantly inferior 5-year OS compared to patients with non-Ph-like ALL—23.8% and 52.4%, respectively (P<0.001). The same was true for 5-year EFS—22.5% and 49.3%, respectively (P<0.001).

Among Ph-like ALL patients, the 5-year EFS rates were 40.4% for young adults, 29.8% for adults, and 18.9% for older adults. The 5-year OS rates were 45.2%, 35.1%, and 16.2%, respectively.

Genomic analysis

The researchers performed genomic analysis of 180 of the Ph-like ALL cases and found that 88% had kinase-activating alterations.

This included CRLF2 rearrangements in 51% of cases, JAK2 or EPOR rearrangements in 12.4%, ABL class fusions in 9.8%, other JAK-STAT sequence mutations in 7.2%, other kinase alterations in 4.1%, and Ras pathway mutations in 3.6%.

“Our comprehensive sequencing showed that Ph-like ALL in adults is the most genetically diverse subtype of leukemia that has been described,” said study author Kathryn Roberts, PhD, of St. Jude.

“Cumulatively, more than 50 different chromosomal rearrangements involving 15 different kinases and cytokine receptors have been identified. In this study, we identified 11 chromosomal rearrangements that are new to Ph-like ALL.”

These 11 rearrangements are FIP1L1-PDGFRA, SNX29-PDGFRB, SMU1-JAK2, ZNF340-JAK2, THADA-EPOR, SMARCA4-TYK2, ZNF340-TYK2, ZYMM2-FLT3, DNTT-BLNK, TMEM2-PTK2B, and KANK1-CBL1.

The diversity of kinase-activating alterations in Ph-like ALL has important clinical implications, said study author Hagop Kantarjian, MD, of the University of Texas MD Anderson Cancer Center in Houston.

“It is important that we now identify patients with Ph-like ALL at diagnosis to provide optimal treatment with targeted agents,” he said.

The findings also highlight the importance of centralized comprehensive genomic sequencing for patients, said study author Elisabeth Paietta, PhD, of the Montefiore Health System and Albert Einstein College of Medicine in Bronx, New York.

“Lymphoblasts from almost half of the patients with Ph-like ALL harbor a genomic rearrangement of CRLF2, which can be detected by flow cytometry using an antibody to CRLF2,” Dr Paietta said. “This is very important as it allows a quick characterization of this Ph-like ALL subtype prior to any detailed sequencing.”

Charles Mullighan, MD, MBBS

Photo courtesy of St. Jude

Children’s Research Hospital

Researchers have found evidence to suggest that a high-risk subtype of acute lymphoblastic leukemia (ALL) is “highly prevalent” in adults with ALL.

In a study of nearly 800 adults with ALL, roughly a quarter of the patients had Philadelphia chromosome-like (Ph-like) ALL.

Patients with Ph-like ALL had inferior overall survival (OS) and event-free survival (EFS), but most of them also had kinase-activating alterations that suggest they might respond well to tyrosine kinase inhibitors.

The researchers reported these findings in the Journal of Clinical Oncology.

“This study establishes that a large percentage of adults with ALL have this high-risk subtype,” said study author Charles Mullighan, MD, MBBS, of St. Jude Children’s Research Hospital in Memphis, Tennessee.

“The finding provides a compelling reason to identify those with Ph-like ALL and move forward with clinical trials of these targeted therapies in combination with current chemotherapeutic regimens.”

This study builds on previous research, which suggested that Ph-like ALL becomes more common with age, is associated with poor prognosis, and is characterized by genomic alterations that appear to make patients responsive to treatment with tyrosine kinase inhibitors.

“Our 2014 findings that the prevalence of Ph-like ALL increased with age and was particularly common in young adults generated tremendous interest because adult ALL is difficult to treat,” Dr Mullighan said. “In this study, we determined that the prevalence remains high across the age spectrum of adults with ALL.”

Prevalence and outcomes

The study included 798 adults who were between the ages of 21 and 86 when diagnosed with ALL. A total of 194 patients (24%) had Ph-like ALL.

The incidence of Ph-like ALL was 27.9% among young adults (ages 21 to 39), 20.4% in adults (ages 40 to 59), and 24.0% in older adults (ages 60 to 86).

Patients with Ph-like ALL had significantly inferior 5-year OS compared to patients with non-Ph-like ALL—23.8% and 52.4%, respectively (P<0.001). The same was true for 5-year EFS—22.5% and 49.3%, respectively (P<0.001).

Among Ph-like ALL patients, the 5-year EFS rates were 40.4% for young adults, 29.8% for adults, and 18.9% for older adults. The 5-year OS rates were 45.2%, 35.1%, and 16.2%, respectively.

Genomic analysis

The researchers performed genomic analysis of 180 of the Ph-like ALL cases and found that 88% had kinase-activating alterations.

This included CRLF2 rearrangements in 51% of cases, JAK2 or EPOR rearrangements in 12.4%, ABL class fusions in 9.8%, other JAK-STAT sequence mutations in 7.2%, other kinase alterations in 4.1%, and Ras pathway mutations in 3.6%.

“Our comprehensive sequencing showed that Ph-like ALL in adults is the most genetically diverse subtype of leukemia that has been described,” said study author Kathryn Roberts, PhD, of St. Jude.

“Cumulatively, more than 50 different chromosomal rearrangements involving 15 different kinases and cytokine receptors have been identified. In this study, we identified 11 chromosomal rearrangements that are new to Ph-like ALL.”

