SAN ANTONIO – Automatically bumping elderly Level 2 trauma patients to Level 1 status reduced mortality and emergency department lengths of stay at Indiana University Health Methodist Hospital, Indianapolis.

Like trauma services elsewhere, the Methodist team is trying to figure out how best to handle the coming increase in elderly patients as the Baby Boom generation ages. It’s known that older trauma patients tend to be undertriaged. To improve the situation, “we need to respond quickly with a lot of resources up front so we don’t delay diagnosis” and treatment, said investigator Dr. Peter Hammer, assistant professor of surgery at Indiana University, Indianapolis.

The solution Methodist has tried since October 2013 is a Level 1 response to any patient aged 70 years or older who meets Level 2 criteria, regardless of vital sign stability or injury mechanism. With Level 1, trauma attendings, residents, respiratory therapists, clinical pharmacists, and others are at the bedside within 15 minutes and CT services and operating rooms are on standby, among other measures. Compared with the 1,271 patients aged 70 years or older treated in the almost 2 years before the change, the 998 treated in the year and a half afterwards were, after controlling for age, comorbidities, and injury severity scores (ISS), more likely to leave the ED in less than 2 hours (odds ratio, 1.614; 95% confidence interval, 1.088-2.394) and less likely to die (OR, 0.689, 95% CI, 0.484-0.979).

The before and after groups were similar, with a mean age of 81 years, a mean ISS of 12.2, a high comorbidity burden, and, for most, a blunt injury: 8.3% died in the before group, versus 7.6% in the after group. The shorter ED stays occurred despite a nursing staff reduction in 2014. Patients who went into cardiac arrest before arrival or died in the ED were excluded from the analysis.

“A simple, focused intervention of a higher level of trauma activation can decrease ED length of stay and in-hospital mortality in elderly trauma patients,” Dr. Hammer said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Among many initiatives as many trauma centers gear up for aging baby boomers, others are trying age as a criteria for higher activation, too, and recent guidelines from EAST recommend a lower threshold for trauma activation for patients 65 years or older, among other steps.

With more expertise and resources to brought to bear, it’s not surprising that Level 1 patients left the ED sooner, but it’s unclear what role that played in reducing mortality. “I wouldn’t hazard [to say] that shorter lengths of stay necessarily” saved lives, Dr. Hammer said.

Before the intervention, just 4.8% of geriatric patients left the ED within 2 hours, versus 6.5% afterwards. The numbers are low because, “as in most hospitals, there are more trauma patients than beds. [Reducing ED] length or stay [remains] an ongoing project” at Methodist, and not just for the elderly. “The ED is always overcrowded come afternoon and into the evening,” Dr. Hammer said.

That’s one of the reasons management supported the project. “They like the concept of getting patients moved through quickly. We have a lot of resources in the ED, so there doesn’t seem to be much of a slowdown” with increased Level 1 activation. It probably costs more up front, “but the hope is we’ll save money on the back end with lower mortality and shorter ED stays,” he said.

The investigators had no disclosures.

[email protected]

SAN ANTONIO – Automatically bumping elderly Level 2 trauma patients to Level 1 status reduced mortality and emergency department lengths of stay at Indiana University Health Methodist Hospital, Indianapolis.

Like trauma services elsewhere, the Methodist team is trying to figure out how best to handle the coming increase in elderly patients as the Baby Boom generation ages. It’s known that older trauma patients tend to be undertriaged. To improve the situation, “we need to respond quickly with a lot of resources up front so we don’t delay diagnosis” and treatment, said investigator Dr. Peter Hammer, assistant professor of surgery at Indiana University, Indianapolis.

The solution Methodist has tried since October 2013 is a Level 1 response to any patient aged 70 years or older who meets Level 2 criteria, regardless of vital sign stability or injury mechanism. With Level 1, trauma attendings, residents, respiratory therapists, clinical pharmacists, and others are at the bedside within 15 minutes and CT services and operating rooms are on standby, among other measures. Compared with the 1,271 patients aged 70 years or older treated in the almost 2 years before the change, the 998 treated in the year and a half afterwards were, after controlling for age, comorbidities, and injury severity scores (ISS), more likely to leave the ED in less than 2 hours (odds ratio, 1.614; 95% confidence interval, 1.088-2.394) and less likely to die (OR, 0.689, 95% CI, 0.484-0.979).

The before and after groups were similar, with a mean age of 81 years, a mean ISS of 12.2, a high comorbidity burden, and, for most, a blunt injury: 8.3% died in the before group, versus 7.6% in the after group. The shorter ED stays occurred despite a nursing staff reduction in 2014. Patients who went into cardiac arrest before arrival or died in the ED were excluded from the analysis.

“A simple, focused intervention of a higher level of trauma activation can decrease ED length of stay and in-hospital mortality in elderly trauma patients,” Dr. Hammer said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Among many initiatives as many trauma centers gear up for aging baby boomers, others are trying age as a criteria for higher activation, too, and recent guidelines from EAST recommend a lower threshold for trauma activation for patients 65 years or older, among other steps.

With more expertise and resources to brought to bear, it’s not surprising that Level 1 patients left the ED sooner, but it’s unclear what role that played in reducing mortality. “I wouldn’t hazard [to say] that shorter lengths of stay necessarily” saved lives, Dr. Hammer said.

Before the intervention, just 4.8% of geriatric patients left the ED within 2 hours, versus 6.5% afterwards. The numbers are low because, “as in most hospitals, there are more trauma patients than beds. [Reducing ED] length or stay [remains] an ongoing project” at Methodist, and not just for the elderly. “The ED is always overcrowded come afternoon and into the evening,” Dr. Hammer said.

That’s one of the reasons management supported the project. “They like the concept of getting patients moved through quickly. We have a lot of resources in the ED, so there doesn’t seem to be much of a slowdown” with increased Level 1 activation. It probably costs more up front, “but the hope is we’ll save money on the back end with lower mortality and shorter ED stays,” he said.

The investigators had no disclosures.

[email protected]

SAN ANTONIO – Automatically bumping elderly Level 2 trauma patients to Level 1 status reduced mortality and emergency department lengths of stay at Indiana University Health Methodist Hospital, Indianapolis.

Like trauma services elsewhere, the Methodist team is trying to figure out how best to handle the coming increase in elderly patients as the Baby Boom generation ages. It’s known that older trauma patients tend to be undertriaged. To improve the situation, “we need to respond quickly with a lot of resources up front so we don’t delay diagnosis” and treatment, said investigator Dr. Peter Hammer, assistant professor of surgery at Indiana University, Indianapolis.

The solution Methodist has tried since October 2013 is a Level 1 response to any patient aged 70 years or older who meets Level 2 criteria, regardless of vital sign stability or injury mechanism. With Level 1, trauma attendings, residents, respiratory therapists, clinical pharmacists, and others are at the bedside within 15 minutes and CT services and operating rooms are on standby, among other measures. Compared with the 1,271 patients aged 70 years or older treated in the almost 2 years before the change, the 998 treated in the year and a half afterwards were, after controlling for age, comorbidities, and injury severity scores (ISS), more likely to leave the ED in less than 2 hours (odds ratio, 1.614; 95% confidence interval, 1.088-2.394) and less likely to die (OR, 0.689, 95% CI, 0.484-0.979).

The before and after groups were similar, with a mean age of 81 years, a mean ISS of 12.2, a high comorbidity burden, and, for most, a blunt injury: 8.3% died in the before group, versus 7.6% in the after group. The shorter ED stays occurred despite a nursing staff reduction in 2014. Patients who went into cardiac arrest before arrival or died in the ED were excluded from the analysis.

“A simple, focused intervention of a higher level of trauma activation can decrease ED length of stay and in-hospital mortality in elderly trauma patients,” Dr. Hammer said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Among many initiatives as many trauma centers gear up for aging baby boomers, others are trying age as a criteria for higher activation, too, and recent guidelines from EAST recommend a lower threshold for trauma activation for patients 65 years or older, among other steps.

With more expertise and resources to brought to bear, it’s not surprising that Level 1 patients left the ED sooner, but it’s unclear what role that played in reducing mortality. “I wouldn’t hazard [to say] that shorter lengths of stay necessarily” saved lives, Dr. Hammer said.

Before the intervention, just 4.8% of geriatric patients left the ED within 2 hours, versus 6.5% afterwards. The numbers are low because, “as in most hospitals, there are more trauma patients than beds. [Reducing ED] length or stay [remains] an ongoing project” at Methodist, and not just for the elderly. “The ED is always overcrowded come afternoon and into the evening,” Dr. Hammer said.

That’s one of the reasons management supported the project. “They like the concept of getting patients moved through quickly. We have a lot of resources in the ED, so there doesn’t seem to be much of a slowdown” with increased Level 1 activation. It probably costs more up front, “but the hope is we’ll save money on the back end with lower mortality and shorter ED stays,” he said.

The investigators had no disclosures.

[email protected]

Every generation of adults seems to worry that the next generation of youth is in trouble. The perception of kids today is no different, with theories abounding as to why the mental health of the newest generation is slipping, compared with previous standards. From mobile phones to helicopter parents, it might seem like a foregone conclusion that our current crop of young people is destined to be insecure, inattentive, and unable to cope with challenges and stress. Many news headlines on the latest mass shooting or standardized test results often seem to confirm these widespread concerns.

Pediatricians often hear parents lamenting the “good old days” when such things as corporal punishment were more easily accepted to help keep kids in line. But taking a step back, it may be worth a more objective look to examine the assumption that child behavioral problems are worse than ever. Measuring overall mental health is not an easy task, but looking at several important metrics indicate that things may not be nearly as bad as many people think.

Substance use

From the latest data from the Monitoring the Future Study, one of the nation’s most reliable sources on teen substance use, the use of both alcohol and tobacco among youth is at the lowest level since the study began in 1975. Use of drugs like heroin and ecstasy also are declining. The only major exception to this trend seems to be cannabis use, which has generally shown stable rates during this climate of marijuana decriminalization and, for some states, legalization.

Teen pregnancy rates

One area where there continues to be sustained progress is in teen pregnancy. According to the government’s Centers for Disease Control and Prevention, the overall pregnancy rate among adolescent females has been cut in half from 1991 to 2011, across many different ethnic groups. The rate fell from 61.8/1,000 teenagers aged 15-19 years to 31.3/1,000 teenagers.

Delinquency

Far fewer adolescents are being held against their will in juvenile detention centers. The number of youth who are incarcerated have dropped from a high of 381/100,000 in 1995 to 225/100,000 in 2010, according to a report by the Annie E. Casey Foundation.

Bullying

Bullying has been increasingly recognized as the public health problem that it is. The use of online technology also has created many new settings in which bullying can take place. Nevertheless, there is reason to be optimistic. From the National Center for Education Statistics and the National Crime Victimization Survey, the number of students who report being bullied at school has dropped from 32% in 2007 to an all-time low of 22% in 2013. Another recent study reached similar conclusions for bullying and many other forms of child victimization between 2003 and 2011 (JAMA Pediatr. 2014 Jun;168[6]:540-6).

Suicide

According to the CDC, the rate of completed suicide in youth peaked in the early1990s and then dropped and stabilized before starting to creep up again over the past 5 or so years. The trends are somewhat different, based on gender and the specific age group that is examined. The majority of completed youth suicides occur in males, with current rates still well below those historical highs.

