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.”

Background Complete remission (CR) in acute myeloid leukemia (AML) is defined as having ≤5% leukemic blast cells in the bone marrow and return of normal hematopoiesis after the first induction cycle. There is a subset of patients, however, who achieve reduction of leukemic blast cells with a subnormal platelet count, designated as CR with incomplete platelet recovery (platelet count, ≤100,000/mcL; normal, 150,000-450,000/mcL), which is associated with inferior outcomes when compared with CR. Furthermore, there is another subset of patients with CR but superior platelet counts (≥400,000/mcL) whose prognostic significance is unclear.

Objective To establish whether CR with superior platelet counts is associated with better outcomes and can be used as a separate entity for prognostication.

Methods A retrospective chart review of 104 cases of AML was conducted. The highest platelet count during days 25-35 from initiation of induction chemotherapy (designated as day 30 platelet count) was documented. A multivariate analysis for other factors such as age, sex, risk categories, day 14+ plasma cell count (average plasma cell percentage at days 14-21), infections, allogeneic bone marrow transplant, and remission status was done.

Results Day 30 platelet count was found to be an independent predictor of survival in AML. On the multivariate analysis, the subgroup with superior platelet counts (≥400,000/mcL) was found to be associated with better outcomes.

Limitations Results need to be validated in a larger cohort.

Conclusions CR with superior platelet recovery (≥400,000/mcL) is a unique subcategory in itself and has prognostic significance. This may help better assess response to chemotherapeutic agents and aid in further decision-making regarding treatment. 

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

Background Complete remission (CR) in acute myeloid leukemia (AML) is defined as having ≤5% leukemic blast cells in the bone marrow and return of normal hematopoiesis after the first induction cycle. There is a subset of patients, however, who achieve reduction of leukemic blast cells with a subnormal platelet count, designated as CR with incomplete platelet recovery (platelet count, ≤100,000/mcL; normal, 150,000-450,000/mcL), which is associated with inferior outcomes when compared with CR. Furthermore, there is another subset of patients with CR but superior platelet counts (≥400,000/mcL) whose prognostic significance is unclear.

Objective To establish whether CR with superior platelet counts is associated with better outcomes and can be used as a separate entity for prognostication.

Methods A retrospective chart review of 104 cases of AML was conducted. The highest platelet count during days 25-35 from initiation of induction chemotherapy (designated as day 30 platelet count) was documented. A multivariate analysis for other factors such as age, sex, risk categories, day 14+ plasma cell count (average plasma cell percentage at days 14-21), infections, allogeneic bone marrow transplant, and remission status was done.

Results Day 30 platelet count was found to be an independent predictor of survival in AML. On the multivariate analysis, the subgroup with superior platelet counts (≥400,000/mcL) was found to be associated with better outcomes.

Limitations Results need to be validated in a larger cohort.

Conclusions CR with superior platelet recovery (≥400,000/mcL) is a unique subcategory in itself and has prognostic significance. This may help better assess response to chemotherapeutic agents and aid in further decision-making regarding treatment. 

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

Background Complete remission (CR) in acute myeloid leukemia (AML) is defined as having ≤5% leukemic blast cells in the bone marrow and return of normal hematopoiesis after the first induction cycle. There is a subset of patients, however, who achieve reduction of leukemic blast cells with a subnormal platelet count, designated as CR with incomplete platelet recovery (platelet count, ≤100,000/mcL; normal, 150,000-450,000/mcL), which is associated with inferior outcomes when compared with CR. Furthermore, there is another subset of patients with CR but superior platelet counts (≥400,000/mcL) whose prognostic significance is unclear.

Objective To establish whether CR with superior platelet counts is associated with better outcomes and can be used as a separate entity for prognostication.

Methods A retrospective chart review of 104 cases of AML was conducted. The highest platelet count during days 25-35 from initiation of induction chemotherapy (designated as day 30 platelet count) was documented. A multivariate analysis for other factors such as age, sex, risk categories, day 14+ plasma cell count (average plasma cell percentage at days 14-21), infections, allogeneic bone marrow transplant, and remission status was done.

Results Day 30 platelet count was found to be an independent predictor of survival in AML. On the multivariate analysis, the subgroup with superior platelet counts (≥400,000/mcL) was found to be associated with better outcomes.

Limitations Results need to be validated in a larger cohort.

Conclusions CR with superior platelet recovery (≥400,000/mcL) is a unique subcategory in itself and has prognostic significance. This may help better assess response to chemotherapeutic agents and aid in further decision-making regarding treatment. 

