Are you ready?

The Centers for Medicare & Medicaid Services (CMS) recently released new emergency preparedness requirements to ensure that providers and suppliers are duly prepared to adequately serve their community during disasters or emergencies. These requirements were stimulated by unexpected and catastrophic events, such as the September 11 terrorist attacks, the 2009 H1N1 pandemic, and innumerable natural disasters (tornados, floods, and hurricanes, to name a few). The CMS final rule issued “requirements that establish a comprehensive, consistent, flexible, and dynamic regulatory approach to emergency preparedness and response that incorporates the lessons learned from the past, combined with the proven best practices of the present.” In the rule, CMS outlines three essential guiding principles that any healthcare facility or supplier would need to preserve in the event of a disaster:

• Safeguard human resources.
• Maintain business continuity.
• Protect physical resources.

4 Ways to Be Prepared

What does having a comprehensive disaster preparedness program mean for hospitalists, regardless of site of practice? CMS recommends having four key elements for an adequate program:

1. Perform a risk assessment that focuses on the capacities and capabilities that are critical for a full spectrum of types of emergencies or disasters. This risk assessment should take into consideration the type and location of the facility as well as the disasters that are most likely to occur in its area. It should include at a minimum “care-related emergencies; equipment and power failures; interruptions in communications, including cyber attacks; loss of a portion or all of a facility; and interruptions in the normal supply of essentials, such as water and food.”

2. Develop and implement policies and procedures that support the emergency plan. Hospitalists should know about organizational policies and procedures that support the implementation of the emergency plan and how their team is factored into that plan.

3. Develop and maintain a communication plan that also complies with state and federal law. All the preparations in the world can be crippled without a robust and clear communication plan. The facility must have primary and backup mechanisms to contact providers, staff, and personnel in a timely fashion; this should include mechanisms to repeatedly update providers as the event evolves so that everyone knows what they are supposed to be doing and when.

4. Develop and maintain a training and testing program for all personnel. This includes onboarding and annual refreshers, including drills and exercises that test the plan and identify any gaps in performance. Hospitalists will undoubtedly be key members in developing, implementing, and receiving such critical training.

Expectations

There isn’t a single U.S. healthcare facility or provider that will not be affected by these provisions. An estimated 72,000 healthcare providers and suppliers (from nursing homes to dialysis facilities to home health agencies) will be expected to comply with these requirements within about a year.

In addition to hospitals, CMS also extended the requirements to many types of facilities and suppliers so that such providers can more likely stay open and provide care during disasters and emergencies, or at least can resume operations as soon as possible, to provide the very best ongoing care to the affected community. In most of these scenarios, the need for complex and varied care goes up, not down, further exacerbating gaps in basic care if ambulatory facilities and home care providers are unavailable.

CMS does acknowledge that these requirements will be more difficult to execute in facilities that previously did not have requirements or in smaller facilities with more limited resources. It also acknowledges that the cost of implementation could reach up to $279 million, which some argue is actually an underestimation. Despite these challenges, it is hard to argue against basic disaster preparedness for any healthcare facility or provider as a standard and positive business practice. While most acute-care hospitals have long had disaster preparedness plans and programs, gaps in these programs have become readily apparent during natural disasters such as Hurricane Katrina and Superstorm Sandy. CMS also stresses the need for a community approach to planning and implementation and that there is no reason during planning, or during an actual event, that facilities should operate in isolation but rather train and respond together as a community.

As hospitalists, regardless of site of practice, we should all be involved in at least understanding, if not developing and implementing, these basic requirements in our facilities. It is without a doubt that hospitalists will be a core group of physicians who will be called upon to serve within or outside healthcare facilities in the event of a disaster or emergency. In fact, in most recent disasters, we already have. It is better, of course, to be prepared and ready to serve than unprepared and regretful.

Reference

1. The Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. Federal Register website. Accessed October 6, 2016.

Are you ready?

The Centers for Medicare & Medicaid Services (CMS) recently released new emergency preparedness requirements to ensure that providers and suppliers are duly prepared to adequately serve their community during disasters or emergencies. These requirements were stimulated by unexpected and catastrophic events, such as the September 11 terrorist attacks, the 2009 H1N1 pandemic, and innumerable natural disasters (tornados, floods, and hurricanes, to name a few). The CMS final rule issued “requirements that establish a comprehensive, consistent, flexible, and dynamic regulatory approach to emergency preparedness and response that incorporates the lessons learned from the past, combined with the proven best practices of the present.” In the rule, CMS outlines three essential guiding principles that any healthcare facility or supplier would need to preserve in the event of a disaster:

• Safeguard human resources.
• Maintain business continuity.
• Protect physical resources.

4 Ways to Be Prepared

What does having a comprehensive disaster preparedness program mean for hospitalists, regardless of site of practice? CMS recommends having four key elements for an adequate program:

1. Perform a risk assessment that focuses on the capacities and capabilities that are critical for a full spectrum of types of emergencies or disasters. This risk assessment should take into consideration the type and location of the facility as well as the disasters that are most likely to occur in its area. It should include at a minimum “care-related emergencies; equipment and power failures; interruptions in communications, including cyber attacks; loss of a portion or all of a facility; and interruptions in the normal supply of essentials, such as water and food.”

2. Develop and implement policies and procedures that support the emergency plan. Hospitalists should know about organizational policies and procedures that support the implementation of the emergency plan and how their team is factored into that plan.

3. Develop and maintain a communication plan that also complies with state and federal law. All the preparations in the world can be crippled without a robust and clear communication plan. The facility must have primary and backup mechanisms to contact providers, staff, and personnel in a timely fashion; this should include mechanisms to repeatedly update providers as the event evolves so that everyone knows what they are supposed to be doing and when.

4. Develop and maintain a training and testing program for all personnel. This includes onboarding and annual refreshers, including drills and exercises that test the plan and identify any gaps in performance. Hospitalists will undoubtedly be key members in developing, implementing, and receiving such critical training.

Expectations

There isn’t a single U.S. healthcare facility or provider that will not be affected by these provisions. An estimated 72,000 healthcare providers and suppliers (from nursing homes to dialysis facilities to home health agencies) will be expected to comply with these requirements within about a year.

In addition to hospitals, CMS also extended the requirements to many types of facilities and suppliers so that such providers can more likely stay open and provide care during disasters and emergencies, or at least can resume operations as soon as possible, to provide the very best ongoing care to the affected community. In most of these scenarios, the need for complex and varied care goes up, not down, further exacerbating gaps in basic care if ambulatory facilities and home care providers are unavailable.

CMS does acknowledge that these requirements will be more difficult to execute in facilities that previously did not have requirements or in smaller facilities with more limited resources. It also acknowledges that the cost of implementation could reach up to $279 million, which some argue is actually an underestimation. Despite these challenges, it is hard to argue against basic disaster preparedness for any healthcare facility or provider as a standard and positive business practice. While most acute-care hospitals have long had disaster preparedness plans and programs, gaps in these programs have become readily apparent during natural disasters such as Hurricane Katrina and Superstorm Sandy. CMS also stresses the need for a community approach to planning and implementation and that there is no reason during planning, or during an actual event, that facilities should operate in isolation but rather train and respond together as a community.

As hospitalists, regardless of site of practice, we should all be involved in at least understanding, if not developing and implementing, these basic requirements in our facilities. It is without a doubt that hospitalists will be a core group of physicians who will be called upon to serve within or outside healthcare facilities in the event of a disaster or emergency. In fact, in most recent disasters, we already have. It is better, of course, to be prepared and ready to serve than unprepared and regretful.

Reference

1. The Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. Federal Register website. Accessed October 6, 2016.

Are you ready?

