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The modern physician-communicator
Forty years ago, the revered physician was a walking textbook able to recall vast amounts of information. Things have changed. A photographic memory is less valuable since Google was created. Medical knowledge has a much shorter shelf life. Specialization has become increasingly fragmented. The orthopedic surgeon who replaced my hip 5 years ago would not see me for a shoulder problem. He only does hips and knees. Ingrown toenails are referred to a podiatrist. Now the ideal physician is a team player able to communicate well with many other physicians and allied health care providers so that the patches of individual expertise combine to create a quilt that covers the patient’s needs. Poor communicators are like odd-shaped and frayed pieces of fabric that are hard to fit into the quilt.
Medical errors were identified by the Institute of Medicine (IOM) in 1999 as a major cause of preventable deaths. What has become clear in research since then is that most of these errors are not caused by deficits in knowledge or to carelessness. They are partly because of communication skills and because of attitudes that impede collaborative comanagement. Errors are mostly systemic problems and should be addressed in that paradigm.
Since that first IOM report, several other areas have been identified as major causes of preventable deaths in hospitals. These problems include nosocomial infections, antibiotic stewardship, medication list reconciliation, overdiagnosis, and the handoff of care at discharge (N Engl J Med. 2014 Nov 6;371[19]:1803-12). The lack of a cure for Ebola is a minor problem, compared with these weaknesses in the hospital care system. Too much futile care and the delay of palliative care also are frequent problems, more so with adults than pediatrics. Pediatric hospitalists have been more focused on value (Pediatrics 2015 Aug 1. [doi: 10.1542/peds.2015-1549A]).
Most of these issues were never discussed in the pathophysiology courses of medical school. They are outside the biological sciences. As a result, it has become a major part of graduate Continuing Medical Education. The schedule for the recent Pediatric Hospital Medicine 2015 conference reflects this. The 830 attendees could choose from 12 simultaneous breakout sessions, but typically only 3 or 4 were primarily about clinical medicine. Quality improvement, education, research, and practice management made up the lion’s share of the topics.
This emphasis on systems is the core of hospital medicine. It isn’t about knowing which antibiotic is best for a given patient with a particular pneumonia because usually we don’t know the organism. It is about saying, “We will admit 300 patients with pneumonia to this hospital this year. What are best practices?” In pediatrics, many pneumonias will be viral. The vast majority of bacterial pneumonia will be pneumococcal. Staphylococcus aureus is involved in less than 1% and most of those cases present differently. So what criteria do we use to determine who gets narrow-spectrum antibiotics, who gets broad spectrum, who gets mycoplasma coverage, and who gets supportive care without unnecessary antibiotics? Practice guidelines for the provision of oxygen, intravenous fluids, and the use of continuous pulse oximetry monitoring each were covered in other presentations at the 2015 pediatric hospitalist meeting. More importantly, as Dr. Brian K. Alverson, director, division of pediatric hospital medicine, Hasbro Children’s Hospital in Providence, R.I., explained, guidelines are meant to cover only 95% of patients. It is the job of the patient’s physician to decide whether that patient fits into the 95% or is one of the 5% who need customized, less evidence-based plans of care. Perhaps most importantly, the guidelines themselves are undergoing continuous quality improvement. The Infectious Diseases Society of American (IDSA) guidelines for pediatric community-acquired pneumonia were published just 4 years ago, but already have recommendations that are refuted by more recent research.
Author Robert Fulghum is right. Most of the lessons I learned in kindergarten are still applicable. Medical school – not so much.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected]. Dr. Powell said he had no relevant financial disclosures.
Forty years ago, the revered physician was a walking textbook able to recall vast amounts of information. Things have changed. A photographic memory is less valuable since Google was created. Medical knowledge has a much shorter shelf life. Specialization has become increasingly fragmented. The orthopedic surgeon who replaced my hip 5 years ago would not see me for a shoulder problem. He only does hips and knees. Ingrown toenails are referred to a podiatrist. Now the ideal physician is a team player able to communicate well with many other physicians and allied health care providers so that the patches of individual expertise combine to create a quilt that covers the patient’s needs. Poor communicators are like odd-shaped and frayed pieces of fabric that are hard to fit into the quilt.
Medical errors were identified by the Institute of Medicine (IOM) in 1999 as a major cause of preventable deaths. What has become clear in research since then is that most of these errors are not caused by deficits in knowledge or to carelessness. They are partly because of communication skills and because of attitudes that impede collaborative comanagement. Errors are mostly systemic problems and should be addressed in that paradigm.
Since that first IOM report, several other areas have been identified as major causes of preventable deaths in hospitals. These problems include nosocomial infections, antibiotic stewardship, medication list reconciliation, overdiagnosis, and the handoff of care at discharge (N Engl J Med. 2014 Nov 6;371[19]:1803-12). The lack of a cure for Ebola is a minor problem, compared with these weaknesses in the hospital care system. Too much futile care and the delay of palliative care also are frequent problems, more so with adults than pediatrics. Pediatric hospitalists have been more focused on value (Pediatrics 2015 Aug 1. [doi: 10.1542/peds.2015-1549A]).
Most of these issues were never discussed in the pathophysiology courses of medical school. They are outside the biological sciences. As a result, it has become a major part of graduate Continuing Medical Education. The schedule for the recent Pediatric Hospital Medicine 2015 conference reflects this. The 830 attendees could choose from 12 simultaneous breakout sessions, but typically only 3 or 4 were primarily about clinical medicine. Quality improvement, education, research, and practice management made up the lion’s share of the topics.
This emphasis on systems is the core of hospital medicine. It isn’t about knowing which antibiotic is best for a given patient with a particular pneumonia because usually we don’t know the organism. It is about saying, “We will admit 300 patients with pneumonia to this hospital this year. What are best practices?” In pediatrics, many pneumonias will be viral. The vast majority of bacterial pneumonia will be pneumococcal. Staphylococcus aureus is involved in less than 1% and most of those cases present differently. So what criteria do we use to determine who gets narrow-spectrum antibiotics, who gets broad spectrum, who gets mycoplasma coverage, and who gets supportive care without unnecessary antibiotics? Practice guidelines for the provision of oxygen, intravenous fluids, and the use of continuous pulse oximetry monitoring each were covered in other presentations at the 2015 pediatric hospitalist meeting. More importantly, as Dr. Brian K. Alverson, director, division of pediatric hospital medicine, Hasbro Children’s Hospital in Providence, R.I., explained, guidelines are meant to cover only 95% of patients. It is the job of the patient’s physician to decide whether that patient fits into the 95% or is one of the 5% who need customized, less evidence-based plans of care. Perhaps most importantly, the guidelines themselves are undergoing continuous quality improvement. The Infectious Diseases Society of American (IDSA) guidelines for pediatric community-acquired pneumonia were published just 4 years ago, but already have recommendations that are refuted by more recent research.
Author Robert Fulghum is right. Most of the lessons I learned in kindergarten are still applicable. Medical school – not so much.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected]. Dr. Powell said he had no relevant financial disclosures.
Forty years ago, the revered physician was a walking textbook able to recall vast amounts of information. Things have changed. A photographic memory is less valuable since Google was created. Medical knowledge has a much shorter shelf life. Specialization has become increasingly fragmented. The orthopedic surgeon who replaced my hip 5 years ago would not see me for a shoulder problem. He only does hips and knees. Ingrown toenails are referred to a podiatrist. Now the ideal physician is a team player able to communicate well with many other physicians and allied health care providers so that the patches of individual expertise combine to create a quilt that covers the patient’s needs. Poor communicators are like odd-shaped and frayed pieces of fabric that are hard to fit into the quilt.
Medical errors were identified by the Institute of Medicine (IOM) in 1999 as a major cause of preventable deaths. What has become clear in research since then is that most of these errors are not caused by deficits in knowledge or to carelessness. They are partly because of communication skills and because of attitudes that impede collaborative comanagement. Errors are mostly systemic problems and should be addressed in that paradigm.