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

Background The 3 fluoroquinolone (FQ) antibiotics – ciprofoxacin, levofoxacin, and moxifoxacin – are commonly administered to oncology patients. Although these oral antibiotics are approved by the US Food and Drug Administration (FDA) for treatment of urinary tract infections, acute bacterial sinusitis, or bacterial infection in patients with chronic obstructive pulmonary disease, they are commonly prescribed off-label to neutropenic cancer patients for the prevention and treatment of infections associated with febrile neutropenia. New serious FQ-associated safety concerns have been identified through novel collaborations between FQ-treated persons who have developed long-term neuropsychiatric (NP) toxicity, pharmacovigilance experts, and basic scientists.

Objective To conduct basic science and clinical investigations of a newly identified adverse drug reaction, termed FQ-associated disability.

Methods 5 groups of C57BL/6 mice receiving the antibiotic ciprofoxacin in 10-mg increments (10 mg/kg-50 mg/kg) and 1 group of control mice were evaluated. The Southern Network on Adverse Reactions (SONAR) and a social network of FQ-treated persons with long-term NP toxicity (the Floxed Network) conducted a web-based survey. The clinical toxicity manifestations reported by 94 respondents to the web-based survey of persons who had received 1 or more doses of an FQ prescribed for any indication (generally at FDA-approved dosages) and who subsequently experienced possible adverse drug reactions were compared with adverse event information included on the product label for levofoxacin and with FQ-associated adverse events reported to the FDA’s MedWatch program.

Results Mice treated with ciprofoxacin had lower grip strengths, reduced balance, and depressive behavior compared with the controls. For the survey, 93 of 94 respondents reported FQ-associated events including anxiety, depression, insomnia, panic attacks, clouded thinking, depersonalization, suicidal thoughts, psychosis, nightmares, and impaired memory beginning within days of FQ initiation or days to months of FQ discontinuation. The FDA Adverse Event Reporting System (FAERS) included 210,705 adverse events and 2,991 fatalities for FQs. Levofoxacin and ciprofoxacin toxicities were neurologic (30% and 26%, respectively), tendon damage (8% and 6%), and psychiatric (10% and 2%). In 2013, an FDA safety review reported that FQs affect mammalian topoisomerase II, especially in mitochondria. In 2013 and 2014, SONAR fled citizen petitions requesting black box revisions identifying neuropsychiatric toxicities and mitochrondrial toxicity as serious levofoxacin-associated adverse drug reactions. In 2015, FDA advisors recommended that FQ product labels be revised to include information about this newly identified disability syndrome termed “FQ-associated disability” (FQAD).

Limitations Basic science studies evaluated NP toxicity for only 1 FQ, ciprofoxacin.

Conclusion Pharmacovigilance investigators, a social network, and basic scientists can collaborate on pharmacovigilance investigations. Revised product labels describing a new serious adverse drug reaction, levofoxacin-associated long-term disability, as recommended by an FDA advisory committee, are advised.

Funding This work was funded partly by the National Cancer Institute (1R01CA165609-01A1), the American Cancer Society (IRG-13-043-01), the South Carolina SmartState Program, and an unrestricted from Doris Levkoff Meddin to the South Carolina College of Pharmacy Center for Medication Safety and Efficacy.

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

Background The 3 fluoroquinolone (FQ) antibiotics – ciprofoxacin, levofoxacin, and moxifoxacin – are commonly administered to oncology patients. Although these oral antibiotics are approved by the US Food and Drug Administration (FDA) for treatment of urinary tract infections, acute bacterial sinusitis, or bacterial infection in patients with chronic obstructive pulmonary disease, they are commonly prescribed off-label to neutropenic cancer patients for the prevention and treatment of infections associated with febrile neutropenia. New serious FQ-associated safety concerns have been identified through novel collaborations between FQ-treated persons who have developed long-term neuropsychiatric (NP) toxicity, pharmacovigilance experts, and basic scientists.

Objective To conduct basic science and clinical investigations of a newly identified adverse drug reaction, termed FQ-associated disability.

Methods 5 groups of C57BL/6 mice receiving the antibiotic ciprofoxacin in 10-mg increments (10 mg/kg-50 mg/kg) and 1 group of control mice were evaluated. The Southern Network on Adverse Reactions (SONAR) and a social network of FQ-treated persons with long-term NP toxicity (the Floxed Network) conducted a web-based survey. The clinical toxicity manifestations reported by 94 respondents to the web-based survey of persons who had received 1 or more doses of an FQ prescribed for any indication (generally at FDA-approved dosages) and who subsequently experienced possible adverse drug reactions were compared with adverse event information included on the product label for levofoxacin and with FQ-associated adverse events reported to the FDA’s MedWatch program.

