Injuries among professional baseball players have been on the rise for several years.^1,2 From 1989 to 1999, the number of disabled list (DL) reports increased 38% (266 to 367 annual reports),¹ and a similar increase in injury rates was noted from the 2002 to the 2008 seasons (37%).² These injuries have important implications for future injury risk and time away from play. Identifying these injuries and determining correlates and risk factors is important for targeted prevention efforts.

Several studies have explored the prevalence of upper extremity injuries in professional and collegiate baseball players;^2-4 however, detailed epidemiology of knee injuries in Major League Baseball (MLB) and Minor League Baseball (MiLB) players is lacking. Much more is known about the prevalence, treatment, and outcomes of knee injuries in other professional sporting organizations, such as the National Basketball Association (NBA), National Football League (NFL), and National Hockey League (NHL).^4-12 A recent meta-analysis exploring injuries in professional athletes found that studies on lower extremity injuries comprised approximately 12% of the literature reporting injuries in MLB players.⁴ In other professional leagues, publications on lower extremity injuries comprise approximately 56% of the sports medicine literature in the NFL, 54% in the NBA, and 62% in the NHL.⁴ Since few studies have investigated lower extremity injuries among professional baseball players, there is an opportunity for additional research to guide evidence-based prevention strategies.

A better understanding of the nature of these injuries is one of the first steps towards developing targeted injury prevention programs and treatment algorithms. The study of injury epidemiology among professional baseball players has been aided by the creation of an injury tracking system initiated by the MLB, its minor league affiliates, and the Major League Baseball Players Association.^5,13,14 This surveillance system allows for the tracking of medical histories and injuries to players as they move across major and minor league organizations. Similar systems have been utilized in the National Collegiate Athletic Association and other professional sports organizations.^3,15-17 A unique advantage of the MLB surveillance system is the required participation of all major and minor league teams, which allows for investigation of the entire population of players rather than simply a sample of players from select teams. This system has propelled an effort to identify injury patterns as a means of developing appropriate targets for potential preventative measures.⁵

The purpose of this descriptive epidemiologic study is to better understand the distribution and characteristics of knee injuries in these elite athletes by reporting on all knee injuries occurring over a span of 4 seasons (2011-2014). Additionally, this study seeks to characterize the impact of these injuries by analyzing the time required for return to play and the treatments rendered (surgical and nonsurgical).

Materials and Methods

After approval from the Johns Hopkins Bloomberg School of Public Health Institutional Review Board, detailed data regarding knee injuries in both MLB and MiLB baseball players were extracted from the de-identified MLB Health and Injury Tracking System (HITS). The HITS database is a centralized database that contains data on injuries from an electronic medical record (EMR). All players provided consent to have their data included in this EMR. HITS system captures injuries reported by the athletic trainers for all professional baseball players from 30 MLB clubs and their 230 minor league affiliates. Additional details on this population of professional baseball players have been published elsewhere.⁵ Only injuries that result in time out of play (≥1 day missed) are included in the database, and they are logged with basic information such as region of the body, diagnosis, date, player position, activity leading to injury, and general treatment. Any injury that affects participation in any aspect of baseball-related activity (eg, game, practice, warm-up, conditioning, weight training) is captured in HITS.

All baseball-related knee injuries occurring during the 2011-2014 seasons that resulted in time out of sport were included in the study. These injuries were identified based on the Sports Medicine Diagnostic Coding System (SMDCS) to capture injuries by diagnostic groups.¹⁸ Knee injuries were included if they occurred during spring training, regular season, or postseason play. Offseason injuries were not included. Injury events that were classified as “season-ending” were not included in the analysis of days missed because many of these players may not have been cleared to play until the beginning of the following season. To determine the proportion of knee injuries during the study period, all injuries were included for comparative purposes (subdivided based on 30 anatomic regions or types).

For each knee injury, a number of variables were analyzed, including diagnosis, level of play (MLB vs. MiLB), age, player position at the time of injury (pitcher, catcher, infield, outfield, base runner, or batter), field location where the injury occurred (home plate, pitcher’s mound, infield, outfield, foul territory or bullpen, or other), mechanism of injury, days missed, and treatment rendered (conservative vs surgical). The classification used to describe the mechanism of injury consisted of contact with ball, contact with ground, contact with another player, contact with another object, or noncontact.

Statistical Analysis
Epidemiologic data are presented with descriptive statistics such as mean, median, frequency, and percentage where appropriate. When comparing player age, days missed, and surgical vs nonsurgical treatment between MLB and MiLB players, t-tests and tests for difference in proportions were applied as appropriate. Statistical significance was established for P values < .05.

The distribution of days missed for the variables considered was often skewed to the right (ie, days missed mostly concentrated on the low to moderate number of days, with fewer values in the much higher days missed range), even after excluding the season-ending injuries; hence the mean (or average) days missed was often larger than the median days missed. Reporting the median would allow for a robust estimate of the expected number of days missed, but would down weight those instances when knee injuries result in much longer missed days, as reflected by the mean. Because of the importance of the days missed measure for professional baseball, both the mean and median are presented.

In order to estimate exposure, the average number of players per team per game was calculated based on analysis of regular season game participation via box scores. This average number over a season, multiplied by the number of team games at each professional level of baseball, was used as an estimate of athlete exposures in order to provide rates comparable to those of other injury surveillance systems. Injury rates were reported as injuries per 1000 athlete-exposures (AE) for those knee injuries that occurred during the regular season. It should be noted that the number of regular season knee injuries and the subsequent AE rates are based on injuries that were deemed work-related during the regular season. This does not necessarily only include injuries occurring during the course of a game, but injuries in game preparation as well. Due to the variations in spring training games and fluctuating rosters, an exposure rate could not be calculated for spring training knee injuries.

RESULTS

Overall Summary

Of the 30 general body regions/systems included in the HITS database, injuries to the knee were the fifth most common reason for days missed in all of professional baseball from 2011-2014 (Table 1). Injuries to the knee represented 6.5% of the nearly 34,000 injuries sustained during the study period. Knee injuries were the fifth most common reason for time out of play for players in both the MiLB and MLB.

A total of 2171 isolated knee injuries resulted in time out of sport for professional baseball players (Table 2). Of these, 410 (19%) occurred in MLB players and 1761 (81%) occurred in MiLB players. MLB players were older than MiLB players at the time of injury (29.5 vs 22.8 years, respectively). Overall mean number of days missed was 16.2 days per knee injury, with MLB players missing an approximately 7 days more per injury than MiLB athletes (21.8 vs. 14.9 days respectively; P = .001).Over the course of the 4 seasons, a total of 30,449 days were missed due to knee injuries in professional baseball, giving an average rate of 7612 days lost per season. Surgery was performed for 263 (12.1%) of the 2171 knee injuries, with a greater proportion of MLB players requiring surgery than MiLB players (17.3% vs 10.9%) (P < .001). With respect to number of days missed per injury, 26% of knee injuries in the minor leagues resulted in greater than 30 days missed, while this number rose to 32% for knee injuries in MLB players (Table 3).

For regular season games, it was estimated that there were 1,197,738 MiLB and 276,608 MLB AE, respectively, over the course of the 4 seasons (2011-2014). The overall knee injury rate across both the MiLB and MLB was 1.2 per 1000 AE, based on the subset of 308 and 1473 regular season knee injuries in MiLB and MLB, respectively. The rate of knee injury was similar and not significantly different between the MiLB and MLB (1.2 per 1000 AE in the MiLB and 1.1 per 1000 AE in the MLB).

Characteristics of Injuries

When considering the position of the player during injury, defensive players were most frequently injured (n = 742, 56.5%), with pitchers (n = 227, 17.3%), infielders (n =193, 14.7%), outfielders (n = 193, 14.7%), and catchers (n = 129, 9.8%) sustaining injuries in decreasing frequency. Injuries while on offense (n = 571, 43.5%) were most frequent in base runners (n = 320, 24.4%) followed by batters (n = 251, 19.1%) (Table 4). Injuries while on defense occurring in infielders and catchers resulted in the longest period of time away from play (average of 22.4 and 20.8 days missed, respectively), while those occurring in batters resulted in the least average days missed (8.9 days).

The most common field location for knee injuries to occur was the infield, which was responsible for n = 647 (29.8%) of the total knee injuries (Table 4). This was followed by home plate (n = 493, 22.7%), other locations outside those specified (n = 394, 18.1%), outfield (n = 320, 14.7%), pitcher’s mound (n = 210, 9.7%), and foul territory or the bullpen (n = 107, 4.9%). Of the knee injuries with a specified location, those occurring in foul territory or the bullpen resulted in the highest mean days missed (18.4), while those occurring at home plate resulted in the least mean days missed (13.4 days).

When analyzed by mechanism of injury, noncontact injuries (n = 953, 43.9%) were more common than being hit with the ball (n = 374, 17.2%), striking the ground (n = 409, 18.8%), other mechanisms not listed (n = 196, 9%), contact with another player (n = 176, 8.1%), or contact with other objects (n = 63, 2.9%) (Table 4). Noncontact injuries and player to player collisions resulted in the greatest number of missed days (21.6 and 17.1 days, respectively) while being struck by the ball resulted in the least mean days missed (5.1).

Of the n = 493 knee injuries occurring at home plate, n = 212 (43%) occurred to the batter, n = 100 (20%) to the catcher, n = 34 (6.9%) to base runners, and n = 7 (1.4%) to pitchers (Table 5). The majority of knee injuries in the infield occurred to base runners (n = 283, 43.7%). Player-to-player collisions at home plate were responsible for 51 (2.3%) knee injuries, while 163 (24%) were noncontact injuries and 376 (56%) were the result of a player being hit by the ball (Table 5).

Injury Diagnosis

By diagnosis, the most common knee injuries observed were contusions or hematomas (n = 662, 30.5%), other injuries (n = 415, 19.1%), sprains or ligament injuries (n = 380, 17.5%), tendinopathies or bursitis (n = 367, 16.9%), and meniscal or cartilage injury (n = 200, 9.2%) (Table 6). Injuries resulting in the greatest mean number of days missed included meniscal or cartilage injuries (44 days), sprains or ligament injuries (30 days), or dislocations (22 days).

Based on specific SMDCS descriptors, the most frequent knee injuries reported were contusion (n = 662, 30.5%), patella tendinopathy (n = 222, 10.2%), and meniscal tears (n = 200, 9.2%) (Table 6). Complete anterior cruciate ligament tears, although infrequent, were responsible for the greatest mean days missed (156.2 days). This was followed by lateral meniscus tears (47.5 days) and medial meniscus tears (41.2 days). Knee contusions, although very common, resulted in the least number of days missed (6.0 days).

Discussion

Although much is known about knee injuries in other professional athletic leagues, little is known about knee injuries in professional baseball players.^2-4 The majority of epidemiologic studies regarding baseball players at any level emphasizes the study of shoulder and elbow injuries.^3,4,19 Since the implementation of the electronic medical record and the HITS database in professional baseball, there has been increased effort to document injuries that have received less attention in the existing literature. Understanding the epidemiology of these injuries is important for the development of targeted prevention efforts.

Prior studies of injuries in professional baseball relied on data captured by the publicly available DL. Posner and colleagues² provide one of the most comprehensive reports on MLB injuries in a report utilizing DL assignment data over a period of 7 seasons.They demonstrated that knee injuries were responsible for 7.7% (12.5% for fielders and 3.7% for pitchers) of assignments to the DL. The current study utilized a comprehensive surveillance and builds on this existing knowledge. The present study found similar trends to Posner and colleagues² in that knee injuries were responsible for 6.5% of injuries in professional baseball players that resulted in missed games. From the 2002 season to the 2008 season, knee injuries were the fifth most common reason MLB players were placed on the DL,² and the current study indicates that they remain the fifth most common reason for missed time from play based on the HITS data. Since the prevalence of these injuries have remained constant since the 2002 season, efforts to better understand these injuries are warranted in order to identify strategies to prevent them. These analyses have generated important data towards achieving this understanding.

As with most injuries in professional sports, goals for treatment are aimed at maximizing patient function and performance while minimizing time out of play. For the 2011-2014 professional baseball seasons, a total of 2171 players sustained knee injuries and missed an average of 16.2 days per injury. Knee injuries were responsible for a total of 7612 days of missed work for MLB and MiLB players per season (30,449 days over the 4-season study period). This is equivalent to a total of 20.9 years of players’ time lost in professional baseball per season over the last 4 years. The implications of this amount of time away from sport are significant, and further study should be targeted at prevention of these injuries and optimizing return to play times.