Psychiatric disorders

This one is particularly tricky. While the rates of many specific psychiatric disorders such as ADHD and bipolar disorder have been rising in youth, as well as the use of psychiatric medications, it is much less clear whether this represents a true rise in these disorders versus other factors such as improved detection and a lower diagnostic threshold. One study by Achenbach et al. that measured quantitative levels of child behavior problems from the same rating scale over a 23-year time span found some increases in overall levels from the 1970s to the early 1990s, but then levels began to fall by the end of the millennium (J Abnorm Child Psychol. 2003 Feb;31[1]:1-11).

Of course, these hopeful trends in many significant areas do not mean that these problems have been overcome. While much work remains to be done on many fronts, it is still worth keeping in mind that the overall condition of youth mental health may not be as dire as we might be led to believe and that there is evidence that our efforts, perhaps, are leading to some progress.

Dr. Rettew is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].

Every generation of adults seems to worry that the next generation of youth is in trouble. The perception of kids today is no different, with theories abounding as to why the mental health of the newest generation is slipping, compared with previous standards. From mobile phones to helicopter parents, it might seem like a foregone conclusion that our current crop of young people is destined to be insecure, inattentive, and unable to cope with challenges and stress. Many news headlines on the latest mass shooting or standardized test results often seem to confirm these widespread concerns.

Pediatricians often hear parents lamenting the “good old days” when such things as corporal punishment were more easily accepted to help keep kids in line. But taking a step back, it may be worth a more objective look to examine the assumption that child behavioral problems are worse than ever. Measuring overall mental health is not an easy task, but looking at several important metrics indicate that things may not be nearly as bad as many people think.

Substance use

From the latest data from the Monitoring the Future Study, one of the nation’s most reliable sources on teen substance use, the use of both alcohol and tobacco among youth is at the lowest level since the study began in 1975. Use of drugs like heroin and ecstasy also are declining. The only major exception to this trend seems to be cannabis use, which has generally shown stable rates during this climate of marijuana decriminalization and, for some states, legalization.

Teen pregnancy rates

One area where there continues to be sustained progress is in teen pregnancy. According to the government’s Centers for Disease Control and Prevention, the overall pregnancy rate among adolescent females has been cut in half from 1991 to 2011, across many different ethnic groups. The rate fell from 61.8/1,000 teenagers aged 15-19 years to 31.3/1,000 teenagers.

Delinquency

Far fewer adolescents are being held against their will in juvenile detention centers. The number of youth who are incarcerated have dropped from a high of 381/100,000 in 1995 to 225/100,000 in 2010, according to a report by the Annie E. Casey Foundation.

Bullying

Bullying has been increasingly recognized as the public health problem that it is. The use of online technology also has created many new settings in which bullying can take place. Nevertheless, there is reason to be optimistic. From the National Center for Education Statistics and the National Crime Victimization Survey, the number of students who report being bullied at school has dropped from 32% in 2007 to an all-time low of 22% in 2013. Another recent study reached similar conclusions for bullying and many other forms of child victimization between 2003 and 2011 (JAMA Pediatr. 2014 Jun;168[6]:540-6).

Suicide

According to the CDC, the rate of completed suicide in youth peaked in the early1990s and then dropped and stabilized before starting to creep up again over the past 5 or so years. The trends are somewhat different, based on gender and the specific age group that is examined. The majority of completed youth suicides occur in males, with current rates still well below those historical highs.

Psychiatric disorders

This one is particularly tricky. While the rates of many specific psychiatric disorders such as ADHD and bipolar disorder have been rising in youth, as well as the use of psychiatric medications, it is much less clear whether this represents a true rise in these disorders versus other factors such as improved detection and a lower diagnostic threshold. One study by Achenbach et al. that measured quantitative levels of child behavior problems from the same rating scale over a 23-year time span found some increases in overall levels from the 1970s to the early 1990s, but then levels began to fall by the end of the millennium (J Abnorm Child Psychol. 2003 Feb;31[1]:1-11).

Of course, these hopeful trends in many significant areas do not mean that these problems have been overcome. While much work remains to be done on many fronts, it is still worth keeping in mind that the overall condition of youth mental health may not be as dire as we might be led to believe and that there is evidence that our efforts, perhaps, are leading to some progress.

Dr. Rettew is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].

Every generation of adults seems to worry that the next generation of youth is in trouble. The perception of kids today is no different, with theories abounding as to why the mental health of the newest generation is slipping, compared with previous standards. From mobile phones to helicopter parents, it might seem like a foregone conclusion that our current crop of young people is destined to be insecure, inattentive, and unable to cope with challenges and stress. Many news headlines on the latest mass shooting or standardized test results often seem to confirm these widespread concerns.

Pediatricians often hear parents lamenting the “good old days” when such things as corporal punishment were more easily accepted to help keep kids in line. But taking a step back, it may be worth a more objective look to examine the assumption that child behavioral problems are worse than ever. Measuring overall mental health is not an easy task, but looking at several important metrics indicate that things may not be nearly as bad as many people think.

Substance use

From the latest data from the Monitoring the Future Study, one of the nation’s most reliable sources on teen substance use, the use of both alcohol and tobacco among youth is at the lowest level since the study began in 1975. Use of drugs like heroin and ecstasy also are declining. The only major exception to this trend seems to be cannabis use, which has generally shown stable rates during this climate of marijuana decriminalization and, for some states, legalization.

Teen pregnancy rates

One area where there continues to be sustained progress is in teen pregnancy. According to the government’s Centers for Disease Control and Prevention, the overall pregnancy rate among adolescent females has been cut in half from 1991 to 2011, across many different ethnic groups. The rate fell from 61.8/1,000 teenagers aged 15-19 years to 31.3/1,000 teenagers.

Delinquency

Far fewer adolescents are being held against their will in juvenile detention centers. The number of youth who are incarcerated have dropped from a high of 381/100,000 in 1995 to 225/100,000 in 2010, according to a report by the Annie E. Casey Foundation.

Bullying

Bullying has been increasingly recognized as the public health problem that it is. The use of online technology also has created many new settings in which bullying can take place. Nevertheless, there is reason to be optimistic. From the National Center for Education Statistics and the National Crime Victimization Survey, the number of students who report being bullied at school has dropped from 32% in 2007 to an all-time low of 22% in 2013. Another recent study reached similar conclusions for bullying and many other forms of child victimization between 2003 and 2011 (JAMA Pediatr. 2014 Jun;168[6]:540-6).

Suicide

According to the CDC, the rate of completed suicide in youth peaked in the early1990s and then dropped and stabilized before starting to creep up again over the past 5 or so years. The trends are somewhat different, based on gender and the specific age group that is examined. The majority of completed youth suicides occur in males, with current rates still well below those historical highs.

Psychiatric disorders

This one is particularly tricky. While the rates of many specific psychiatric disorders such as ADHD and bipolar disorder have been rising in youth, as well as the use of psychiatric medications, it is much less clear whether this represents a true rise in these disorders versus other factors such as improved detection and a lower diagnostic threshold. One study by Achenbach et al. that measured quantitative levels of child behavior problems from the same rating scale over a 23-year time span found some increases in overall levels from the 1970s to the early 1990s, but then levels began to fall by the end of the millennium (J Abnorm Child Psychol. 2003 Feb;31[1]:1-11).

Of course, these hopeful trends in many significant areas do not mean that these problems have been overcome. While much work remains to be done on many fronts, it is still worth keeping in mind that the overall condition of youth mental health may not be as dire as we might be led to believe and that there is evidence that our efforts, perhaps, are leading to some progress.

Dr. Rettew is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. He said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at [email protected].

Human Tregs

Image by Kathryn Iacono

Researchers say they have discovered how regulatory T cells (Tregs) remain intact and functional during activation.

The team found that once Tregs are activated, they are protected by autophagy, which maintains metabolic balance.

Hongbo Chi, PhD, of St. Jude Children’s Hospital in Memphis, Tennessee, and his colleagues described this discovery in Nature Immunology.

Until this study, no one knew how Tregs maintained themselves when activated.

“Regulatory T cells are very specialized cells that require activation to perform their function in curtailing undesirable immune responses,” Dr Chi explained. “But this activation is a double-edged sword, in that this very activation can destabilize them. They need to modulate this activation, or they will lose their stability and many of them will die. That could damage immune function.”

Dr Chi and his colleagues performed imaging studies in activated Tregs and found that autophagy was functional in the cells.

In experiments with mice, the researchers deleted Atg7 or Atg5, genes whose functions are necessary for autophagy in Tregs.

The mice showed key characteristics of Treg malfunction, including inflammatory and autoimmune disorders. The mice also more readily cleared tumors from their bodies, due to activated immune systems.

Dr Chi said that eliminating autophagy also affected the fate of Tregs.

“Once those T cells lack autophagy activity, they tend to undergo excessive cell death,” he said. “But even for the remaining surviving cells, they tend to be overly activated and lose their identity because they start to behave like non-regulatory T cells. That is why loss of autophagy in regulatory T cells produces a 2-fold effect on both survival and stability.”

Detailed analysis also revealed how the elimination of autophagy affected the basic energy-producing metabolic pathways of Tregs, compromising their function.

Dr Chi said this new understanding of autophagy’s role in Tregs could enable a 2-fold approach to immune therapy for cancers. Namely, by strengthening tumor-associated immune responses, targeting Treg autophagy could act in synergy with strategies that block autophagy in tumor cells.

In this study, the researchers used a transplanted colon cancer cell line. In further studies, they plan to explore the role of autophagy in immune reactions toward other tumor cell types to determine whether such therapies might be effective in a broad range of cancers.

The team also hopes to gain a better understanding of the detailed biochemical mechanisms regulating how autophagy connects to the cell’s metabolic pathways.

Human Tregs

Image by Kathryn Iacono

Researchers say they have discovered how regulatory T cells (Tregs) remain intact and functional during activation.

The team found that once Tregs are activated, they are protected by autophagy, which maintains metabolic balance.

Hongbo Chi, PhD, of St. Jude Children’s Hospital in Memphis, Tennessee, and his colleagues described this discovery in Nature Immunology.

Until this study, no one knew how Tregs maintained themselves when activated.

“Regulatory T cells are very specialized cells that require activation to perform their function in curtailing undesirable immune responses,” Dr Chi explained. “But this activation is a double-edged sword, in that this very activation can destabilize them. They need to modulate this activation, or they will lose their stability and many of them will die. That could damage immune function.”

Dr Chi and his colleagues performed imaging studies in activated Tregs and found that autophagy was functional in the cells.

In experiments with mice, the researchers deleted Atg7 or Atg5, genes whose functions are necessary for autophagy in Tregs.

The mice showed key characteristics of Treg malfunction, including inflammatory and autoimmune disorders. The mice also more readily cleared tumors from their bodies, due to activated immune systems.

Dr Chi said that eliminating autophagy also affected the fate of Tregs.

“Once those T cells lack autophagy activity, they tend to undergo excessive cell death,” he said. “But even for the remaining surviving cells, they tend to be overly activated and lose their identity because they start to behave like non-regulatory T cells. That is why loss of autophagy in regulatory T cells produces a 2-fold effect on both survival and stability.”