Results Mice treated with ciprofoxacin had lower grip strengths, reduced balance, and depressive behavior compared with the controls. For the survey, 93 of 94 respondents reported FQ-associated events including anxiety, depression, insomnia, panic attacks, clouded thinking, depersonalization, suicidal thoughts, psychosis, nightmares, and impaired memory beginning within days of FQ initiation or days to months of FQ discontinuation. The FDA Adverse Event Reporting System (FAERS) included 210,705 adverse events and 2,991 fatalities for FQs. Levofoxacin and ciprofoxacin toxicities were neurologic (30% and 26%, respectively), tendon damage (8% and 6%), and psychiatric (10% and 2%). In 2013, an FDA safety review reported that FQs affect mammalian topoisomerase II, especially in mitochondria. In 2013 and 2014, SONAR fled citizen petitions requesting black box revisions identifying neuropsychiatric toxicities and mitochrondrial toxicity as serious levofoxacin-associated adverse drug reactions. In 2015, FDA advisors recommended that FQ product labels be revised to include information about this newly identified disability syndrome termed “FQ-associated disability” (FQAD).

Limitations Basic science studies evaluated NP toxicity for only 1 FQ, ciprofoxacin.

Conclusion Pharmacovigilance investigators, a social network, and basic scientists can collaborate on pharmacovigilance investigations. Revised product labels describing a new serious adverse drug reaction, levofoxacin-associated long-term disability, as recommended by an FDA advisory committee, are advised.

Funding This work was funded partly by the National Cancer Institute (1R01CA165609-01A1), the American Cancer Society (IRG-13-043-01), the South Carolina SmartState Program, and an unrestricted from Doris Levkoff Meddin to the South Carolina College of Pharmacy Center for Medication Safety and Efficacy.

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

Background The 3 fluoroquinolone (FQ) antibiotics – ciprofoxacin, levofoxacin, and moxifoxacin – are commonly administered to oncology patients. Although these oral antibiotics are approved by the US Food and Drug Administration (FDA) for treatment of urinary tract infections, acute bacterial sinusitis, or bacterial infection in patients with chronic obstructive pulmonary disease, they are commonly prescribed off-label to neutropenic cancer patients for the prevention and treatment of infections associated with febrile neutropenia. New serious FQ-associated safety concerns have been identified through novel collaborations between FQ-treated persons who have developed long-term neuropsychiatric (NP) toxicity, pharmacovigilance experts, and basic scientists.

Objective To conduct basic science and clinical investigations of a newly identified adverse drug reaction, termed FQ-associated disability.

Methods 5 groups of C57BL/6 mice receiving the antibiotic ciprofoxacin in 10-mg increments (10 mg/kg-50 mg/kg) and 1 group of control mice were evaluated. The Southern Network on Adverse Reactions (SONAR) and a social network of FQ-treated persons with long-term NP toxicity (the Floxed Network) conducted a web-based survey. The clinical toxicity manifestations reported by 94 respondents to the web-based survey of persons who had received 1 or more doses of an FQ prescribed for any indication (generally at FDA-approved dosages) and who subsequently experienced possible adverse drug reactions were compared with adverse event information included on the product label for levofoxacin and with FQ-associated adverse events reported to the FDA’s MedWatch program.

Results Mice treated with ciprofoxacin had lower grip strengths, reduced balance, and depressive behavior compared with the controls. For the survey, 93 of 94 respondents reported FQ-associated events including anxiety, depression, insomnia, panic attacks, clouded thinking, depersonalization, suicidal thoughts, psychosis, nightmares, and impaired memory beginning within days of FQ initiation or days to months of FQ discontinuation. The FDA Adverse Event Reporting System (FAERS) included 210,705 adverse events and 2,991 fatalities for FQs. Levofoxacin and ciprofoxacin toxicities were neurologic (30% and 26%, respectively), tendon damage (8% and 6%), and psychiatric (10% and 2%). In 2013, an FDA safety review reported that FQs affect mammalian topoisomerase II, especially in mitochondria. In 2013 and 2014, SONAR fled citizen petitions requesting black box revisions identifying neuropsychiatric toxicities and mitochrondrial toxicity as serious levofoxacin-associated adverse drug reactions. In 2015, FDA advisors recommended that FQ product labels be revised to include information about this newly identified disability syndrome termed “FQ-associated disability” (FQAD).

Limitations Basic science studies evaluated NP toxicity for only 1 FQ, ciprofoxacin.

Conclusion Pharmacovigilance investigators, a social network, and basic scientists can collaborate on pharmacovigilance investigations. Revised product labels describing a new serious adverse drug reaction, levofoxacin-associated long-term disability, as recommended by an FDA advisory committee, are advised.