When attempting to reduce the burden of knee injuries in professional baseball, it may prove beneficial to first understand how the injuries occur, where on the field, and who is at greatest risk. From 2011 to 2014, nearly 44% of knee injuries occurred by noncontact mechanisms. Among all locations on the field where knee injuries occurred, those occurring in the infield were responsible for the greatest mean days missed. The players who seem to be at greatest risk for knee injuries appear to be base runners. These data suggest the need for prevention efforts targeting base runners and infield players, as well as players in MiLB, where the largest number of injuries occurred.

Recently, playing rules implemented by MLB after consultation with players have focused on reducing the number of player-to-player collisions at home plate in an attempt to decrease the injury burden to catchers and base runners.²⁰ This present analysis suggests that this rule change may also reduce the occurrence of knee injuries, as player collisions at home plate were responsible for a total of 51 knee injuries during the study period. The impact of this rule change on injury rates should also be explored. Interestingly, of the 51 knees injuries occurring due to contact at home plate, 23 occurred in 2011, and only 2 occurred in 2014—the first year of the new rule. Additional areas that resulted in high numbers of knee injuries were player-to-player contact in the infield and player contact with the ground in the infield.

Attempting to reduce injury burden and time out of play related to knee injuries in professional baseball players will likely prove to be a difficult task. In order to generate meaningful improvement, a comprehensive approach that involves players, management, trainers, therapists, and physicians will likely be required. As the first report of the epidemiology of knee injuries in professional baseball players, this study is one important step in that process. The strengths of this study are its comprehensive nature that analyzes injuries from an entire population of players on more than 200 teams over a 3-year period. Also, this research is strengthened by its focus on one particular region of the body that has received limited attention in the empirical literature, but represents a significant source of lost time during the baseball season.

There are some limitations to this study. As with any injury surveillance system, there is the possibility that not all cases were captured. Additionally, since the surveillance system is based on data from multiple teams, data entry discrepancy is possible; however, the presence of dropdown boxes and systematic definitions for injuries reduces this risk. Finally, this study did not investigate the various treatments for knee injuries beyond whether or not the injury required surgery. Since this was the first comprehensive exploration of knee injuries in professional baseball, future studies are needed to explore additional facets including outcomes related to treatment, return to play, and performance.

Conclusion

Knee injuries represent 6.5% of all injuries in professional baseball, occurring at a rate of 1.3 per 1000 AE. The burden of these injuries is significant for professional baseball players. This study fills a critical gap in sports injury research by contributing to the knowledge about the effect of knee injuries in professional baseball. It also provides an important foundation for future epidemiologic inquiry to identify modifiable risk factors and interventions that may reduce the impact of these injuries in athletes.

Injuries among professional baseball players have been on the rise for several years.^1,2 From 1989 to 1999, the number of disabled list (DL) reports increased 38% (266 to 367 annual reports),¹ and a similar increase in injury rates was noted from the 2002 to the 2008 seasons (37%).² These injuries have important implications for future injury risk and time away from play. Identifying these injuries and determining correlates and risk factors is important for targeted prevention efforts.

Several studies have explored the prevalence of upper extremity injuries in professional and collegiate baseball players;^2-4 however, detailed epidemiology of knee injuries in Major League Baseball (MLB) and Minor League Baseball (MiLB) players is lacking. Much more is known about the prevalence, treatment, and outcomes of knee injuries in other professional sporting organizations, such as the National Basketball Association (NBA), National Football League (NFL), and National Hockey League (NHL).^4-12 A recent meta-analysis exploring injuries in professional athletes found that studies on lower extremity injuries comprised approximately 12% of the literature reporting injuries in MLB players.⁴ In other professional leagues, publications on lower extremity injuries comprise approximately 56% of the sports medicine literature in the NFL, 54% in the NBA, and 62% in the NHL.⁴ Since few studies have investigated lower extremity injuries among professional baseball players, there is an opportunity for additional research to guide evidence-based prevention strategies.

A better understanding of the nature of these injuries is one of the first steps towards developing targeted injury prevention programs and treatment algorithms. The study of injury epidemiology among professional baseball players has been aided by the creation of an injury tracking system initiated by the MLB, its minor league affiliates, and the Major League Baseball Players Association.^5,13,14 This surveillance system allows for the tracking of medical histories and injuries to players as they move across major and minor league organizations. Similar systems have been utilized in the National Collegiate Athletic Association and other professional sports organizations.^3,15-17 A unique advantage of the MLB surveillance system is the required participation of all major and minor league teams, which allows for investigation of the entire population of players rather than simply a sample of players from select teams. This system has propelled an effort to identify injury patterns as a means of developing appropriate targets for potential preventative measures.⁵

The purpose of this descriptive epidemiologic study is to better understand the distribution and characteristics of knee injuries in these elite athletes by reporting on all knee injuries occurring over a span of 4 seasons (2011-2014). Additionally, this study seeks to characterize the impact of these injuries by analyzing the time required for return to play and the treatments rendered (surgical and nonsurgical).

Materials and Methods

After approval from the Johns Hopkins Bloomberg School of Public Health Institutional Review Board, detailed data regarding knee injuries in both MLB and MiLB baseball players were extracted from the de-identified MLB Health and Injury Tracking System (HITS). The HITS database is a centralized database that contains data on injuries from an electronic medical record (EMR). All players provided consent to have their data included in this EMR. HITS system captures injuries reported by the athletic trainers for all professional baseball players from 30 MLB clubs and their 230 minor league affiliates. Additional details on this population of professional baseball players have been published elsewhere.⁵ Only injuries that result in time out of play (≥1 day missed) are included in the database, and they are logged with basic information such as region of the body, diagnosis, date, player position, activity leading to injury, and general treatment. Any injury that affects participation in any aspect of baseball-related activity (eg, game, practice, warm-up, conditioning, weight training) is captured in HITS.

All baseball-related knee injuries occurring during the 2011-2014 seasons that resulted in time out of sport were included in the study. These injuries were identified based on the Sports Medicine Diagnostic Coding System (SMDCS) to capture injuries by diagnostic groups.¹⁸ Knee injuries were included if they occurred during spring training, regular season, or postseason play. Offseason injuries were not included. Injury events that were classified as “season-ending” were not included in the analysis of days missed because many of these players may not have been cleared to play until the beginning of the following season. To determine the proportion of knee injuries during the study period, all injuries were included for comparative purposes (subdivided based on 30 anatomic regions or types).

For each knee injury, a number of variables were analyzed, including diagnosis, level of play (MLB vs. MiLB), age, player position at the time of injury (pitcher, catcher, infield, outfield, base runner, or batter), field location where the injury occurred (home plate, pitcher’s mound, infield, outfield, foul territory or bullpen, or other), mechanism of injury, days missed, and treatment rendered (conservative vs surgical). The classification used to describe the mechanism of injury consisted of contact with ball, contact with ground, contact with another player, contact with another object, or noncontact.

Statistical Analysis
Epidemiologic data are presented with descriptive statistics such as mean, median, frequency, and percentage where appropriate. When comparing player age, days missed, and surgical vs nonsurgical treatment between MLB and MiLB players, t-tests and tests for difference in proportions were applied as appropriate. Statistical significance was established for P values < .05.

The distribution of days missed for the variables considered was often skewed to the right (ie, days missed mostly concentrated on the low to moderate number of days, with fewer values in the much higher days missed range), even after excluding the season-ending injuries; hence the mean (or average) days missed was often larger than the median days missed. Reporting the median would allow for a robust estimate of the expected number of days missed, but would down weight those instances when knee injuries result in much longer missed days, as reflected by the mean. Because of the importance of the days missed measure for professional baseball, both the mean and median are presented.

In order to estimate exposure, the average number of players per team per game was calculated based on analysis of regular season game participation via box scores. This average number over a season, multiplied by the number of team games at each professional level of baseball, was used as an estimate of athlete exposures in order to provide rates comparable to those of other injury surveillance systems. Injury rates were reported as injuries per 1000 athlete-exposures (AE) for those knee injuries that occurred during the regular season. It should be noted that the number of regular season knee injuries and the subsequent AE rates are based on injuries that were deemed work-related during the regular season. This does not necessarily only include injuries occurring during the course of a game, but injuries in game preparation as well. Due to the variations in spring training games and fluctuating rosters, an exposure rate could not be calculated for spring training knee injuries.

RESULTS

Overall Summary

Of the 30 general body regions/systems included in the HITS database, injuries to the knee were the fifth most common reason for days missed in all of professional baseball from 2011-2014 (Table 1). Injuries to the knee represented 6.5% of the nearly 34,000 injuries sustained during the study period. Knee injuries were the fifth most common reason for time out of play for players in both the MiLB and MLB.

A total of 2171 isolated knee injuries resulted in time out of sport for professional baseball players (Table 2). Of these, 410 (19%) occurred in MLB players and 1761 (81%) occurred in MiLB players. MLB players were older than MiLB players at the time of injury (29.5 vs 22.8 years, respectively). Overall mean number of days missed was 16.2 days per knee injury, with MLB players missing an approximately 7 days more per injury than MiLB athletes (21.8 vs. 14.9 days respectively; P = .001).Over the course of the 4 seasons, a total of 30,449 days were missed due to knee injuries in professional baseball, giving an average rate of 7612 days lost per season. Surgery was performed for 263 (12.1%) of the 2171 knee injuries, with a greater proportion of MLB players requiring surgery than MiLB players (17.3% vs 10.9%) (P < .001). With respect to number of days missed per injury, 26% of knee injuries in the minor leagues resulted in greater than 30 days missed, while this number rose to 32% for knee injuries in MLB players (Table 3).

For regular season games, it was estimated that there were 1,197,738 MiLB and 276,608 MLB AE, respectively, over the course of the 4 seasons (2011-2014). The overall knee injury rate across both the MiLB and MLB was 1.2 per 1000 AE, based on the subset of 308 and 1473 regular season knee injuries in MiLB and MLB, respectively. The rate of knee injury was similar and not significantly different between the MiLB and MLB (1.2 per 1000 AE in the MiLB and 1.1 per 1000 AE in the MLB).

Characteristics of Injuries

When considering the position of the player during injury, defensive players were most frequently injured (n = 742, 56.5%), with pitchers (n = 227, 17.3%), infielders (n =193, 14.7%), outfielders (n = 193, 14.7%), and catchers (n = 129, 9.8%) sustaining injuries in decreasing frequency. Injuries while on offense (n = 571, 43.5%) were most frequent in base runners (n = 320, 24.4%) followed by batters (n = 251, 19.1%) (Table 4). Injuries while on defense occurring in infielders and catchers resulted in the longest period of time away from play (average of 22.4 and 20.8 days missed, respectively), while those occurring in batters resulted in the least average days missed (8.9 days).

The most common field location for knee injuries to occur was the infield, which was responsible for n = 647 (29.8%) of the total knee injuries (Table 4). This was followed by home plate (n = 493, 22.7%), other locations outside those specified (n = 394, 18.1%), outfield (n = 320, 14.7%), pitcher’s mound (n = 210, 9.7%), and foul territory or the bullpen (n = 107, 4.9%). Of the knee injuries with a specified location, those occurring in foul territory or the bullpen resulted in the highest mean days missed (18.4), while those occurring at home plate resulted in the least mean days missed (13.4 days).

When analyzed by mechanism of injury, noncontact injuries (n = 953, 43.9%) were more common than being hit with the ball (n = 374, 17.2%), striking the ground (n = 409, 18.8%), other mechanisms not listed (n = 196, 9%), contact with another player (n = 176, 8.1%), or contact with other objects (n = 63, 2.9%) (Table 4). Noncontact injuries and player to player collisions resulted in the greatest number of missed days (21.6 and 17.1 days, respectively) while being struck by the ball resulted in the least mean days missed (5.1).

Of the n = 493 knee injuries occurring at home plate, n = 212 (43%) occurred to the batter, n = 100 (20%) to the catcher, n = 34 (6.9%) to base runners, and n = 7 (1.4%) to pitchers (Table 5). The majority of knee injuries in the infield occurred to base runners (n = 283, 43.7%). Player-to-player collisions at home plate were responsible for 51 (2.3%) knee injuries, while 163 (24%) were noncontact injuries and 376 (56%) were the result of a player being hit by the ball (Table 5).

Injury Diagnosis

By diagnosis, the most common knee injuries observed were contusions or hematomas (n = 662, 30.5%), other injuries (n = 415, 19.1%), sprains or ligament injuries (n = 380, 17.5%), tendinopathies or bursitis (n = 367, 16.9%), and meniscal or cartilage injury (n = 200, 9.2%) (Table 6). Injuries resulting in the greatest mean number of days missed included meniscal or cartilage injuries (44 days), sprains or ligament injuries (30 days), or dislocations (22 days).

Based on specific SMDCS descriptors, the most frequent knee injuries reported were contusion (n = 662, 30.5%), patella tendinopathy (n = 222, 10.2%), and meniscal tears (n = 200, 9.2%) (Table 6). Complete anterior cruciate ligament tears, although infrequent, were responsible for the greatest mean days missed (156.2 days). This was followed by lateral meniscus tears (47.5 days) and medial meniscus tears (41.2 days). Knee contusions, although very common, resulted in the least number of days missed (6.0 days).