Since that first IOM report, several other areas have been identified as major causes of preventable deaths in hospitals. These problems include nosocomial infections, antibiotic stewardship, medication list reconciliation, overdiagnosis, and the handoff of care at discharge (N Engl J Med. 2014 Nov 6;371[19]:1803-12). The lack of a cure for Ebola is a minor problem, compared with these weaknesses in the hospital care system. Too much futile care and the delay of palliative care also are frequent problems, more so with adults than pediatrics. Pediatric hospitalists have been more focused on value (Pediatrics 2015 Aug 1. [doi: 10.1542/peds.2015-1549A]).
Most of these issues were never discussed in the pathophysiology courses of medical school. They are outside the biological sciences. As a result, it has become a major part of graduate Continuing Medical Education. The schedule for the recent Pediatric Hospital Medicine 2015 conference reflects this. The 830 attendees could choose from 12 simultaneous breakout sessions, but typically only 3 or 4 were primarily about clinical medicine. Quality improvement, education, research, and practice management made up the lion’s share of the topics.
This emphasis on systems is the core of hospital medicine. It isn’t about knowing which antibiotic is best for a given patient with a particular pneumonia because usually we don’t know the organism. It is about saying, “We will admit 300 patients with pneumonia to this hospital this year. What are best practices?” In pediatrics, many pneumonias will be viral. The vast majority of bacterial pneumonia will be pneumococcal. Staphylococcus aureus is involved in less than 1% and most of those cases present differently. So what criteria do we use to determine who gets narrow-spectrum antibiotics, who gets broad spectrum, who gets mycoplasma coverage, and who gets supportive care without unnecessary antibiotics? Practice guidelines for the provision of oxygen, intravenous fluids, and the use of continuous pulse oximetry monitoring each were covered in other presentations at the 2015 pediatric hospitalist meeting. More importantly, as Dr. Brian K. Alverson, director, division of pediatric hospital medicine, Hasbro Children’s Hospital in Providence, R.I., explained, guidelines are meant to cover only 95% of patients. It is the job of the patient’s physician to decide whether that patient fits into the 95% or is one of the 5% who need customized, less evidence-based plans of care. Perhaps most importantly, the guidelines themselves are undergoing continuous quality improvement. The Infectious Diseases Society of American (IDSA) guidelines for pediatric community-acquired pneumonia were published just 4 years ago, but already have recommendations that are refuted by more recent research.
Author Robert Fulghum is right. Most of the lessons I learned in kindergarten are still applicable. Medical school – not so much.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected]. Dr. Powell said he had no relevant financial disclosures.
Selective eating
You may not have read the much ballyhooed article about selective eating in preschoolers that was distributed to the media prior to publication because it was buried online, but I bet that you have heard or read something about it (“Psychological and Psychosocial Impairment in Preschoolers with Selective Eating” by Zucker et al., [Pediatrics. 2015 Aug 3. doi: 10.1542/peds.2014-2386]). In fact, there were so many news stories, both print and electronic, and the headlines were so divergent that my wife asked me if there were actually two studies released simultaneously.
Some news reports emphasized the reassuring observation by the authors that most picky eating preschoolers will mature into older children with less selective eating habits. However, others highlighted the authors’ primary message that young children with severe selective eating behavior often have significant psychopathology (anxiety, depression, attention-deficit/hyperactivity disorder), and those with even moderate picky eating may be manifesting the effects of living in a dysfunctional family.
The authors recommend that we pediatricians rethink our traditional party line on selective eating. Instead of simply administering frequent doses of reassurance to the parents of “picky eaters,” we should begin to view even moderate selective eating as a red flag that the child and his or her family need help.
This shift in emphasis is long overdue. I always have felt that problem picky eating is an example of normal infant behavior that has been mismanaged by the child’s family. And in some cases physicians also must share in the blame for not having given the most appropriate advice in a timely fashion to parents who have complained about their child’s selective eating.
It would help if we all took a deep breath, stepped back a few steps, and looked at the bigger picture. We are talking about eating, one of the critical life-sustaining activities. One can understand why most infants are wired to initially reject new tastes and textures. Neophobia – fear of anything new – has probably saved millions of infants from the serious consequences of unsupervised foraging. But don’t you think that these aversions are for the most part weak enough to be easily overridden by every child’s innate drive for self-preservation? “I don’t like how this smells, tastes, looks, or feels, but darn it, I’m getting hungry, and I have to eat to survive. So I will eat it.”
The problem is that while some parents can agree with that line of reasoning, many parents, including those who buy the rationale, can’t bring themselves to quietly accept their new role as merely being providers of a healthy diet. For 9 or 10 months, it was their job to get food into their child because the poor little thing lacked the skill to do it himself. But once a child can chew solids and put things in his mouth, he can not only survive but thrive if someone will simply present him a balanced diet of appropriate consistency and volume … and then step back and shut up.
Obviously, this transition is difficult to a significant number of parents. In many cases, it is because no one has told them that toddlers will appear to eat less than they did as infants or that allowing children unlimited access to energy-containing fluid will blunt their appetites. Or that it is okay that a child only eats one-and-a-half meals on some days. Or that it if you wait long enough without resorting to coaxing, bribing, or begging, a child will eat what his body needs. And failing to be patient and instead making an issue of eating (or not eating), what began as a normal infant aversion to new tastes and textures can spiral into a divisive family catastrophe.
Are there some infants who are so hypersensitive to new tastes and textures that waiting will endanger their health? If they exist, in my experience they are very rare. However, there are certainly toddlers who have become hypersensitive. In my opinion, they were always vulnerable and would have been much less of a problem had they been properly managed early on when they were just a little neophobic.
Are there clues during the child’s infancy that his family is more likely to have significant difficulty making the transition from “feeding” to “presenting” food? This new study observed that high maternal anxiety was frequently observed in both moderate and severe selective-eating children. This is another example of how we need to be aware from a very early stage when a parent is anxious or depressed. The failure to identify and see that those issues are addressed can seriously impair the whole family’s wellness.
Finally, on the other end of the spectrum, is usual garden variety selective eating outgrown? Have you tried to host a dinner party lately? I don’t mean a pot luck supper – I’m talking about a sit-down meal with a single menu. My wife and I have almost given up trying. “Martha is gluten free (without a diagnosis), Bob is watching his cholesterol, Rachel is pretty sure she is lactose intolerant, and you know Charlie hates vegetables. The Wilsons only do organic and are vegetarians.”
Next time we are considering mailing them gift certificates for their favorite restaurants along with an invitation to come over to our place for an after dinner drink. BYOB.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”
You may not have read the much ballyhooed article about selective eating in preschoolers that was distributed to the media prior to publication because it was buried online, but I bet that you have heard or read something about it (“Psychological and Psychosocial Impairment in Preschoolers with Selective Eating” by Zucker et al., [Pediatrics. 2015 Aug 3. doi: 10.1542/peds.2014-2386]). In fact, there were so many news stories, both print and electronic, and the headlines were so divergent that my wife asked me if there were actually two studies released simultaneously.
Some news reports emphasized the reassuring observation by the authors that most picky eating preschoolers will mature into older children with less selective eating habits. However, others highlighted the authors’ primary message that young children with severe selective eating behavior often have significant psychopathology (anxiety, depression, attention-deficit/hyperactivity disorder), and those with even moderate picky eating may be manifesting the effects of living in a dysfunctional family.
The authors recommend that we pediatricians rethink our traditional party line on selective eating. Instead of simply administering frequent doses of reassurance to the parents of “picky eaters,” we should begin to view even moderate selective eating as a red flag that the child and his or her family need help.
This shift in emphasis is long overdue. I always have felt that problem picky eating is an example of normal infant behavior that has been mismanaged by the child’s family. And in some cases physicians also must share in the blame for not having given the most appropriate advice in a timely fashion to parents who have complained about their child’s selective eating.