Detailed analysis also revealed how the elimination of autophagy affected the basic energy-producing metabolic pathways of Tregs, compromising their function.

Dr Chi said this new understanding of autophagy’s role in Tregs could enable a 2-fold approach to immune therapy for cancers. Namely, by strengthening tumor-associated immune responses, targeting Treg autophagy could act in synergy with strategies that block autophagy in tumor cells.

In this study, the researchers used a transplanted colon cancer cell line. In further studies, they plan to explore the role of autophagy in immune reactions toward other tumor cell types to determine whether such therapies might be effective in a broad range of cancers.

The team also hopes to gain a better understanding of the detailed biochemical mechanisms regulating how autophagy connects to the cell’s metabolic pathways.

Human Tregs

Image by Kathryn Iacono

Researchers say they have discovered how regulatory T cells (Tregs) remain intact and functional during activation.

The team found that once Tregs are activated, they are protected by autophagy, which maintains metabolic balance.

Hongbo Chi, PhD, of St. Jude Children’s Hospital in Memphis, Tennessee, and his colleagues described this discovery in Nature Immunology.

Until this study, no one knew how Tregs maintained themselves when activated.

“Regulatory T cells are very specialized cells that require activation to perform their function in curtailing undesirable immune responses,” Dr Chi explained. “But this activation is a double-edged sword, in that this very activation can destabilize them. They need to modulate this activation, or they will lose their stability and many of them will die. That could damage immune function.”

Dr Chi and his colleagues performed imaging studies in activated Tregs and found that autophagy was functional in the cells.

In experiments with mice, the researchers deleted Atg7 or Atg5, genes whose functions are necessary for autophagy in Tregs.

The mice showed key characteristics of Treg malfunction, including inflammatory and autoimmune disorders. The mice also more readily cleared tumors from their bodies, due to activated immune systems.

Dr Chi said that eliminating autophagy also affected the fate of Tregs.

“Once those T cells lack autophagy activity, they tend to undergo excessive cell death,” he said. “But even for the remaining surviving cells, they tend to be overly activated and lose their identity because they start to behave like non-regulatory T cells. That is why loss of autophagy in regulatory T cells produces a 2-fold effect on both survival and stability.”

Detailed analysis also revealed how the elimination of autophagy affected the basic energy-producing metabolic pathways of Tregs, compromising their function.

Dr Chi said this new understanding of autophagy’s role in Tregs could enable a 2-fold approach to immune therapy for cancers. Namely, by strengthening tumor-associated immune responses, targeting Treg autophagy could act in synergy with strategies that block autophagy in tumor cells.

In this study, the researchers used a transplanted colon cancer cell line. In further studies, they plan to explore the role of autophagy in immune reactions toward other tumor cell types to determine whether such therapies might be effective in a broad range of cancers.

The team also hopes to gain a better understanding of the detailed biochemical mechanisms regulating how autophagy connects to the cell’s metabolic pathways.

Case No. 1

A 41-year-old woman with a history of asthma presents to the emergency department (ED) with shortness of breath and wheezing. She is diagnosed with a mild asthma exacerbation. After three albuterol nebulizer treatments, she still has wheezing on physical examination but appears comfortable and has no oxygen requirement. She has a primary medical doctor at the hospital and follows up with her regularly.

The hospitalist recommends that she stay in the hospital for further treatment, but the patient says she has a nebulizer machine at home and asks to be discharged. In addition, she is worried about her frail elderly mother, for whom she is the primary caretaker. The hospitalist acknowledges her concerns but continues to recommend that she remain in the hospital for additional care and monitoring. She becomes visibly upset and insists that she must return home. She asks for prescriptions for albuterol and prednisone and is discharged against medical advice (AMA).

Case No. 2

A 52-year-old man with a history of hypertension and diabetes presents to the ED with left foot pain. He frequently presents with this complaint but often leaves AMA before treatment is completed. He has no known physical address or telephone number and has no known outpatient healthcare providers. Physical examination reveals several ulcers on the dorsum of the foot, one with purulent drainage, and generalized lower extremity pallor. His left leg is cool to the touch, and vascular surgery is consulted for suspected limb-threatening ischemia; IV antibiotics are started for suspected osteomyelitis.

During the interview, he states that he wishes to leave the hospital because he has “things to take care of.” The hospitalist recommends that he remain in the hospital for limb-preserving surgery and antibiotics. He then explains that he is homeless and needs to return to his shelter to keep his bed. He is able to articulate the risks of premature discharge and the medical concerns, and it is determined that he has the capacity to participate in discharge planning. The hospitalist therefore discharges him AMA.

Background

AMA discharges represent 1%–2% of all inpatient discharges.¹,² Despite being a small percentage of total discharges, these patients have disproportionately high healthcare costs. One study reported that healthcare costs among these patients were 56% higher than expected.² Furthermore, AMA patients suffer higher than expected rates of morbidity, mortality, and hospital readmission.

For example, in one case-control study in an urban teaching hospital, patients discharged AMA from the general medicine service had a 21% 15-day readmission rate compared to a 3% readmission rate among age, gender, and diagnosis-matched controls.^3,4,5

Additionally, history of AMA discharge appears to confer risk of increased future utilization of healthcare resources. In a cohort study of hospital admissions among HIV-infected patients with high rates of intravenous drug abuse, patients discharged AMA (13% of the cohort) were not only more likely to be readmitted within 30 days for a related diagnosis (odds ratio = 5.0) but also were more likely to have increased length of stay during the year following the index admission.⁶

These studies highlight the barriers to safe and effective transitions of care for this vulnerable population and demonstrate the increased burden that this population places on the health system.

Several retrospective studies have identified psychosocial and demographic risk factors associated with AMA discharge. These include younger age, male sex, substance abuse, lack of a primary care physician or health insurance, and history of previous AMA discharge.^1,3,7,8 Insurance status is also associated with AMA discharge, with increased odds of AMA discharge among Medicare and Medicaid patients and patients without health insurance.^9,10

Of note, one study found that race did not act as an independent predictor of AMA discharge when adjusted for age, gender, and socioeconomic factors.¹¹

The AMA population is clinically heterogeneous. Among patients with pneumonia, for example, Saitz et al showed that a patient’s documented clinical severity did not independently predict AMA discharge, suggesting that there is great clinical heterogeneity even among AMA patients with similar admission diagnoses.¹²

These studies highlight the clinical and demographic heterogeneity within this population, suggesting that patients discharged AMA require individualized attention from hospitalists and other healthcare providers.

Patients describe numerous motivations for leaving the hospital prematurely, including needing to pick up public-assistance checks, personal financial issues, and familial obligations.¹³ Interestingly, in the cohort of HIV patients referenced above, discharge on the day welfare checks were distributed was an independent predictor of AMA discharge.⁶ In focus groups composed of patients discharged AMA and their treating nurses and physicians, several themes were identified as potential contributors to AMA discharge, including drug addiction, pain management issues, external obligations, wait time, the physician’s bedside manner, being in a teaching hospital, and communication issues.¹⁴

Clearly, patients have a diversity of reasons for requesting to be discharged AMA, and further research is necessary to define clear and potentially modifiable risk factors.

Discussion

The clinical scenarios outlined above present two patients with very different clinical presentations and outpatient support systems as well as demonstrate the great variability in clinical risk at the time of discharge AMA. These examples emphasize the importance of an individualized approach to care for each patient.

In Case No. 1, the patient is admitted with a mild asthma exacerbation with persistent bronchospasm, though she clinically appears well and has reliable follow-up. In contrast, in Case No. 2, the patient has life-threatening disease and no established primary care physician or mechanism for outpatient care. These examples demonstrate extremes on the clinical and psychosocial spectrum of patients requesting an “early” discharge and suggest that no two patients at risk of AMA discharge are the same. Patient 1 could likely be safely managed at home with close outpatient follow-up, while Patient 2 presents a high-risk scenario with very few safe outpatient treatment options.

We suggest that an individualized approach be taken for each patient, with attention to both clinical and psychosocial risk. In clinically low-risk cases (e.g., Case No. 1), an approach that prioritizes shared decision making and coordination with the outpatient care team may be preferable to an AMA discharge, particularly given the often adversarial nature of the later.² In such cases, a collaborative approach may provide greater opportunity for harm reduction, provision of appropriate prescriptions, and follow-up appointments. In clinically high-risk patients such as Case No. 2, however, premature discharge is clearly inappropriate. Even in such clinically high-risk cases, however, we argue that a collaborative strategy aimed at identifying and addressing the patient’s psychosocial concerns is appropriate, as such an approach promotes shared decision making, builds trust between the patient and the care team, and therefore may facilitate improved follow-up at the time of discharge. Research is needed to formally assess the optimal approach for this patient population, including impact on rates of AMA discharge and the quality of post-discharge follow-up.

At present, the decision to classify a discharge as AMA falls solely on the treating provider, and we suspect that there is great variability in practice patterns, particularly as there are few established professional society practice guidelines regarding this difficult issue. As with all discharges from the hospital, the burden falls on the provider to engage the patient in shared decision making and ensure that the patient has the capacity to understand the risks and benefits of the proposed treatment plan. It is in this spirit that simply “filling out an AMA form” does not provide legal protection to a physician who does not adequately explain the full risks and benefits of refusal of inpatient treatment.^2,15

We propose that a high-quality AMA discharge be defined as a discharge in which the patient is informed of the clinical team’s determination that further hospitalization is required but elects to leave the hospital, and it includes a clear discussion of the risks of outpatient treatment, a determination of capacity, and an exploration of safe alternative care plans that could satisfy both the patient’s medical and social needs. This definition places the burden on hospitalists and other providers to fully explore the motivations behind a patient’s request to leave the hospital and treats psychosocial motivators for premature discharge as variables in the complex risk-benefit analysis that underlies the informed consent discussion prior to AMA discharge.

Furthermore, AMA discharge does not obviate a physician’s responsibility to advocate for a patient’s well-being, and therefore an AMA discharge should be accompanied by reasonable efforts to coordinate a patient’s ongoing outpatient care. Of note, this approach is consistent with previous reviews and attempts to balance the physician’s duty to honor a patient’s autonomy with the responsibility to protect the patient from harm.^2,16

Conclusion

Patients discharged AMA are a diverse population at markedly increased risk of morbidity, readmissions, and subsequent healthcare cost. We argue that in all cases of a potential premature discharge, a collaborative and patient-centered approach is crucial. Such an approach allows the provider to identify and address the patient’s concerns regarding further inpatient care, to explore possible safe outpatient treatment options, to document patient capacity, and to provide appropriate harm-reduction measures such as prescriptions.

Further research into the current practice patterns of hospitalists and other providers is necessary to allow for the formulation and adoption of best practices and implementation of appropriate harm-reduction strategies. TH

Dr. Tummalapalli is an internal medicine resident in the department of medicine at Icahn School of Medicine at Mount Sinai in New York City. Dr. Goodman is a hospitalist in the division of hospital medicine, department of medicine, at the Icahn School of Medicine at Mount Sinai.