Discussion

Although much is known about knee injuries in other professional athletic leagues, little is known about knee injuries in professional baseball players.^2-4 The majority of epidemiologic studies regarding baseball players at any level emphasizes the study of shoulder and elbow injuries.^3,4,19 Since the implementation of the electronic medical record and the HITS database in professional baseball, there has been increased effort to document injuries that have received less attention in the existing literature. Understanding the epidemiology of these injuries is important for the development of targeted prevention efforts.

Prior studies of injuries in professional baseball relied on data captured by the publicly available DL. Posner and colleagues² provide one of the most comprehensive reports on MLB injuries in a report utilizing DL assignment data over a period of 7 seasons.They demonstrated that knee injuries were responsible for 7.7% (12.5% for fielders and 3.7% for pitchers) of assignments to the DL. The current study utilized a comprehensive surveillance and builds on this existing knowledge. The present study found similar trends to Posner and colleagues² in that knee injuries were responsible for 6.5% of injuries in professional baseball players that resulted in missed games. From the 2002 season to the 2008 season, knee injuries were the fifth most common reason MLB players were placed on the DL,² and the current study indicates that they remain the fifth most common reason for missed time from play based on the HITS data. Since the prevalence of these injuries have remained constant since the 2002 season, efforts to better understand these injuries are warranted in order to identify strategies to prevent them. These analyses have generated important data towards achieving this understanding.

As with most injuries in professional sports, goals for treatment are aimed at maximizing patient function and performance while minimizing time out of play. For the 2011-2014 professional baseball seasons, a total of 2171 players sustained knee injuries and missed an average of 16.2 days per injury. Knee injuries were responsible for a total of 7612 days of missed work for MLB and MiLB players per season (30,449 days over the 4-season study period). This is equivalent to a total of 20.9 years of players’ time lost in professional baseball per season over the last 4 years. The implications of this amount of time away from sport are significant, and further study should be targeted at prevention of these injuries and optimizing return to play times.

When attempting to reduce the burden of knee injuries in professional baseball, it may prove beneficial to first understand how the injuries occur, where on the field, and who is at greatest risk. From 2011 to 2014, nearly 44% of knee injuries occurred by noncontact mechanisms. Among all locations on the field where knee injuries occurred, those occurring in the infield were responsible for the greatest mean days missed. The players who seem to be at greatest risk for knee injuries appear to be base runners. These data suggest the need for prevention efforts targeting base runners and infield players, as well as players in MiLB, where the largest number of injuries occurred.

Recently, playing rules implemented by MLB after consultation with players have focused on reducing the number of player-to-player collisions at home plate in an attempt to decrease the injury burden to catchers and base runners.²⁰ This present analysis suggests that this rule change may also reduce the occurrence of knee injuries, as player collisions at home plate were responsible for a total of 51 knee injuries during the study period. The impact of this rule change on injury rates should also be explored. Interestingly, of the 51 knees injuries occurring due to contact at home plate, 23 occurred in 2011, and only 2 occurred in 2014—the first year of the new rule. Additional areas that resulted in high numbers of knee injuries were player-to-player contact in the infield and player contact with the ground in the infield.

Attempting to reduce injury burden and time out of play related to knee injuries in professional baseball players will likely prove to be a difficult task. In order to generate meaningful improvement, a comprehensive approach that involves players, management, trainers, therapists, and physicians will likely be required. As the first report of the epidemiology of knee injuries in professional baseball players, this study is one important step in that process. The strengths of this study are its comprehensive nature that analyzes injuries from an entire population of players on more than 200 teams over a 3-year period. Also, this research is strengthened by its focus on one particular region of the body that has received limited attention in the empirical literature, but represents a significant source of lost time during the baseball season.

There are some limitations to this study. As with any injury surveillance system, there is the possibility that not all cases were captured. Additionally, since the surveillance system is based on data from multiple teams, data entry discrepancy is possible; however, the presence of dropdown boxes and systematic definitions for injuries reduces this risk. Finally, this study did not investigate the various treatments for knee injuries beyond whether or not the injury required surgery. Since this was the first comprehensive exploration of knee injuries in professional baseball, future studies are needed to explore additional facets including outcomes related to treatment, return to play, and performance.

Conclusion

Knee injuries represent 6.5% of all injuries in professional baseball, occurring at a rate of 1.3 per 1000 AE. The burden of these injuries is significant for professional baseball players. This study fills a critical gap in sports injury research by contributing to the knowledge about the effect of knee injuries in professional baseball. It also provides an important foundation for future epidemiologic inquiry to identify modifiable risk factors and interventions that may reduce the impact of these injuries in athletes.

Injuries among professional baseball players have been on the rise for several years.^1,2 From 1989 to 1999, the number of disabled list (DL) reports increased 38% (266 to 367 annual reports),¹ and a similar increase in injury rates was noted from the 2002 to the 2008 seasons (37%).² These injuries have important implications for future injury risk and time away from play. Identifying these injuries and determining correlates and risk factors is important for targeted prevention efforts.

Several studies have explored the prevalence of upper extremity injuries in professional and collegiate baseball players;^2-4 however, detailed epidemiology of knee injuries in Major League Baseball (MLB) and Minor League Baseball (MiLB) players is lacking. Much more is known about the prevalence, treatment, and outcomes of knee injuries in other professional sporting organizations, such as the National Basketball Association (NBA), National Football League (NFL), and National Hockey League (NHL).^4-12 A recent meta-analysis exploring injuries in professional athletes found that studies on lower extremity injuries comprised approximately 12% of the literature reporting injuries in MLB players.⁴ In other professional leagues, publications on lower extremity injuries comprise approximately 56% of the sports medicine literature in the NFL, 54% in the NBA, and 62% in the NHL.⁴ Since few studies have investigated lower extremity injuries among professional baseball players, there is an opportunity for additional research to guide evidence-based prevention strategies.

A better understanding of the nature of these injuries is one of the first steps towards developing targeted injury prevention programs and treatment algorithms. The study of injury epidemiology among professional baseball players has been aided by the creation of an injury tracking system initiated by the MLB, its minor league affiliates, and the Major League Baseball Players Association.^5,13,14 This surveillance system allows for the tracking of medical histories and injuries to players as they move across major and minor league organizations. Similar systems have been utilized in the National Collegiate Athletic Association and other professional sports organizations.^3,15-17 A unique advantage of the MLB surveillance system is the required participation of all major and minor league teams, which allows for investigation of the entire population of players rather than simply a sample of players from select teams. This system has propelled an effort to identify injury patterns as a means of developing appropriate targets for potential preventative measures.⁵

The purpose of this descriptive epidemiologic study is to better understand the distribution and characteristics of knee injuries in these elite athletes by reporting on all knee injuries occurring over a span of 4 seasons (2011-2014). Additionally, this study seeks to characterize the impact of these injuries by analyzing the time required for return to play and the treatments rendered (surgical and nonsurgical).

Materials and Methods

After approval from the Johns Hopkins Bloomberg School of Public Health Institutional Review Board, detailed data regarding knee injuries in both MLB and MiLB baseball players were extracted from the de-identified MLB Health and Injury Tracking System (HITS). The HITS database is a centralized database that contains data on injuries from an electronic medical record (EMR). All players provided consent to have their data included in this EMR. HITS system captures injuries reported by the athletic trainers for all professional baseball players from 30 MLB clubs and their 230 minor league affiliates. Additional details on this population of professional baseball players have been published elsewhere.⁵ Only injuries that result in time out of play (≥1 day missed) are included in the database, and they are logged with basic information such as region of the body, diagnosis, date, player position, activity leading to injury, and general treatment. Any injury that affects participation in any aspect of baseball-related activity (eg, game, practice, warm-up, conditioning, weight training) is captured in HITS.

All baseball-related knee injuries occurring during the 2011-2014 seasons that resulted in time out of sport were included in the study. These injuries were identified based on the Sports Medicine Diagnostic Coding System (SMDCS) to capture injuries by diagnostic groups.¹⁸ Knee injuries were included if they occurred during spring training, regular season, or postseason play. Offseason injuries were not included. Injury events that were classified as “season-ending” were not included in the analysis of days missed because many of these players may not have been cleared to play until the beginning of the following season. To determine the proportion of knee injuries during the study period, all injuries were included for comparative purposes (subdivided based on 30 anatomic regions or types).

For each knee injury, a number of variables were analyzed, including diagnosis, level of play (MLB vs. MiLB), age, player position at the time of injury (pitcher, catcher, infield, outfield, base runner, or batter), field location where the injury occurred (home plate, pitcher’s mound, infield, outfield, foul territory or bullpen, or other), mechanism of injury, days missed, and treatment rendered (conservative vs surgical). The classification used to describe the mechanism of injury consisted of contact with ball, contact with ground, contact with another player, contact with another object, or noncontact.

Statistical Analysis
Epidemiologic data are presented with descriptive statistics such as mean, median, frequency, and percentage where appropriate. When comparing player age, days missed, and surgical vs nonsurgical treatment between MLB and MiLB players, t-tests and tests for difference in proportions were applied as appropriate. Statistical significance was established for P values < .05.

The distribution of days missed for the variables considered was often skewed to the right (ie, days missed mostly concentrated on the low to moderate number of days, with fewer values in the much higher days missed range), even after excluding the season-ending injuries; hence the mean (or average) days missed was often larger than the median days missed. Reporting the median would allow for a robust estimate of the expected number of days missed, but would down weight those instances when knee injuries result in much longer missed days, as reflected by the mean. Because of the importance of the days missed measure for professional baseball, both the mean and median are presented.

In order to estimate exposure, the average number of players per team per game was calculated based on analysis of regular season game participation via box scores. This average number over a season, multiplied by the number of team games at each professional level of baseball, was used as an estimate of athlete exposures in order to provide rates comparable to those of other injury surveillance systems. Injury rates were reported as injuries per 1000 athlete-exposures (AE) for those knee injuries that occurred during the regular season. It should be noted that the number of regular season knee injuries and the subsequent AE rates are based on injuries that were deemed work-related during the regular season. This does not necessarily only include injuries occurring during the course of a game, but injuries in game preparation as well. Due to the variations in spring training games and fluctuating rosters, an exposure rate could not be calculated for spring training knee injuries.

RESULTS

Overall Summary

Of the 30 general body regions/systems included in the HITS database, injuries to the knee were the fifth most common reason for days missed in all of professional baseball from 2011-2014 (Table 1). Injuries to the knee represented 6.5% of the nearly 34,000 injuries sustained during the study period. Knee injuries were the fifth most common reason for time out of play for players in both the MiLB and MLB.

A total of 2171 isolated knee injuries resulted in time out of sport for professional baseball players (Table 2). Of these, 410 (19%) occurred in MLB players and 1761 (81%) occurred in MiLB players. MLB players were older than MiLB players at the time of injury (29.5 vs 22.8 years, respectively). Overall mean number of days missed was 16.2 days per knee injury, with MLB players missing an approximately 7 days more per injury than MiLB athletes (21.8 vs. 14.9 days respectively; P = .001).Over the course of the 4 seasons, a total of 30,449 days were missed due to knee injuries in professional baseball, giving an average rate of 7612 days lost per season. Surgery was performed for 263 (12.1%) of the 2171 knee injuries, with a greater proportion of MLB players requiring surgery than MiLB players (17.3% vs 10.9%) (P < .001). With respect to number of days missed per injury, 26% of knee injuries in the minor leagues resulted in greater than 30 days missed, while this number rose to 32% for knee injuries in MLB players (Table 3).

For regular season games, it was estimated that there were 1,197,738 MiLB and 276,608 MLB AE, respectively, over the course of the 4 seasons (2011-2014). The overall knee injury rate across both the MiLB and MLB was 1.2 per 1000 AE, based on the subset of 308 and 1473 regular season knee injuries in MiLB and MLB, respectively. The rate of knee injury was similar and not significantly different between the MiLB and MLB (1.2 per 1000 AE in the MiLB and 1.1 per 1000 AE in the MLB).

Characteristics of Injuries

When considering the position of the player during injury, defensive players were most frequently injured (n = 742, 56.5%), with pitchers (n = 227, 17.3%), infielders (n =193, 14.7%), outfielders (n = 193, 14.7%), and catchers (n = 129, 9.8%) sustaining injuries in decreasing frequency. Injuries while on offense (n = 571, 43.5%) were most frequent in base runners (n = 320, 24.4%) followed by batters (n = 251, 19.1%) (Table 4). Injuries while on defense occurring in infielders and catchers resulted in the longest period of time away from play (average of 22.4 and 20.8 days missed, respectively), while those occurring in batters resulted in the least average days missed (8.9 days).