The Centers for Medicare & Medicaid Services (CMS) recently released new emergency preparedness requirements to ensure that providers and suppliers are duly prepared to adequately serve their community during disasters or emergencies. These requirements were stimulated by unexpected and catastrophic events, such as the September 11 terrorist attacks, the 2009 H1N1 pandemic, and innumerable natural disasters (tornados, floods, and hurricanes, to name a few). The CMS final rule issued “requirements that establish a comprehensive, consistent, flexible, and dynamic regulatory approach to emergency preparedness and response that incorporates the lessons learned from the past, combined with the proven best practices of the present.” In the rule, CMS outlines three essential guiding principles that any healthcare facility or supplier would need to preserve in the event of a disaster:

• Safeguard human resources.
• Maintain business continuity.
• Protect physical resources.

4 Ways to Be Prepared

What does having a comprehensive disaster preparedness program mean for hospitalists, regardless of site of practice? CMS recommends having four key elements for an adequate program:

1. Perform a risk assessment that focuses on the capacities and capabilities that are critical for a full spectrum of types of emergencies or disasters. This risk assessment should take into consideration the type and location of the facility as well as the disasters that are most likely to occur in its area. It should include at a minimum “care-related emergencies; equipment and power failures; interruptions in communications, including cyber attacks; loss of a portion or all of a facility; and interruptions in the normal supply of essentials, such as water and food.”

2. Develop and implement policies and procedures that support the emergency plan. Hospitalists should know about organizational policies and procedures that support the implementation of the emergency plan and how their team is factored into that plan.

3. Develop and maintain a communication plan that also complies with state and federal law. All the preparations in the world can be crippled without a robust and clear communication plan. The facility must have primary and backup mechanisms to contact providers, staff, and personnel in a timely fashion; this should include mechanisms to repeatedly update providers as the event evolves so that everyone knows what they are supposed to be doing and when.

4. Develop and maintain a training and testing program for all personnel. This includes onboarding and annual refreshers, including drills and exercises that test the plan and identify any gaps in performance. Hospitalists will undoubtedly be key members in developing, implementing, and receiving such critical training.

Expectations

There isn’t a single U.S. healthcare facility or provider that will not be affected by these provisions. An estimated 72,000 healthcare providers and suppliers (from nursing homes to dialysis facilities to home health agencies) will be expected to comply with these requirements within about a year.

In addition to hospitals, CMS also extended the requirements to many types of facilities and suppliers so that such providers can more likely stay open and provide care during disasters and emergencies, or at least can resume operations as soon as possible, to provide the very best ongoing care to the affected community. In most of these scenarios, the need for complex and varied care goes up, not down, further exacerbating gaps in basic care if ambulatory facilities and home care providers are unavailable.

CMS does acknowledge that these requirements will be more difficult to execute in facilities that previously did not have requirements or in smaller facilities with more limited resources. It also acknowledges that the cost of implementation could reach up to $279 million, which some argue is actually an underestimation. Despite these challenges, it is hard to argue against basic disaster preparedness for any healthcare facility or provider as a standard and positive business practice. While most acute-care hospitals have long had disaster preparedness plans and programs, gaps in these programs have become readily apparent during natural disasters such as Hurricane Katrina and Superstorm Sandy. CMS also stresses the need for a community approach to planning and implementation and that there is no reason during planning, or during an actual event, that facilities should operate in isolation but rather train and respond together as a community.

As hospitalists, regardless of site of practice, we should all be involved in at least understanding, if not developing and implementing, these basic requirements in our facilities. It is without a doubt that hospitalists will be a core group of physicians who will be called upon to serve within or outside healthcare facilities in the event of a disaster or emergency. In fact, in most recent disasters, we already have. It is better, of course, to be prepared and ready to serve than unprepared and regretful.

Reference

1. The Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. Federal Register website. Accessed October 6, 2016.

EBV-infected cell (green/red)

among uninfected cells (blue)

Image courtesy of

Benjamin Chaigne-Delalande

The European Medicines Agency (EMA) has accepted into its Priority Medicines (PRIME) program an allogeneic cytotoxic T-lymphocyte product that targets Epstein-Barr virus (EBV-CTLs).

EBV-CTLs have been accepted as a treatment for patients with rituximab-refractory EBV-associated post-transplant lymphoproliferative disorder (EBV-PTLD).

The goal of the EMA’s PRIME program is to accelerate the development of therapies that target unmet medical needs.

The program provides enhanced EMA support and increased interaction to developers, in order to optimize development plans and speed regulatory evaluations to potentially bring these therapies to patients more quickly.

To be accepted for PRIME, a therapy must demonstrate the potential to benefit patients with unmet medical need through early clinical or nonclinical data.

About EBV-CTLs

The EBV-CTLs are being developed by Atara Biotherapeutics, Inc.

To create EBV-CTLs, T cells are collected from the blood of third-party donors and exposed to EBV antigens. The activated T cells are then expanded, characterized, and stored for future use in a partially HLA-matched patient.

The EBV-CTLs are designed to find cancer cells expressing EBV and kill them.

Atara Bio’s EBV-CTLs are currently being studied in phase 2 trials of patients with EBV-associated cancers, including PTLD and nasopharyngeal carcinoma.

Results from 2 studies of EBV-CTLs in rituximab-refractory PTLD were presented at the 2015 AACR Annual Meeting.

Atara Bio’s EBV-CTLs have been classified as an advanced therapy medicinal product by the EMA and have orphan designation in the European Union.

EBV-infected cell (green/red)

among uninfected cells (blue)

Image courtesy of

Benjamin Chaigne-Delalande

The European Medicines Agency (EMA) has accepted into its Priority Medicines (PRIME) program an allogeneic cytotoxic T-lymphocyte product that targets Epstein-Barr virus (EBV-CTLs).

EBV-CTLs have been accepted as a treatment for patients with rituximab-refractory EBV-associated post-transplant lymphoproliferative disorder (EBV-PTLD).

The goal of the EMA’s PRIME program is to accelerate the development of therapies that target unmet medical needs.

The program provides enhanced EMA support and increased interaction to developers, in order to optimize development plans and speed regulatory evaluations to potentially bring these therapies to patients more quickly.

To be accepted for PRIME, a therapy must demonstrate the potential to benefit patients with unmet medical need through early clinical or nonclinical data.

About EBV-CTLs

The EBV-CTLs are being developed by Atara Biotherapeutics, Inc.

To create EBV-CTLs, T cells are collected from the blood of third-party donors and exposed to EBV antigens. The activated T cells are then expanded, characterized, and stored for future use in a partially HLA-matched patient.

The EBV-CTLs are designed to find cancer cells expressing EBV and kill them.

Atara Bio’s EBV-CTLs are currently being studied in phase 2 trials of patients with EBV-associated cancers, including PTLD and nasopharyngeal carcinoma.

Results from 2 studies of EBV-CTLs in rituximab-refractory PTLD were presented at the 2015 AACR Annual Meeting.

Atara Bio’s EBV-CTLs have been classified as an advanced therapy medicinal product by the EMA and have orphan designation in the European Union.

EBV-infected cell (green/red)

among uninfected cells (blue)

Image courtesy of

Benjamin Chaigne-Delalande

The European Medicines Agency (EMA) has accepted into its Priority Medicines (PRIME) program an allogeneic cytotoxic T-lymphocyte product that targets Epstein-Barr virus (EBV-CTLs).

EBV-CTLs have been accepted as a treatment for patients with rituximab-refractory EBV-associated post-transplant lymphoproliferative disorder (EBV-PTLD).

The goal of the EMA’s PRIME program is to accelerate the development of therapies that target unmet medical needs.