These 11 rearrangements are FIP1L1-PDGFRA, SNX29-PDGFRB, SMU1-JAK2, ZNF340-JAK2, THADA-EPOR, SMARCA4-TYK2, ZNF340-TYK2, ZYMM2-FLT3, DNTT-BLNK, TMEM2-PTK2B, and KANK1-CBL1.

The diversity of kinase-activating alterations in Ph-like ALL has important clinical implications, said study author Hagop Kantarjian, MD, of the University of Texas MD Anderson Cancer Center in Houston.

“It is important that we now identify patients with Ph-like ALL at diagnosis to provide optimal treatment with targeted agents,” he said.

The findings also highlight the importance of centralized comprehensive genomic sequencing for patients, said study author Elisabeth Paietta, PhD, of the Montefiore Health System and Albert Einstein College of Medicine in Bronx, New York.

“Lymphoblasts from almost half of the patients with Ph-like ALL harbor a genomic rearrangement of CRLF2, which can be detected by flow cytometry using an antibody to CRLF2,” Dr Paietta said. “This is very important as it allows a quick characterization of this Ph-like ALL subtype prior to any detailed sequencing.”

Charles Mullighan, MD, MBBS

Photo courtesy of St. Jude

Children’s Research Hospital

Researchers have found evidence to suggest that a high-risk subtype of acute lymphoblastic leukemia (ALL) is “highly prevalent” in adults with ALL.

In a study of nearly 800 adults with ALL, roughly a quarter of the patients had Philadelphia chromosome-like (Ph-like) ALL.

Patients with Ph-like ALL had inferior overall survival (OS) and event-free survival (EFS), but most of them also had kinase-activating alterations that suggest they might respond well to tyrosine kinase inhibitors.

The researchers reported these findings in the Journal of Clinical Oncology.

“This study establishes that a large percentage of adults with ALL have this high-risk subtype,” said study author Charles Mullighan, MD, MBBS, of St. Jude Children’s Research Hospital in Memphis, Tennessee.

“The finding provides a compelling reason to identify those with Ph-like ALL and move forward with clinical trials of these targeted therapies in combination with current chemotherapeutic regimens.”

This study builds on previous research, which suggested that Ph-like ALL becomes more common with age, is associated with poor prognosis, and is characterized by genomic alterations that appear to make patients responsive to treatment with tyrosine kinase inhibitors.

“Our 2014 findings that the prevalence of Ph-like ALL increased with age and was particularly common in young adults generated tremendous interest because adult ALL is difficult to treat,” Dr Mullighan said. “In this study, we determined that the prevalence remains high across the age spectrum of adults with ALL.”

Prevalence and outcomes

The study included 798 adults who were between the ages of 21 and 86 when diagnosed with ALL. A total of 194 patients (24%) had Ph-like ALL.

The incidence of Ph-like ALL was 27.9% among young adults (ages 21 to 39), 20.4% in adults (ages 40 to 59), and 24.0% in older adults (ages 60 to 86).

Patients with Ph-like ALL had significantly inferior 5-year OS compared to patients with non-Ph-like ALL—23.8% and 52.4%, respectively (P<0.001). The same was true for 5-year EFS—22.5% and 49.3%, respectively (P<0.001).

Among Ph-like ALL patients, the 5-year EFS rates were 40.4% for young adults, 29.8% for adults, and 18.9% for older adults. The 5-year OS rates were 45.2%, 35.1%, and 16.2%, respectively.

Genomic analysis

The researchers performed genomic analysis of 180 of the Ph-like ALL cases and found that 88% had kinase-activating alterations.

This included CRLF2 rearrangements in 51% of cases, JAK2 or EPOR rearrangements in 12.4%, ABL class fusions in 9.8%, other JAK-STAT sequence mutations in 7.2%, other kinase alterations in 4.1%, and Ras pathway mutations in 3.6%.

“Our comprehensive sequencing showed that Ph-like ALL in adults is the most genetically diverse subtype of leukemia that has been described,” said study author Kathryn Roberts, PhD, of St. Jude.

“Cumulatively, more than 50 different chromosomal rearrangements involving 15 different kinases and cytokine receptors have been identified. In this study, we identified 11 chromosomal rearrangements that are new to Ph-like ALL.”

These 11 rearrangements are FIP1L1-PDGFRA, SNX29-PDGFRB, SMU1-JAK2, ZNF340-JAK2, THADA-EPOR, SMARCA4-TYK2, ZNF340-TYK2, ZYMM2-FLT3, DNTT-BLNK, TMEM2-PTK2B, and KANK1-CBL1.

The diversity of kinase-activating alterations in Ph-like ALL has important clinical implications, said study author Hagop Kantarjian, MD, of the University of Texas MD Anderson Cancer Center in Houston.

“It is important that we now identify patients with Ph-like ALL at diagnosis to provide optimal treatment with targeted agents,” he said.

The findings also highlight the importance of centralized comprehensive genomic sequencing for patients, said study author Elisabeth Paietta, PhD, of the Montefiore Health System and Albert Einstein College of Medicine in Bronx, New York.

“Lymphoblasts from almost half of the patients with Ph-like ALL harbor a genomic rearrangement of CRLF2, which can be detected by flow cytometry using an antibody to CRLF2,” Dr Paietta said. “This is very important as it allows a quick characterization of this Ph-like ALL subtype prior to any detailed sequencing.”