It would help if we all took a deep breath, stepped back a few steps, and looked at the bigger picture. We are talking about eating, one of the critical life-sustaining activities. One can understand why most infants are wired to initially reject new tastes and textures. Neophobia – fear of anything new – has probably saved millions of infants from the serious consequences of unsupervised foraging. But don’t you think that these aversions are for the most part weak enough to be easily overridden by every child’s innate drive for self-preservation? “I don’t like how this smells, tastes, looks, or feels, but darn it, I’m getting hungry, and I have to eat to survive. So I will eat it.”
The problem is that while some parents can agree with that line of reasoning, many parents, including those who buy the rationale, can’t bring themselves to quietly accept their new role as merely being providers of a healthy diet. For 9 or 10 months, it was their job to get food into their child because the poor little thing lacked the skill to do it himself. But once a child can chew solids and put things in his mouth, he can not only survive but thrive if someone will simply present him a balanced diet of appropriate consistency and volume … and then step back and shut up.
Obviously, this transition is difficult to a significant number of parents. In many cases, it is because no one has told them that toddlers will appear to eat less than they did as infants or that allowing children unlimited access to energy-containing fluid will blunt their appetites. Or that it is okay that a child only eats one-and-a-half meals on some days. Or that it if you wait long enough without resorting to coaxing, bribing, or begging, a child will eat what his body needs. And failing to be patient and instead making an issue of eating (or not eating), what began as a normal infant aversion to new tastes and textures can spiral into a divisive family catastrophe.
Are there some infants who are so hypersensitive to new tastes and textures that waiting will endanger their health? If they exist, in my experience they are very rare. However, there are certainly toddlers who have become hypersensitive. In my opinion, they were always vulnerable and would have been much less of a problem had they been properly managed early on when they were just a little neophobic.
Are there clues during the child’s infancy that his family is more likely to have significant difficulty making the transition from “feeding” to “presenting” food? This new study observed that high maternal anxiety was frequently observed in both moderate and severe selective-eating children. This is another example of how we need to be aware from a very early stage when a parent is anxious or depressed. The failure to identify and see that those issues are addressed can seriously impair the whole family’s wellness.
Finally, on the other end of the spectrum, is usual garden variety selective eating outgrown? Have you tried to host a dinner party lately? I don’t mean a pot luck supper – I’m talking about a sit-down meal with a single menu. My wife and I have almost given up trying. “Martha is gluten free (without a diagnosis), Bob is watching his cholesterol, Rachel is pretty sure she is lactose intolerant, and you know Charlie hates vegetables. The Wilsons only do organic and are vegetarians.”
Next time we are considering mailing them gift certificates for their favorite restaurants along with an invitation to come over to our place for an after dinner drink. BYOB.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”
You may not have read the much ballyhooed article about selective eating in preschoolers that was distributed to the media prior to publication because it was buried online, but I bet that you have heard or read something about it (“Psychological and Psychosocial Impairment in Preschoolers with Selective Eating” by Zucker et al., [Pediatrics. 2015 Aug 3. doi: 10.1542/peds.2014-2386]). In fact, there were so many news stories, both print and electronic, and the headlines were so divergent that my wife asked me if there were actually two studies released simultaneously.
Some news reports emphasized the reassuring observation by the authors that most picky eating preschoolers will mature into older children with less selective eating habits. However, others highlighted the authors’ primary message that young children with severe selective eating behavior often have significant psychopathology (anxiety, depression, attention-deficit/hyperactivity disorder), and those with even moderate picky eating may be manifesting the effects of living in a dysfunctional family.
The authors recommend that we pediatricians rethink our traditional party line on selective eating. Instead of simply administering frequent doses of reassurance to the parents of “picky eaters,” we should begin to view even moderate selective eating as a red flag that the child and his or her family need help.
This shift in emphasis is long overdue. I always have felt that problem picky eating is an example of normal infant behavior that has been mismanaged by the child’s family. And in some cases physicians also must share in the blame for not having given the most appropriate advice in a timely fashion to parents who have complained about their child’s selective eating.
It would help if we all took a deep breath, stepped back a few steps, and looked at the bigger picture. We are talking about eating, one of the critical life-sustaining activities. One can understand why most infants are wired to initially reject new tastes and textures. Neophobia – fear of anything new – has probably saved millions of infants from the serious consequences of unsupervised foraging. But don’t you think that these aversions are for the most part weak enough to be easily overridden by every child’s innate drive for self-preservation? “I don’t like how this smells, tastes, looks, or feels, but darn it, I’m getting hungry, and I have to eat to survive. So I will eat it.”
The problem is that while some parents can agree with that line of reasoning, many parents, including those who buy the rationale, can’t bring themselves to quietly accept their new role as merely being providers of a healthy diet. For 9 or 10 months, it was their job to get food into their child because the poor little thing lacked the skill to do it himself. But once a child can chew solids and put things in his mouth, he can not only survive but thrive if someone will simply present him a balanced diet of appropriate consistency and volume … and then step back and shut up.
Obviously, this transition is difficult to a significant number of parents. In many cases, it is because no one has told them that toddlers will appear to eat less than they did as infants or that allowing children unlimited access to energy-containing fluid will blunt their appetites. Or that it is okay that a child only eats one-and-a-half meals on some days. Or that it if you wait long enough without resorting to coaxing, bribing, or begging, a child will eat what his body needs. And failing to be patient and instead making an issue of eating (or not eating), what began as a normal infant aversion to new tastes and textures can spiral into a divisive family catastrophe.
Are there some infants who are so hypersensitive to new tastes and textures that waiting will endanger their health? If they exist, in my experience they are very rare. However, there are certainly toddlers who have become hypersensitive. In my opinion, they were always vulnerable and would have been much less of a problem had they been properly managed early on when they were just a little neophobic.
Are there clues during the child’s infancy that his family is more likely to have significant difficulty making the transition from “feeding” to “presenting” food? This new study observed that high maternal anxiety was frequently observed in both moderate and severe selective-eating children. This is another example of how we need to be aware from a very early stage when a parent is anxious or depressed. The failure to identify and see that those issues are addressed can seriously impair the whole family’s wellness.
Finally, on the other end of the spectrum, is usual garden variety selective eating outgrown? Have you tried to host a dinner party lately? I don’t mean a pot luck supper – I’m talking about a sit-down meal with a single menu. My wife and I have almost given up trying. “Martha is gluten free (without a diagnosis), Bob is watching his cholesterol, Rachel is pretty sure she is lactose intolerant, and you know Charlie hates vegetables. The Wilsons only do organic and are vegetarians.”
Next time we are considering mailing them gift certificates for their favorite restaurants along with an invitation to come over to our place for an after dinner drink. BYOB.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”
Bedtime (and/or) stories
I’m not much of a reader. In fact, there was a 10-year period during which I wrote more books (four) than I read. In high school and college, I can’t recall ever finishing an assigned novel or play. I would read just enough to create the desired illusion. Even now that I have more time, I’m good for about 20 minutes before I have to put a book down and do something … anything. If my feet are level with my waist, four pages is my max before sleep overtakes me.
But I could be the poster boy for the value of reading to young children. My father was a great reader. At heart he was an actor, and I could listen to his theatrical voice read for hours. I was still being read to regularly until I was 8 or 9 years old. I am convinced that it was his gift for reading aloud when I was young that helped me develop a facility with language that was crucial to my academic successes. It certainly wasn’t my own reading.
Two recent studies have added to the growing body of evidence that reading to young children is critical to their later language development and success in school (“Home Reading Environment and Brain Activation in Preschool Children Listening to Stories,” by Hutton et al. [Pediatrics. 2015 Aug 10. pii: peds.2015-0359. Epub ahead of print] and “The Words Children Hear: Picture Books and the Statistics for Language Learning,” by Montag, Jones, and Smith [Psychol Sci. Aug 4, 2015. doi: 10.1177/0956797615594361. E-pub ahead of print]). Parents in your practice have probably not read either of these peer-reviewed studies, but they may have read the New York Times and an op-ed by pediatrician Perri Klass, in which she emphasizes the importance of reading (Bed Time Stories for Young Brains, August 17, 2015). They have received free books at your office and know that you recommend they read to their children every day.