The program provides enhanced EMA support and increased interaction to developers, in order to optimize development plans and speed regulatory evaluations to potentially bring these therapies to patients more quickly.

To be accepted for PRIME, a therapy must demonstrate the potential to benefit patients with unmet medical need through early clinical or nonclinical data.

About EBV-CTLs

The EBV-CTLs are being developed by Atara Biotherapeutics, Inc.

To create EBV-CTLs, T cells are collected from the blood of third-party donors and exposed to EBV antigens. The activated T cells are then expanded, characterized, and stored for future use in a partially HLA-matched patient.

The EBV-CTLs are designed to find cancer cells expressing EBV and kill them.

Atara Bio’s EBV-CTLs are currently being studied in phase 2 trials of patients with EBV-associated cancers, including PTLD and nasopharyngeal carcinoma.

Results from 2 studies of EBV-CTLs in rituximab-refractory PTLD were presented at the 2015 AACR Annual Meeting.

Atara Bio’s EBV-CTLs have been classified as an advanced therapy medicinal product by the EMA and have orphan designation in the European Union.

Cancer patient receives therapy

Photo by Rhoda Baer

A new study suggests that leukemia and non-Hodgkin lymphoma (NHL) are among the top 10 cancers with the greatest burden (most years of healthy life lost) in the US.

The research also showed that the burden of different cancer types varied between patients belonging to different racial/ethnic groups.

For example, the contribution of leukemia to the overall cancer burden was twice as high in Hispanics as it was in non-Hispanic blacks. The same was true for NHL.

Joannie Lortet-Tieulent, of the American Cancer Society in Atlanta, Georgia, and her colleagues conducted this study and reported the results in the American Journal of Preventive Medicine.

The researchers calculated the burden of cancer in the US in 2011 for 24 cancer types. They calculated burden using disability-adjusted life years (DALYs), which combine cancer incidence, mortality, survival, and quality of life into a summary indicator.

The results suggested the burden of cancer in 2011 was over 9.8 million DALYs, which was equally shared between men and women—4.9 million DALYs for each sex.

DALYs lost to cancer were mostly related to premature death due to cancer (91%). The remaining 9% were related to impaired quality of life because of the disease or its treatment, or other disease-related issues.

Top 10 contributors

The researchers calculated the proportion of DALYs lost for each of the cancer types. And they found that lung cancer was the largest contributor to the loss of healthy years, accounting for 24% of the burden (2.4 million DALYs).

The second biggest contributor to the loss of healthy years was breast cancer (10%), followed by colorectal cancer (9%), pancreatic cancer (6%), prostate cancer (5%), leukemia (4%), liver cancer (4%), brain cancer (3%), NHL (3%), and ovarian cancer (3%).

The researchers also calculated the proportion of DALYs lost from the top 10 cancer types according to race/ethnicity.

They found the contribution of leukemia to the loss of healthy years was greatest for Hispanics (6%), followed by non-Hispanic Asians (5%), non-Hispanic whites (4%), and non-Hispanic blacks (3%).

The contribution of NHL to the loss of healthy years was greatest for Hispanics (4%), followed by non-Hispanic Asians/non-Hispanic whites (3% for both), and non-Hispanic blacks (2%).

DALYs by race/ethnicity

The researchers found that, overall, the cancer burden was highest in non-Hispanic blacks, followed by non-Hispanic whites, Hispanics, and non-Hispanic Asians. However, this pattern was not consistent across the different cancer types.

Age-standardized DALYs lost (per 100,000 individuals) were as follows:

All cancers combined

3588 for non-Hispanic blacks

2898 for non-Hispanic whites

1978 for Hispanics

1798 for non-Hispanic Asians.

Leukemia

115 for non-Hispanic blacks and non-Hispanic whites

98 for Hispanics

82 for non-Hispanic Asians.

NHL

93 for non-Hispanic whites

86 for non-Hispanic blacks

78 for Hispanics

60 for non-Hispanic Asians.

Hodgkin lymphoma

11 for non-Hispanic blacks

10 for non-Hispanic whites and Hispanics

3 for non-Hispanic Asians.

Myeloma

93 for non-Hispanic blacks

43 for non-Hispanic whites

42 for Hispanics

26 for non-Hispanic Asians.

The researchers noted that, despite these differences, the cancer burden in all races/ethnicities was driven by years of life lost. They said this highlights the need to prevent deaths by improving prevention, early detection, and treatment of cancers.

Cancer patient receives therapy

Photo by Rhoda Baer

A new study suggests that leukemia and non-Hodgkin lymphoma (NHL) are among the top 10 cancers with the greatest burden (most years of healthy life lost) in the US.

The research also showed that the burden of different cancer types varied between patients belonging to different racial/ethnic groups.

For example, the contribution of leukemia to the overall cancer burden was twice as high in Hispanics as it was in non-Hispanic blacks. The same was true for NHL.

Joannie Lortet-Tieulent, of the American Cancer Society in Atlanta, Georgia, and her colleagues conducted this study and reported the results in the American Journal of Preventive Medicine.

The researchers calculated the burden of cancer in the US in 2011 for 24 cancer types. They calculated burden using disability-adjusted life years (DALYs), which combine cancer incidence, mortality, survival, and quality of life into a summary indicator.

The results suggested the burden of cancer in 2011 was over 9.8 million DALYs, which was equally shared between men and women—4.9 million DALYs for each sex.

DALYs lost to cancer were mostly related to premature death due to cancer (91%). The remaining 9% were related to impaired quality of life because of the disease or its treatment, or other disease-related issues.

Top 10 contributors

The researchers calculated the proportion of DALYs lost for each of the cancer types. And they found that lung cancer was the largest contributor to the loss of healthy years, accounting for 24% of the burden (2.4 million DALYs).

The second biggest contributor to the loss of healthy years was breast cancer (10%), followed by colorectal cancer (9%), pancreatic cancer (6%), prostate cancer (5%), leukemia (4%), liver cancer (4%), brain cancer (3%), NHL (3%), and ovarian cancer (3%).

The researchers also calculated the proportion of DALYs lost from the top 10 cancer types according to race/ethnicity.

They found the contribution of leukemia to the loss of healthy years was greatest for Hispanics (6%), followed by non-Hispanic Asians (5%), non-Hispanic whites (4%), and non-Hispanic blacks (3%).

The contribution of NHL to the loss of healthy years was greatest for Hispanics (4%), followed by non-Hispanic Asians/non-Hispanic whites (3% for both), and non-Hispanic blacks (2%).

DALYs by race/ethnicity

The researchers found that, overall, the cancer burden was highest in non-Hispanic blacks, followed by non-Hispanic whites, Hispanics, and non-Hispanic Asians. However, this pattern was not consistent across the different cancer types.

Age-standardized DALYs lost (per 100,000 individuals) were as follows:

All cancers combined

3588 for non-Hispanic blacks

2898 for non-Hispanic whites

1978 for Hispanics

1798 for non-Hispanic Asians.

Leukemia

115 for non-Hispanic blacks and non-Hispanic whites

98 for Hispanics

82 for non-Hispanic Asians.

NHL

93 for non-Hispanic whites

86 for non-Hispanic blacks

78 for Hispanics

60 for non-Hispanic Asians.

Hodgkin lymphoma

11 for non-Hispanic blacks

10 for non-Hispanic whites and Hispanics

3 for non-Hispanic Asians.

Myeloma

93 for non-Hispanic blacks

43 for non-Hispanic whites

42 for Hispanics

26 for non-Hispanic Asians.

The researchers noted that, despite these differences, the cancer burden in all races/ethnicities was driven by years of life lost. They said this highlights the need to prevent deaths by improving prevention, early detection, and treatment of cancers.