Funding This work was funded partly by the National Cancer Institute (1R01CA165609-01A1), the American Cancer Society (IRG-13-043-01), the South Carolina SmartState Program, and an unrestricted from Doris Levkoff Meddin to the South Carolina College of Pharmacy Center for Medication Safety and Efficacy.

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

NEW ORLEANS – A decline in levels of anti-müllerian hormone as women approach menopause – a phenomenon dubbed ovarian decline – appears associated with clinical disability and brain atrophy in women with multiple sclerosis, according to the findings of a study of more than 400 women with multiple sclerosis followed up for a decade.

This “accumulation of disability” may explain the often rapid transition from a benign disease course to secondary progressive multiple sclerosis (MS) in women as they approach menopause, Dr. Jennifer S. Graves reported at a meeting held by at the Americas Committee for Treatment and Research in Multiple Sclerosis.

Earlier in life, females often have a more benign initial course of MS than males. The mean age of onset of primary progressive MS and secondary progressive MS are both approximately 45 years. The mean age of menopause is 51 years. Ovarian aging involves up to a 10-year period of decline in ovarian function. After age 50, “women catch up in terms of disability with males” with MS, said Dr. Graves of the University of California, San Francisco. One explanation could be that ovarian aging contributes to the development of progressive disease.

The objective was to determine if ovarian decline as measured by the levels of anti-müllerian hormone (AMH) is associated with clinical disability or brain atrophy in women with MS. The cohort of 412 female patients with MS (mean age, 43 years) was from the UCSF EPIC (Expression, Proteomics, Imaging, Clinical) study, which has followed more than 500 people with MS since 2004 with the aim of identifying factors that drive the disease. Also included were 180 healthy controls with the exact same mean age. AMH levels were measured using an ultrasensitive enzyme-linked immunosorbent assay at baseline and at years 3, 5, 8, 9, and 10. Brain magnetic resonance imaging data also were acquired.

When the data were adjusted for chronologic age, women with MS and healthy controls displayed similar AMH levels (P = .97), implying a normal follicular reserve and rate of ovarian decline in those with MS. White matter volume was associated with AMH levels at baseline (P = .047). The association did not persist when adjusted for age as well as disease duration and body mass index (P = .24), while ovarian reserve was associated with normalized gray matter volume (P = .049) and MS functional composite z scores (P = .036) at baseline. Scrutiny of the follow-up period revealed that a twofold decrease in AMH was associated with a 1.85-mm³ decrease in gray matter volume (P = .060) in MS patients. Almost a third of the MS patients had undetectable levels of AMH, which was associated with a 0.60-point higher expanded disability status scale score (P =.039)

The results support the hypothesized association of ovarian decline with increased severity of MS. Furthermore, AMH may be a useful biomarker of MS progression, said Dr. Graves. “The advantage of this biomarker would be that it captures biological activity in women in their 40s, and so could let you know of imminent change.”

Validation of the findings needs to be done.

The study was funded by the National Institutes of Health, National MS Society, Race to Erase MS, Foundation for the Cedars-Sinai Medical Center, Biogen, and Genentech. Dr. Graves had no relevant financial disclosures.

NEW ORLEANS – A decline in levels of anti-müllerian hormone as women approach menopause – a phenomenon dubbed ovarian decline – appears associated with clinical disability and brain atrophy in women with multiple sclerosis, according to the findings of a study of more than 400 women with multiple sclerosis followed up for a decade.

This “accumulation of disability” may explain the often rapid transition from a benign disease course to secondary progressive multiple sclerosis (MS) in women as they approach menopause, Dr. Jennifer S. Graves reported at a meeting held by at the Americas Committee for Treatment and Research in Multiple Sclerosis.

Earlier in life, females often have a more benign initial course of MS than males. The mean age of onset of primary progressive MS and secondary progressive MS are both approximately 45 years. The mean age of menopause is 51 years. Ovarian aging involves up to a 10-year period of decline in ovarian function. After age 50, “women catch up in terms of disability with males” with MS, said Dr. Graves of the University of California, San Francisco. One explanation could be that ovarian aging contributes to the development of progressive disease.

The objective was to determine if ovarian decline as measured by the levels of anti-müllerian hormone (AMH) is associated with clinical disability or brain atrophy in women with MS. The cohort of 412 female patients with MS (mean age, 43 years) was from the UCSF EPIC (Expression, Proteomics, Imaging, Clinical) study, which has followed more than 500 people with MS since 2004 with the aim of identifying factors that drive the disease. Also included were 180 healthy controls with the exact same mean age. AMH levels were measured using an ultrasensitive enzyme-linked immunosorbent assay at baseline and at years 3, 5, 8, 9, and 10. Brain magnetic resonance imaging data also were acquired.