Many of those parents who have bought into the value of reading also understand the importance of a good night’s sleep. But for some of those families, those two priorities can collide when it comes time for the warm and fuzzy tradition of reading a bedtime story.
Work schedules and other family obligations may have pushed their young child’s bedtime to the brink of and beyond a healthy hour. Adding a bedtime story – and we all know there is seldom just one story – will only compound the problem. Which is more important … a bedtime story or a healthy bedtime?
Of course if we are talking about a single isolated night, the answer is obvious … do both. But I’m talking about the family that is overbooked and always running late. On a “good” night, bedtime ritual for the 2-year-old may start at 7:30 p.m. Adding a story will push start time to a clearly unhealthy 8:00. As a physician long obsessed with the underappreciated and at times catastrophic effects of sleep deprivation, my answer would clearly be forget the bedtime story and turn off the light.
But families need not allow themselves to fall into situations that force such a binary decision of reading or not reading a bedtime story. In some cases, it is an adult-centered decision by one parent who selfishly expects his or her child to be kept up until the parent can be home to participate in the bedtime ritual. In other cases, instead of building the day’s schedule around a healthy bedtime, some families treat bedtime as an afterthought, something they will get to when they can get around to it.
In addition to enhancing a child’s language development, reading stories at bedtime can be a bonding and family-building activity. Reading also can be a calming ingredient and a sleep-enhancing component in an effective bedtime ritual. And for the child who resists bedtime, reading can be used a reward that can be withheld or increased as the situation requires.
While I sense that the practice of saying one’s prayers at bedtime has fallen out of fashion for many families, the bedtime story is alive and well. We must help remind parents that the bedtime is at least as important as the story.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater” and “Is My Child Overtired?: The Sleep Solution for Raising Happier, Healthier Children.” Email him at [email protected].
I’m not much of a reader. In fact, there was a 10-year period during which I wrote more books (four) than I read. In high school and college, I can’t recall ever finishing an assigned novel or play. I would read just enough to create the desired illusion. Even now that I have more time, I’m good for about 20 minutes before I have to put a book down and do something … anything. If my feet are level with my waist, four pages is my max before sleep overtakes me.
But I could be the poster boy for the value of reading to young children. My father was a great reader. At heart he was an actor, and I could listen to his theatrical voice read for hours. I was still being read to regularly until I was 8 or 9 years old. I am convinced that it was his gift for reading aloud when I was young that helped me develop a facility with language that was crucial to my academic successes. It certainly wasn’t my own reading.
Two recent studies have added to the growing body of evidence that reading to young children is critical to their later language development and success in school (“Home Reading Environment and Brain Activation in Preschool Children Listening to Stories,” by Hutton et al. [Pediatrics. 2015 Aug 10. pii: peds.2015-0359. Epub ahead of print] and “The Words Children Hear: Picture Books and the Statistics for Language Learning,” by Montag, Jones, and Smith [Psychol Sci. Aug 4, 2015. doi: 10.1177/0956797615594361. E-pub ahead of print]). Parents in your practice have probably not read either of these peer-reviewed studies, but they may have read the New York Times and an op-ed by pediatrician Perri Klass, in which she emphasizes the importance of reading (Bed Time Stories for Young Brains, August 17, 2015). They have received free books at your office and know that you recommend they read to their children every day.
Many of those parents who have bought into the value of reading also understand the importance of a good night’s sleep. But for some of those families, those two priorities can collide when it comes time for the warm and fuzzy tradition of reading a bedtime story.
Work schedules and other family obligations may have pushed their young child’s bedtime to the brink of and beyond a healthy hour. Adding a bedtime story – and we all know there is seldom just one story – will only compound the problem. Which is more important … a bedtime story or a healthy bedtime?
Of course if we are talking about a single isolated night, the answer is obvious … do both. But I’m talking about the family that is overbooked and always running late. On a “good” night, bedtime ritual for the 2-year-old may start at 7:30 p.m. Adding a story will push start time to a clearly unhealthy 8:00. As a physician long obsessed with the underappreciated and at times catastrophic effects of sleep deprivation, my answer would clearly be forget the bedtime story and turn off the light.
But families need not allow themselves to fall into situations that force such a binary decision of reading or not reading a bedtime story. In some cases, it is an adult-centered decision by one parent who selfishly expects his or her child to be kept up until the parent can be home to participate in the bedtime ritual. In other cases, instead of building the day’s schedule around a healthy bedtime, some families treat bedtime as an afterthought, something they will get to when they can get around to it.
In addition to enhancing a child’s language development, reading stories at bedtime can be a bonding and family-building activity. Reading also can be a calming ingredient and a sleep-enhancing component in an effective bedtime ritual. And for the child who resists bedtime, reading can be used a reward that can be withheld or increased as the situation requires.
While I sense that the practice of saying one’s prayers at bedtime has fallen out of fashion for many families, the bedtime story is alive and well. We must help remind parents that the bedtime is at least as important as the story.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater” and “Is My Child Overtired?: The Sleep Solution for Raising Happier, Healthier Children.” Email him at [email protected].
I’m not much of a reader. In fact, there was a 10-year period during which I wrote more books (four) than I read. In high school and college, I can’t recall ever finishing an assigned novel or play. I would read just enough to create the desired illusion. Even now that I have more time, I’m good for about 20 minutes before I have to put a book down and do something … anything. If my feet are level with my waist, four pages is my max before sleep overtakes me.
But I could be the poster boy for the value of reading to young children. My father was a great reader. At heart he was an actor, and I could listen to his theatrical voice read for hours. I was still being read to regularly until I was 8 or 9 years old. I am convinced that it was his gift for reading aloud when I was young that helped me develop a facility with language that was crucial to my academic successes. It certainly wasn’t my own reading.
Two recent studies have added to the growing body of evidence that reading to young children is critical to their later language development and success in school (“Home Reading Environment and Brain Activation in Preschool Children Listening to Stories,” by Hutton et al. [Pediatrics. 2015 Aug 10. pii: peds.2015-0359. Epub ahead of print] and “The Words Children Hear: Picture Books and the Statistics for Language Learning,” by Montag, Jones, and Smith [Psychol Sci. Aug 4, 2015. doi: 10.1177/0956797615594361. E-pub ahead of print]). Parents in your practice have probably not read either of these peer-reviewed studies, but they may have read the New York Times and an op-ed by pediatrician Perri Klass, in which she emphasizes the importance of reading (Bed Time Stories for Young Brains, August 17, 2015). They have received free books at your office and know that you recommend they read to their children every day.
Many of those parents who have bought into the value of reading also understand the importance of a good night’s sleep. But for some of those families, those two priorities can collide when it comes time for the warm and fuzzy tradition of reading a bedtime story.
Work schedules and other family obligations may have pushed their young child’s bedtime to the brink of and beyond a healthy hour. Adding a bedtime story – and we all know there is seldom just one story – will only compound the problem. Which is more important … a bedtime story or a healthy bedtime?
Of course if we are talking about a single isolated night, the answer is obvious … do both. But I’m talking about the family that is overbooked and always running late. On a “good” night, bedtime ritual for the 2-year-old may start at 7:30 p.m. Adding a story will push start time to a clearly unhealthy 8:00. As a physician long obsessed with the underappreciated and at times catastrophic effects of sleep deprivation, my answer would clearly be forget the bedtime story and turn off the light.
But families need not allow themselves to fall into situations that force such a binary decision of reading or not reading a bedtime story. In some cases, it is an adult-centered decision by one parent who selfishly expects his or her child to be kept up until the parent can be home to participate in the bedtime ritual. In other cases, instead of building the day’s schedule around a healthy bedtime, some families treat bedtime as an afterthought, something they will get to when they can get around to it.