Cancer patient receives therapy

Photo by Rhoda Baer

A new study suggests that leukemia and non-Hodgkin lymphoma (NHL) are among the top 10 cancers with the greatest burden (most years of healthy life lost) in the US.

The research also showed that the burden of different cancer types varied between patients belonging to different racial/ethnic groups.

For example, the contribution of leukemia to the overall cancer burden was twice as high in Hispanics as it was in non-Hispanic blacks. The same was true for NHL.

Joannie Lortet-Tieulent, of the American Cancer Society in Atlanta, Georgia, and her colleagues conducted this study and reported the results in the American Journal of Preventive Medicine.

The researchers calculated the burden of cancer in the US in 2011 for 24 cancer types. They calculated burden using disability-adjusted life years (DALYs), which combine cancer incidence, mortality, survival, and quality of life into a summary indicator.

The results suggested the burden of cancer in 2011 was over 9.8 million DALYs, which was equally shared between men and women—4.9 million DALYs for each sex.

DALYs lost to cancer were mostly related to premature death due to cancer (91%). The remaining 9% were related to impaired quality of life because of the disease or its treatment, or other disease-related issues.

Top 10 contributors

The researchers calculated the proportion of DALYs lost for each of the cancer types. And they found that lung cancer was the largest contributor to the loss of healthy years, accounting for 24% of the burden (2.4 million DALYs).

The second biggest contributor to the loss of healthy years was breast cancer (10%), followed by colorectal cancer (9%), pancreatic cancer (6%), prostate cancer (5%), leukemia (4%), liver cancer (4%), brain cancer (3%), NHL (3%), and ovarian cancer (3%).

The researchers also calculated the proportion of DALYs lost from the top 10 cancer types according to race/ethnicity.

They found the contribution of leukemia to the loss of healthy years was greatest for Hispanics (6%), followed by non-Hispanic Asians (5%), non-Hispanic whites (4%), and non-Hispanic blacks (3%).

The contribution of NHL to the loss of healthy years was greatest for Hispanics (4%), followed by non-Hispanic Asians/non-Hispanic whites (3% for both), and non-Hispanic blacks (2%).

DALYs by race/ethnicity

The researchers found that, overall, the cancer burden was highest in non-Hispanic blacks, followed by non-Hispanic whites, Hispanics, and non-Hispanic Asians. However, this pattern was not consistent across the different cancer types.

Age-standardized DALYs lost (per 100,000 individuals) were as follows:

All cancers combined

3588 for non-Hispanic blacks

2898 for non-Hispanic whites

1978 for Hispanics

1798 for non-Hispanic Asians.

Leukemia

115 for non-Hispanic blacks and non-Hispanic whites

98 for Hispanics

82 for non-Hispanic Asians.

NHL

93 for non-Hispanic whites

86 for non-Hispanic blacks

78 for Hispanics

60 for non-Hispanic Asians.

Hodgkin lymphoma

11 for non-Hispanic blacks

10 for non-Hispanic whites and Hispanics

3 for non-Hispanic Asians.

Myeloma

93 for non-Hispanic blacks

43 for non-Hispanic whites

42 for Hispanics

26 for non-Hispanic Asians.

The researchers noted that, despite these differences, the cancer burden in all races/ethnicities was driven by years of life lost. They said this highlights the need to prevent deaths by improving prevention, early detection, and treatment of cancers.

CLL cells

Researchers say they have found a better way to examine individual cells, and this tool provided insight that could inform the treatment of leukemia.

The team used a technique called microarrayed single-cell sequencing (MASC-seq) to examine individual cells in samples from patients with chronic lymphocytic leukemia (CLL).

This revealed a number of CLL subclones within each sample that exhibited different gene expression.

“With this new, highly cost-effective technology, we can now get a whole new view of this complexity within the blood cancer sample,” said study author Joakim Lundeberg, PhD, of KTH Royal Institute of Technology in Stockholm, Sweden.

“Molecular resolution of single cells is likely to become a more widely used therapy option.”

Dr Lundeberg and his colleagues described this work in Nature Communications.

The researchers said current methods of single-cell analysis don’t allow for the combination of cell imaging and transcriptome profiling, exhibit low-throughput by analyzing a single cell at a time, or require expensive droplet instrumentation for high-throughput analysis.

MASC-seq, on the other hand, can image cells to provide information on morphology and profile the expression of thousands of single cells per day at a cost of $0.13 USD per cell.

Dr Lundeberg and his colleagues tested MASC-seq by analyzing samples from 3 patients with different subtypes of CLL.

The team found clear differences in the average gene expression levels of cells from the different CLL subtypes, but they also found subtle differences between single cells within each of the subtypes.

The researchers therefore concluded that MASC-seq has the potential to accelerate the study of subtle clonal dynamics and help provide insight into the development of CLL and other diseases.

CLL cells

Researchers say they have found a better way to examine individual cells, and this tool provided insight that could inform the treatment of leukemia.

The team used a technique called microarrayed single-cell sequencing (MASC-seq) to examine individual cells in samples from patients with chronic lymphocytic leukemia (CLL).

This revealed a number of CLL subclones within each sample that exhibited different gene expression.

“With this new, highly cost-effective technology, we can now get a whole new view of this complexity within the blood cancer sample,” said study author Joakim Lundeberg, PhD, of KTH Royal Institute of Technology in Stockholm, Sweden.

“Molecular resolution of single cells is likely to become a more widely used therapy option.”

Dr Lundeberg and his colleagues described this work in Nature Communications.

The researchers said current methods of single-cell analysis don’t allow for the combination of cell imaging and transcriptome profiling, exhibit low-throughput by analyzing a single cell at a time, or require expensive droplet instrumentation for high-throughput analysis.

MASC-seq, on the other hand, can image cells to provide information on morphology and profile the expression of thousands of single cells per day at a cost of $0.13 USD per cell.

Dr Lundeberg and his colleagues tested MASC-seq by analyzing samples from 3 patients with different subtypes of CLL.

The team found clear differences in the average gene expression levels of cells from the different CLL subtypes, but they also found subtle differences between single cells within each of the subtypes.

The researchers therefore concluded that MASC-seq has the potential to accelerate the study of subtle clonal dynamics and help provide insight into the development of CLL and other diseases.

CLL cells

Researchers say they have found a better way to examine individual cells, and this tool provided insight that could inform the treatment of leukemia.

The team used a technique called microarrayed single-cell sequencing (MASC-seq) to examine individual cells in samples from patients with chronic lymphocytic leukemia (CLL).

This revealed a number of CLL subclones within each sample that exhibited different gene expression.

“With this new, highly cost-effective technology, we can now get a whole new view of this complexity within the blood cancer sample,” said study author Joakim Lundeberg, PhD, of KTH Royal Institute of Technology in Stockholm, Sweden.

“Molecular resolution of single cells is likely to become a more widely used therapy option.”

Dr Lundeberg and his colleagues described this work in Nature Communications.

The researchers said current methods of single-cell analysis don’t allow for the combination of cell imaging and transcriptome profiling, exhibit low-throughput by analyzing a single cell at a time, or require expensive droplet instrumentation for high-throughput analysis.

MASC-seq, on the other hand, can image cells to provide information on morphology and profile the expression of thousands of single cells per day at a cost of $0.13 USD per cell.

Dr Lundeberg and his colleagues tested MASC-seq by analyzing samples from 3 patients with different subtypes of CLL.

The team found clear differences in the average gene expression levels of cells from the different CLL subtypes, but they also found subtle differences between single cells within each of the subtypes.

The researchers therefore concluded that MASC-seq has the potential to accelerate the study of subtle clonal dynamics and help provide insight into the development of CLL and other diseases.