References

1. Aliyu ZY. Discharge against medical advice: sociodemographic, clinical and financial perspectives. Int J Clin Pract. 2002;56(5):325-327.
2. Kahle CH, Rubio ML, Santos RA. Discharges against medical advice: considerations for the hospitalist and the patient. Hospital Medicine Clinics. 2015;4(3):421-429.
3. Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes. J Allergy Clin Immunol. 2007;119(4):924-929.
4. Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ. 2003;168(4):417-420.
5. Glasgow JM, Vaughn-Sarrazin MV, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Int Med. 2010;25(9):926-929.
6. Anis AH, Sun H, Guh DP, Palepu A, Schechter MT, O’Shaughnessy MV. Leaving hospital against medical advice among HIV-positive patients. CMAJ. 2002;167(6):633-637.
7. Jeremiah J, O’Sullivan P, Stein MD. Who leaves against medical advice? J Gen Int Med. 1995; 10(7);403-405.
8. O’Hara D, Hart W, McDonald I. Leaving hospital against medical advice. J Qual Clin Pract.1996;16(3):157-164.
9. Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health. 2007;97(12): 2204-2208.
10. Weingart SN, Davis RB, Phillips RS. Patients discharged against medical advice from a general medicine service. J Gen Intern Med. 1998;13(8):568-571.
11. Franks P, Meldrum S, Fiscella K. Discharges against medical advice: are race/ethnicity predictors? J Gen Intern Med. 2006;21(9):955-960.
12. Saitz R, Ghali WA, Moskowitz MA. Characteristics of patients with pneumonia who are discharged from hospitals against medical advice. Am J Med. 1999;107(5):507-509.
13. Alfandre, DJ. “I’m going home”: discharges against medical advice. Mayo Clin Proc. 2009;84(3):255-260.
14. Onukwugha E, Saunders E, Mullins CD, Pradel FG, Zuckerman M, Weir MR. Reasons for discharges against medical advice: a qualitative study. Qual Saf Health Care. 2010;19(5):420-424. doi: 10.1136/qshc.2009.036269.
15. Battenfeld v. Gregory, 589 A.2d 1059, 1061 (N.J. Super. Ct. App. Div. 1991).
16. Berger J. Discharge against medical advice: ethical considerations and professional obligations. J Hosp Med. 2008;3(5):403-408.

Case No. 1

A 41-year-old woman with a history of asthma presents to the emergency department (ED) with shortness of breath and wheezing. She is diagnosed with a mild asthma exacerbation. After three albuterol nebulizer treatments, she still has wheezing on physical examination but appears comfortable and has no oxygen requirement. She has a primary medical doctor at the hospital and follows up with her regularly.

The hospitalist recommends that she stay in the hospital for further treatment, but the patient says she has a nebulizer machine at home and asks to be discharged. In addition, she is worried about her frail elderly mother, for whom she is the primary caretaker. The hospitalist acknowledges her concerns but continues to recommend that she remain in the hospital for additional care and monitoring. She becomes visibly upset and insists that she must return home. She asks for prescriptions for albuterol and prednisone and is discharged against medical advice (AMA).

Case No. 2

A 52-year-old man with a history of hypertension and diabetes presents to the ED with left foot pain. He frequently presents with this complaint but often leaves AMA before treatment is completed. He has no known physical address or telephone number and has no known outpatient healthcare providers. Physical examination reveals several ulcers on the dorsum of the foot, one with purulent drainage, and generalized lower extremity pallor. His left leg is cool to the touch, and vascular surgery is consulted for suspected limb-threatening ischemia; IV antibiotics are started for suspected osteomyelitis.

During the interview, he states that he wishes to leave the hospital because he has “things to take care of.” The hospitalist recommends that he remain in the hospital for limb-preserving surgery and antibiotics. He then explains that he is homeless and needs to return to his shelter to keep his bed. He is able to articulate the risks of premature discharge and the medical concerns, and it is determined that he has the capacity to participate in discharge planning. The hospitalist therefore discharges him AMA.

Background

AMA discharges represent 1%–2% of all inpatient discharges.¹,² Despite being a small percentage of total discharges, these patients have disproportionately high healthcare costs. One study reported that healthcare costs among these patients were 56% higher than expected.² Furthermore, AMA patients suffer higher than expected rates of morbidity, mortality, and hospital readmission.

For example, in one case-control study in an urban teaching hospital, patients discharged AMA from the general medicine service had a 21% 15-day readmission rate compared to a 3% readmission rate among age, gender, and diagnosis-matched controls.^3,4,5

Additionally, history of AMA discharge appears to confer risk of increased future utilization of healthcare resources. In a cohort study of hospital admissions among HIV-infected patients with high rates of intravenous drug abuse, patients discharged AMA (13% of the cohort) were not only more likely to be readmitted within 30 days for a related diagnosis (odds ratio = 5.0) but also were more likely to have increased length of stay during the year following the index admission.⁶

These studies highlight the barriers to safe and effective transitions of care for this vulnerable population and demonstrate the increased burden that this population places on the health system.

Several retrospective studies have identified psychosocial and demographic risk factors associated with AMA discharge. These include younger age, male sex, substance abuse, lack of a primary care physician or health insurance, and history of previous AMA discharge.^1,3,7,8 Insurance status is also associated with AMA discharge, with increased odds of AMA discharge among Medicare and Medicaid patients and patients without health insurance.^9,10

Of note, one study found that race did not act as an independent predictor of AMA discharge when adjusted for age, gender, and socioeconomic factors.¹¹

The AMA population is clinically heterogeneous. Among patients with pneumonia, for example, Saitz et al showed that a patient’s documented clinical severity did not independently predict AMA discharge, suggesting that there is great clinical heterogeneity even among AMA patients with similar admission diagnoses.¹²

These studies highlight the clinical and demographic heterogeneity within this population, suggesting that patients discharged AMA require individualized attention from hospitalists and other healthcare providers.

Patients describe numerous motivations for leaving the hospital prematurely, including needing to pick up public-assistance checks, personal financial issues, and familial obligations.¹³ Interestingly, in the cohort of HIV patients referenced above, discharge on the day welfare checks were distributed was an independent predictor of AMA discharge.⁶ In focus groups composed of patients discharged AMA and their treating nurses and physicians, several themes were identified as potential contributors to AMA discharge, including drug addiction, pain management issues, external obligations, wait time, the physician’s bedside manner, being in a teaching hospital, and communication issues.¹⁴

Clearly, patients have a diversity of reasons for requesting to be discharged AMA, and further research is necessary to define clear and potentially modifiable risk factors.

Discussion

The clinical scenarios outlined above present two patients with very different clinical presentations and outpatient support systems as well as demonstrate the great variability in clinical risk at the time of discharge AMA. These examples emphasize the importance of an individualized approach to care for each patient.

In Case No. 1, the patient is admitted with a mild asthma exacerbation with persistent bronchospasm, though she clinically appears well and has reliable follow-up. In contrast, in Case No. 2, the patient has life-threatening disease and no established primary care physician or mechanism for outpatient care. These examples demonstrate extremes on the clinical and psychosocial spectrum of patients requesting an “early” discharge and suggest that no two patients at risk of AMA discharge are the same. Patient 1 could likely be safely managed at home with close outpatient follow-up, while Patient 2 presents a high-risk scenario with very few safe outpatient treatment options.

We suggest that an individualized approach be taken for each patient, with attention to both clinical and psychosocial risk. In clinically low-risk cases (e.g., Case No. 1), an approach that prioritizes shared decision making and coordination with the outpatient care team may be preferable to an AMA discharge, particularly given the often adversarial nature of the later.² In such cases, a collaborative approach may provide greater opportunity for harm reduction, provision of appropriate prescriptions, and follow-up appointments. In clinically high-risk patients such as Case No. 2, however, premature discharge is clearly inappropriate. Even in such clinically high-risk cases, however, we argue that a collaborative strategy aimed at identifying and addressing the patient’s psychosocial concerns is appropriate, as such an approach promotes shared decision making, builds trust between the patient and the care team, and therefore may facilitate improved follow-up at the time of discharge. Research is needed to formally assess the optimal approach for this patient population, including impact on rates of AMA discharge and the quality of post-discharge follow-up.

At present, the decision to classify a discharge as AMA falls solely on the treating provider, and we suspect that there is great variability in practice patterns, particularly as there are few established professional society practice guidelines regarding this difficult issue. As with all discharges from the hospital, the burden falls on the provider to engage the patient in shared decision making and ensure that the patient has the capacity to understand the risks and benefits of the proposed treatment plan. It is in this spirit that simply “filling out an AMA form” does not provide legal protection to a physician who does not adequately explain the full risks and benefits of refusal of inpatient treatment.^2,15

We propose that a high-quality AMA discharge be defined as a discharge in which the patient is informed of the clinical team’s determination that further hospitalization is required but elects to leave the hospital, and it includes a clear discussion of the risks of outpatient treatment, a determination of capacity, and an exploration of safe alternative care plans that could satisfy both the patient’s medical and social needs. This definition places the burden on hospitalists and other providers to fully explore the motivations behind a patient’s request to leave the hospital and treats psychosocial motivators for premature discharge as variables in the complex risk-benefit analysis that underlies the informed consent discussion prior to AMA discharge.

Furthermore, AMA discharge does not obviate a physician’s responsibility to advocate for a patient’s well-being, and therefore an AMA discharge should be accompanied by reasonable efforts to coordinate a patient’s ongoing outpatient care. Of note, this approach is consistent with previous reviews and attempts to balance the physician’s duty to honor a patient’s autonomy with the responsibility to protect the patient from harm.^2,16

Conclusion

Patients discharged AMA are a diverse population at markedly increased risk of morbidity, readmissions, and subsequent healthcare cost. We argue that in all cases of a potential premature discharge, a collaborative and patient-centered approach is crucial. Such an approach allows the provider to identify and address the patient’s concerns regarding further inpatient care, to explore possible safe outpatient treatment options, to document patient capacity, and to provide appropriate harm-reduction measures such as prescriptions.

Further research into the current practice patterns of hospitalists and other providers is necessary to allow for the formulation and adoption of best practices and implementation of appropriate harm-reduction strategies. TH

Dr. Tummalapalli is an internal medicine resident in the department of medicine at Icahn School of Medicine at Mount Sinai in New York City. Dr. Goodman is a hospitalist in the division of hospital medicine, department of medicine, at the Icahn School of Medicine at Mount Sinai.