In addition to enhancing a child’s language development, reading stories at bedtime can be a bonding and family-building activity. Reading also can be a calming ingredient and a sleep-enhancing component in an effective bedtime ritual. And for the child who resists bedtime, reading can be used a reward that can be withheld or increased as the situation requires.
While I sense that the practice of saying one’s prayers at bedtime has fallen out of fashion for many families, the bedtime story is alive and well. We must help remind parents that the bedtime is at least as important as the story.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater” and “Is My Child Overtired?: The Sleep Solution for Raising Happier, Healthier Children.” Email him at [email protected].
Stage 0 Breast Cancer May Not Be the Strongest Indicator of Patient Mortality
According to a study published today in JAMA Oncology, a diagnosis of ductal carcinoma in situ (DCIS)—or stage 0 breast cancer—may not be reason enough for treatment.
Researchers conducted a multivariate analysis of 108,196 women, whose data were pulled from the Surveillance, Epidemiology, and End Results (SEER) 18 registries database. The primary outcome of the study was 10- and 20-year cancer-specific mortality. The results showed that age at diagnosis and ethnicity were significant predictors of breast cancer mortality: Women diagnosed before age 35 had a higher risk of death from breast cancer at 20 years than did older women (7.8% vs 3.2%; hazard ratio [HR], 2.58; 95% confidence interval [CI], 1.85-3.60; P < .001), and black women had a higher risk of death from DCIS than did white, non-Hispanic women (7.0% vs 3.0%; adjusted HR, 2.42, 95% CI, 2.05-2.87; P < .001).
Related: Dividing to Conquer Breast Cancer
In addition, the article notes that the finding of greatest clinical importance was that prevention of ipsilateral invasive recurrence did not prevent death from breast cancer. Women diagnosed with DCIS who developed an ipsilateral invasive in-breast recurrence were 18.1 times more likely to die of breast cancer than were women who did not; however, after adjustment for tumor size, grade, and other factors, the difference in survival for mastectomy vs lumpectomy was not significant (HR, 1.20; 95% CI, 0.96-1.50; P = .11).
Patients with breast cancer often undergo the Oncotype DX breast cancer assay to identify those who are at low risk for death from breast cancer and who might not benefit from chemotherapy. However, the researchers of the current study propose that the test be used instead to identify patients who are at high risk for invasive recurrence.
Related: Advances in Targeted Therapy for Breast Cancer
The 10-year mortality rate assessed in this study continues a downward trend established in previous studies, but “it is unlikely that the decline in mortality [for women who received a diagnosis of ductal carcinoma in situ between 1998 and 2011] is due to more effective treatments,” the authors note, “because we show here that mortality rates did not vary with specific treatment.”
View on the News: Reboot needed on DCIS treatment
Source
Narod SA, Iqbal J, Giannakeas V, Sopik V, Sun P. JAMA Oncol. [Published online ahead of print August 20, 2015.]
doi: 10.1001/jamaoncol.2015.2510.
According to a study published today in JAMA Oncology, a diagnosis of ductal carcinoma in situ (DCIS)—or stage 0 breast cancer—may not be reason enough for treatment.
Researchers conducted a multivariate analysis of 108,196 women, whose data were pulled from the Surveillance, Epidemiology, and End Results (SEER) 18 registries database. The primary outcome of the study was 10- and 20-year cancer-specific mortality. The results showed that age at diagnosis and ethnicity were significant predictors of breast cancer mortality: Women diagnosed before age 35 had a higher risk of death from breast cancer at 20 years than did older women (7.8% vs 3.2%; hazard ratio [HR], 2.58; 95% confidence interval [CI], 1.85-3.60; P < .001), and black women had a higher risk of death from DCIS than did white, non-Hispanic women (7.0% vs 3.0%; adjusted HR, 2.42, 95% CI, 2.05-2.87; P < .001).
Related: Dividing to Conquer Breast Cancer
In addition, the article notes that the finding of greatest clinical importance was that prevention of ipsilateral invasive recurrence did not prevent death from breast cancer. Women diagnosed with DCIS who developed an ipsilateral invasive in-breast recurrence were 18.1 times more likely to die of breast cancer than were women who did not; however, after adjustment for tumor size, grade, and other factors, the difference in survival for mastectomy vs lumpectomy was not significant (HR, 1.20; 95% CI, 0.96-1.50; P = .11).
Patients with breast cancer often undergo the Oncotype DX breast cancer assay to identify those who are at low risk for death from breast cancer and who might not benefit from chemotherapy. However, the researchers of the current study propose that the test be used instead to identify patients who are at high risk for invasive recurrence.
Related: Advances in Targeted Therapy for Breast Cancer
The 10-year mortality rate assessed in this study continues a downward trend established in previous studies, but “it is unlikely that the decline in mortality [for women who received a diagnosis of ductal carcinoma in situ between 1998 and 2011] is due to more effective treatments,” the authors note, “because we show here that mortality rates did not vary with specific treatment.”
View on the News: Reboot needed on DCIS treatment
Source
Narod SA, Iqbal J, Giannakeas V, Sopik V, Sun P. JAMA Oncol. [Published online ahead of print August 20, 2015.]
doi: 10.1001/jamaoncol.2015.2510.
According to a study published today in JAMA Oncology, a diagnosis of ductal carcinoma in situ (DCIS)—or stage 0 breast cancer—may not be reason enough for treatment.
Researchers conducted a multivariate analysis of 108,196 women, whose data were pulled from the Surveillance, Epidemiology, and End Results (SEER) 18 registries database. The primary outcome of the study was 10- and 20-year cancer-specific mortality. The results showed that age at diagnosis and ethnicity were significant predictors of breast cancer mortality: Women diagnosed before age 35 had a higher risk of death from breast cancer at 20 years than did older women (7.8% vs 3.2%; hazard ratio [HR], 2.58; 95% confidence interval [CI], 1.85-3.60; P < .001), and black women had a higher risk of death from DCIS than did white, non-Hispanic women (7.0% vs 3.0%; adjusted HR, 2.42, 95% CI, 2.05-2.87; P < .001).
Related: Dividing to Conquer Breast Cancer
In addition, the article notes that the finding of greatest clinical importance was that prevention of ipsilateral invasive recurrence did not prevent death from breast cancer. Women diagnosed with DCIS who developed an ipsilateral invasive in-breast recurrence were 18.1 times more likely to die of breast cancer than were women who did not; however, after adjustment for tumor size, grade, and other factors, the difference in survival for mastectomy vs lumpectomy was not significant (HR, 1.20; 95% CI, 0.96-1.50; P = .11).
Patients with breast cancer often undergo the Oncotype DX breast cancer assay to identify those who are at low risk for death from breast cancer and who might not benefit from chemotherapy. However, the researchers of the current study propose that the test be used instead to identify patients who are at high risk for invasive recurrence.
Related: Advances in Targeted Therapy for Breast Cancer
The 10-year mortality rate assessed in this study continues a downward trend established in previous studies, but “it is unlikely that the decline in mortality [for women who received a diagnosis of ductal carcinoma in situ between 1998 and 2011] is due to more effective treatments,” the authors note, “because we show here that mortality rates did not vary with specific treatment.”
View on the News: Reboot needed on DCIS treatment
Source
Narod SA, Iqbal J, Giannakeas V, Sopik V, Sun P. JAMA Oncol. [Published online ahead of print August 20, 2015.]
doi: 10.1001/jamaoncol.2015.2510.
Assess heart disease risk with online calculators
About half of all Americans have at least one of the three leading risk factors for heart disease: high blood pressure, high low-density lipoprotein cholesterol, and a history of smoking. It is important to keep track of heart disease risks, both potential and real.
Online calculators can be very useful for patients concerned about their heart health. Many such calculators, such as this one from the Mayo Clinic, look at your general risk for heart disease and make recommendations as to lifestyle changes to reduce risk. But there are also calculators focused on specific conditions, such as coronary heart disease, heart attack, and stroke.