The most common field location for knee injuries to occur was the infield, which was responsible for n = 647 (29.8%) of the total knee injuries (Table 4). This was followed by home plate (n = 493, 22.7%), other locations outside those specified (n = 394, 18.1%), outfield (n = 320, 14.7%), pitcher’s mound (n = 210, 9.7%), and foul territory or the bullpen (n = 107, 4.9%). Of the knee injuries with a specified location, those occurring in foul territory or the bullpen resulted in the highest mean days missed (18.4), while those occurring at home plate resulted in the least mean days missed (13.4 days).

When analyzed by mechanism of injury, noncontact injuries (n = 953, 43.9%) were more common than being hit with the ball (n = 374, 17.2%), striking the ground (n = 409, 18.8%), other mechanisms not listed (n = 196, 9%), contact with another player (n = 176, 8.1%), or contact with other objects (n = 63, 2.9%) (Table 4). Noncontact injuries and player to player collisions resulted in the greatest number of missed days (21.6 and 17.1 days, respectively) while being struck by the ball resulted in the least mean days missed (5.1).

Of the n = 493 knee injuries occurring at home plate, n = 212 (43%) occurred to the batter, n = 100 (20%) to the catcher, n = 34 (6.9%) to base runners, and n = 7 (1.4%) to pitchers (Table 5). The majority of knee injuries in the infield occurred to base runners (n = 283, 43.7%). Player-to-player collisions at home plate were responsible for 51 (2.3%) knee injuries, while 163 (24%) were noncontact injuries and 376 (56%) were the result of a player being hit by the ball (Table 5).

Injury Diagnosis

By diagnosis, the most common knee injuries observed were contusions or hematomas (n = 662, 30.5%), other injuries (n = 415, 19.1%), sprains or ligament injuries (n = 380, 17.5%), tendinopathies or bursitis (n = 367, 16.9%), and meniscal or cartilage injury (n = 200, 9.2%) (Table 6). Injuries resulting in the greatest mean number of days missed included meniscal or cartilage injuries (44 days), sprains or ligament injuries (30 days), or dislocations (22 days).

Based on specific SMDCS descriptors, the most frequent knee injuries reported were contusion (n = 662, 30.5%), patella tendinopathy (n = 222, 10.2%), and meniscal tears (n = 200, 9.2%) (Table 6). Complete anterior cruciate ligament tears, although infrequent, were responsible for the greatest mean days missed (156.2 days). This was followed by lateral meniscus tears (47.5 days) and medial meniscus tears (41.2 days). Knee contusions, although very common, resulted in the least number of days missed (6.0 days).

Discussion

Although much is known about knee injuries in other professional athletic leagues, little is known about knee injuries in professional baseball players.^2-4 The majority of epidemiologic studies regarding baseball players at any level emphasizes the study of shoulder and elbow injuries.^3,4,19 Since the implementation of the electronic medical record and the HITS database in professional baseball, there has been increased effort to document injuries that have received less attention in the existing literature. Understanding the epidemiology of these injuries is important for the development of targeted prevention efforts.

Prior studies of injuries in professional baseball relied on data captured by the publicly available DL. Posner and colleagues² provide one of the most comprehensive reports on MLB injuries in a report utilizing DL assignment data over a period of 7 seasons.They demonstrated that knee injuries were responsible for 7.7% (12.5% for fielders and 3.7% for pitchers) of assignments to the DL. The current study utilized a comprehensive surveillance and builds on this existing knowledge. The present study found similar trends to Posner and colleagues² in that knee injuries were responsible for 6.5% of injuries in professional baseball players that resulted in missed games. From the 2002 season to the 2008 season, knee injuries were the fifth most common reason MLB players were placed on the DL,² and the current study indicates that they remain the fifth most common reason for missed time from play based on the HITS data. Since the prevalence of these injuries have remained constant since the 2002 season, efforts to better understand these injuries are warranted in order to identify strategies to prevent them. These analyses have generated important data towards achieving this understanding.

As with most injuries in professional sports, goals for treatment are aimed at maximizing patient function and performance while minimizing time out of play. For the 2011-2014 professional baseball seasons, a total of 2171 players sustained knee injuries and missed an average of 16.2 days per injury. Knee injuries were responsible for a total of 7612 days of missed work for MLB and MiLB players per season (30,449 days over the 4-season study period). This is equivalent to a total of 20.9 years of players’ time lost in professional baseball per season over the last 4 years. The implications of this amount of time away from sport are significant, and further study should be targeted at prevention of these injuries and optimizing return to play times.

When attempting to reduce the burden of knee injuries in professional baseball, it may prove beneficial to first understand how the injuries occur, where on the field, and who is at greatest risk. From 2011 to 2014, nearly 44% of knee injuries occurred by noncontact mechanisms. Among all locations on the field where knee injuries occurred, those occurring in the infield were responsible for the greatest mean days missed. The players who seem to be at greatest risk for knee injuries appear to be base runners. These data suggest the need for prevention efforts targeting base runners and infield players, as well as players in MiLB, where the largest number of injuries occurred.

Recently, playing rules implemented by MLB after consultation with players have focused on reducing the number of player-to-player collisions at home plate in an attempt to decrease the injury burden to catchers and base runners.²⁰ This present analysis suggests that this rule change may also reduce the occurrence of knee injuries, as player collisions at home plate were responsible for a total of 51 knee injuries during the study period. The impact of this rule change on injury rates should also be explored. Interestingly, of the 51 knees injuries occurring due to contact at home plate, 23 occurred in 2011, and only 2 occurred in 2014—the first year of the new rule. Additional areas that resulted in high numbers of knee injuries were player-to-player contact in the infield and player contact with the ground in the infield.

Attempting to reduce injury burden and time out of play related to knee injuries in professional baseball players will likely prove to be a difficult task. In order to generate meaningful improvement, a comprehensive approach that involves players, management, trainers, therapists, and physicians will likely be required. As the first report of the epidemiology of knee injuries in professional baseball players, this study is one important step in that process. The strengths of this study are its comprehensive nature that analyzes injuries from an entire population of players on more than 200 teams over a 3-year period. Also, this research is strengthened by its focus on one particular region of the body that has received limited attention in the empirical literature, but represents a significant source of lost time during the baseball season.

There are some limitations to this study. As with any injury surveillance system, there is the possibility that not all cases were captured. Additionally, since the surveillance system is based on data from multiple teams, data entry discrepancy is possible; however, the presence of dropdown boxes and systematic definitions for injuries reduces this risk. Finally, this study did not investigate the various treatments for knee injuries beyond whether or not the injury required surgery. Since this was the first comprehensive exploration of knee injuries in professional baseball, future studies are needed to explore additional facets including outcomes related to treatment, return to play, and performance.

Conclusion

Knee injuries represent 6.5% of all injuries in professional baseball, occurring at a rate of 1.3 per 1000 AE. The burden of these injuries is significant for professional baseball players. This study fills a critical gap in sports injury research by contributing to the knowledge about the effect of knee injuries in professional baseball. It also provides an important foundation for future epidemiologic inquiry to identify modifiable risk factors and interventions that may reduce the impact of these injuries in athletes.

LOS ANGELES – In asymptomatic patients under 80 years old, carotid stenting and endarterectomy perform equally as well for severe carotid stenosis out to 5 years, according to a randomized trial published online in the New England Journal of Medicine.

Overall, 1,032 patients were stented, and 343 had endarterectomies in the trial, called Asymptomatic Carotid Trial I (ACT I). If stenting didn’t look safe on postrandomization angiography, patients were given the option of medical management or crossover into the surgical group. The subjects all had bifurcation carotid stenosis blocking at least 70% of the lumen. None were at high risk for surgical complications. “Asymptomatic” meant they hadn’t had a stroke, transient ischemic attack, or amaurosis fugax in the 6 months before enrollment. Stenting and endarterectomy were done by physicians and centers well experienced in the techniques (N Engl J Med. 2016 Feb 17. doi: 10.1056/NEJMoa1515706).

At 1 year, stenting was noninferior to endarterectomy for the primary composite endpoint of death, stroke, or myocardial infarction within 30 days after the procedure or ipsilateral stroke within 1 year; the event rate was 3.8% among stent patients and 3.4% among endarterectomy patients (P = .01 for noninferiority, with a noninferiority margin of 3 percentage points).

The cumulative 5-year stroke-free survival rate was 93.1% in the stenting group and 94.7% in the endarterectomy group (P = .44).

For now, the results mean that sometimes choosing between carotid endarterectomy or stenting (or medical management) has as much to do with patient and physician preference as medical science, raising the difficult question of how to choose. In a video interview at the International Stroke Conference, investigator Dr. Lawrence Wechsler, professor of neurology/neurosurgery and chair of the department of neurology at the University of Pittsburgh, shared his thoughts on that and the other implications of the study. The work was funded by Abbott Vascular.

[email protected]

LOS ANGELES – In asymptomatic patients under 80 years old, carotid stenting and endarterectomy perform equally as well for severe carotid stenosis out to 5 years, according to a randomized trial published online in the New England Journal of Medicine.

Overall, 1,032 patients were stented, and 343 had endarterectomies in the trial, called Asymptomatic Carotid Trial I (ACT I). If stenting didn’t look safe on postrandomization angiography, patients were given the option of medical management or crossover into the surgical group. The subjects all had bifurcation carotid stenosis blocking at least 70% of the lumen. None were at high risk for surgical complications. “Asymptomatic” meant they hadn’t had a stroke, transient ischemic attack, or amaurosis fugax in the 6 months before enrollment. Stenting and endarterectomy were done by physicians and centers well experienced in the techniques (N Engl J Med. 2016 Feb 17. doi: 10.1056/NEJMoa1515706).

At 1 year, stenting was noninferior to endarterectomy for the primary composite endpoint of death, stroke, or myocardial infarction within 30 days after the procedure or ipsilateral stroke within 1 year; the event rate was 3.8% among stent patients and 3.4% among endarterectomy patients (P = .01 for noninferiority, with a noninferiority margin of 3 percentage points).

The cumulative 5-year stroke-free survival rate was 93.1% in the stenting group and 94.7% in the endarterectomy group (P = .44).

For now, the results mean that sometimes choosing between carotid endarterectomy or stenting (or medical management) has as much to do with patient and physician preference as medical science, raising the difficult question of how to choose. In a video interview at the International Stroke Conference, investigator Dr. Lawrence Wechsler, professor of neurology/neurosurgery and chair of the department of neurology at the University of Pittsburgh, shared his thoughts on that and the other implications of the study. The work was funded by Abbott Vascular.

[email protected]

LOS ANGELES – In asymptomatic patients under 80 years old, carotid stenting and endarterectomy perform equally as well for severe carotid stenosis out to 5 years, according to a randomized trial published online in the New England Journal of Medicine.

Overall, 1,032 patients were stented, and 343 had endarterectomies in the trial, called Asymptomatic Carotid Trial I (ACT I). If stenting didn’t look safe on postrandomization angiography, patients were given the option of medical management or crossover into the surgical group. The subjects all had bifurcation carotid stenosis blocking at least 70% of the lumen. None were at high risk for surgical complications. “Asymptomatic” meant they hadn’t had a stroke, transient ischemic attack, or amaurosis fugax in the 6 months before enrollment. Stenting and endarterectomy were done by physicians and centers well experienced in the techniques (N Engl J Med. 2016 Feb 17. doi: 10.1056/NEJMoa1515706).

At 1 year, stenting was noninferior to endarterectomy for the primary composite endpoint of death, stroke, or myocardial infarction within 30 days after the procedure or ipsilateral stroke within 1 year; the event rate was 3.8% among stent patients and 3.4% among endarterectomy patients (P = .01 for noninferiority, with a noninferiority margin of 3 percentage points).

The cumulative 5-year stroke-free survival rate was 93.1% in the stenting group and 94.7% in the endarterectomy group (P = .44).

For now, the results mean that sometimes choosing between carotid endarterectomy or stenting (or medical management) has as much to do with patient and physician preference as medical science, raising the difficult question of how to choose. In a video interview at the International Stroke Conference, investigator Dr. Lawrence Wechsler, professor of neurology/neurosurgery and chair of the department of neurology at the University of Pittsburgh, shared his thoughts on that and the other implications of the study. The work was funded by Abbott Vascular.

[email protected]

The Diagnosis: Cutaneous Larva Migrans

Three punch biopsies were obtained. Spongiotic dermatitis with eosinophils was seen. There was a single specimen of tissue that showed a possible intraepidermal larva with a tract in the epidermis. The differential diagnosis included allergic contact dermatitis and arthropod bite eruption, among others, but clinical correlation made cutaneous larva migrans (CLM) the likely diagnosis.