When the data were adjusted for chronologic age, women with MS and healthy controls displayed similar AMH levels (P = .97), implying a normal follicular reserve and rate of ovarian decline in those with MS. White matter volume was associated with AMH levels at baseline (P = .047). The association did not persist when adjusted for age as well as disease duration and body mass index (P = .24), while ovarian reserve was associated with normalized gray matter volume (P = .049) and MS functional composite z scores (P = .036) at baseline. Scrutiny of the follow-up period revealed that a twofold decrease in AMH was associated with a 1.85-mm³ decrease in gray matter volume (P = .060) in MS patients. Almost a third of the MS patients had undetectable levels of AMH, which was associated with a 0.60-point higher expanded disability status scale score (P =.039)

The results support the hypothesized association of ovarian decline with increased severity of MS. Furthermore, AMH may be a useful biomarker of MS progression, said Dr. Graves. “The advantage of this biomarker would be that it captures biological activity in women in their 40s, and so could let you know of imminent change.”

Validation of the findings needs to be done.

The study was funded by the National Institutes of Health, National MS Society, Race to Erase MS, Foundation for the Cedars-Sinai Medical Center, Biogen, and Genentech. Dr. Graves had no relevant financial disclosures.

NEW ORLEANS – A decline in levels of anti-müllerian hormone as women approach menopause – a phenomenon dubbed ovarian decline – appears associated with clinical disability and brain atrophy in women with multiple sclerosis, according to the findings of a study of more than 400 women with multiple sclerosis followed up for a decade.

This “accumulation of disability” may explain the often rapid transition from a benign disease course to secondary progressive multiple sclerosis (MS) in women as they approach menopause, Dr. Jennifer S. Graves reported at a meeting held by at the Americas Committee for Treatment and Research in Multiple Sclerosis.

Earlier in life, females often have a more benign initial course of MS than males. The mean age of onset of primary progressive MS and secondary progressive MS are both approximately 45 years. The mean age of menopause is 51 years. Ovarian aging involves up to a 10-year period of decline in ovarian function. After age 50, “women catch up in terms of disability with males” with MS, said Dr. Graves of the University of California, San Francisco. One explanation could be that ovarian aging contributes to the development of progressive disease.

The objective was to determine if ovarian decline as measured by the levels of anti-müllerian hormone (AMH) is associated with clinical disability or brain atrophy in women with MS. The cohort of 412 female patients with MS (mean age, 43 years) was from the UCSF EPIC (Expression, Proteomics, Imaging, Clinical) study, which has followed more than 500 people with MS since 2004 with the aim of identifying factors that drive the disease. Also included were 180 healthy controls with the exact same mean age. AMH levels were measured using an ultrasensitive enzyme-linked immunosorbent assay at baseline and at years 3, 5, 8, 9, and 10. Brain magnetic resonance imaging data also were acquired.

When the data were adjusted for chronologic age, women with MS and healthy controls displayed similar AMH levels (P = .97), implying a normal follicular reserve and rate of ovarian decline in those with MS. White matter volume was associated with AMH levels at baseline (P = .047). The association did not persist when adjusted for age as well as disease duration and body mass index (P = .24), while ovarian reserve was associated with normalized gray matter volume (P = .049) and MS functional composite z scores (P = .036) at baseline. Scrutiny of the follow-up period revealed that a twofold decrease in AMH was associated with a 1.85-mm³ decrease in gray matter volume (P = .060) in MS patients. Almost a third of the MS patients had undetectable levels of AMH, which was associated with a 0.60-point higher expanded disability status scale score (P =.039)

The results support the hypothesized association of ovarian decline with increased severity of MS. Furthermore, AMH may be a useful biomarker of MS progression, said Dr. Graves. “The advantage of this biomarker would be that it captures biological activity in women in their 40s, and so could let you know of imminent change.”

Validation of the findings needs to be done.

The study was funded by the National Institutes of Health, National MS Society, Race to Erase MS, Foundation for the Cedars-Sinai Medical Center, Biogen, and Genentech. Dr. Graves had no relevant financial disclosures.

NEW ORLEANS – Exercise can be beneficial in transiently improving cognitive impairment in people with multiple sclerosis.

Research presented at a meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis has extended the exercise benefit to cognitive impairment, as measured by reaction time in 24 subjects. The benefit, which was transient, also was evident in 14 subjects who were thermosensitive and displayed elevated core body temperature during exercise. Although preliminary, the data are sufficiently evocative to warrant randomized controlled trials (RCTs).

Brian Hoyle/Frontline Medical News

Cognitive impairment is prevalent in MS, being present in upward of 50% of affected individuals. Exercise may or may not be beneficial in cognitive improvement, given the inconsistent results from three RCTs that have been done. The different types of exercise used in the studies could be one reason for the uncertainty.