Remember that calculators are not a replacement for a real diagnosis. If you suspect you have heart disease, be sure to see a doctor, and if something serious occurs, a visit to the emergency department is certainly valid.
Find more heart disease risk calculators here.
About half of all Americans have at least one of the three leading risk factors for heart disease: high blood pressure, high low-density lipoprotein cholesterol, and a history of smoking. It is important to keep track of heart disease risks, both potential and real.
Online calculators can be very useful for patients concerned about their heart health. Many such calculators, such as this one from the Mayo Clinic, look at your general risk for heart disease and make recommendations as to lifestyle changes to reduce risk. But there are also calculators focused on specific conditions, such as coronary heart disease, heart attack, and stroke.
Remember that calculators are not a replacement for a real diagnosis. If you suspect you have heart disease, be sure to see a doctor, and if something serious occurs, a visit to the emergency department is certainly valid.
Find more heart disease risk calculators here.
About half of all Americans have at least one of the three leading risk factors for heart disease: high blood pressure, high low-density lipoprotein cholesterol, and a history of smoking. It is important to keep track of heart disease risks, both potential and real.
Online calculators can be very useful for patients concerned about their heart health. Many such calculators, such as this one from the Mayo Clinic, look at your general risk for heart disease and make recommendations as to lifestyle changes to reduce risk. But there are also calculators focused on specific conditions, such as coronary heart disease, heart attack, and stroke.
Remember that calculators are not a replacement for a real diagnosis. If you suspect you have heart disease, be sure to see a doctor, and if something serious occurs, a visit to the emergency department is certainly valid.
Find more heart disease risk calculators here.
FDA: Extra steps for cleaner scopes
Addressing recent outbreaks of serious, sometimes fatal infections associated with duodenoscopes, the Food and Drug Administration has issued recommendations for taking extra steps to improve the reprocessing of these devices, which “may further help reduce the risk of infection transmission,” the agency said in an August 4 statement.
The extra measures are microbiological culturing, ethylene oxide sterilization, the use of a liquid chemical sterilant processing system, and repeated high-level disinfection. “Hospitals and health care facilities that utilize duodenoscopes can, in addition to meticulously following manufacturer reprocessing instructions, take one or more of these additional steps to further reduce the risk of infection and increase the safety of these medical devices,” according to the FDA’s statement announcing the measures.
The statement acknowledges that some health care facilities will not be able to implement one or more of these steps, so “it is critical that staff responsible for reprocessing duodenoscopes have the manufacturer’s instructions readily available to promote strict adherence to the reprocessing instructions in the device labeling, understand the importance of their role in reprocessing the device, and maintain proficiency in performing these reprocessing tasks.”
And while it is not possible to completely eliminate the risk of transmitting infections, “the benefits of these devices continue to outweigh the risks in appropriately selected patients,” the statement adds. These recommendations and the statement regarding the risk-benefit profile of these devices, used to perform endoscopic retrograde cholangiopancreatography, reflect comments of panelists at a meeting of the FDA’s s gastroenterology and urology devices panel on May 14 and 15, in which AGA participated, to address recent concerns about duodenoscopes and several outbreaks in U.S. hospitals of serious infections related to the devices.
The FDA’s statement is available here.
Any infections possibly related to duodenoscopes should be reported to the manufacturer and the FDA’s MedWatch program at 800-332-1088.
Addressing recent outbreaks of serious, sometimes fatal infections associated with duodenoscopes, the Food and Drug Administration has issued recommendations for taking extra steps to improve the reprocessing of these devices, which “may further help reduce the risk of infection transmission,” the agency said in an August 4 statement.
The extra measures are microbiological culturing, ethylene oxide sterilization, the use of a liquid chemical sterilant processing system, and repeated high-level disinfection. “Hospitals and health care facilities that utilize duodenoscopes can, in addition to meticulously following manufacturer reprocessing instructions, take one or more of these additional steps to further reduce the risk of infection and increase the safety of these medical devices,” according to the FDA’s statement announcing the measures.
The statement acknowledges that some health care facilities will not be able to implement one or more of these steps, so “it is critical that staff responsible for reprocessing duodenoscopes have the manufacturer’s instructions readily available to promote strict adherence to the reprocessing instructions in the device labeling, understand the importance of their role in reprocessing the device, and maintain proficiency in performing these reprocessing tasks.”
And while it is not possible to completely eliminate the risk of transmitting infections, “the benefits of these devices continue to outweigh the risks in appropriately selected patients,” the statement adds. These recommendations and the statement regarding the risk-benefit profile of these devices, used to perform endoscopic retrograde cholangiopancreatography, reflect comments of panelists at a meeting of the FDA’s s gastroenterology and urology devices panel on May 14 and 15, in which AGA participated, to address recent concerns about duodenoscopes and several outbreaks in U.S. hospitals of serious infections related to the devices.
The FDA’s statement is available here.
Any infections possibly related to duodenoscopes should be reported to the manufacturer and the FDA’s MedWatch program at 800-332-1088.
Addressing recent outbreaks of serious, sometimes fatal infections associated with duodenoscopes, the Food and Drug Administration has issued recommendations for taking extra steps to improve the reprocessing of these devices, which “may further help reduce the risk of infection transmission,” the agency said in an August 4 statement.
The extra measures are microbiological culturing, ethylene oxide sterilization, the use of a liquid chemical sterilant processing system, and repeated high-level disinfection. “Hospitals and health care facilities that utilize duodenoscopes can, in addition to meticulously following manufacturer reprocessing instructions, take one or more of these additional steps to further reduce the risk of infection and increase the safety of these medical devices,” according to the FDA’s statement announcing the measures.
The statement acknowledges that some health care facilities will not be able to implement one or more of these steps, so “it is critical that staff responsible for reprocessing duodenoscopes have the manufacturer’s instructions readily available to promote strict adherence to the reprocessing instructions in the device labeling, understand the importance of their role in reprocessing the device, and maintain proficiency in performing these reprocessing tasks.”
And while it is not possible to completely eliminate the risk of transmitting infections, “the benefits of these devices continue to outweigh the risks in appropriately selected patients,” the statement adds. These recommendations and the statement regarding the risk-benefit profile of these devices, used to perform endoscopic retrograde cholangiopancreatography, reflect comments of panelists at a meeting of the FDA’s s gastroenterology and urology devices panel on May 14 and 15, in which AGA participated, to address recent concerns about duodenoscopes and several outbreaks in U.S. hospitals of serious infections related to the devices.
The FDA’s statement is available here.
Any infections possibly related to duodenoscopes should be reported to the manufacturer and the FDA’s MedWatch program at 800-332-1088.
Team may have found earliest case of leukemia
archaeological dig
(male, Late Bronze Age)
Photo by Wessex Archaeology
ZURICH—Researchers may have discovered the earliest known case of leukemia by imaging a 7000-year-old skeleton.
High-resolution CT scans revealed locally defined trabecular bone resorption in the sternum and humerus, which strongly suggests a case of leukemia, according to the researchers.
Heike Scherf, PhD, of Eberhard Karls Universität Tübingen in Tübingen, Germany, and her colleagues presented this discovery at the Evolutionary Medicine Conference: Interdisciplinary Perspectives on Human Health and Disease (abstract P-07).
A poster describing the research is available on ResearchGate.
Dr Scherf and her colleagues described a skeleton recovered from the early Neolithic Linear Pottery Culture site Stuttgart-Muhlhausen in southwest Germany, which dates back to 5700-4900 BP.
The skeleton belonged to a woman who was thought to be 30 to 40 years old at the time of her death. Previous analysis had revealed a severe case of dental caries with alveolar inflammation in this woman.
The high-resolution CT scans revealed loss of trabecular bone in both the humerus and the sternum.
Dr Scherf and her colleagues said the level of trabecular resorption in this skeleton is significantly higher than that observed in specimens of the same age group from the same site, as well as in recent human samples.
The researchers were able to rule out other conditions that might explain the bone resorption, including osteoporosis, hyperparathyroidism, and solid tumor malignancy.