The patient was treated empirically with albendazole 400 mg once daily for 3 days. In addition, he was prescribed triamcinolone for symptomatic relief and remained asymptomatic for 8 weeks at which time he presented again to the dermatology clinic with a similar rash in the same distribution. He was treated with a repeat course of albendazole and further educated on the etiology of the infection. The patient has not exhibited a recurrence after treatment of the second episode of CLM.

Cutaneous larva migrans is a dermatosis of the skin caused by the larvae of parasitic nematodes from the hookworm family, most commonly Ancylostoma caninum and Ancylostoma braziliense.^1,2 These hookworms thrive in warm moist climates and are most frequently found in tropical coastal regions. They normally inhabit the intestines of animals such as dogs and cats and are transmitted to soil and sand via feces. Humans become accidental hosts through contact with the contaminated sand or soil³; however, the larvae are unable to penetrate deeper than the upper dermis of the skin in humans, subsequently limiting the infection. Because humans are accidental hosts, the larvae are unable to complete their life cycle and larval death occurs within weeks to months after the initial infection³; thus treatment may be unnecessary unless complications arise.

Cutaneous larva migrans is most commonly observed in travelers or inhabitants of tropical coastal regions but can occur anywhere in the world.¹ Clinically, CLM presents as an enlarging, intensely pruritic, erythematous linear or serpiginous tract,³ most commonly on the hands, feet, abdomen, and buttocks.¹ Complications may include allergic reactions, secondary bacterial infections, and hookworm folliculitis.⁴ Although rare, migration to the intestinal tract⁵ and/or hematological spread with Löffler syndrome has been described.⁶ Although this dermatological disease has been well described in the medical literature, it is not well recognized by Western physicians and is consequently either not diagnosed or misdiagnosed, leading to delays in treatment.⁴ Although the infection is usually self-limiting without treatment, the risk for prolonged active disease may occur, with 1 reported case lasting up to 18 months.^4,5 The first indicator of CLM is intense pruritus localized to the site of infection.⁴ As the larvae migrate or creep, they create a lesion that may appear edematous with vesiculobullous lesions that are either serpiginous or linear.⁴ The differential diagnosis may include fungal infection, bacterial infection, and atypical herpes simplex infections; however, the key finding in CLM is the presence of undulating tracts localized to the borders of the lesion.² Patients may report experiencing a stinging sensation prior to the formation of the erythematous scaly papule,⁵ which is attributed to the initial penetration of the larva into the skin. This development, accompanied with a history of travel to tropical or subtropical regions, should elicit CLM as a likely diagnosis. Because hookworms are a type of helminth, they likely elicit an eosinophilic immune response and thus peripheral eosinophilia may be present.⁵

Effective treatment of CLM is accomplished with oral albendazole 400 mg once daily for 3 to 7 days.^2,7 Alternatively, oral ivermectin, topical thiabendazole, and cryosurgery can be used,² though albendazole currently is the preferred treatment of CLM.⁷

The Diagnosis: Cutaneous Larva Migrans

Three punch biopsies were obtained. Spongiotic dermatitis with eosinophils was seen. There was a single specimen of tissue that showed a possible intraepidermal larva with a tract in the epidermis. The differential diagnosis included allergic contact dermatitis and arthropod bite eruption, among others, but clinical correlation made cutaneous larva migrans (CLM) the likely diagnosis.

The patient was treated empirically with albendazole 400 mg once daily for 3 days. In addition, he was prescribed triamcinolone for symptomatic relief and remained asymptomatic for 8 weeks at which time he presented again to the dermatology clinic with a similar rash in the same distribution. He was treated with a repeat course of albendazole and further educated on the etiology of the infection. The patient has not exhibited a recurrence after treatment of the second episode of CLM.

Cutaneous larva migrans is a dermatosis of the skin caused by the larvae of parasitic nematodes from the hookworm family, most commonly Ancylostoma caninum and Ancylostoma braziliense.^1,2 These hookworms thrive in warm moist climates and are most frequently found in tropical coastal regions. They normally inhabit the intestines of animals such as dogs and cats and are transmitted to soil and sand via feces. Humans become accidental hosts through contact with the contaminated sand or soil³; however, the larvae are unable to penetrate deeper than the upper dermis of the skin in humans, subsequently limiting the infection. Because humans are accidental hosts, the larvae are unable to complete their life cycle and larval death occurs within weeks to months after the initial infection³; thus treatment may be unnecessary unless complications arise.

Cutaneous larva migrans is most commonly observed in travelers or inhabitants of tropical coastal regions but can occur anywhere in the world.¹ Clinically, CLM presents as an enlarging, intensely pruritic, erythematous linear or serpiginous tract,³ most commonly on the hands, feet, abdomen, and buttocks.¹ Complications may include allergic reactions, secondary bacterial infections, and hookworm folliculitis.⁴ Although rare, migration to the intestinal tract⁵ and/or hematological spread with Löffler syndrome has been described.⁶ Although this dermatological disease has been well described in the medical literature, it is not well recognized by Western physicians and is consequently either not diagnosed or misdiagnosed, leading to delays in treatment.⁴ Although the infection is usually self-limiting without treatment, the risk for prolonged active disease may occur, with 1 reported case lasting up to 18 months.^4,5 The first indicator of CLM is intense pruritus localized to the site of infection.⁴ As the larvae migrate or creep, they create a lesion that may appear edematous with vesiculobullous lesions that are either serpiginous or linear.⁴ The differential diagnosis may include fungal infection, bacterial infection, and atypical herpes simplex infections; however, the key finding in CLM is the presence of undulating tracts localized to the borders of the lesion.² Patients may report experiencing a stinging sensation prior to the formation of the erythematous scaly papule,⁵ which is attributed to the initial penetration of the larva into the skin. This development, accompanied with a history of travel to tropical or subtropical regions, should elicit CLM as a likely diagnosis. Because hookworms are a type of helminth, they likely elicit an eosinophilic immune response and thus peripheral eosinophilia may be present.⁵

Effective treatment of CLM is accomplished with oral albendazole 400 mg once daily for 3 to 7 days.^2,7 Alternatively, oral ivermectin, topical thiabendazole, and cryosurgery can be used,² though albendazole currently is the preferred treatment of CLM.⁷

The Diagnosis: Cutaneous Larva Migrans

Three punch biopsies were obtained. Spongiotic dermatitis with eosinophils was seen. There was a single specimen of tissue that showed a possible intraepidermal larva with a tract in the epidermis. The differential diagnosis included allergic contact dermatitis and arthropod bite eruption, among others, but clinical correlation made cutaneous larva migrans (CLM) the likely diagnosis.

The patient was treated empirically with albendazole 400 mg once daily for 3 days. In addition, he was prescribed triamcinolone for symptomatic relief and remained asymptomatic for 8 weeks at which time he presented again to the dermatology clinic with a similar rash in the same distribution. He was treated with a repeat course of albendazole and further educated on the etiology of the infection. The patient has not exhibited a recurrence after treatment of the second episode of CLM.

Cutaneous larva migrans is a dermatosis of the skin caused by the larvae of parasitic nematodes from the hookworm family, most commonly Ancylostoma caninum and Ancylostoma braziliense.^1,2 These hookworms thrive in warm moist climates and are most frequently found in tropical coastal regions. They normally inhabit the intestines of animals such as dogs and cats and are transmitted to soil and sand via feces. Humans become accidental hosts through contact with the contaminated sand or soil³; however, the larvae are unable to penetrate deeper than the upper dermis of the skin in humans, subsequently limiting the infection. Because humans are accidental hosts, the larvae are unable to complete their life cycle and larval death occurs within weeks to months after the initial infection³; thus treatment may be unnecessary unless complications arise.

Cutaneous larva migrans is most commonly observed in travelers or inhabitants of tropical coastal regions but can occur anywhere in the world.¹ Clinically, CLM presents as an enlarging, intensely pruritic, erythematous linear or serpiginous tract,³ most commonly on the hands, feet, abdomen, and buttocks.¹ Complications may include allergic reactions, secondary bacterial infections, and hookworm folliculitis.⁴ Although rare, migration to the intestinal tract⁵ and/or hematological spread with Löffler syndrome has been described.⁶ Although this dermatological disease has been well described in the medical literature, it is not well recognized by Western physicians and is consequently either not diagnosed or misdiagnosed, leading to delays in treatment.⁴ Although the infection is usually self-limiting without treatment, the risk for prolonged active disease may occur, with 1 reported case lasting up to 18 months.^4,5 The first indicator of CLM is intense pruritus localized to the site of infection.⁴ As the larvae migrate or creep, they create a lesion that may appear edematous with vesiculobullous lesions that are either serpiginous or linear.⁴ The differential diagnosis may include fungal infection, bacterial infection, and atypical herpes simplex infections; however, the key finding in CLM is the presence of undulating tracts localized to the borders of the lesion.² Patients may report experiencing a stinging sensation prior to the formation of the erythematous scaly papule,⁵ which is attributed to the initial penetration of the larva into the skin. This development, accompanied with a history of travel to tropical or subtropical regions, should elicit CLM as a likely diagnosis. Because hookworms are a type of helminth, they likely elicit an eosinophilic immune response and thus peripheral eosinophilia may be present.⁵

Effective treatment of CLM is accomplished with oral albendazole 400 mg once daily for 3 to 7 days.^2,7 Alternatively, oral ivermectin, topical thiabendazole, and cryosurgery can be used,² though albendazole currently is the preferred treatment of CLM.⁷

NEW ORLEANS—Levels of anti-Mullerian hormone, a marker of the perimenopausal period, are associated with total gray matter volume and disability in patients with multiple sclerosis (MS), independent of chronological age and disease duration, according to data presented at the ACTRIMS 2016 Forum. The study also indicates that women with MS have no reduction in follicular reserve, compared with healthy women, and therefore have normal fertility.

Women with MS tend to have a more benign initial course than men with MS do, but the former often transition to secondary progressive disease near the time of menopause. To date, research has not clarified whether ovarian decline contributes to the accumulation of disability in women with MS.

Jennifer S. Graves, MD, PhD, a neurologist at the University of California, San Francisco Medical Center, and colleagues initiated a study to determine whether ovarian decline, as measured by levels of anti-Mullerian hormone, is associated with clinical disability or brain atrophy in women with MS. They examined 412 women with MS (mean age, 42.6) and 180 healthy controls (mean age, 44) from a longitudinal research cohort that had as many as 10 years of clinical and MRI follow-up. The investigators measured anti-Mullerian hormone levels in batch using a highly sensitive enzyme-linked immunosorbent assay on plasma samples from baseline, year 3, year 5, and years 8 to 10. They analyzed the data with logistic, linear, and mixed-model regression techniques, with adjustments for age, disease duration, smoking, race, ethnicity, vitamin D level, disease modifying therapy, birth control, and hormone replacement therapy as appropriate.

Jennifer S. Graves, MD, PhD

Dr. Graves and colleagues found that in models controlling for age, anti-Mullerian hormone levels were similar in women with MS and healthy controls. In a multivariable model of women with MS, including rigorous adjustments for age and disease duration, ovarian reserve (per twofold decrease in anti-Mullerian hormone pg/mL) was associated with total normalized gray matter volume (β = -3.29 mm³) and MS Functional Composite z-scores (β = -0.060) at baseline. After adjustment for age, white matter volumes were also associated with anti-Mullerian hormone levels (β = -2.64 mm³) at baseline, but the association did not remain statistically significant after additional adjustments (β = -1.49 mm³).

Having undetectable levels of anti-Mullerian hormone (28% of subjects) was associated with 0.60-point higher Expanded Disability Status Scale score. In a multivariable random-intercept-random-slope model using all observations over time, a twofold decrease in anti-Mullerian hormone (pg/mL) was associated with a 1.85-mm³ decrease in gray matter volume over the follow-up period. The researchers' longitudinal analyses of participants' clinical outcomes is ongoing.

NEW ORLEANS—Levels of anti-Mullerian hormone, a marker of the perimenopausal period, are associated with total gray matter volume and disability in patients with multiple sclerosis (MS), independent of chronological age and disease duration, according to data presented at the ACTRIMS 2016 Forum. The study also indicates that women with MS have no reduction in follicular reserve, compared with healthy women, and therefore have normal fertility.

Women with MS tend to have a more benign initial course than men with MS do, but the former often transition to secondary progressive disease near the time of menopause. To date, research has not clarified whether ovarian decline contributes to the accumulation of disability in women with MS.