Vials of drug

Photo by Bill Branson

A 2-drug combination has shown promise for treating patients with FLT3-ITD acute myeloid leukemia (AML), according to research published in Science Translational Medicine.

Researchers found that omacetaxine mepesuccinate (formerly known as homoharringtonine) exhibits preferential antileukemic activity against FLT3-ITD AML.

Subsequent preclinical experiments revealed that omacetaxine synergizes with sorafenib and other FLT3 inhibitors.

So researchers tested omacetaxine in combination with sorafenib in a phase 2 trial of patients with FLT3-ITD AML.

The combination produced complete responses (CRs) or CRs with incomplete hematologic recovery (CRis) in a majority of patients, and researchers said the treatment was well-tolerated.

Anskar Y. H. Leung, MD, PhD, of The University of Hong Kong, and his colleagues conducted this research.

The team first performed an in vitro screen on AML patient samples to determine their responses to various drugs.

One of the compounds tested, the protein translation inhibitor omacetaxine mepesuccinate, showed strong antileukemic effects against FLT3-ITD AML. In fact, omacetaxine preferentially inhibited the growth of FLT3-ITD cell lines.

The researchers then found that omacetaxine synergizes with sorafenib and other FLT3 inhibitors to suppress leukemia growth in FLT3-ITD AML cell lines.

Omacetaxine and sorafenib in combination also prolonged survival in mouse models of FLT3-ITD AML (mice transplanted with MV4-11 or MOLM-13 cells).

Phase 2 trial

The researchers went on to test omacetaxine and sorafenib in a phase 2 trial. The trial enrolled 24 patients with FLT3-ITD AML and a median age of 50 (range, 21-76).

Most of the patients had relapsed or refractory disease, but 2 were unsuitable for induction chemotherapy because of advanced age and comorbidities.

The patients received omacetaxine and sorafenib continuously until intolerance, disease progression, or allogeneic hematopoietic stem cell transplant (HSCT).

Twenty patients (83.3%) achieved a CR or CRi at a median of 22 days (range, 18-55). Three patients did not respond, and 1 patient experienced a near-CRi—a reduction of blasts without complete clearance.

Fifteen of the responders relapsed, but 3 of these patients received omacetaxine and sorafenib again and achieved a CRi. One patient received re-treatment and failed to achieve a response.

Seven patients proceeded to HSCT after receiving omacetaxine and sorafenib.

At a median follow-up of 7.1 months (range, 2.2 to 20.5), 4 patients were still in CR/CRi (3 patients after HSCT), and 1 patient who had relapsed was still alive.

The remaining 19 patients had died—14 due to relapse, 4 due to non-response (1 after re-treatment), and 1 due to HSCT.

The median leukemia-free survival was 88 days (range, 9-510), and the median overall survival was 228 days (range, 53 to 615).

Adverse events occurring after treatment with omacetaxine and sorafenib included fever (n=14), rash (n=8), hand-foot-skin reactions (n=6), pneumonia (n=2), neutropenic fever (n=1), and bacteremia (n=1).

The researchers said this study validated the principle and clinical relevance of in vitro drug testing and identified a drug combination that might improve the treatment of FLT3-ITD AML.

Vials of drug

Photo by Bill Branson

A 2-drug combination has shown promise for treating patients with FLT3-ITD acute myeloid leukemia (AML), according to research published in Science Translational Medicine.

Researchers found that omacetaxine mepesuccinate (formerly known as homoharringtonine) exhibits preferential antileukemic activity against FLT3-ITD AML.

Subsequent preclinical experiments revealed that omacetaxine synergizes with sorafenib and other FLT3 inhibitors.

So researchers tested omacetaxine in combination with sorafenib in a phase 2 trial of patients with FLT3-ITD AML.

The combination produced complete responses (CRs) or CRs with incomplete hematologic recovery (CRis) in a majority of patients, and researchers said the treatment was well-tolerated.

Anskar Y. H. Leung, MD, PhD, of The University of Hong Kong, and his colleagues conducted this research.

The team first performed an in vitro screen on AML patient samples to determine their responses to various drugs.

One of the compounds tested, the protein translation inhibitor omacetaxine mepesuccinate, showed strong antileukemic effects against FLT3-ITD AML. In fact, omacetaxine preferentially inhibited the growth of FLT3-ITD cell lines.

The researchers then found that omacetaxine synergizes with sorafenib and other FLT3 inhibitors to suppress leukemia growth in FLT3-ITD AML cell lines.

Omacetaxine and sorafenib in combination also prolonged survival in mouse models of FLT3-ITD AML (mice transplanted with MV4-11 or MOLM-13 cells).

Phase 2 trial

The researchers went on to test omacetaxine and sorafenib in a phase 2 trial. The trial enrolled 24 patients with FLT3-ITD AML and a median age of 50 (range, 21-76).

Most of the patients had relapsed or refractory disease, but 2 were unsuitable for induction chemotherapy because of advanced age and comorbidities.

The patients received omacetaxine and sorafenib continuously until intolerance, disease progression, or allogeneic hematopoietic stem cell transplant (HSCT).

Twenty patients (83.3%) achieved a CR or CRi at a median of 22 days (range, 18-55). Three patients did not respond, and 1 patient experienced a near-CRi—a reduction of blasts without complete clearance.

Fifteen of the responders relapsed, but 3 of these patients received omacetaxine and sorafenib again and achieved a CRi. One patient received re-treatment and failed to achieve a response.

Seven patients proceeded to HSCT after receiving omacetaxine and sorafenib.

At a median follow-up of 7.1 months (range, 2.2 to 20.5), 4 patients were still in CR/CRi (3 patients after HSCT), and 1 patient who had relapsed was still alive.

The remaining 19 patients had died—14 due to relapse, 4 due to non-response (1 after re-treatment), and 1 due to HSCT.

The median leukemia-free survival was 88 days (range, 9-510), and the median overall survival was 228 days (range, 53 to 615).

Adverse events occurring after treatment with omacetaxine and sorafenib included fever (n=14), rash (n=8), hand-foot-skin reactions (n=6), pneumonia (n=2), neutropenic fever (n=1), and bacteremia (n=1).

The researchers said this study validated the principle and clinical relevance of in vitro drug testing and identified a drug combination that might improve the treatment of FLT3-ITD AML.

Vials of drug

Photo by Bill Branson

A 2-drug combination has shown promise for treating patients with FLT3-ITD acute myeloid leukemia (AML), according to research published in Science Translational Medicine.

Researchers found that omacetaxine mepesuccinate (formerly known as homoharringtonine) exhibits preferential antileukemic activity against FLT3-ITD AML.

Subsequent preclinical experiments revealed that omacetaxine synergizes with sorafenib and other FLT3 inhibitors.

So researchers tested omacetaxine in combination with sorafenib in a phase 2 trial of patients with FLT3-ITD AML.

The combination produced complete responses (CRs) or CRs with incomplete hematologic recovery (CRis) in a majority of patients, and researchers said the treatment was well-tolerated.

Anskar Y. H. Leung, MD, PhD, of The University of Hong Kong, and his colleagues conducted this research.

The team first performed an in vitro screen on AML patient samples to determine their responses to various drugs.

One of the compounds tested, the protein translation inhibitor omacetaxine mepesuccinate, showed strong antileukemic effects against FLT3-ITD AML. In fact, omacetaxine preferentially inhibited the growth of FLT3-ITD cell lines.

The researchers then found that omacetaxine synergizes with sorafenib and other FLT3 inhibitors to suppress leukemia growth in FLT3-ITD AML cell lines.