They said the locally restricted resorption at sites of hematopoietic stem cell generation strongly suggests leukemia in its initial stages, although they were unable to identify the subtype.
Still, if the researchers’ interpretation of their findings is correct, this is the earliest case of leukemia reported. 
archaeological dig
(male, Late Bronze Age)
Photo by Wessex Archaeology
ZURICH—Researchers may have discovered the earliest known case of leukemia by imaging a 7000-year-old skeleton.
High-resolution CT scans revealed locally defined trabecular bone resorption in the sternum and humerus, which strongly suggests a case of leukemia, according to the researchers.
Heike Scherf, PhD, of Eberhard Karls Universität Tübingen in Tübingen, Germany, and her colleagues presented this discovery at the Evolutionary Medicine Conference: Interdisciplinary Perspectives on Human Health and Disease (abstract P-07).
A poster describing the research is available on ResearchGate.
Dr Scherf and her colleagues described a skeleton recovered from the early Neolithic Linear Pottery Culture site Stuttgart-Muhlhausen in southwest Germany, which dates back to 5700-4900 BP.
The skeleton belonged to a woman who was thought to be 30 to 40 years old at the time of her death. Previous analysis had revealed a severe case of dental caries with alveolar inflammation in this woman.
The high-resolution CT scans revealed loss of trabecular bone in both the humerus and the sternum.
Dr Scherf and her colleagues said the level of trabecular resorption in this skeleton is significantly higher than that observed in specimens of the same age group from the same site, as well as in recent human samples.
The researchers were able to rule out other conditions that might explain the bone resorption, including osteoporosis, hyperparathyroidism, and solid tumor malignancy.
They said the locally restricted resorption at sites of hematopoietic stem cell generation strongly suggests leukemia in its initial stages, although they were unable to identify the subtype.
Still, if the researchers’ interpretation of their findings is correct, this is the earliest case of leukemia reported.
archaeological dig
(male, Late Bronze Age)
Photo by Wessex Archaeology
ZURICH—Researchers may have discovered the earliest known case of leukemia by imaging a 7000-year-old skeleton.
High-resolution CT scans revealed locally defined trabecular bone resorption in the sternum and humerus, which strongly suggests a case of leukemia, according to the researchers.
Heike Scherf, PhD, of Eberhard Karls Universität Tübingen in Tübingen, Germany, and her colleagues presented this discovery at the Evolutionary Medicine Conference: Interdisciplinary Perspectives on Human Health and Disease (abstract P-07).
A poster describing the research is available on ResearchGate.
Dr Scherf and her colleagues described a skeleton recovered from the early Neolithic Linear Pottery Culture site Stuttgart-Muhlhausen in southwest Germany, which dates back to 5700-4900 BP.
The skeleton belonged to a woman who was thought to be 30 to 40 years old at the time of her death. Previous analysis had revealed a severe case of dental caries with alveolar inflammation in this woman.
The high-resolution CT scans revealed loss of trabecular bone in both the humerus and the sternum.
Dr Scherf and her colleagues said the level of trabecular resorption in this skeleton is significantly higher than that observed in specimens of the same age group from the same site, as well as in recent human samples.
The researchers were able to rule out other conditions that might explain the bone resorption, including osteoporosis, hyperparathyroidism, and solid tumor malignancy.
They said the locally restricted resorption at sites of hematopoietic stem cell generation strongly suggests leukemia in its initial stages, although they were unable to identify the subtype.
Still, if the researchers’ interpretation of their findings is correct, this is the earliest case of leukemia reported.
Product can eliminate inhibitors in hemophilia A
A plasma-derived factor VIII/von Willebrand factor product (Octanate) can eliminate inhibitors in patients with hemophilia A, according to research published in Haemophilia.
Octanate eradicated inhibitors in nearly 80% of patients studied, and patients who became inhibitor-free experienced an 86% reduction in monthly bleeding.
Adverse drug reactions occurred in about 42% of patients, and 4 of the 124 adverse events were considered serious.
Wolfhart Kreuz, MD, of HZRM (Haemophilia Centre Rhein Main) in Mörfelden-Walldorf, Germany, and his colleagues conducted this research as part of the ongoing ObsITI study. The trial enrolled 48 patients with hemophilia A and inhibitors.
Most patients–83.3% (n=40)—had 1 or more poor prognostic factors for immune tolerance induction (ITI) success. This includes age of 7 or older, having been diagnosed with inhibitors for 2 years or more, having an inhibitor titer of 10 BU or higher at the start of ITI, and prior ITI failure.
Patients received Octanate as the sole factor VIII product between December 2005 and October 2010. Patients who were “low responders” at the start of ITI (<5 BU) received 50–100 IU factor VIII kg-1 daily or every other day. And “high responders” (≥5 BU) received 100 IU factor VIII kg-1 every 12 hours.
During ITI, 4 patients received prophylaxis with bypassing agents—2 with activated prothrombin complex concentrates and 2 with recombinant factor VIIa.
The researchers assessed ITI efficacy according to 3 criteria. These were: (1) inhibitor titer <0.6 BU, (2) factor VIII recovery ≥80% of the predefined reference value of 1.5% IU-1 kg-1 body weight ≤1 hour post-injection, and (3) factor VIII half-life ≥7 hours.
The researchers defined “complete success” as meeting all 3 efficacy criteria, “partial success” as meeting 2 criteria, and “partial response” as meeting 1 criterion. If none of the criteria were met within the 36-month observation period, this was considered an ITI failure. Withdrawal from the study for administrative reasons was considered an ITI failure as well.
Treatment was deemed a complete success in 70.8% of patients (n=34) and a partial success in 6.3% (n=3). One patient (2.1%) had a partial response. Treatment failed in 20.8% of patients (n=10), all of whom had poor prognostic factors.
Overall, 79.2% of patients (38/48) became negative for inhibitors. These patients saw an 86% reduction in their monthly bleeding rate (P<0.0001), which decreased most dramatically during the initial 4 months of ITI. During that period, the mean monthly bleeding rate fell from 1.05 to 0.26.
The researchers noted that treatment outcome was significantly associated with a patient’s inhibitor titer level at the start of ITI (P=0.0068), the number of poor prognostic factors (P=0.0187), the monthly bleeding rate during ITI (P=0.0005), and peak inhibitor titer during ITI (P=0.0007).
There were 124 adverse drug reactions reported in 20 patients (41.7%). And there were 4 serious adverse drug reactions—intravenous catheter infection, febrile convulsion, gingivitis, and pyrexia. One reaction—allergic dermatitis—was considered possibly or probably related to treatment.
A plasma-derived factor VIII/von Willebrand factor product (Octanate) can eliminate inhibitors in patients with hemophilia A, according to research published in Haemophilia.
Octanate eradicated inhibitors in nearly 80% of patients studied, and patients who became inhibitor-free experienced an 86% reduction in monthly bleeding.
Adverse drug reactions occurred in about 42% of patients, and 4 of the 124 adverse events were considered serious.
Wolfhart Kreuz, MD, of HZRM (Haemophilia Centre Rhein Main) in Mörfelden-Walldorf, Germany, and his colleagues conducted this research as part of the ongoing ObsITI study. The trial enrolled 48 patients with hemophilia A and inhibitors.
Most patients–83.3% (n=40)—had 1 or more poor prognostic factors for immune tolerance induction (ITI) success. This includes age of 7 or older, having been diagnosed with inhibitors for 2 years or more, having an inhibitor titer of 10 BU or higher at the start of ITI, and prior ITI failure.
Patients received Octanate as the sole factor VIII product between December 2005 and October 2010. Patients who were “low responders” at the start of ITI (<5 BU) received 50–100 IU factor VIII kg-1 daily or every other day. And “high responders” (≥5 BU) received 100 IU factor VIII kg-1 every 12 hours.
During ITI, 4 patients received prophylaxis with bypassing agents—2 with activated prothrombin complex concentrates and 2 with recombinant factor VIIa.