References

1. Aliyu ZY. Discharge against medical advice: sociodemographic, clinical and financial perspectives. Int J Clin Pract. 2002;56(5):325-327.
2. Kahle CH, Rubio ML, Santos RA. Discharges against medical advice: considerations for the hospitalist and the patient. Hospital Medicine Clinics. 2015;4(3):421-429.
3. Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes. J Allergy Clin Immunol. 2007;119(4):924-929.
4. Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ. 2003;168(4):417-420.
5. Glasgow JM, Vaughn-Sarrazin MV, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Int Med. 2010;25(9):926-929.
6. Anis AH, Sun H, Guh DP, Palepu A, Schechter MT, O’Shaughnessy MV. Leaving hospital against medical advice among HIV-positive patients. CMAJ. 2002;167(6):633-637.
7. Jeremiah J, O’Sullivan P, Stein MD. Who leaves against medical advice? J Gen Int Med. 1995; 10(7);403-405.
8. O’Hara D, Hart W, McDonald I. Leaving hospital against medical advice. J Qual Clin Pract.1996;16(3):157-164.
9. Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health. 2007;97(12): 2204-2208.
10. Weingart SN, Davis RB, Phillips RS. Patients discharged against medical advice from a general medicine service. J Gen Intern Med. 1998;13(8):568-571.
11. Franks P, Meldrum S, Fiscella K. Discharges against medical advice: are race/ethnicity predictors? J Gen Intern Med. 2006;21(9):955-960.
12. Saitz R, Ghali WA, Moskowitz MA. Characteristics of patients with pneumonia who are discharged from hospitals against medical advice. Am J Med. 1999;107(5):507-509.
13. Alfandre, DJ. “I’m going home”: discharges against medical advice. Mayo Clin Proc. 2009;84(3):255-260.
14. Onukwugha E, Saunders E, Mullins CD, Pradel FG, Zuckerman M, Weir MR. Reasons for discharges against medical advice: a qualitative study. Qual Saf Health Care. 2010;19(5):420-424. doi: 10.1136/qshc.2009.036269.
15. Battenfeld v. Gregory, 589 A.2d 1059, 1061 (N.J. Super. Ct. App. Div. 1991).
16. Berger J. Discharge against medical advice: ethical considerations and professional obligations. J Hosp Med. 2008;3(5):403-408.

Case No. 1

A 41-year-old woman with a history of asthma presents to the emergency department (ED) with shortness of breath and wheezing. She is diagnosed with a mild asthma exacerbation. After three albuterol nebulizer treatments, she still has wheezing on physical examination but appears comfortable and has no oxygen requirement. She has a primary medical doctor at the hospital and follows up with her regularly.

The hospitalist recommends that she stay in the hospital for further treatment, but the patient says she has a nebulizer machine at home and asks to be discharged. In addition, she is worried about her frail elderly mother, for whom she is the primary caretaker. The hospitalist acknowledges her concerns but continues to recommend that she remain in the hospital for additional care and monitoring. She becomes visibly upset and insists that she must return home. She asks for prescriptions for albuterol and prednisone and is discharged against medical advice (AMA).

Case No. 2

A 52-year-old man with a history of hypertension and diabetes presents to the ED with left foot pain. He frequently presents with this complaint but often leaves AMA before treatment is completed. He has no known physical address or telephone number and has no known outpatient healthcare providers. Physical examination reveals several ulcers on the dorsum of the foot, one with purulent drainage, and generalized lower extremity pallor. His left leg is cool to the touch, and vascular surgery is consulted for suspected limb-threatening ischemia; IV antibiotics are started for suspected osteomyelitis.

During the interview, he states that he wishes to leave the hospital because he has “things to take care of.” The hospitalist recommends that he remain in the hospital for limb-preserving surgery and antibiotics. He then explains that he is homeless and needs to return to his shelter to keep his bed. He is able to articulate the risks of premature discharge and the medical concerns, and it is determined that he has the capacity to participate in discharge planning. The hospitalist therefore discharges him AMA.

Background

AMA discharges represent 1%–2% of all inpatient discharges.¹,² Despite being a small percentage of total discharges, these patients have disproportionately high healthcare costs. One study reported that healthcare costs among these patients were 56% higher than expected.² Furthermore, AMA patients suffer higher than expected rates of morbidity, mortality, and hospital readmission.

For example, in one case-control study in an urban teaching hospital, patients discharged AMA from the general medicine service had a 21% 15-day readmission rate compared to a 3% readmission rate among age, gender, and diagnosis-matched controls.^3,4,5

Additionally, history of AMA discharge appears to confer risk of increased future utilization of healthcare resources. In a cohort study of hospital admissions among HIV-infected patients with high rates of intravenous drug abuse, patients discharged AMA (13% of the cohort) were not only more likely to be readmitted within 30 days for a related diagnosis (odds ratio = 5.0) but also were more likely to have increased length of stay during the year following the index admission.⁶

These studies highlight the barriers to safe and effective transitions of care for this vulnerable population and demonstrate the increased burden that this population places on the health system.

Several retrospective studies have identified psychosocial and demographic risk factors associated with AMA discharge. These include younger age, male sex, substance abuse, lack of a primary care physician or health insurance, and history of previous AMA discharge.^1,3,7,8 Insurance status is also associated with AMA discharge, with increased odds of AMA discharge among Medicare and Medicaid patients and patients without health insurance.^9,10

Of note, one study found that race did not act as an independent predictor of AMA discharge when adjusted for age, gender, and socioeconomic factors.¹¹

The AMA population is clinically heterogeneous. Among patients with pneumonia, for example, Saitz et al showed that a patient’s documented clinical severity did not independently predict AMA discharge, suggesting that there is great clinical heterogeneity even among AMA patients with similar admission diagnoses.¹²

These studies highlight the clinical and demographic heterogeneity within this population, suggesting that patients discharged AMA require individualized attention from hospitalists and other healthcare providers.

Patients describe numerous motivations for leaving the hospital prematurely, including needing to pick up public-assistance checks, personal financial issues, and familial obligations.¹³ Interestingly, in the cohort of HIV patients referenced above, discharge on the day welfare checks were distributed was an independent predictor of AMA discharge.⁶ In focus groups composed of patients discharged AMA and their treating nurses and physicians, several themes were identified as potential contributors to AMA discharge, including drug addiction, pain management issues, external obligations, wait time, the physician’s bedside manner, being in a teaching hospital, and communication issues.¹⁴

Clearly, patients have a diversity of reasons for requesting to be discharged AMA, and further research is necessary to define clear and potentially modifiable risk factors.

Discussion

The clinical scenarios outlined above present two patients with very different clinical presentations and outpatient support systems as well as demonstrate the great variability in clinical risk at the time of discharge AMA. These examples emphasize the importance of an individualized approach to care for each patient.

In Case No. 1, the patient is admitted with a mild asthma exacerbation with persistent bronchospasm, though she clinically appears well and has reliable follow-up. In contrast, in Case No. 2, the patient has life-threatening disease and no established primary care physician or mechanism for outpatient care. These examples demonstrate extremes on the clinical and psychosocial spectrum of patients requesting an “early” discharge and suggest that no two patients at risk of AMA discharge are the same. Patient 1 could likely be safely managed at home with close outpatient follow-up, while Patient 2 presents a high-risk scenario with very few safe outpatient treatment options.

We suggest that an individualized approach be taken for each patient, with attention to both clinical and psychosocial risk. In clinically low-risk cases (e.g., Case No. 1), an approach that prioritizes shared decision making and coordination with the outpatient care team may be preferable to an AMA discharge, particularly given the often adversarial nature of the later.² In such cases, a collaborative approach may provide greater opportunity for harm reduction, provision of appropriate prescriptions, and follow-up appointments. In clinically high-risk patients such as Case No. 2, however, premature discharge is clearly inappropriate. Even in such clinically high-risk cases, however, we argue that a collaborative strategy aimed at identifying and addressing the patient’s psychosocial concerns is appropriate, as such an approach promotes shared decision making, builds trust between the patient and the care team, and therefore may facilitate improved follow-up at the time of discharge. Research is needed to formally assess the optimal approach for this patient population, including impact on rates of AMA discharge and the quality of post-discharge follow-up.

At present, the decision to classify a discharge as AMA falls solely on the treating provider, and we suspect that there is great variability in practice patterns, particularly as there are few established professional society practice guidelines regarding this difficult issue. As with all discharges from the hospital, the burden falls on the provider to engage the patient in shared decision making and ensure that the patient has the capacity to understand the risks and benefits of the proposed treatment plan. It is in this spirit that simply “filling out an AMA form” does not provide legal protection to a physician who does not adequately explain the full risks and benefits of refusal of inpatient treatment.^2,15

We propose that a high-quality AMA discharge be defined as a discharge in which the patient is informed of the clinical team’s determination that further hospitalization is required but elects to leave the hospital, and it includes a clear discussion of the risks of outpatient treatment, a determination of capacity, and an exploration of safe alternative care plans that could satisfy both the patient’s medical and social needs. This definition places the burden on hospitalists and other providers to fully explore the motivations behind a patient’s request to leave the hospital and treats psychosocial motivators for premature discharge as variables in the complex risk-benefit analysis that underlies the informed consent discussion prior to AMA discharge.

Furthermore, AMA discharge does not obviate a physician’s responsibility to advocate for a patient’s well-being, and therefore an AMA discharge should be accompanied by reasonable efforts to coordinate a patient’s ongoing outpatient care. Of note, this approach is consistent with previous reviews and attempts to balance the physician’s duty to honor a patient’s autonomy with the responsibility to protect the patient from harm.^2,16

Conclusion

Patients discharged AMA are a diverse population at markedly increased risk of morbidity, readmissions, and subsequent healthcare cost. We argue that in all cases of a potential premature discharge, a collaborative and patient-centered approach is crucial. Such an approach allows the provider to identify and address the patient’s concerns regarding further inpatient care, to explore possible safe outpatient treatment options, to document patient capacity, and to provide appropriate harm-reduction measures such as prescriptions.

Further research into the current practice patterns of hospitalists and other providers is necessary to allow for the formulation and adoption of best practices and implementation of appropriate harm-reduction strategies. TH

Dr. Tummalapalli is an internal medicine resident in the department of medicine at Icahn School of Medicine at Mount Sinai in New York City. Dr. Goodman is a hospitalist in the division of hospital medicine, department of medicine, at the Icahn School of Medicine at Mount Sinai.

References

1. Aliyu ZY. Discharge against medical advice: sociodemographic, clinical and financial perspectives. Int J Clin Pract. 2002;56(5):325-327.
2. Kahle CH, Rubio ML, Santos RA. Discharges against medical advice: considerations for the hospitalist and the patient. Hospital Medicine Clinics. 2015;4(3):421-429.
3. Baptist AP, Warrier I, Arora R, Ager J, Massanari RM. Hospitalized patients with asthma who leave against medical advice: characteristics, reasons, and outcomes. J Allergy Clin Immunol. 2007;119(4):924-929.
4. Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice? CMAJ. 2003;168(4):417-420.
5. Glasgow JM, Vaughn-Sarrazin MV, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Int Med. 2010;25(9):926-929.
6. Anis AH, Sun H, Guh DP, Palepu A, Schechter MT, O’Shaughnessy MV. Leaving hospital against medical advice among HIV-positive patients. CMAJ. 2002;167(6):633-637.
7. Jeremiah J, O’Sullivan P, Stein MD. Who leaves against medical advice? J Gen Int Med. 1995; 10(7);403-405.
8. O’Hara D, Hart W, McDonald I. Leaving hospital against medical advice. J Qual Clin Pract.1996;16(3):157-164.
9. Ibrahim SA, Kwoh CK, Krishnan E. Factors associated with patients who leave acute-care hospitals against medical advice. Am J Public Health. 2007;97(12): 2204-2208.
10. Weingart SN, Davis RB, Phillips RS. Patients discharged against medical advice from a general medicine service. J Gen Intern Med. 1998;13(8):568-571.
11. Franks P, Meldrum S, Fiscella K. Discharges against medical advice: are race/ethnicity predictors? J Gen Intern Med. 2006;21(9):955-960.
12. Saitz R, Ghali WA, Moskowitz MA. Characteristics of patients with pneumonia who are discharged from hospitals against medical advice. Am J Med. 1999;107(5):507-509.
13. Alfandre, DJ. “I’m going home”: discharges against medical advice. Mayo Clin Proc. 2009;84(3):255-260.
14. Onukwugha E, Saunders E, Mullins CD, Pradel FG, Zuckerman M, Weir MR. Reasons for discharges against medical advice: a qualitative study. Qual Saf Health Care. 2010;19(5):420-424. doi: 10.1136/qshc.2009.036269.
15. Battenfeld v. Gregory, 589 A.2d 1059, 1061 (N.J. Super. Ct. App. Div. 1991).
16. Berger J. Discharge against medical advice: ethical considerations and professional obligations. J Hosp Med. 2008;3(5):403-408.