Jennifer S. Graves, MD, PhD, a neurologist at the University of California, San Francisco Medical Center, and colleagues initiated a study to determine whether ovarian decline, as measured by levels of anti-Mullerian hormone, is associated with clinical disability or brain atrophy in women with MS. They examined 412 women with MS (mean age, 42.6) and 180 healthy controls (mean age, 44) from a longitudinal research cohort that had as many as 10 years of clinical and MRI follow-up. The investigators measured anti-Mullerian hormone levels in batch using a highly sensitive enzyme-linked immunosorbent assay on plasma samples from baseline, year 3, year 5, and years 8 to 10. They analyzed the data with logistic, linear, and mixed-model regression techniques, with adjustments for age, disease duration, smoking, race, ethnicity, vitamin D level, disease modifying therapy, birth control, and hormone replacement therapy as appropriate.

Jennifer S. Graves, MD, PhD

Dr. Graves and colleagues found that in models controlling for age, anti-Mullerian hormone levels were similar in women with MS and healthy controls. In a multivariable model of women with MS, including rigorous adjustments for age and disease duration, ovarian reserve (per twofold decrease in anti-Mullerian hormone pg/mL) was associated with total normalized gray matter volume (β = -3.29 mm³) and MS Functional Composite z-scores (β = -0.060) at baseline. After adjustment for age, white matter volumes were also associated with anti-Mullerian hormone levels (β = -2.64 mm³) at baseline, but the association did not remain statistically significant after additional adjustments (β = -1.49 mm³).

Having undetectable levels of anti-Mullerian hormone (28% of subjects) was associated with 0.60-point higher Expanded Disability Status Scale score. In a multivariable random-intercept-random-slope model using all observations over time, a twofold decrease in anti-Mullerian hormone (pg/mL) was associated with a 1.85-mm³ decrease in gray matter volume over the follow-up period. The researchers' longitudinal analyses of participants' clinical outcomes is ongoing.

NEW ORLEANS—Levels of anti-Mullerian hormone, a marker of the perimenopausal period, are associated with total gray matter volume and disability in patients with multiple sclerosis (MS), independent of chronological age and disease duration, according to data presented at the ACTRIMS 2016 Forum. The study also indicates that women with MS have no reduction in follicular reserve, compared with healthy women, and therefore have normal fertility.

Women with MS tend to have a more benign initial course than men with MS do, but the former often transition to secondary progressive disease near the time of menopause. To date, research has not clarified whether ovarian decline contributes to the accumulation of disability in women with MS.

Jennifer S. Graves, MD, PhD, a neurologist at the University of California, San Francisco Medical Center, and colleagues initiated a study to determine whether ovarian decline, as measured by levels of anti-Mullerian hormone, is associated with clinical disability or brain atrophy in women with MS. They examined 412 women with MS (mean age, 42.6) and 180 healthy controls (mean age, 44) from a longitudinal research cohort that had as many as 10 years of clinical and MRI follow-up. The investigators measured anti-Mullerian hormone levels in batch using a highly sensitive enzyme-linked immunosorbent assay on plasma samples from baseline, year 3, year 5, and years 8 to 10. They analyzed the data with logistic, linear, and mixed-model regression techniques, with adjustments for age, disease duration, smoking, race, ethnicity, vitamin D level, disease modifying therapy, birth control, and hormone replacement therapy as appropriate.

Jennifer S. Graves, MD, PhD

Dr. Graves and colleagues found that in models controlling for age, anti-Mullerian hormone levels were similar in women with MS and healthy controls. In a multivariable model of women with MS, including rigorous adjustments for age and disease duration, ovarian reserve (per twofold decrease in anti-Mullerian hormone pg/mL) was associated with total normalized gray matter volume (β = -3.29 mm³) and MS Functional Composite z-scores (β = -0.060) at baseline. After adjustment for age, white matter volumes were also associated with anti-Mullerian hormone levels (β = -2.64 mm³) at baseline, but the association did not remain statistically significant after additional adjustments (β = -1.49 mm³).

Having undetectable levels of anti-Mullerian hormone (28% of subjects) was associated with 0.60-point higher Expanded Disability Status Scale score. In a multivariable random-intercept-random-slope model using all observations over time, a twofold decrease in anti-Mullerian hormone (pg/mL) was associated with a 1.85-mm³ decrease in gray matter volume over the follow-up period. The researchers' longitudinal analyses of participants' clinical outcomes is ongoing.

For the February podcast for The Journal of Community and Supportive Oncology, Editor-in-Chief Dr David Henry examines two Original Reports, one on a collaborative investigation by scientists and members of a social network into fluoroquinolone-related neuropsychiatric and mitochondrial toxicity and another on the prognostic value of complete remission with superior platelet counts in patients with acute myeloid leukemia. The Case Reports this month focus on rare tumors: in one case, it is a metastatic primary bladder adenocarcinoma for which a novel treatment approach prolonged survival; and in a second, an 18-year follow-up on a rare, indolent form of T-cell prolymphocytic leukemia. The Community Translations column features the novel MEK inhibitor, cobimetinib, which was approved last year in combination with the BRAF inhibitor, vemurafenib, for metastatic melanoma with BRAF V600E or V600K mutation. Dr Henry also discusses articles on new therapies for gastrointestinal cancers and on selected practice-changing presentations from the 2015 annual meeting of the San Antonio Breast Cancer Symposium in Orlando last year. 

Listen to the podcast below.

For the February podcast for The Journal of Community and Supportive Oncology, Editor-in-Chief Dr David Henry examines two Original Reports, one on a collaborative investigation by scientists and members of a social network into fluoroquinolone-related neuropsychiatric and mitochondrial toxicity and another on the prognostic value of complete remission with superior platelet counts in patients with acute myeloid leukemia. The Case Reports this month focus on rare tumors: in one case, it is a metastatic primary bladder adenocarcinoma for which a novel treatment approach prolonged survival; and in a second, an 18-year follow-up on a rare, indolent form of T-cell prolymphocytic leukemia. The Community Translations column features the novel MEK inhibitor, cobimetinib, which was approved last year in combination with the BRAF inhibitor, vemurafenib, for metastatic melanoma with BRAF V600E or V600K mutation. Dr Henry also discusses articles on new therapies for gastrointestinal cancers and on selected practice-changing presentations from the 2015 annual meeting of the San Antonio Breast Cancer Symposium in Orlando last year. 

Listen to the podcast below.

For the February podcast for The Journal of Community and Supportive Oncology, Editor-in-Chief Dr David Henry examines two Original Reports, one on a collaborative investigation by scientists and members of a social network into fluoroquinolone-related neuropsychiatric and mitochondrial toxicity and another on the prognostic value of complete remission with superior platelet counts in patients with acute myeloid leukemia. The Case Reports this month focus on rare tumors: in one case, it is a metastatic primary bladder adenocarcinoma for which a novel treatment approach prolonged survival; and in a second, an 18-year follow-up on a rare, indolent form of T-cell prolymphocytic leukemia. The Community Translations column features the novel MEK inhibitor, cobimetinib, which was approved last year in combination with the BRAF inhibitor, vemurafenib, for metastatic melanoma with BRAF V600E or V600K mutation. Dr Henry also discusses articles on new therapies for gastrointestinal cancers and on selected practice-changing presentations from the 2015 annual meeting of the San Antonio Breast Cancer Symposium in Orlando last year. 

Listen to the podcast below.

 

 

Person on a scale

 

A new analysis indicates that having a higher body weight and taller stature during adolescence may increase the risk of developing non-Hodgkin lymphoma (NHL).

Global rates of NHL have been on the rise in recent years, and research suggests that rising rates of obesity may be contributing to this trend.

With this in mind, investigators examined whether adolescent weight and height might be associated with the risk of developing NHL later in life.

They reported their results in Cancer.

The study included 2,352,988 subjects, ages 16 to 19, who were examined between 1967 and 2011. Their information was linked to the Israel National Cancer Registry, which included 4021 cases of NHL from 1967 through 2012.

The data showed that being overweight or obese in adolescence was associated with an increased risk of NHL later in life. When compared to adolescents of normal weight, the hazard ratio (HR) was 1.25 for subjects who were overweight or obese. The HR for underweight individuals was 0.98.

Being overweight or obese in adolescence was a significant predictor for marginal zone lymphoma (HR=1.70), primary cutaneous lymphoma (PCL, HR=1.44), and diffuse large B-cell lymphoma (DLBCL, HR=1.31). Excess weight was a borderline predictor for follicular lymphoma (HR=1.28).

“It is important to be aware that overweight and obesity are not risk factors only for diabetes and cardiovascular disease but also for lymphomas,” said study author Merav Leiba, MD, of the Sheba Medical Center in Israel.

Dr Leiba and her colleagues also observed an increased risk of NHL corresponding with increases in subjects’ height. When compared with the mid-range height category, shorter individuals had an HR of 1.25, and the tallest individuals had an HR of 1.28.

The strongest associations between taller height and NHL were observed for primary cutaneous lymphoma and diffuse large B-cell lymphoma. The HRs for the tallest group, compared to the shortest group, were 3.19 for PCL and 2.21 for DLBCL.

The investigators said additional research is needed to help explain the links between height, weight, and NHL.

 

 

Person on a scale

 

A new analysis indicates that having a higher body weight and taller stature during adolescence may increase the risk of developing non-Hodgkin lymphoma (NHL).

Global rates of NHL have been on the rise in recent years, and research suggests that rising rates of obesity may be contributing to this trend.

With this in mind, investigators examined whether adolescent weight and height might be associated with the risk of developing NHL later in life.

They reported their results in Cancer.

The study included 2,352,988 subjects, ages 16 to 19, who were examined between 1967 and 2011. Their information was linked to the Israel National Cancer Registry, which included 4021 cases of NHL from 1967 through 2012.

The data showed that being overweight or obese in adolescence was associated with an increased risk of NHL later in life. When compared to adolescents of normal weight, the hazard ratio (HR) was 1.25 for subjects who were overweight or obese. The HR for underweight individuals was 0.98.

Being overweight or obese in adolescence was a significant predictor for marginal zone lymphoma (HR=1.70), primary cutaneous lymphoma (PCL, HR=1.44), and diffuse large B-cell lymphoma (DLBCL, HR=1.31). Excess weight was a borderline predictor for follicular lymphoma (HR=1.28).

“It is important to be aware that overweight and obesity are not risk factors only for diabetes and cardiovascular disease but also for lymphomas,” said study author Merav Leiba, MD, of the Sheba Medical Center in Israel.

Dr Leiba and her colleagues also observed an increased risk of NHL corresponding with increases in subjects’ height. When compared with the mid-range height category, shorter individuals had an HR of 1.25, and the tallest individuals had an HR of 1.28.

The strongest associations between taller height and NHL were observed for primary cutaneous lymphoma and diffuse large B-cell lymphoma. The HRs for the tallest group, compared to the shortest group, were 3.19 for PCL and 2.21 for DLBCL.

The investigators said additional research is needed to help explain the links between height, weight, and NHL.

 

 

Person on a scale

 

A new analysis indicates that having a higher body weight and taller stature during adolescence may increase the risk of developing non-Hodgkin lymphoma (NHL).

Global rates of NHL have been on the rise in recent years, and research suggests that rising rates of obesity may be contributing to this trend.

With this in mind, investigators examined whether adolescent weight and height might be associated with the risk of developing NHL later in life.

They reported their results in Cancer.

The study included 2,352,988 subjects, ages 16 to 19, who were examined between 1967 and 2011. Their information was linked to the Israel National Cancer Registry, which included 4021 cases of NHL from 1967 through 2012.

The data showed that being overweight or obese in adolescence was associated with an increased risk of NHL later in life. When compared to adolescents of normal weight, the hazard ratio (HR) was 1.25 for subjects who were overweight or obese. The HR for underweight individuals was 0.98.

Being overweight or obese in adolescence was a significant predictor for marginal zone lymphoma (HR=1.70), primary cutaneous lymphoma (PCL, HR=1.44), and diffuse large B-cell lymphoma (DLBCL, HR=1.31). Excess weight was a borderline predictor for follicular lymphoma (HR=1.28).

“It is important to be aware that overweight and obesity are not risk factors only for diabetes and cardiovascular disease but also for lymphomas,” said study author Merav Leiba, MD, of the Sheba Medical Center in Israel.

Dr Leiba and her colleagues also observed an increased risk of NHL corresponding with increases in subjects’ height. When compared with the mid-range height category, shorter individuals had an HR of 1.25, and the tallest individuals had an HR of 1.28.

The strongest associations between taller height and NHL were observed for primary cutaneous lymphoma and diffuse large B-cell lymphoma. The HRs for the tallest group, compared to the shortest group, were 3.19 for PCL and 2.21 for DLBCL.

The investigators said additional research is needed to help explain the links between height, weight, and NHL.

Clinical question: Can physician counseling for asthma care be improved by using low-literacy asthma action plans?

Background: Although asthma action plans are recommended for all children with asthma and have been associated with improved medication adherence, written asthma action plans are given to fewer than half of patients with asthma. Children with asthma whose parents have low health literacy have worse asthma-related outcomes; most asthma action plans do not use principles of health literacy. Researchers sought to investigate if asthma counseling was improved when providers were given a low-literacy asthma action plan versus a standard plan to structure their counseling.