For people with MS who are fully ambulatory, treadmill walking could be the best form of exercise. But it’s not known how long and at what intensity someone should walk to realize any cognitive benefit. The investigators, led by Brian M. Sandroff, Ph.D., a postdoctoral fellow at the Kessler Foundation, West Orange, N.J., designed the study to assess these unknowns.

The study compared the influence of light, moderate, and vigorous treadmill walking on what is known as inhibitory control – a mental ability to react to stimuli. A period of quiet rest also was included prior to treadmill walking to assess the effects of no walking. The four conditions were tested in random order by the 24 participants with MS who had an Expanded Disability Status Scale (EDSS) score greater than or equal to 4, indicative of minimal or moderate disability. Prior to and soon after 20 minutes of treadmill walking, the reaction time of each participant was judged using a modified flanker task. The test requires a subject to respond to specific relevant information or ignore irrelevant information. The time for a correct response was the reaction time.

Light, moderate, and vigorous treadmill walking similarly and significantly improved reaction time, compared with quiet rest. To assess whether an increase in core body temperature might negate the exercise-related benefit, core body temperature was assessed in 14 thermosensitive MS patients (EDSS less than or equal to 4.0). Core body temperature was recorded every 10 seconds using an ingested sensor capsule and wireless data recorder during 20 minutes of vigorous treadmill exercise and 20 minutes of quiet rest. The core temperature of the subjects rose significantly by about 0.6° C during exercise. But this did not affect the exercise-related improved reaction time.

“There have been no published studies comparing the acute (transient) versus chronic effects of exercise on cognition in MS. We have hypothesized that the acute effects of single bouts of exercise on cognition will be both additive and cumulative over time, when delivered in a longitudinal intervention – much like the effects of a single bout of aerobic exercise on aerobic fitness. In this example, you get small, transient improvements in aerobic fitness after a single session of aerobic exercise; these small improvements add up with continued training, and eventually result in a meaningful improvement,” Dr. Sandroff said in an interview.

The researchers are planning an RCT on the longer-term effects of treadmill walking exercise training on cognition and brain structure/function.

The study was not funded by an external grant. Dr. Sandroff had no relevant financial disclosures.

NEW ORLEANS – Exercise can be beneficial in transiently improving cognitive impairment in people with multiple sclerosis.

Research presented at a meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis has extended the exercise benefit to cognitive impairment, as measured by reaction time in 24 subjects. The benefit, which was transient, also was evident in 14 subjects who were thermosensitive and displayed elevated core body temperature during exercise. Although preliminary, the data are sufficiently evocative to warrant randomized controlled trials (RCTs).

Brian Hoyle/Frontline Medical News

Cognitive impairment is prevalent in MS, being present in upward of 50% of affected individuals. Exercise may or may not be beneficial in cognitive improvement, given the inconsistent results from three RCTs that have been done. The different types of exercise used in the studies could be one reason for the uncertainty.

For people with MS who are fully ambulatory, treadmill walking could be the best form of exercise. But it’s not known how long and at what intensity someone should walk to realize any cognitive benefit. The investigators, led by Brian M. Sandroff, Ph.D., a postdoctoral fellow at the Kessler Foundation, West Orange, N.J., designed the study to assess these unknowns.

The study compared the influence of light, moderate, and vigorous treadmill walking on what is known as inhibitory control – a mental ability to react to stimuli. A period of quiet rest also was included prior to treadmill walking to assess the effects of no walking. The four conditions were tested in random order by the 24 participants with MS who had an Expanded Disability Status Scale (EDSS) score greater than or equal to 4, indicative of minimal or moderate disability. Prior to and soon after 20 minutes of treadmill walking, the reaction time of each participant was judged using a modified flanker task. The test requires a subject to respond to specific relevant information or ignore irrelevant information. The time for a correct response was the reaction time.

Light, moderate, and vigorous treadmill walking similarly and significantly improved reaction time, compared with quiet rest. To assess whether an increase in core body temperature might negate the exercise-related benefit, core body temperature was assessed in 14 thermosensitive MS patients (EDSS less than or equal to 4.0). Core body temperature was recorded every 10 seconds using an ingested sensor capsule and wireless data recorder during 20 minutes of vigorous treadmill exercise and 20 minutes of quiet rest. The core temperature of the subjects rose significantly by about 0.6° C during exercise. But this did not affect the exercise-related improved reaction time.

“There have been no published studies comparing the acute (transient) versus chronic effects of exercise on cognition in MS. We have hypothesized that the acute effects of single bouts of exercise on cognition will be both additive and cumulative over time, when delivered in a longitudinal intervention – much like the effects of a single bout of aerobic exercise on aerobic fitness. In this example, you get small, transient improvements in aerobic fitness after a single session of aerobic exercise; these small improvements add up with continued training, and eventually result in a meaningful improvement,” Dr. Sandroff said in an interview.