Malaria-infected cell bursting

Image by Peter H. Seeberger

A malaria test called illumigene® Malaria has received the CE mark, which suggests it meets European health and safety standards.

illumigene Malaria is a molecular test that involves the use of loop-mediated isothermal amplification (LAMP) technology.

According to the test’s developers, it provides results in under an hour, doesn’t require a high level technical expertise, and is up to 80,000 times more sensitive than conventional malaria tests.

illumigene Malaria was developed by Meridian Bioscience, Inc., with technical assistance from the US Centers for Disease Control and Prevention (CDC) and Cheikh Anta Diop University in Dakar, Senegal.

“illumigene Malaria has the potential to change current practices,” said Daouda NDIAYE, PharmD, PhD, of Cheikh Anta Diop University.

“Faster and more accurate diagnosis is vital in the fight against malaria. Earlier diagnosis enables the correct treatment to be prescribed, which leads to better clinical outcomes for the person with malaria and keeps malaria treatments for the right people.”

“Because of submicroscopic parasitemia carriage among the populations, a robust, sensitive, and field-community-deployable screening tool is needed to track the malaria reservoir in pre-elimination regions.  illumigene Malaria shows this capacity.”

illumigene Malaria uses LAMP technology to amplify DNA and detect the presence of the malaria parasite.

LAMP technology is isothermal and can be used at room temperature without the need to heat reagents or the material being tested, unlike the rapid diagnostic tests currently used in malaria, which use polymerase chain reaction technology. illumigene Malaria does not require refrigeration.

Meridian Bioscience has worked with experts at the CDC and the Cheikh Anta Diop University of Dakar during the development of illumigene Malaria and collaborated with these organizations to design clinical trials.

According to Meridian, data from more than 200 patients in Senegal validated the performance of illumigene Malaria. The test demonstrated 100% sensitivity and detected infected patients that were missed by conventional testing methods.

Meridian said illumigene Malaria will be distributed in the European, Middle Eastern, and African regions by Meridian Bioscience Europe and in additional international markets by the company’s global distribution network.

Malaria-infected cell bursting

Image by Peter H. Seeberger

A malaria test called illumigene® Malaria has received the CE mark, which suggests it meets European health and safety standards.

illumigene Malaria is a molecular test that involves the use of loop-mediated isothermal amplification (LAMP) technology.

According to the test’s developers, it provides results in under an hour, doesn’t require a high level technical expertise, and is up to 80,000 times more sensitive than conventional malaria tests.

illumigene Malaria was developed by Meridian Bioscience, Inc., with technical assistance from the US Centers for Disease Control and Prevention (CDC) and Cheikh Anta Diop University in Dakar, Senegal.

“illumigene Malaria has the potential to change current practices,” said Daouda NDIAYE, PharmD, PhD, of Cheikh Anta Diop University.

“Faster and more accurate diagnosis is vital in the fight against malaria. Earlier diagnosis enables the correct treatment to be prescribed, which leads to better clinical outcomes for the person with malaria and keeps malaria treatments for the right people.”

“Because of submicroscopic parasitemia carriage among the populations, a robust, sensitive, and field-community-deployable screening tool is needed to track the malaria reservoir in pre-elimination regions.  illumigene Malaria shows this capacity.”

illumigene Malaria uses LAMP technology to amplify DNA and detect the presence of the malaria parasite.

LAMP technology is isothermal and can be used at room temperature without the need to heat reagents or the material being tested, unlike the rapid diagnostic tests currently used in malaria, which use polymerase chain reaction technology. illumigene Malaria does not require refrigeration.

Meridian Bioscience has worked with experts at the CDC and the Cheikh Anta Diop University of Dakar during the development of illumigene Malaria and collaborated with these organizations to design clinical trials.

According to Meridian, data from more than 200 patients in Senegal validated the performance of illumigene Malaria. The test demonstrated 100% sensitivity and detected infected patients that were missed by conventional testing methods.

Meridian said illumigene Malaria will be distributed in the European, Middle Eastern, and African regions by Meridian Bioscience Europe and in additional international markets by the company’s global distribution network.

Malaria-infected cell bursting

Image by Peter H. Seeberger

A malaria test called illumigene® Malaria has received the CE mark, which suggests it meets European health and safety standards.

illumigene Malaria is a molecular test that involves the use of loop-mediated isothermal amplification (LAMP) technology.

According to the test’s developers, it provides results in under an hour, doesn’t require a high level technical expertise, and is up to 80,000 times more sensitive than conventional malaria tests.

illumigene Malaria was developed by Meridian Bioscience, Inc., with technical assistance from the US Centers for Disease Control and Prevention (CDC) and Cheikh Anta Diop University in Dakar, Senegal.

“illumigene Malaria has the potential to change current practices,” said Daouda NDIAYE, PharmD, PhD, of Cheikh Anta Diop University.

“Faster and more accurate diagnosis is vital in the fight against malaria. Earlier diagnosis enables the correct treatment to be prescribed, which leads to better clinical outcomes for the person with malaria and keeps malaria treatments for the right people.”

“Because of submicroscopic parasitemia carriage among the populations, a robust, sensitive, and field-community-deployable screening tool is needed to track the malaria reservoir in pre-elimination regions.  illumigene Malaria shows this capacity.”

illumigene Malaria uses LAMP technology to amplify DNA and detect the presence of the malaria parasite.

LAMP technology is isothermal and can be used at room temperature without the need to heat reagents or the material being tested, unlike the rapid diagnostic tests currently used in malaria, which use polymerase chain reaction technology. illumigene Malaria does not require refrigeration.

Meridian Bioscience has worked with experts at the CDC and the Cheikh Anta Diop University of Dakar during the development of illumigene Malaria and collaborated with these organizations to design clinical trials.

According to Meridian, data from more than 200 patients in Senegal validated the performance of illumigene Malaria. The test demonstrated 100% sensitivity and detected infected patients that were missed by conventional testing methods.

Meridian said illumigene Malaria will be distributed in the European, Middle Eastern, and African regions by Meridian Bioscience Europe and in additional international markets by the company’s global distribution network.

Time-lapse images showing

apoptosis in cancer cells

Preclinical research suggests a new class of small-molecule inhibitors could potentially treat leukemias and lymphomas.

Researchers identified compounds targeting the Mdm2–MdmX RING–RING interaction as a new class of E3 ligase inhibitors.

Experiments showed that these compounds, dubbed MMRis, can induce apoptosis in leukemia and lymphoma cells.

The researchers detailed these experiments in Cell Death and Disease.

“We are excited about the unique activities of these compounds and will continue to focus our research efforts on development of their clinical potential,” said study author Xinjiang Wang, PhD, of Roswell Park Cancer Institute in Buffalo, New York.

“These compounds kill cancer cells. [They don’t] just stop cancer cell growth temporarily. These types of agents offer the promise of therapeutic benefit.”

Dr Wang and his colleagues found that MMRis specifically inhibit Mdm2–MdmX E3 ligase activity toward Mdm2 and p53 substrates.

The team said MMRis have an advantage over p53-activating agents that are currently in use as cancer therapies.

That is because MMRis activate the pro-apoptotic function of the p53 pathway, whereas current p53-activating agents temporarily prevent cancer growth but don’t damage existing cancer cells or prevent cancer growth long-term.

The researchers found that 2 MMRi compounds—MMRi6 and its analog, MMRi64—can disrupt Mdm2–MdmX interactions and activate p53 in vitro.

And MMRi64 selectively induces the apoptotic arm of the p53 pathway in leukemia and lymphoma cells.

The team noted that, unlike Nutlin3a, MMRi64 only induces expression of the pro-apoptotic gene PUMA, with minimal induction of the growth-arresting gene p21. However, combining MMRi64 and Nutlin3a produces a synergistic apoptotic effect.

“This study opens a new area for anticancer drug development,” Dr Wang said. “MMRi compounds also can be used as a tool for better understanding the anti-death mechanisms developed by cancer cells.”

“We are moving the research of MMRi compounds forward using both preclinical models and human cancer cell lines. Our hope is that further development of clinically useful MMRi will eventually provide a new treatment option for cancer patients.”

Time-lapse images showing

apoptosis in cancer cells

Preclinical research suggests a new class of small-molecule inhibitors could potentially treat leukemias and lymphomas.

Researchers identified compounds targeting the Mdm2–MdmX RING–RING interaction as a new class of E3 ligase inhibitors.

Experiments showed that these compounds, dubbed MMRis, can induce apoptosis in leukemia and lymphoma cells.

The researchers detailed these experiments in Cell Death and Disease.

“We are excited about the unique activities of these compounds and will continue to focus our research efforts on development of their clinical potential,” said study author Xinjiang Wang, PhD, of Roswell Park Cancer Institute in Buffalo, New York.

“These compounds kill cancer cells. [They don’t] just stop cancer cell growth temporarily. These types of agents offer the promise of therapeutic benefit.”

Dr Wang and his colleagues found that MMRis specifically inhibit Mdm2–MdmX E3 ligase activity toward Mdm2 and p53 substrates.

The team said MMRis have an advantage over p53-activating agents that are currently in use as cancer therapies.

That is because MMRis activate the pro-apoptotic function of the p53 pathway, whereas current p53-activating agents temporarily prevent cancer growth but don’t damage existing cancer cells or prevent cancer growth long-term.

The researchers found that 2 MMRi compounds—MMRi6 and its analog, MMRi64—can disrupt Mdm2–MdmX interactions and activate p53 in vitro.

And MMRi64 selectively induces the apoptotic arm of the p53 pathway in leukemia and lymphoma cells.

The team noted that, unlike Nutlin3a, MMRi64 only induces expression of the pro-apoptotic gene PUMA, with minimal induction of the growth-arresting gene p21. However, combining MMRi64 and Nutlin3a produces a synergistic apoptotic effect.

“This study opens a new area for anticancer drug development,” Dr Wang said. “MMRi compounds also can be used as a tool for better understanding the anti-death mechanisms developed by cancer cells.”

“We are moving the research of MMRi compounds forward using both preclinical models and human cancer cell lines. Our hope is that further development of clinically useful MMRi will eventually provide a new treatment option for cancer patients.”

Time-lapse images showing

apoptosis in cancer cells

Preclinical research suggests a new class of small-molecule inhibitors could potentially treat leukemias and lymphomas.

Researchers identified compounds targeting the Mdm2–MdmX RING–RING interaction as a new class of E3 ligase inhibitors.

Experiments showed that these compounds, dubbed MMRis, can induce apoptosis in leukemia and lymphoma cells.

The researchers detailed these experiments in Cell Death and Disease.

“We are excited about the unique activities of these compounds and will continue to focus our research efforts on development of their clinical potential,” said study author Xinjiang Wang, PhD, of Roswell Park Cancer Institute in Buffalo, New York.