Omacetaxine and sorafenib in combination also prolonged survival in mouse models of FLT3-ITD AML (mice transplanted with MV4-11 or MOLM-13 cells).

Phase 2 trial

The researchers went on to test omacetaxine and sorafenib in a phase 2 trial. The trial enrolled 24 patients with FLT3-ITD AML and a median age of 50 (range, 21-76).

Most of the patients had relapsed or refractory disease, but 2 were unsuitable for induction chemotherapy because of advanced age and comorbidities.

The patients received omacetaxine and sorafenib continuously until intolerance, disease progression, or allogeneic hematopoietic stem cell transplant (HSCT).

Twenty patients (83.3%) achieved a CR or CRi at a median of 22 days (range, 18-55). Three patients did not respond, and 1 patient experienced a near-CRi—a reduction of blasts without complete clearance.

Fifteen of the responders relapsed, but 3 of these patients received omacetaxine and sorafenib again and achieved a CRi. One patient received re-treatment and failed to achieve a response.

Seven patients proceeded to HSCT after receiving omacetaxine and sorafenib.

At a median follow-up of 7.1 months (range, 2.2 to 20.5), 4 patients were still in CR/CRi (3 patients after HSCT), and 1 patient who had relapsed was still alive.

The remaining 19 patients had died—14 due to relapse, 4 due to non-response (1 after re-treatment), and 1 due to HSCT.

The median leukemia-free survival was 88 days (range, 9-510), and the median overall survival was 228 days (range, 53 to 615).

Adverse events occurring after treatment with omacetaxine and sorafenib included fever (n=14), rash (n=8), hand-foot-skin reactions (n=6), pneumonia (n=2), neutropenic fever (n=1), and bacteremia (n=1).

The researchers said this study validated the principle and clinical relevance of in vitro drug testing and identified a drug combination that might improve the treatment of FLT3-ITD AML.

Primary care physicians (PCPs) often don’t have the time to manage the complex medication needs of patients with chronic conditions. PCPs working in federally qualified health centers (FQHCs) while caring for low-income at-risk patients also face “particularly large barriers,” according to the Agency for Health Care Research and Quality (AHRQ). But that lack of time can contribute to low patient adherence to medication regimens.

While clinical pharmacists can help, they may not be available to FQHCs, PCP offices, and other primary care settings. To address this, innovators in Ohio established a statewide consortium or “shared learning community” that provides the resources for FQHCs to offer pharmacist-led medication therapy management (MTM) services to patients with diabetes or hypertension. The collaborating organizations include the Ohio Association for Community Health Centers, the Health Services Advisory Group, and 6 Ohio-based colleges of pharmacy.

Related: Best Practices: Utilization of Oncology Pharmacists in the VA

The program developers, Jennifer Rodis, PharmD, BCPS, FAPhA, Assistant Dean for Outreach and Engagement at Ohio State University College of Pharmacy, and Barbara Pryor, MS, RD, LD, manager, Chronic Disease Section, Ohio Department of Health, reported on the consortium’s program and successes in AHRQ’s Health Care Innovations Exchange.

Program leaders meet with participating pharmacists to orient them; those pharmacists then introduce the program to clinicians and staff at their respective practice sites. Every month, the participating pharmacists check in with program leaders from the Ohio Department of Health, the Ohio State University College of Pharmacy, and Ohio Association of Community Health Centers to give status updates and get guidance and troubleshooting advice.

Related: VA Treats Patients’ Impatience With Clinical Pharmacists

The consortium has markedly increased the number of FQHCs offering pharmacist-led MTM services, as well as boosting awareness and interest in MTM. When the program began in 2013, very few of the 41 FQCHs in Ohio had pharmacist-led MTM programs, the AHRQ report says. Nine FQHCs now participate in the consortium.

During the first year, the 3  participating sites enrolled nearly 400 eligible patients with out-of-control hypertension or diabetes. By the end of that year, 68% of hypertensive patients had controlled their blood pressure and 45% of patients with diabetes were controlling their hemoglobin A1c. What’s more, the pharmacists providing MTM addressed 75 adverse drug events and remedied 145 potential events.

Primary care physicians (PCPs) often don’t have the time to manage the complex medication needs of patients with chronic conditions. PCPs working in federally qualified health centers (FQHCs) while caring for low-income at-risk patients also face “particularly large barriers,” according to the Agency for Health Care Research and Quality (AHRQ). But that lack of time can contribute to low patient adherence to medication regimens.

While clinical pharmacists can help, they may not be available to FQHCs, PCP offices, and other primary care settings. To address this, innovators in Ohio established a statewide consortium or “shared learning community” that provides the resources for FQHCs to offer pharmacist-led medication therapy management (MTM) services to patients with diabetes or hypertension. The collaborating organizations include the Ohio Association for Community Health Centers, the Health Services Advisory Group, and 6 Ohio-based colleges of pharmacy.

Related: Best Practices: Utilization of Oncology Pharmacists in the VA

The program developers, Jennifer Rodis, PharmD, BCPS, FAPhA, Assistant Dean for Outreach and Engagement at Ohio State University College of Pharmacy, and Barbara Pryor, MS, RD, LD, manager, Chronic Disease Section, Ohio Department of Health, reported on the consortium’s program and successes in AHRQ’s Health Care Innovations Exchange.

Program leaders meet with participating pharmacists to orient them; those pharmacists then introduce the program to clinicians and staff at their respective practice sites. Every month, the participating pharmacists check in with program leaders from the Ohio Department of Health, the Ohio State University College of Pharmacy, and Ohio Association of Community Health Centers to give status updates and get guidance and troubleshooting advice.

Related: VA Treats Patients’ Impatience With Clinical Pharmacists

The consortium has markedly increased the number of FQHCs offering pharmacist-led MTM services, as well as boosting awareness and interest in MTM. When the program began in 2013, very few of the 41 FQCHs in Ohio had pharmacist-led MTM programs, the AHRQ report says. Nine FQHCs now participate in the consortium.

During the first year, the 3  participating sites enrolled nearly 400 eligible patients with out-of-control hypertension or diabetes. By the end of that year, 68% of hypertensive patients had controlled their blood pressure and 45% of patients with diabetes were controlling their hemoglobin A1c. What’s more, the pharmacists providing MTM addressed 75 adverse drug events and remedied 145 potential events.

Primary care physicians (PCPs) often don’t have the time to manage the complex medication needs of patients with chronic conditions. PCPs working in federally qualified health centers (FQHCs) while caring for low-income at-risk patients also face “particularly large barriers,” according to the Agency for Health Care Research and Quality (AHRQ). But that lack of time can contribute to low patient adherence to medication regimens.

While clinical pharmacists can help, they may not be available to FQHCs, PCP offices, and other primary care settings. To address this, innovators in Ohio established a statewide consortium or “shared learning community” that provides the resources for FQHCs to offer pharmacist-led medication therapy management (MTM) services to patients with diabetes or hypertension. The collaborating organizations include the Ohio Association for Community Health Centers, the Health Services Advisory Group, and 6 Ohio-based colleges of pharmacy.

Related: Best Practices: Utilization of Oncology Pharmacists in the VA

The program developers, Jennifer Rodis, PharmD, BCPS, FAPhA, Assistant Dean for Outreach and Engagement at Ohio State University College of Pharmacy, and Barbara Pryor, MS, RD, LD, manager, Chronic Disease Section, Ohio Department of Health, reported on the consortium’s program and successes in AHRQ’s Health Care Innovations Exchange.

Program leaders meet with participating pharmacists to orient them; those pharmacists then introduce the program to clinicians and staff at their respective practice sites. Every month, the participating pharmacists check in with program leaders from the Ohio Department of Health, the Ohio State University College of Pharmacy, and Ohio Association of Community Health Centers to give status updates and get guidance and troubleshooting advice.