The researchers are planning an RCT on the longer-term effects of treadmill walking exercise training on cognition and brain structure/function.

The study was not funded by an external grant. Dr. Sandroff had no relevant financial disclosures.

NEW ORLEANS – Exercise can be beneficial in transiently improving cognitive impairment in people with multiple sclerosis.

Research presented at a meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis has extended the exercise benefit to cognitive impairment, as measured by reaction time in 24 subjects. The benefit, which was transient, also was evident in 14 subjects who were thermosensitive and displayed elevated core body temperature during exercise. Although preliminary, the data are sufficiently evocative to warrant randomized controlled trials (RCTs).

Brian Hoyle/Frontline Medical News

Cognitive impairment is prevalent in MS, being present in upward of 50% of affected individuals. Exercise may or may not be beneficial in cognitive improvement, given the inconsistent results from three RCTs that have been done. The different types of exercise used in the studies could be one reason for the uncertainty.

For people with MS who are fully ambulatory, treadmill walking could be the best form of exercise. But it’s not known how long and at what intensity someone should walk to realize any cognitive benefit. The investigators, led by Brian M. Sandroff, Ph.D., a postdoctoral fellow at the Kessler Foundation, West Orange, N.J., designed the study to assess these unknowns.

The study compared the influence of light, moderate, and vigorous treadmill walking on what is known as inhibitory control – a mental ability to react to stimuli. A period of quiet rest also was included prior to treadmill walking to assess the effects of no walking. The four conditions were tested in random order by the 24 participants with MS who had an Expanded Disability Status Scale (EDSS) score greater than or equal to 4, indicative of minimal or moderate disability. Prior to and soon after 20 minutes of treadmill walking, the reaction time of each participant was judged using a modified flanker task. The test requires a subject to respond to specific relevant information or ignore irrelevant information. The time for a correct response was the reaction time.

Light, moderate, and vigorous treadmill walking similarly and significantly improved reaction time, compared with quiet rest. To assess whether an increase in core body temperature might negate the exercise-related benefit, core body temperature was assessed in 14 thermosensitive MS patients (EDSS less than or equal to 4.0). Core body temperature was recorded every 10 seconds using an ingested sensor capsule and wireless data recorder during 20 minutes of vigorous treadmill exercise and 20 minutes of quiet rest. The core temperature of the subjects rose significantly by about 0.6° C during exercise. But this did not affect the exercise-related improved reaction time.

“There have been no published studies comparing the acute (transient) versus chronic effects of exercise on cognition in MS. We have hypothesized that the acute effects of single bouts of exercise on cognition will be both additive and cumulative over time, when delivered in a longitudinal intervention – much like the effects of a single bout of aerobic exercise on aerobic fitness. In this example, you get small, transient improvements in aerobic fitness after a single session of aerobic exercise; these small improvements add up with continued training, and eventually result in a meaningful improvement,” Dr. Sandroff said in an interview.

The researchers are planning an RCT on the longer-term effects of treadmill walking exercise training on cognition and brain structure/function.

The study was not funded by an external grant. Dr. Sandroff had no relevant financial disclosures.

Eight hospitalists have joined Team Hospitalist, the only reader involvement group of its kind in hospital medicine. Each of the new members has experience in the practice of HM; many offer specialized backgrounds in pediatrics, academics, quality and patient safety, and group administration. The new members will serve two-year terms and act as special editorial consultants to the magazine.

Geeta Arora, MD, is a locum tenens hospitalist.  She travels around the country practicing hospitalist medicine, telemedicine and travels the world practicing global medicine. Dr. Arora currently resides in New York City and holds board certifications in both internal medicine as well as integrative holistic medicine.

Michael J. Beck, MD, FAAP, is division chief of pediatric hospital medicine in the Department of Pediatrics, associate professor of pediatrics and internal medicine, and assistant program director, medicine/pediatrics residency program at Penn State Children's Hospital and Milton S. Hershey Medical Center in Pennsylvania.

Kevin M. Conrad, MD, MBA, is a hospitalist and medical director of community affairs and health policy at Ochsner Health Systems in New Orleans, La. He is an associate professor of medicine at Tulane University.

Stella Fitzgibbons, MD, FACP, FHM, is a hospitalist and emergency physician with Mint Physicians, primarily in Apollo Hospital System.

Benjamin Frizner, MD, FHM, is a hospitalist and director of the ventilator unit at Future Care, a Baltimore, Md.-based organization providing post-acute care across 12 facilities throughout southern Maryland.