Study design: Randomized controlled trial.

Setting: Two large, academic medical centers.

Synopsis: The study enrolled 126 physicians, of which 119 were randomized, with 61 counseling based on the low-literacy asthma action plan and 58 counseling based on a standard asthma action plan. There were no significant differences between the two groups of physicians in terms of age, gender, frequency in providing asthma care, confidence in asthma counseling, or training category (resident, fellow, attending).

These physicians counseled research assistants acting in the role of parents of children with moderate persistent asthma. The children were on a regimen of daily orally inhaled fluticasone and montelukast by mouth and as-needed albuterol. The low-literacy plan used photographs of medications, pictograms, and colors to delineate asthma severity and was prepopulated with the patient’s regimen. The standard plan was from the American Academy of Allergy, Asthma & Immunology (AAAAI); it required the physician to write in the names and doses of the patient’s medications and had no photos or pictograms. Counseling sessions were recorded and coded for content.

Using health literacy principles, the authors valued plain-language descriptions (e.g., “ribs show when breathing”) over jargon (e.g., “respiratory distress”) and specific times (e.g., “morning and night”) over times-per-day dosing (e.g., “two times a day”).

Physicians using the low-literacy plan were much more likely to use specific time of day rather than doses per day (odds ratio = 27.5; 95% CI, 6.1–123.4), much more likely to mention spacers (odds ratio = 6; 95% CI, 2.8–15), and much more likely to use plain-language descriptors of respiratory distress (odds ratio = 33; 95% CI, 7.4–147.5). These differences were present regardless of physicians’ stated comfort with asthma counseling or experience level. There was no significant difference in duration of counseling between the two plans. Physicians stated a preference for the low-literacy plan.

Bottom line: Use of low-literacy asthma action plans improves the quality of physician counseling for asthma.

Citation: Yin HS, Gupta RS, Tomopoulos S, et al. A low-literacy asthma action plan to improve provider asthma counseling: a randomized study. Pediatrics. 2016;137(1):1-11. doi:10.1542/peds.2015-0468.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: Can physician counseling for asthma care be improved by using low-literacy asthma action plans?

Background: Although asthma action plans are recommended for all children with asthma and have been associated with improved medication adherence, written asthma action plans are given to fewer than half of patients with asthma. Children with asthma whose parents have low health literacy have worse asthma-related outcomes; most asthma action plans do not use principles of health literacy. Researchers sought to investigate if asthma counseling was improved when providers were given a low-literacy asthma action plan versus a standard plan to structure their counseling.

Study design: Randomized controlled trial.

Setting: Two large, academic medical centers.

Synopsis: The study enrolled 126 physicians, of which 119 were randomized, with 61 counseling based on the low-literacy asthma action plan and 58 counseling based on a standard asthma action plan. There were no significant differences between the two groups of physicians in terms of age, gender, frequency in providing asthma care, confidence in asthma counseling, or training category (resident, fellow, attending).

These physicians counseled research assistants acting in the role of parents of children with moderate persistent asthma. The children were on a regimen of daily orally inhaled fluticasone and montelukast by mouth and as-needed albuterol. The low-literacy plan used photographs of medications, pictograms, and colors to delineate asthma severity and was prepopulated with the patient’s regimen. The standard plan was from the American Academy of Allergy, Asthma & Immunology (AAAAI); it required the physician to write in the names and doses of the patient’s medications and had no photos or pictograms. Counseling sessions were recorded and coded for content.

Using health literacy principles, the authors valued plain-language descriptions (e.g., “ribs show when breathing”) over jargon (e.g., “respiratory distress”) and specific times (e.g., “morning and night”) over times-per-day dosing (e.g., “two times a day”).

Physicians using the low-literacy plan were much more likely to use specific time of day rather than doses per day (odds ratio = 27.5; 95% CI, 6.1–123.4), much more likely to mention spacers (odds ratio = 6; 95% CI, 2.8–15), and much more likely to use plain-language descriptors of respiratory distress (odds ratio = 33; 95% CI, 7.4–147.5). These differences were present regardless of physicians’ stated comfort with asthma counseling or experience level. There was no significant difference in duration of counseling between the two plans. Physicians stated a preference for the low-literacy plan.

Bottom line: Use of low-literacy asthma action plans improves the quality of physician counseling for asthma.

Citation: Yin HS, Gupta RS, Tomopoulos S, et al. A low-literacy asthma action plan to improve provider asthma counseling: a randomized study. Pediatrics. 2016;137(1):1-11. doi:10.1542/peds.2015-0468.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical question: Can physician counseling for asthma care be improved by using low-literacy asthma action plans?

Background: Although asthma action plans are recommended for all children with asthma and have been associated with improved medication adherence, written asthma action plans are given to fewer than half of patients with asthma. Children with asthma whose parents have low health literacy have worse asthma-related outcomes; most asthma action plans do not use principles of health literacy. Researchers sought to investigate if asthma counseling was improved when providers were given a low-literacy asthma action plan versus a standard plan to structure their counseling.

Study design: Randomized controlled trial.

Setting: Two large, academic medical centers.

Synopsis: The study enrolled 126 physicians, of which 119 were randomized, with 61 counseling based on the low-literacy asthma action plan and 58 counseling based on a standard asthma action plan. There were no significant differences between the two groups of physicians in terms of age, gender, frequency in providing asthma care, confidence in asthma counseling, or training category (resident, fellow, attending).

These physicians counseled research assistants acting in the role of parents of children with moderate persistent asthma. The children were on a regimen of daily orally inhaled fluticasone and montelukast by mouth and as-needed albuterol. The low-literacy plan used photographs of medications, pictograms, and colors to delineate asthma severity and was prepopulated with the patient’s regimen. The standard plan was from the American Academy of Allergy, Asthma & Immunology (AAAAI); it required the physician to write in the names and doses of the patient’s medications and had no photos or pictograms. Counseling sessions were recorded and coded for content.

Using health literacy principles, the authors valued plain-language descriptions (e.g., “ribs show when breathing”) over jargon (e.g., “respiratory distress”) and specific times (e.g., “morning and night”) over times-per-day dosing (e.g., “two times a day”).

Physicians using the low-literacy plan were much more likely to use specific time of day rather than doses per day (odds ratio = 27.5; 95% CI, 6.1–123.4), much more likely to mention spacers (odds ratio = 6; 95% CI, 2.8–15), and much more likely to use plain-language descriptors of respiratory distress (odds ratio = 33; 95% CI, 7.4–147.5). These differences were present regardless of physicians’ stated comfort with asthma counseling or experience level. There was no significant difference in duration of counseling between the two plans. Physicians stated a preference for the low-literacy plan.

Bottom line: Use of low-literacy asthma action plans improves the quality of physician counseling for asthma.

Citation: Yin HS, Gupta RS, Tomopoulos S, et al. A low-literacy asthma action plan to improve provider asthma counseling: a randomized study. Pediatrics. 2016;137(1):1-11. doi:10.1542/peds.2015-0468.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

(Reuters Health) - Medicaid, the U.S. health program for the poor, pays far less for common surgical procedures in many states than does Medicare, the federal insurance plan for the elderly, according to a new study.

Some of the discounts are so steep that they may threaten access to care, the authors argue.

Medicaid is the biggest public health program in the U.S. and currently accounts for about $1 out of every $6 spent on medical care. Medicaid expenditures also represent almost half of all federal funds spent by states.

When Medicaid fees are too low relative to payments from Medicare, doctors may refuse to treat Medicaid patients, potentially making it much harder for poor people to get treatment, argue Dr. Charles Mabry of the University of Arkansas in Little Rock and colleagues in a paper released online January 13 in the Journal of the American College of Surgeons.

"Lack of proper payment can cause some Medicaid patients to have needed surgical procedures delayed," Mabry told Reuters Health by email. "Our hope was that by researching and publishing on these wide variations in payment, it would spur states to rethink the methodology for how they determine payment."

Even though the federal government picks up part of the tab for care, Medicaid payment rates as well as enrollment eligibility and covered benefits are determined by individual states.

To assess the degree of variation between Medicare and Medicaid payments for surgery, Mabry and colleagues calculated how much fees varied for some of the most common procedures done by general surgeons in nearly every state across the country.

The analysis excluded only Kansas and Tennessee.

The largest discount they found was in New Jersey, where Medicaid paid $1,011 (about 933 euros) less than Medicare for surgery to remove all or part of the small intestine.

At the other extreme, the biggest premium was in Alaska, which paid $1,382 more for insertion of a tunneled central venous port under Medicaid than Medicare would pay for the procedure.

When they looked at mastectomy, Medicaid paid $226.47 in Connecticut, 69% less than the $725.35 Medicare payment for the same procedure in the same state.

For an enterectomy, New Jersey's Medicaid payment of $332 was 75% less than the $1,343.16 payment under Medicare.

To fix a ventral hernia, Medicaid in New Hampshire pays $300, 61% less than the $762.28 Medicare payment in the state.

The analysis has several limitations, including the narrow focus on a handful of surgical procedures and the reliance on published payment schedules in each state, which may not necessarily reflect what surgeons actually get paid, the authors note. The analysis also lacked data on certain bulk payments or additional funds paid by Medicaid that might minimize the apparent discounts in some cases.

The paper didn't examine how access to care might be adversely affected by steep discounts in Medicaid payments relative to Medicare or private insurance. But, the authors conclude, it's likely some people struggle to find surgeons or experience delays in care as a direct result of low fees that motivate doctors to refuse Medicaid patients.

One woman with sickle-cell disease and Medicaid coverage is a case-in-point for Dr. Constantine Manthous, who retired from Yale University and works in private practice in New London, Connecticut.

He recalled meeting her after she had spent a decade in a wheelchair because she couldn't find a surgeon to repair her hip. She didn't receive surgery until the hip fell out of its socket, requiring constant hospitalization and morphine.

"By that time she was so ill she died of late complications from the decade delay," Manthous, who wasn't involved in the study, said by email. "You and I would have gotten the hip immediately."

(Reuters Health) - Medicaid, the U.S. health program for the poor, pays far less for common surgical procedures in many states than does Medicare, the federal insurance plan for the elderly, according to a new study.

Some of the discounts are so steep that they may threaten access to care, the authors argue.

Medicaid is the biggest public health program in the U.S. and currently accounts for about $1 out of every $6 spent on medical care. Medicaid expenditures also represent almost half of all federal funds spent by states.

When Medicaid fees are too low relative to payments from Medicare, doctors may refuse to treat Medicaid patients, potentially making it much harder for poor people to get treatment, argue Dr. Charles Mabry of the University of Arkansas in Little Rock and colleagues in a paper released online January 13 in the Journal of the American College of Surgeons.

"Lack of proper payment can cause some Medicaid patients to have needed surgical procedures delayed," Mabry told Reuters Health by email. "Our hope was that by researching and publishing on these wide variations in payment, it would spur states to rethink the methodology for how they determine payment."

Even though the federal government picks up part of the tab for care, Medicaid payment rates as well as enrollment eligibility and covered benefits are determined by individual states.

To assess the degree of variation between Medicare and Medicaid payments for surgery, Mabry and colleagues calculated how much fees varied for some of the most common procedures done by general surgeons in nearly every state across the country.

The analysis excluded only Kansas and Tennessee.

The largest discount they found was in New Jersey, where Medicaid paid $1,011 (about 933 euros) less than Medicare for surgery to remove all or part of the small intestine.

At the other extreme, the biggest premium was in Alaska, which paid $1,382 more for insertion of a tunneled central venous port under Medicaid than Medicare would pay for the procedure.

When they looked at mastectomy, Medicaid paid $226.47 in Connecticut, 69% less than the $725.35 Medicare payment for the same procedure in the same state.

For an enterectomy, New Jersey's Medicaid payment of $332 was 75% less than the $1,343.16 payment under Medicare.

To fix a ventral hernia, Medicaid in New Hampshire pays $300, 61% less than the $762.28 Medicare payment in the state.

The analysis has several limitations, including the narrow focus on a handful of surgical procedures and the reliance on published payment schedules in each state, which may not necessarily reflect what surgeons actually get paid, the authors note. The analysis also lacked data on certain bulk payments or additional funds paid by Medicaid that might minimize the apparent discounts in some cases.

The paper didn't examine how access to care might be adversely affected by steep discounts in Medicaid payments relative to Medicare or private insurance. But, the authors conclude, it's likely some people struggle to find surgeons or experience delays in care as a direct result of low fees that motivate doctors to refuse Medicaid patients.

One woman with sickle-cell disease and Medicaid coverage is a case-in-point for Dr. Constantine Manthous, who retired from Yale University and works in private practice in New London, Connecticut.