Related: VA Treats Patients’ Impatience With Clinical Pharmacists

The consortium has markedly increased the number of FQHCs offering pharmacist-led MTM services, as well as boosting awareness and interest in MTM. When the program began in 2013, very few of the 41 FQCHs in Ohio had pharmacist-led MTM programs, the AHRQ report says. Nine FQHCs now participate in the consortium.

During the first year, the 3  participating sites enrolled nearly 400 eligible patients with out-of-control hypertension or diabetes. By the end of that year, 68% of hypertensive patients had controlled their blood pressure and 45% of patients with diabetes were controlling their hemoglobin A1c. What’s more, the pharmacists providing MTM addressed 75 adverse drug events and remedied 145 potential events.

The FP suspected tinea incognito (fungus caused by steroids because of a misdiagnosis) and wanted to perform a potassium hydroxide (KOH) preparation. (See video on how to perform a KOH preparation here.)

Unfortunately, the FP’s health system had removed microscopes from all of the offices because of regulatory issues from The Joint Commission. So the physician did the next best thing: He scraped the outer edge of the rash and put the scale in a sterile urine cup to send to the lab for fungal stain and culture. He recommended that the patient stop using the triamcinolone cream and start using a topical terbinafine (now an over-the-counter antifungal cream). He also made a mental note that most topical steroids only need to be used twice daily, even when the electronic medical record populates 3 times a day as the default setting.

The FP set up an appointment to see the patient the following week, hoping to have some answers from the laboratory. Two days later, the KOH with Calcofluor white fungal stain was positive for fungal elements. When the patient returned, the culture was growing Trichophyton rubrum. The patient noted that the rash had improved a little, but wondered if there was something stronger to help her.

Now that the diagnosis of tinea incognito was finalized, the FP offered her oral terbinafine. The patient did not have any liver disease and rarely drank alcohol, so the FP prescribed terbinafine 250 mg/d for 3 weeks. One month later, the patient was pleased that the itching, scaling, and raised areas had resolved. However, she asked if the dark area on her chest would remain that way forever. The FP told her that the postinflammatory hyperpigmentation would likely fade over time, but might not ever return to her normal skin color. The patient was upset, as she’d been wearing different clothes to hide the dark mark, and was hoping it would go away completely.

The FP suggested that she return in 2 months to see how her skin was doing. He told her about the use of an over-the-counter 3% hydroquinone cream, but warned her that it sometimes darkened skin rather than lightening it. He also suggested keeping the area protected from the sun and told her to stop using the bleaching cream if it caused irritation or darkened her skin.

This case is a dramatic example of how treating an unknown rash with topical steroids can have potentially permanent consequences for the patient. Even FPs who don't have microscopes or don't know how to create a KOH preparation can do what this doctor did (send a specimen to the laboratory). It’s always better to have a diagnosis before treatment, as topical steroids are not the answer to all pruritic rashes.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Jimenez A. Tinea corporis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:788-794.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP suspected tinea incognito (fungus caused by steroids because of a misdiagnosis) and wanted to perform a potassium hydroxide (KOH) preparation. (See video on how to perform a KOH preparation here.)

Unfortunately, the FP’s health system had removed microscopes from all of the offices because of regulatory issues from The Joint Commission. So the physician did the next best thing: He scraped the outer edge of the rash and put the scale in a sterile urine cup to send to the lab for fungal stain and culture. He recommended that the patient stop using the triamcinolone cream and start using a topical terbinafine (now an over-the-counter antifungal cream). He also made a mental note that most topical steroids only need to be used twice daily, even when the electronic medical record populates 3 times a day as the default setting.

The FP set up an appointment to see the patient the following week, hoping to have some answers from the laboratory. Two days later, the KOH with Calcofluor white fungal stain was positive for fungal elements. When the patient returned, the culture was growing Trichophyton rubrum. The patient noted that the rash had improved a little, but wondered if there was something stronger to help her.

Now that the diagnosis of tinea incognito was finalized, the FP offered her oral terbinafine. The patient did not have any liver disease and rarely drank alcohol, so the FP prescribed terbinafine 250 mg/d for 3 weeks. One month later, the patient was pleased that the itching, scaling, and raised areas had resolved. However, she asked if the dark area on her chest would remain that way forever. The FP told her that the postinflammatory hyperpigmentation would likely fade over time, but might not ever return to her normal skin color. The patient was upset, as she’d been wearing different clothes to hide the dark mark, and was hoping it would go away completely.

The FP suggested that she return in 2 months to see how her skin was doing. He told her about the use of an over-the-counter 3% hydroquinone cream, but warned her that it sometimes darkened skin rather than lightening it. He also suggested keeping the area protected from the sun and told her to stop using the bleaching cream if it caused irritation or darkened her skin.

This case is a dramatic example of how treating an unknown rash with topical steroids can have potentially permanent consequences for the patient. Even FPs who don't have microscopes or don't know how to create a KOH preparation can do what this doctor did (send a specimen to the laboratory). It’s always better to have a diagnosis before treatment, as topical steroids are not the answer to all pruritic rashes.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Jimenez A. Tinea corporis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:788-794.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP suspected tinea incognito (fungus caused by steroids because of a misdiagnosis) and wanted to perform a potassium hydroxide (KOH) preparation. (See video on how to perform a KOH preparation here.)

Unfortunately, the FP’s health system had removed microscopes from all of the offices because of regulatory issues from The Joint Commission. So the physician did the next best thing: He scraped the outer edge of the rash and put the scale in a sterile urine cup to send to the lab for fungal stain and culture. He recommended that the patient stop using the triamcinolone cream and start using a topical terbinafine (now an over-the-counter antifungal cream). He also made a mental note that most topical steroids only need to be used twice daily, even when the electronic medical record populates 3 times a day as the default setting.

The FP set up an appointment to see the patient the following week, hoping to have some answers from the laboratory. Two days later, the KOH with Calcofluor white fungal stain was positive for fungal elements. When the patient returned, the culture was growing Trichophyton rubrum. The patient noted that the rash had improved a little, but wondered if there was something stronger to help her.

Now that the diagnosis of tinea incognito was finalized, the FP offered her oral terbinafine. The patient did not have any liver disease and rarely drank alcohol, so the FP prescribed terbinafine 250 mg/d for 3 weeks. One month later, the patient was pleased that the itching, scaling, and raised areas had resolved. However, she asked if the dark area on her chest would remain that way forever. The FP told her that the postinflammatory hyperpigmentation would likely fade over time, but might not ever return to her normal skin color. The patient was upset, as she’d been wearing different clothes to hide the dark mark, and was hoping it would go away completely.

The FP suggested that she return in 2 months to see how her skin was doing. He told her about the use of an over-the-counter 3% hydroquinone cream, but warned her that it sometimes darkened skin rather than lightening it. He also suggested keeping the area protected from the sun and told her to stop using the bleaching cream if it caused irritation or darkened her skin.

This case is a dramatic example of how treating an unknown rash with topical steroids can have potentially permanent consequences for the patient. Even FPs who don't have microscopes or don't know how to create a KOH preparation can do what this doctor did (send a specimen to the laboratory). It’s always better to have a diagnosis before treatment, as topical steroids are not the answer to all pruritic rashes.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Jimenez A. Tinea corporis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:788-794.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

MONTREAL – Vedolizumab, 2 years out from its entry onto the U.S. market as an option for treating adults with inflammatory bowel disease, also has shown early safety and efficacy in 52 pediatric patients with ulcerative colitis or Crohn’s disease.