“These compounds kill cancer cells. [They don’t] just stop cancer cell growth temporarily. These types of agents offer the promise of therapeutic benefit.”

Dr Wang and his colleagues found that MMRis specifically inhibit Mdm2–MdmX E3 ligase activity toward Mdm2 and p53 substrates.

The team said MMRis have an advantage over p53-activating agents that are currently in use as cancer therapies.

That is because MMRis activate the pro-apoptotic function of the p53 pathway, whereas current p53-activating agents temporarily prevent cancer growth but don’t damage existing cancer cells or prevent cancer growth long-term.

The researchers found that 2 MMRi compounds—MMRi6 and its analog, MMRi64—can disrupt Mdm2–MdmX interactions and activate p53 in vitro.

And MMRi64 selectively induces the apoptotic arm of the p53 pathway in leukemia and lymphoma cells.

The team noted that, unlike Nutlin3a, MMRi64 only induces expression of the pro-apoptotic gene PUMA, with minimal induction of the growth-arresting gene p21. However, combining MMRi64 and Nutlin3a produces a synergistic apoptotic effect.

“This study opens a new area for anticancer drug development,” Dr Wang said. “MMRi compounds also can be used as a tool for better understanding the anti-death mechanisms developed by cancer cells.”

“We are moving the research of MMRi compounds forward using both preclinical models and human cancer cell lines. Our hope is that further development of clinically useful MMRi will eventually provide a new treatment option for cancer patients.”

Cancer patient

receiving chemotherapy

Photo by Rhoda Baer

Projections for 2016 suggest that leukemia deaths are on the decline in the European Union (EU), particularly for children and young adults.

Leukemia death rates are expected to fall 19% in men and 16% in women in 2016, when compared to 2007 data.

Rates are projected to fall 38% in boys and 20% in girls ages 0 to 14, 26% in men and 22% in women ages 15 to 44, and 19% in men and women ages 45 to 69.

Researchers said improvements in management, multidrug chemotherapy, immunotherapies, stem cell transplants, radiotherapy, and targeted therapies have all contributed to improvements in survival for leukemia patients.

However, some leukemias remain hard to treat, particularly those that are more common in adults and the elderly.

“Predictions of death rates from leukemia are complicated by the fact that leukemias are a varied collection of blood cancers, with some being more treatable than others,” said study author Carlo La Vecchia, MD, of the University of Milan in Italy.

“However, the important falls in overall death rates from this group of diseases are very encouraging and are a testament to the hard work of researchers and clinicians in developing and implementing better diagnosis and treatments.”

Dr Vecchia and his colleagues reported the results of this research in Annals of Oncology.

The researchers looked at cancer deaths in the EU as a whole and in the 6 largest countries—France, Germany, Italy, Poland, Spain, and the UK.

The team assessed mortality for all cancers and looked at individual data for cancers of the stomach, intestines, pancreas, lung, prostate, breast, and uterus (including cervix), as well as leukemias.

All cancers

The researchers’ projections suggest that total cancer mortality rates will decrease for both sexes in 2016, despite a rise in the absolute number of deaths due to the aging population. The team said the median age of the total EU population was 41 in 2011 and will be 42 in 2016.

So a total of 1,359,500 EU citizens are expected to die of cancer in 2016—753,600 men and 605,900 women. This is compared to 1,314,787 cancer deaths in 2011—734,259 men and 580,528 women.

The age-standardized mortality rates for 2016 are 133.5 per 100,000 men and 85.2 per 100,000 women, compared to 144.6 per 100,000 men and 88.1 per 100,000 women in 2011.

So that’s a 7.7% fall in cancer death rates for men and a 3.3% fall for women from 2011 through 2016, despite a 3.3% increase in the absolute number of cancer deaths.

Leukemias

The researchers predict that, in 2016, age-standardized leukemia mortality rates will be 3.95 per 100,000  men and 2.46 per 100,000 women.

In comparison, the age-standardized mortality rates for 2000-2004 were 5.23 for men and 3.20 for women. The rates for 2005-2009 were 4.85 for men and 2.92 for women.

For males ages 0 to 14, the age-standardized mortality rates are 1.10 for 2000-2004, 0.87 for 2005-2009, and 0.54 for 2016. For females in this age group, the rates are 0.85 for 2000-2004, 0.69 for 2005-2009, and 0.55 for 2016.

For males ages 15 to 44, the age-standardized mortality rates are 1.50 for 2000-2004, 1.28 for 2005-2009, and 0.95 for 2016. For females, the rates are 1.07 for 2000-2004, 0.92 for 2005-2009, and 0.72 for 2016.

For males ages 45 to 69, the age-standardized mortality rates are 9.19 for 2000-2004, 8.39 for 2005-2009, and 6.79 for 2016. For females, the rates are 5.74 for 2000-2004, 5.12 for 2005-2009, and 4.16 for 2016.

Cancer patient

receiving chemotherapy

Photo by Rhoda Baer

Projections for 2016 suggest that leukemia deaths are on the decline in the European Union (EU), particularly for children and young adults.

Leukemia death rates are expected to fall 19% in men and 16% in women in 2016, when compared to 2007 data.

Rates are projected to fall 38% in boys and 20% in girls ages 0 to 14, 26% in men and 22% in women ages 15 to 44, and 19% in men and women ages 45 to 69.

Researchers said improvements in management, multidrug chemotherapy, immunotherapies, stem cell transplants, radiotherapy, and targeted therapies have all contributed to improvements in survival for leukemia patients.

However, some leukemias remain hard to treat, particularly those that are more common in adults and the elderly.

“Predictions of death rates from leukemia are complicated by the fact that leukemias are a varied collection of blood cancers, with some being more treatable than others,” said study author Carlo La Vecchia, MD, of the University of Milan in Italy.

“However, the important falls in overall death rates from this group of diseases are very encouraging and are a testament to the hard work of researchers and clinicians in developing and implementing better diagnosis and treatments.”

Dr Vecchia and his colleagues reported the results of this research in Annals of Oncology.

The researchers looked at cancer deaths in the EU as a whole and in the 6 largest countries—France, Germany, Italy, Poland, Spain, and the UK.

The team assessed mortality for all cancers and looked at individual data for cancers of the stomach, intestines, pancreas, lung, prostate, breast, and uterus (including cervix), as well as leukemias.

All cancers

The researchers’ projections suggest that total cancer mortality rates will decrease for both sexes in 2016, despite a rise in the absolute number of deaths due to the aging population. The team said the median age of the total EU population was 41 in 2011 and will be 42 in 2016.

So a total of 1,359,500 EU citizens are expected to die of cancer in 2016—753,600 men and 605,900 women. This is compared to 1,314,787 cancer deaths in 2011—734,259 men and 580,528 women.

The age-standardized mortality rates for 2016 are 133.5 per 100,000 men and 85.2 per 100,000 women, compared to 144.6 per 100,000 men and 88.1 per 100,000 women in 2011.

So that’s a 7.7% fall in cancer death rates for men and a 3.3% fall for women from 2011 through 2016, despite a 3.3% increase in the absolute number of cancer deaths.

Leukemias

The researchers predict that, in 2016, age-standardized leukemia mortality rates will be 3.95 per 100,000  men and 2.46 per 100,000 women.

In comparison, the age-standardized mortality rates for 2000-2004 were 5.23 for men and 3.20 for women. The rates for 2005-2009 were 4.85 for men and 2.92 for women.

For males ages 0 to 14, the age-standardized mortality rates are 1.10 for 2000-2004, 0.87 for 2005-2009, and 0.54 for 2016. For females in this age group, the rates are 0.85 for 2000-2004, 0.69 for 2005-2009, and 0.55 for 2016.

For males ages 15 to 44, the age-standardized mortality rates are 1.50 for 2000-2004, 1.28 for 2005-2009, and 0.95 for 2016. For females, the rates are 1.07 for 2000-2004, 0.92 for 2005-2009, and 0.72 for 2016.

For males ages 45 to 69, the age-standardized mortality rates are 9.19 for 2000-2004, 8.39 for 2005-2009, and 6.79 for 2016. For females, the rates are 5.74 for 2000-2004, 5.12 for 2005-2009, and 4.16 for 2016.

Cancer patient

receiving chemotherapy

Photo by Rhoda Baer

Projections for 2016 suggest that leukemia deaths are on the decline in the European Union (EU), particularly for children and young adults.

Leukemia death rates are expected to fall 19% in men and 16% in women in 2016, when compared to 2007 data.

Rates are projected to fall 38% in boys and 20% in girls ages 0 to 14, 26% in men and 22% in women ages 15 to 44, and 19% in men and women ages 45 to 69.

Researchers said improvements in management, multidrug chemotherapy, immunotherapies, stem cell transplants, radiotherapy, and targeted therapies have all contributed to improvements in survival for leukemia patients.

However, some leukemias remain hard to treat, particularly those that are more common in adults and the elderly.

“Predictions of death rates from leukemia are complicated by the fact that leukemias are a varied collection of blood cancers, with some being more treatable than others,” said study author Carlo La Vecchia, MD, of the University of Milan in Italy.

“However, the important falls in overall death rates from this group of diseases are very encouraging and are a testament to the hard work of researchers and clinicians in developing and implementing better diagnosis and treatments.”

Dr Vecchia and his colleagues reported the results of this research in Annals of Oncology.

The researchers looked at cancer deaths in the EU as a whole and in the 6 largest countries—France, Germany, Italy, Poland, Spain, and the UK.

The team assessed mortality for all cancers and looked at individual data for cancers of the stomach, intestines, pancreas, lung, prostate, breast, and uterus (including cervix), as well as leukemias.

All cancers

The researchers’ projections suggest that total cancer mortality rates will decrease for both sexes in 2016, despite a rise in the absolute number of deaths due to the aging population. The team said the median age of the total EU population was 41 in 2011 and will be 42 in 2016.

So a total of 1,359,500 EU citizens are expected to die of cancer in 2016—753,600 men and 605,900 women. This is compared to 1,314,787 cancer deaths in 2011—734,259 men and 580,528 women.

The age-standardized mortality rates for 2016 are 133.5 per 100,000 men and 85.2 per 100,000 women, compared to 144.6 per 100,000 men and 88.1 per 100,000 women in 2011.

So that’s a 7.7% fall in cancer death rates for men and a 3.3% fall for women from 2011 through 2016, despite a 3.3% increase in the absolute number of cancer deaths.

Leukemias

The researchers predict that, in 2016, age-standardized leukemia mortality rates will be 3.95 per 100,000  men and 2.46 per 100,000 women.

In comparison, the age-standardized mortality rates for 2000-2004 were 5.23 for men and 3.20 for women. The rates for 2005-2009 were 4.85 for men and 2.92 for women.

For males ages 0 to 14, the age-standardized mortality rates are 1.10 for 2000-2004, 0.87 for 2005-2009, and 0.54 for 2016. For females in this age group, the rates are 0.85 for 2000-2004, 0.69 for 2005-2009, and 0.55 for 2016.

For males ages 15 to 44, the age-standardized mortality rates are 1.50 for 2000-2004, 1.28 for 2005-2009, and 0.95 for 2016. For females, the rates are 1.07 for 2000-2004, 0.92 for 2005-2009, and 0.72 for 2016.