He recalled meeting her after she had spent a decade in a wheelchair because she couldn't find a surgeon to repair her hip. She didn't receive surgery until the hip fell out of its socket, requiring constant hospitalization and morphine.

"By that time she was so ill she died of late complications from the decade delay," Manthous, who wasn't involved in the study, said by email. "You and I would have gotten the hip immediately."

(Reuters Health) - Medicaid, the U.S. health program for the poor, pays far less for common surgical procedures in many states than does Medicare, the federal insurance plan for the elderly, according to a new study.

Some of the discounts are so steep that they may threaten access to care, the authors argue.

Medicaid is the biggest public health program in the U.S. and currently accounts for about $1 out of every $6 spent on medical care. Medicaid expenditures also represent almost half of all federal funds spent by states.

When Medicaid fees are too low relative to payments from Medicare, doctors may refuse to treat Medicaid patients, potentially making it much harder for poor people to get treatment, argue Dr. Charles Mabry of the University of Arkansas in Little Rock and colleagues in a paper released online January 13 in the Journal of the American College of Surgeons.

"Lack of proper payment can cause some Medicaid patients to have needed surgical procedures delayed," Mabry told Reuters Health by email. "Our hope was that by researching and publishing on these wide variations in payment, it would spur states to rethink the methodology for how they determine payment."

Even though the federal government picks up part of the tab for care, Medicaid payment rates as well as enrollment eligibility and covered benefits are determined by individual states.

To assess the degree of variation between Medicare and Medicaid payments for surgery, Mabry and colleagues calculated how much fees varied for some of the most common procedures done by general surgeons in nearly every state across the country.

The analysis excluded only Kansas and Tennessee.

The largest discount they found was in New Jersey, where Medicaid paid $1,011 (about 933 euros) less than Medicare for surgery to remove all or part of the small intestine.

At the other extreme, the biggest premium was in Alaska, which paid $1,382 more for insertion of a tunneled central venous port under Medicaid than Medicare would pay for the procedure.

When they looked at mastectomy, Medicaid paid $226.47 in Connecticut, 69% less than the $725.35 Medicare payment for the same procedure in the same state.

For an enterectomy, New Jersey's Medicaid payment of $332 was 75% less than the $1,343.16 payment under Medicare.

To fix a ventral hernia, Medicaid in New Hampshire pays $300, 61% less than the $762.28 Medicare payment in the state.

The analysis has several limitations, including the narrow focus on a handful of surgical procedures and the reliance on published payment schedules in each state, which may not necessarily reflect what surgeons actually get paid, the authors note. The analysis also lacked data on certain bulk payments or additional funds paid by Medicaid that might minimize the apparent discounts in some cases.

The paper didn't examine how access to care might be adversely affected by steep discounts in Medicaid payments relative to Medicare or private insurance. But, the authors conclude, it's likely some people struggle to find surgeons or experience delays in care as a direct result of low fees that motivate doctors to refuse Medicaid patients.

One woman with sickle-cell disease and Medicaid coverage is a case-in-point for Dr. Constantine Manthous, who retired from Yale University and works in private practice in New London, Connecticut.

He recalled meeting her after she had spent a decade in a wheelchair because she couldn't find a surgeon to repair her hip. She didn't receive surgery until the hip fell out of its socket, requiring constant hospitalization and morphine.

"By that time she was so ill she died of late complications from the decade delay," Manthous, who wasn't involved in the study, said by email. "You and I would have gotten the hip immediately."

Cancer patient

receiving chemotherapy

Photo by Rhoda Baer

A study published in the British Journal of Hematology has revealed factors that appear to affect survival in patients with acute myeloid leukemia (AML).

The research showed that death was more likely among AML patients treated at centers not affiliated with the National Cancer Institute (NCI).

Death was also more likely for black patients, older patients, those without health insurance, and those who lived in poorer neighborhoods.

“Our study reveals that survival inequalities persist among vulnerable patients with acute myeloid leukemia, such as the uninsured, those of black race/ethnicity, and adolescents and young adults,” said study author Renata Abrahão, MD, of Cancer Prevention Institute of California.

“This study can serve as a baseline to compare changes in survival that may result from potential improvements in health insurance coverage following the implementation of the Affordable Care Act.”

Dr Abrahão and her colleagues analyzed 3935 AML patients who were 39 or younger between 1988 and 2011. The team used data from the California Cancer Registry, which participates in the Surveillance, Epidemiology and End Results program of the NCI.

The data revealed an increase over time in the 5-year survival rate, from 32.9% in 1988–1995 to 50% in 2004–2011. However, 58% of the patients (n=2272) died during follow-up. The overall median follow-up was 10 years, and the median time to death was 0.9 years.

A multivariate analysis revealed several subgroups of patients with worse survival.

Older patients had a greater risk of death when compared to patients ages 0 to 9. The hazard ratio (HR) was 1.23 for patients ages 10 to 19, 1.34 for patients ages 20 to 29, and 1.55 for patients ages 30 to 39.

Black patients had an increased risk of death as well. When compared with white patients, the HR was 1.27 for black patients, 1.05 for Hispanic patients, and 0.98 for Asian/Pacific Islanders.

Patients living in the neighborhoods with the lowest socioeconomic status had an HR of 1.14. And patients who received their initial care at a hospital not affiliated with the NCI had an HR of 1.18.

Health insurance information was only available for patients diagnosed from 1996 to 2011. Among these patients, the risk of death was higher among uninsured patients (HR=1.34) than among privately insured patients, but there was no difference between privately and publicly insured patients.

Explaining the findings

The researchers said AML diagnosis in older children, adolescents, and young adults may require more intensive treatment than in young children, which may lead to a higher probability of treatment-related complications. And recent studies have shown the biology of pediatric AML differs from adult AML, which may lead to a favorable prognosis in younger patients.

In addition, older children, adolescents, and young adults are less likely to participate in clinical trials and more likely to receive treatment at hospitals not affiliated with the NCI, when compared to younger children.

The researchers said it is not clear what factors accounted for the inferior survival observed among black patients. The team speculated that genetics may contribute to the difference in chemotherapy response or that black patients had less access to chemotherapy and other treatments such as hematopoietic stem cell transplant.

The association between lower socioeconomic status and death suggests a lack of access to treatment. The same can be said for the association between death and a lack of insurance.

“[T]his study showed that survival after AML remains low among young patients and highlights the need for new therapeutic regimens to treat this disease with various subtypes,” Dr Abrahão said.

“We emphasized the importance of linking population-based data with genetic and clinical information contained in the patients’ medical records in order to better understand the causes of survival inequalities.”

Cancer patient

receiving chemotherapy

Photo by Rhoda Baer

A study published in the British Journal of Hematology has revealed factors that appear to affect survival in patients with acute myeloid leukemia (AML).

The research showed that death was more likely among AML patients treated at centers not affiliated with the National Cancer Institute (NCI).

Death was also more likely for black patients, older patients, those without health insurance, and those who lived in poorer neighborhoods.

“Our study reveals that survival inequalities persist among vulnerable patients with acute myeloid leukemia, such as the uninsured, those of black race/ethnicity, and adolescents and young adults,” said study author Renata Abrahão, MD, of Cancer Prevention Institute of California.

“This study can serve as a baseline to compare changes in survival that may result from potential improvements in health insurance coverage following the implementation of the Affordable Care Act.”

Dr Abrahão and her colleagues analyzed 3935 AML patients who were 39 or younger between 1988 and 2011. The team used data from the California Cancer Registry, which participates in the Surveillance, Epidemiology and End Results program of the NCI.

The data revealed an increase over time in the 5-year survival rate, from 32.9% in 1988–1995 to 50% in 2004–2011. However, 58% of the patients (n=2272) died during follow-up. The overall median follow-up was 10 years, and the median time to death was 0.9 years.

A multivariate analysis revealed several subgroups of patients with worse survival.

Older patients had a greater risk of death when compared to patients ages 0 to 9. The hazard ratio (HR) was 1.23 for patients ages 10 to 19, 1.34 for patients ages 20 to 29, and 1.55 for patients ages 30 to 39.

Black patients had an increased risk of death as well. When compared with white patients, the HR was 1.27 for black patients, 1.05 for Hispanic patients, and 0.98 for Asian/Pacific Islanders.

Patients living in the neighborhoods with the lowest socioeconomic status had an HR of 1.14. And patients who received their initial care at a hospital not affiliated with the NCI had an HR of 1.18.

Health insurance information was only available for patients diagnosed from 1996 to 2011. Among these patients, the risk of death was higher among uninsured patients (HR=1.34) than among privately insured patients, but there was no difference between privately and publicly insured patients.

Explaining the findings

The researchers said AML diagnosis in older children, adolescents, and young adults may require more intensive treatment than in young children, which may lead to a higher probability of treatment-related complications. And recent studies have shown the biology of pediatric AML differs from adult AML, which may lead to a favorable prognosis in younger patients.

In addition, older children, adolescents, and young adults are less likely to participate in clinical trials and more likely to receive treatment at hospitals not affiliated with the NCI, when compared to younger children.

The researchers said it is not clear what factors accounted for the inferior survival observed among black patients. The team speculated that genetics may contribute to the difference in chemotherapy response or that black patients had less access to chemotherapy and other treatments such as hematopoietic stem cell transplant.

The association between lower socioeconomic status and death suggests a lack of access to treatment. The same can be said for the association between death and a lack of insurance.

“[T]his study showed that survival after AML remains low among young patients and highlights the need for new therapeutic regimens to treat this disease with various subtypes,” Dr Abrahão said.

“We emphasized the importance of linking population-based data with genetic and clinical information contained in the patients’ medical records in order to better understand the causes of survival inequalities.”

Cancer patient

receiving chemotherapy

Photo by Rhoda Baer

A study published in the British Journal of Hematology has revealed factors that appear to affect survival in patients with acute myeloid leukemia (AML).

The research showed that death was more likely among AML patients treated at centers not affiliated with the National Cancer Institute (NCI).

Death was also more likely for black patients, older patients, those without health insurance, and those who lived in poorer neighborhoods.

“Our study reveals that survival inequalities persist among vulnerable patients with acute myeloid leukemia, such as the uninsured, those of black race/ethnicity, and adolescents and young adults,” said study author Renata Abrahão, MD, of Cancer Prevention Institute of California.

“This study can serve as a baseline to compare changes in survival that may result from potential improvements in health insurance coverage following the implementation of the Affordable Care Act.”

Dr Abrahão and her colleagues analyzed 3935 AML patients who were 39 or younger between 1988 and 2011. The team used data from the California Cancer Registry, which participates in the Surveillance, Epidemiology and End Results program of the NCI.

The data revealed an increase over time in the 5-year survival rate, from 32.9% in 1988–1995 to 50% in 2004–2011. However, 58% of the patients (n=2272) died during follow-up. The overall median follow-up was 10 years, and the median time to death was 0.9 years.

A multivariate analysis revealed several subgroups of patients with worse survival.

Older patients had a greater risk of death when compared to patients ages 0 to 9. The hazard ratio (HR) was 1.23 for patients ages 10 to 19, 1.34 for patients ages 20 to 29, and 1.55 for patients ages 30 to 39.

Black patients had an increased risk of death as well. When compared with white patients, the HR was 1.27 for black patients, 1.05 for Hispanic patients, and 0.98 for Asian/Pacific Islanders.

Patients living in the neighborhoods with the lowest socioeconomic status had an HR of 1.14. And patients who received their initial care at a hospital not affiliated with the NCI had an HR of 1.18.

Health insurance information was only available for patients diagnosed from 1996 to 2011. Among these patients, the risk of death was higher among uninsured patients (HR=1.34) than among privately insured patients, but there was no difference between privately and publicly insured patients.

Explaining the findings

The researchers said AML diagnosis in older children, adolescents, and young adults may require more intensive treatment than in young children, which may lead to a higher probability of treatment-related complications. And recent studies have shown the biology of pediatric AML differs from adult AML, which may lead to a favorable prognosis in younger patients.

In addition, older children, adolescents, and young adults are less likely to participate in clinical trials and more likely to receive treatment at hospitals not affiliated with the NCI, when compared to younger children.

The researchers said it is not clear what factors accounted for the inferior survival observed among black patients. The team speculated that genetics may contribute to the difference in chemotherapy response or that black patients had less access to chemotherapy and other treatments such as hematopoietic stem cell transplant.

The association between lower socioeconomic status and death suggests a lack of access to treatment. The same can be said for the association between death and a lack of insurance.

“[T]his study showed that survival after AML remains low among young patients and highlights the need for new therapeutic regimens to treat this disease with various subtypes,” Dr Abrahão said.

“We emphasized the importance of linking population-based data with genetic and clinical information contained in the patients’ medical records in order to better understand the causes of survival inequalities.”