Retrospective review of a patients series assembled from three U.S. centers showed 13 (76%) ulcerative colitis patients in remission among 17 treated and followed for 14 weeks, the study’s primary outcome. Among 24 Crohn’s disease patients treated and followed for 14 weeks, 10 (42%) had remissions, Namita Singh, MD, said at the World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition.

Mitchel L. Zoler/Frontline Medical News

Dr. Singh has been a consultant to Janssen and Prometheus and received grant support from Janssen.

[email protected]

On Twitter @mitchelzoler

MONTREAL – Vedolizumab, 2 years out from its entry onto the U.S. market as an option for treating adults with inflammatory bowel disease, also has shown early safety and efficacy in 52 pediatric patients with ulcerative colitis or Crohn’s disease.

Retrospective review of a patients series assembled from three U.S. centers showed 13 (76%) ulcerative colitis patients in remission among 17 treated and followed for 14 weeks, the study’s primary outcome. Among 24 Crohn’s disease patients treated and followed for 14 weeks, 10 (42%) had remissions, Namita Singh, MD, said at the World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition.

Mitchel L. Zoler/Frontline Medical News

Dr. Singh has been a consultant to Janssen and Prometheus and received grant support from Janssen.

[email protected]

On Twitter @mitchelzoler

MONTREAL – Vedolizumab, 2 years out from its entry onto the U.S. market as an option for treating adults with inflammatory bowel disease, also has shown early safety and efficacy in 52 pediatric patients with ulcerative colitis or Crohn’s disease.

Retrospective review of a patients series assembled from three U.S. centers showed 13 (76%) ulcerative colitis patients in remission among 17 treated and followed for 14 weeks, the study’s primary outcome. Among 24 Crohn’s disease patients treated and followed for 14 weeks, 10 (42%) had remissions, Namita Singh, MD, said at the World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition.

Mitchel L. Zoler/Frontline Medical News

Dr. Singh has been a consultant to Janssen and Prometheus and received grant support from Janssen.

[email protected]

On Twitter @mitchelzoler

NEW YORK – Three “Achilles heels” of multiple myeloma offer exciting promise for additional advances that will begin to see therapeutic payoffs within the next year, according to Kenneth C. Anderson, MD.

The three targets – excess protein production, immune suppression, and genomic abnormalities – can be addressed by focusing on protein degradation, restoring anti–multiple myeloma immunity, and targeting and overcoming genomic abnormalities, respectively, Dr. Anderson of Dana-Farber Cancer Institute in Boston said at Imedex: Lymphoma & Myeloma, an international congress on hematologic malignancies.

Courtesy Wikimedia Commons/KGH/Creative Commons License

[email protected]

NEW YORK – Three “Achilles heels” of multiple myeloma offer exciting promise for additional advances that will begin to see therapeutic payoffs within the next year, according to Kenneth C. Anderson, MD.

The three targets – excess protein production, immune suppression, and genomic abnormalities – can be addressed by focusing on protein degradation, restoring anti–multiple myeloma immunity, and targeting and overcoming genomic abnormalities, respectively, Dr. Anderson of Dana-Farber Cancer Institute in Boston said at Imedex: Lymphoma & Myeloma, an international congress on hematologic malignancies.

Courtesy Wikimedia Commons/KGH/Creative Commons License

[email protected]

NEW YORK – Three “Achilles heels” of multiple myeloma offer exciting promise for additional advances that will begin to see therapeutic payoffs within the next year, according to Kenneth C. Anderson, MD.

The three targets – excess protein production, immune suppression, and genomic abnormalities – can be addressed by focusing on protein degradation, restoring anti–multiple myeloma immunity, and targeting and overcoming genomic abnormalities, respectively, Dr. Anderson of Dana-Farber Cancer Institute in Boston said at Imedex: Lymphoma & Myeloma, an international congress on hematologic malignancies.

Courtesy Wikimedia Commons/KGH/Creative Commons License

[email protected]

When specifically looked for, pulmonary embolism was identified in approximately 17% of adults hospitalized for a first episode of syncope, according to a report published in the New England Journal of Medicine.

Most medical textbooks include pulmonary embolism (PE) in the differential diagnosis of syncope, but “current international guidelines, including those from the European Society of Cardiology and the American Heart Association, pay little attention to establishing a diagnostic workup for PE in these patients. Hence, when a patient is admitted to a hospital for an episode of syncope, PE – a potentially fatal disease that can be effectively treated – is rarely considered as a possible cause,” said Paolo Prandoni, MD, PhD, of the vascular medicine unit, University of Padua (Italy), and his associates in the PESY (Prevalence of Pulmonary Embolism in Patients With Syncope) trial.

The investigators used a systematic diagnostic work-up to determine the prevalence of PE in a cross-sectional study involving 560 adults hospitalized for syncope at 11 medical centers across Italy during a 2.5-year period. Most of these patients were elderly (mean age, 76 years), and most had clinical evidence indicating that a factor other than PE had caused their fainting. For this study, syncope was defined as a transient loss of consciousness with rapid onset, short duration (less than 1 minute), and spontaneous resolution, with obvious causes ruled out (such as epileptic seizure, stroke, or head trauma).

Copyright pixelheadphoto/Thinkstock

When specifically looked for, pulmonary embolism was identified in approximately 17% of adults hospitalized for a first episode of syncope, according to a report published in the New England Journal of Medicine.

Most medical textbooks include pulmonary embolism (PE) in the differential diagnosis of syncope, but “current international guidelines, including those from the European Society of Cardiology and the American Heart Association, pay little attention to establishing a diagnostic workup for PE in these patients. Hence, when a patient is admitted to a hospital for an episode of syncope, PE – a potentially fatal disease that can be effectively treated – is rarely considered as a possible cause,” said Paolo Prandoni, MD, PhD, of the vascular medicine unit, University of Padua (Italy), and his associates in the PESY (Prevalence of Pulmonary Embolism in Patients With Syncope) trial.

The investigators used a systematic diagnostic work-up to determine the prevalence of PE in a cross-sectional study involving 560 adults hospitalized for syncope at 11 medical centers across Italy during a 2.5-year period. Most of these patients were elderly (mean age, 76 years), and most had clinical evidence indicating that a factor other than PE had caused their fainting. For this study, syncope was defined as a transient loss of consciousness with rapid onset, short duration (less than 1 minute), and spontaneous resolution, with obvious causes ruled out (such as epileptic seizure, stroke, or head trauma).

Copyright pixelheadphoto/Thinkstock

When specifically looked for, pulmonary embolism was identified in approximately 17% of adults hospitalized for a first episode of syncope, according to a report published in the New England Journal of Medicine.

Most medical textbooks include pulmonary embolism (PE) in the differential diagnosis of syncope, but “current international guidelines, including those from the European Society of Cardiology and the American Heart Association, pay little attention to establishing a diagnostic workup for PE in these patients. Hence, when a patient is admitted to a hospital for an episode of syncope, PE – a potentially fatal disease that can be effectively treated – is rarely considered as a possible cause,” said Paolo Prandoni, MD, PhD, of the vascular medicine unit, University of Padua (Italy), and his associates in the PESY (Prevalence of Pulmonary Embolism in Patients With Syncope) trial.

The investigators used a systematic diagnostic work-up to determine the prevalence of PE in a cross-sectional study involving 560 adults hospitalized for syncope at 11 medical centers across Italy during a 2.5-year period. Most of these patients were elderly (mean age, 76 years), and most had clinical evidence indicating that a factor other than PE had caused their fainting. For this study, syncope was defined as a transient loss of consciousness with rapid onset, short duration (less than 1 minute), and spontaneous resolution, with obvious causes ruled out (such as epileptic seizure, stroke, or head trauma).

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