For males ages 45 to 69, the age-standardized mortality rates are 9.19 for 2000-2004, 8.39 for 2005-2009, and 6.79 for 2016. For females, the rates are 5.74 for 2000-2004, 5.12 for 2005-2009, and 4.16 for 2016.

In his January podcast for The Journal of Community and Supportive Oncology, Editor-in-Chief Dr David Henry discusses a Commentary by Dr Thomas Strouse on the use on cannabinoids in the cancer treatment setting and a Community Translations article on the recent approval of idarucizumab as the first specific oral anticoagulant reversal agent. Also included in the line-up are two Review articles, one on new therapies for antiemetic prophylaxis for chemotherapy-induced nausea and vomiting and another on the management of epidermal growth factor receptor inhibitor-associated rash; and Original Reports on cyclical hypofractionated radiotherapy for palliative treatment in locally advanced head and neck cancer and on the impact of surgery for early-stage non-small-cell lung cancer on patient quality of life.

Listen to the podcast below.

In his January podcast for The Journal of Community and Supportive Oncology, Editor-in-Chief Dr David Henry discusses a Commentary by Dr Thomas Strouse on the use on cannabinoids in the cancer treatment setting and a Community Translations article on the recent approval of idarucizumab as the first specific oral anticoagulant reversal agent. Also included in the line-up are two Review articles, one on new therapies for antiemetic prophylaxis for chemotherapy-induced nausea and vomiting and another on the management of epidermal growth factor receptor inhibitor-associated rash; and Original Reports on cyclical hypofractionated radiotherapy for palliative treatment in locally advanced head and neck cancer and on the impact of surgery for early-stage non-small-cell lung cancer on patient quality of life.

Listen to the podcast below.

In his January podcast for The Journal of Community and Supportive Oncology, Editor-in-Chief Dr David Henry discusses a Commentary by Dr Thomas Strouse on the use on cannabinoids in the cancer treatment setting and a Community Translations article on the recent approval of idarucizumab as the first specific oral anticoagulant reversal agent. Also included in the line-up are two Review articles, one on new therapies for antiemetic prophylaxis for chemotherapy-induced nausea and vomiting and another on the management of epidermal growth factor receptor inhibitor-associated rash; and Original Reports on cyclical hypofractionated radiotherapy for palliative treatment in locally advanced head and neck cancer and on the impact of surgery for early-stage non-small-cell lung cancer on patient quality of life.

Listen to the podcast below.

All adults, including pregnant and postpartum women, should be screened for depression, according to new recommendations of the U.S. Preventive Services Task Force.

The recommendation also calls for screening to be coupled with “adequate systems” to ensure diagnosis, treatment, and follow-up (JAMA. 2016 Jan 26;315[4]:380-7).

The depression screening recommendation, authored by Dr. Albert L. Siu and the other members of the USPSTF, is a level B recommendation, meaning that it has either high certainty of moderate net benefit, or moderate certainty of moderate to substantial net benefit.

The new guidance in screening for depression helps address a disorder that is “the leading cause of disability among adults in high-income countries,” said Dr. Siu and his coauthors. Lost productivity attributable to depression cost $23 billion in the United States in 2011, and $22.8 billion was spent on treatments for depression in 2009, the last year for which figures are available.

Dr. Siu, chair of geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai, New York, and his coauthors cited “convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings, including pregnant and postpartum women.”
 
In addition, the task force found convincing evidence that for older adults as well as the general adult population, treatment of “depression identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity.”
For pregnant and postpartum women with depression, Dr. Siu and his coauthors found “adequate” evidence that cognitive behavioral therapy (CBT) improves outcomes.

The recommendation does not identify optimal timing and intervals for depression screening, citing a need for more research in this area. However, “a pragmatic approach might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted,” explained Dr. Siu and his coauthors.

The new depression screening recommendation from USPSTF updates the 2009 recommendation, which recommended universal screening if “staff-assisted depression care supports” were in place, and targeted screening based on clinical judgment and patient preference if such support were unavailable.
The rationale for the current recommendation of universal screening for those 18 years and older is the “recognition that such support is now much more widely available and accepted as part of mental health care,” the task force members said.

Any potential harms of screening, said Dr. Siu and his coauthors, were minimal to nonexistent.
 
Overall, the USPSTF assigned a small to moderate risk to the use of medication in depression. However, the use of “second-generation” antidepressants – mostly SSRIs – was associated with some harms, including increased risk of suicidal behavior in young adults and of gastrointestinal bleeding in older adults, as well as potential fetal harms in pregnant women taking antidepressants.

Using CBT to treat depression in pregnant and postpartum women was also associated with minimal to no harm.

The USPSTF screening recommendation is aligned with the American Academy of Family Physicians’ recommendation to screen the general adult population for depression, and with the American Academy of Pediatrics’ recommendation that pediatricians screen mothers for depression at their babies’ 1-, 2-, and 4-month office visits.

Released in draft form in July 2015, the depression screening recommendation was available for public comment for a period of 4 weeks. In response to public input, the final recommendation’s implementation section clarifies and characterizes an “adequate system” of screening, and gives more resources for evidence-based depression screening and treatment.

The Agency for Healthcare Research and Quality supports the operations of the USPSTF, but the task force’s recommendations are independent of the federal government. Dr. Siu and the other task force members reported no conflicts of interest.

[email protected]
On Twitter @karioakes

All adults, including pregnant and postpartum women, should be screened for depression, according to new recommendations of the U.S. Preventive Services Task Force.

The recommendation also calls for screening to be coupled with “adequate systems” to ensure diagnosis, treatment, and follow-up (JAMA. 2016 Jan 26;315[4]:380-7).

The depression screening recommendation, authored by Dr. Albert L. Siu and the other members of the USPSTF, is a level B recommendation, meaning that it has either high certainty of moderate net benefit, or moderate certainty of moderate to substantial net benefit.

The new guidance in screening for depression helps address a disorder that is “the leading cause of disability among adults in high-income countries,” said Dr. Siu and his coauthors. Lost productivity attributable to depression cost $23 billion in the United States in 2011, and $22.8 billion was spent on treatments for depression in 2009, the last year for which figures are available.

Dr. Siu, chair of geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai, New York, and his coauthors cited “convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings, including pregnant and postpartum women.”
 
In addition, the task force found convincing evidence that for older adults as well as the general adult population, treatment of “depression identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity.”
For pregnant and postpartum women with depression, Dr. Siu and his coauthors found “adequate” evidence that cognitive behavioral therapy (CBT) improves outcomes.

The recommendation does not identify optimal timing and intervals for depression screening, citing a need for more research in this area. However, “a pragmatic approach might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted,” explained Dr. Siu and his coauthors.

The new depression screening recommendation from USPSTF updates the 2009 recommendation, which recommended universal screening if “staff-assisted depression care supports” were in place, and targeted screening based on clinical judgment and patient preference if such support were unavailable.
The rationale for the current recommendation of universal screening for those 18 years and older is the “recognition that such support is now much more widely available and accepted as part of mental health care,” the task force members said.

Any potential harms of screening, said Dr. Siu and his coauthors, were minimal to nonexistent.
 
Overall, the USPSTF assigned a small to moderate risk to the use of medication in depression. However, the use of “second-generation” antidepressants – mostly SSRIs – was associated with some harms, including increased risk of suicidal behavior in young adults and of gastrointestinal bleeding in older adults, as well as potential fetal harms in pregnant women taking antidepressants.

Using CBT to treat depression in pregnant and postpartum women was also associated with minimal to no harm.

The USPSTF screening recommendation is aligned with the American Academy of Family Physicians’ recommendation to screen the general adult population for depression, and with the American Academy of Pediatrics’ recommendation that pediatricians screen mothers for depression at their babies’ 1-, 2-, and 4-month office visits.

Released in draft form in July 2015, the depression screening recommendation was available for public comment for a period of 4 weeks. In response to public input, the final recommendation’s implementation section clarifies and characterizes an “adequate system” of screening, and gives more resources for evidence-based depression screening and treatment.

The Agency for Healthcare Research and Quality supports the operations of the USPSTF, but the task force’s recommendations are independent of the federal government. Dr. Siu and the other task force members reported no conflicts of interest.

[email protected]
On Twitter @karioakes

All adults, including pregnant and postpartum women, should be screened for depression, according to new recommendations of the U.S. Preventive Services Task Force.

The recommendation also calls for screening to be coupled with “adequate systems” to ensure diagnosis, treatment, and follow-up (JAMA. 2016 Jan 26;315[4]:380-7).

The depression screening recommendation, authored by Dr. Albert L. Siu and the other members of the USPSTF, is a level B recommendation, meaning that it has either high certainty of moderate net benefit, or moderate certainty of moderate to substantial net benefit.

The new guidance in screening for depression helps address a disorder that is “the leading cause of disability among adults in high-income countries,” said Dr. Siu and his coauthors. Lost productivity attributable to depression cost $23 billion in the United States in 2011, and $22.8 billion was spent on treatments for depression in 2009, the last year for which figures are available.

Dr. Siu, chair of geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai, New York, and his coauthors cited “convincing evidence that screening improves the accurate identification of adult patients with depression in primary care settings, including pregnant and postpartum women.”
 
In addition, the task force found convincing evidence that for older adults as well as the general adult population, treatment of “depression identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity.”
For pregnant and postpartum women with depression, Dr. Siu and his coauthors found “adequate” evidence that cognitive behavioral therapy (CBT) improves outcomes.

The recommendation does not identify optimal timing and intervals for depression screening, citing a need for more research in this area. However, “a pragmatic approach might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted,” explained Dr. Siu and his coauthors.

The new depression screening recommendation from USPSTF updates the 2009 recommendation, which recommended universal screening if “staff-assisted depression care supports” were in place, and targeted screening based on clinical judgment and patient preference if such support were unavailable.
The rationale for the current recommendation of universal screening for those 18 years and older is the “recognition that such support is now much more widely available and accepted as part of mental health care,” the task force members said.

Any potential harms of screening, said Dr. Siu and his coauthors, were minimal to nonexistent.
 
Overall, the USPSTF assigned a small to moderate risk to the use of medication in depression. However, the use of “second-generation” antidepressants – mostly SSRIs – was associated with some harms, including increased risk of suicidal behavior in young adults and of gastrointestinal bleeding in older adults, as well as potential fetal harms in pregnant women taking antidepressants.

Using CBT to treat depression in pregnant and postpartum women was also associated with minimal to no harm.

The USPSTF screening recommendation is aligned with the American Academy of Family Physicians’ recommendation to screen the general adult population for depression, and with the American Academy of Pediatrics’ recommendation that pediatricians screen mothers for depression at their babies’ 1-, 2-, and 4-month office visits.

Released in draft form in July 2015, the depression screening recommendation was available for public comment for a period of 4 weeks. In response to public input, the final recommendation’s implementation section clarifies and characterizes an “adequate system” of screening, and gives more resources for evidence-based depression screening and treatment.

The Agency for Healthcare Research and Quality supports the operations of the USPSTF, but the task force’s recommendations are independent of the federal government. Dr. Siu and the other task force members reported no conflicts of interest.

[email protected]
On Twitter @karioakes