Sarah A. Stella, MD, is an academic hospitalist in the division of hospital medicine and physician advisor for the department of care management at Denver Health in Colorado. She is an assistant professor of medicine at the University of Colorado School of Medicine in Aurora.

Miguel Angel Villagra Diaz, MD, is a hospitalist and medical director for the hospital medicine program at White River Medical Center in Batesville, Ark.

Jill Slater Waldman, MD, SFHM, is director of the adult hospital service at Phelps Memorial Hospital Center in Sleepy Hollow, N.Y. She is medical director and physician advisor for utilization management, assistant to the CMO, and course coordinator for the internal medicine rotation.

Eight hospitalists have joined Team Hospitalist, the only reader involvement group of its kind in hospital medicine. Each of the new members has experience in the practice of HM; many offer specialized backgrounds in pediatrics, academics, quality and patient safety, and group administration. The new members will serve two-year terms and act as special editorial consultants to the magazine.

Geeta Arora, MD, is a locum tenens hospitalist.  She travels around the country practicing hospitalist medicine, telemedicine and travels the world practicing global medicine. Dr. Arora currently resides in New York City and holds board certifications in both internal medicine as well as integrative holistic medicine.

Michael J. Beck, MD, FAAP, is division chief of pediatric hospital medicine in the Department of Pediatrics, associate professor of pediatrics and internal medicine, and assistant program director, medicine/pediatrics residency program at Penn State Children's Hospital and Milton S. Hershey Medical Center in Pennsylvania.

Kevin M. Conrad, MD, MBA, is a hospitalist and medical director of community affairs and health policy at Ochsner Health Systems in New Orleans, La. He is an associate professor of medicine at Tulane University.

Stella Fitzgibbons, MD, FACP, FHM, is a hospitalist and emergency physician with Mint Physicians, primarily in Apollo Hospital System.

Benjamin Frizner, MD, FHM, is a hospitalist and director of the ventilator unit at Future Care, a Baltimore, Md.-based organization providing post-acute care across 12 facilities throughout southern Maryland.

Sarah A. Stella, MD, is an academic hospitalist in the division of hospital medicine and physician advisor for the department of care management at Denver Health in Colorado. She is an assistant professor of medicine at the University of Colorado School of Medicine in Aurora.

Miguel Angel Villagra Diaz, MD, is a hospitalist and medical director for the hospital medicine program at White River Medical Center in Batesville, Ark.

Jill Slater Waldman, MD, SFHM, is director of the adult hospital service at Phelps Memorial Hospital Center in Sleepy Hollow, N.Y. She is medical director and physician advisor for utilization management, assistant to the CMO, and course coordinator for the internal medicine rotation.

Eight hospitalists have joined Team Hospitalist, the only reader involvement group of its kind in hospital medicine. Each of the new members has experience in the practice of HM; many offer specialized backgrounds in pediatrics, academics, quality and patient safety, and group administration. The new members will serve two-year terms and act as special editorial consultants to the magazine.

Geeta Arora, MD, is a locum tenens hospitalist.  She travels around the country practicing hospitalist medicine, telemedicine and travels the world practicing global medicine. Dr. Arora currently resides in New York City and holds board certifications in both internal medicine as well as integrative holistic medicine.

Michael J. Beck, MD, FAAP, is division chief of pediatric hospital medicine in the Department of Pediatrics, associate professor of pediatrics and internal medicine, and assistant program director, medicine/pediatrics residency program at Penn State Children's Hospital and Milton S. Hershey Medical Center in Pennsylvania.

Kevin M. Conrad, MD, MBA, is a hospitalist and medical director of community affairs and health policy at Ochsner Health Systems in New Orleans, La. He is an associate professor of medicine at Tulane University.

Stella Fitzgibbons, MD, FACP, FHM, is a hospitalist and emergency physician with Mint Physicians, primarily in Apollo Hospital System.

Benjamin Frizner, MD, FHM, is a hospitalist and director of the ventilator unit at Future Care, a Baltimore, Md.-based organization providing post-acute care across 12 facilities throughout southern Maryland.

Sarah A. Stella, MD, is an academic hospitalist in the division of hospital medicine and physician advisor for the department of care management at Denver Health in Colorado. She is an assistant professor of medicine at the University of Colorado School of Medicine in Aurora.

Miguel Angel Villagra Diaz, MD, is a hospitalist and medical director for the hospital medicine program at White River Medical Center in Batesville, Ark.

Jill Slater Waldman, MD, SFHM, is director of the adult hospital service at Phelps Memorial Hospital Center in Sleepy Hollow, N.Y. She is medical director and physician advisor for utilization management, assistant to the CMO, and course coordinator for the internal medicine rotation.