The researchers assessed ITI efficacy according to 3 criteria. These were: (1) inhibitor titer <0.6 BU, (2) factor VIII recovery ≥80% of the predefined reference value of 1.5% IU-1 kg-1 body weight ≤1 hour post-injection, and (3) factor VIII half-life ≥7 hours.
The researchers defined “complete success” as meeting all 3 efficacy criteria, “partial success” as meeting 2 criteria, and “partial response” as meeting 1 criterion. If none of the criteria were met within the 36-month observation period, this was considered an ITI failure. Withdrawal from the study for administrative reasons was considered an ITI failure as well.
Treatment was deemed a complete success in 70.8% of patients (n=34) and a partial success in 6.3% (n=3). One patient (2.1%) had a partial response. Treatment failed in 20.8% of patients (n=10), all of whom had poor prognostic factors.
Overall, 79.2% of patients (38/48) became negative for inhibitors. These patients saw an 86% reduction in their monthly bleeding rate (P<0.0001), which decreased most dramatically during the initial 4 months of ITI. During that period, the mean monthly bleeding rate fell from 1.05 to 0.26.
The researchers noted that treatment outcome was significantly associated with a patient’s inhibitor titer level at the start of ITI (P=0.0068), the number of poor prognostic factors (P=0.0187), the monthly bleeding rate during ITI (P=0.0005), and peak inhibitor titer during ITI (P=0.0007).
There were 124 adverse drug reactions reported in 20 patients (41.7%). And there were 4 serious adverse drug reactions—intravenous catheter infection, febrile convulsion, gingivitis, and pyrexia. One reaction—allergic dermatitis—was considered possibly or probably related to treatment.
A plasma-derived factor VIII/von Willebrand factor product (Octanate) can eliminate inhibitors in patients with hemophilia A, according to research published in Haemophilia.
Octanate eradicated inhibitors in nearly 80% of patients studied, and patients who became inhibitor-free experienced an 86% reduction in monthly bleeding.
Adverse drug reactions occurred in about 42% of patients, and 4 of the 124 adverse events were considered serious.
Wolfhart Kreuz, MD, of HZRM (Haemophilia Centre Rhein Main) in Mörfelden-Walldorf, Germany, and his colleagues conducted this research as part of the ongoing ObsITI study. The trial enrolled 48 patients with hemophilia A and inhibitors.
Most patients–83.3% (n=40)—had 1 or more poor prognostic factors for immune tolerance induction (ITI) success. This includes age of 7 or older, having been diagnosed with inhibitors for 2 years or more, having an inhibitor titer of 10 BU or higher at the start of ITI, and prior ITI failure.
Patients received Octanate as the sole factor VIII product between December 2005 and October 2010. Patients who were “low responders” at the start of ITI (<5 BU) received 50–100 IU factor VIII kg-1 daily or every other day. And “high responders” (≥5 BU) received 100 IU factor VIII kg-1 every 12 hours.
During ITI, 4 patients received prophylaxis with bypassing agents—2 with activated prothrombin complex concentrates and 2 with recombinant factor VIIa.
The researchers assessed ITI efficacy according to 3 criteria. These were: (1) inhibitor titer <0.6 BU, (2) factor VIII recovery ≥80% of the predefined reference value of 1.5% IU-1 kg-1 body weight ≤1 hour post-injection, and (3) factor VIII half-life ≥7 hours.
The researchers defined “complete success” as meeting all 3 efficacy criteria, “partial success” as meeting 2 criteria, and “partial response” as meeting 1 criterion. If none of the criteria were met within the 36-month observation period, this was considered an ITI failure. Withdrawal from the study for administrative reasons was considered an ITI failure as well.
Treatment was deemed a complete success in 70.8% of patients (n=34) and a partial success in 6.3% (n=3). One patient (2.1%) had a partial response. Treatment failed in 20.8% of patients (n=10), all of whom had poor prognostic factors.
Overall, 79.2% of patients (38/48) became negative for inhibitors. These patients saw an 86% reduction in their monthly bleeding rate (P<0.0001), which decreased most dramatically during the initial 4 months of ITI. During that period, the mean monthly bleeding rate fell from 1.05 to 0.26.
The researchers noted that treatment outcome was significantly associated with a patient’s inhibitor titer level at the start of ITI (P=0.0068), the number of poor prognostic factors (P=0.0187), the monthly bleeding rate during ITI (P=0.0005), and peak inhibitor titer during ITI (P=0.0007).
There were 124 adverse drug reactions reported in 20 patients (41.7%). And there were 4 serious adverse drug reactions—intravenous catheter infection, febrile convulsion, gingivitis, and pyrexia. One reaction—allergic dermatitis—was considered possibly or probably related to treatment.
FDA clears automated system for testing blood
Photo courtesy of
Ortho Clinical Diagnostics
The US Food and Drug Administration (FDA) has granted 510(k) clearance to the ORTHO VISIONTM Analyzer, a system that automates in vitro testing of human blood.
The system is now commercially available in the US and Puerto Rico.
The ORTHO VISION Analyzer automates test processing functions, including liquid pipetting, reagent handling, incubation, centrifugation, reaction grading, and interpretation and data management requirements using ID-MTS Gel Cards and digital image processing.
Tests that can be performed with the system include:
- ABO/Rh/grouping
- ABO/Rh confirmation
- Antibody screen
- Antibody identification
- Selected cell panel
- Rh phenotype (C,c,E,e)
- Donor confirmation
- Crossmatch (AHG)
- Antigen typing
- Serial dilutions for titration studies
- DAT (polyspecific)
- DAT (IGG)
- Cord blood testing
The system can be used as a standalone instrument or interfaced to a laboratory information system.
The ORTHO VISION Analyzer was designed with secure monitoring technologies for safety checks and balances, and it allows transfusion medicine professionals to track steps in the immunohematology testing process.
Through Ortho Clinical Diagnostics’ proprietary Intellicheck Technology, the ORTHO VISION Analyzer verifies and documents diagnostic checks throughout the testing process, while e-Connectivity Technology provides 24/7 remote data tracking that monitors instrument performance while maximizing uptime. Laboratory personnel can log on anytime, anywhere to collaborate on interpreting results in real time.
“With the launch of the ORTHO VISION Analyzer, our goal is to help improve the safety of blood transfusions by reducing the lab’s reliance on manual methods,” said Robert Yates, chief operating officer of Ortho Clinical Diagnostics, the company developing the ORTHO VISION Analyzer.
A version of the ORTHO VISION Analyzer is already commercially available in Europe, Japan, Latin America, Canada, and Australia.
For more information on the system, visit the Ortho Clinical Diagnostics website.
Photo courtesy of
Ortho Clinical Diagnostics
The US Food and Drug Administration (FDA) has granted 510(k) clearance to the ORTHO VISIONTM Analyzer, a system that automates in vitro testing of human blood.
The system is now commercially available in the US and Puerto Rico.
The ORTHO VISION Analyzer automates test processing functions, including liquid pipetting, reagent handling, incubation, centrifugation, reaction grading, and interpretation and data management requirements using ID-MTS Gel Cards and digital image processing.
Tests that can be performed with the system include:
- ABO/Rh/grouping
- ABO/Rh confirmation
- Antibody screen
- Antibody identification
- Selected cell panel
- Rh phenotype (C,c,E,e)
- Donor confirmation
- Crossmatch (AHG)
- Antigen typing
- Serial dilutions for titration studies
- DAT (polyspecific)
- DAT (IGG)
- Cord blood testing
The system can be used as a standalone instrument or interfaced to a laboratory information system.
The ORTHO VISION Analyzer was designed with secure monitoring technologies for safety checks and balances, and it allows transfusion medicine professionals to track steps in the immunohematology testing process.
Through Ortho Clinical Diagnostics’ proprietary Intellicheck Technology, the ORTHO VISION Analyzer verifies and documents diagnostic checks throughout the testing process, while e-Connectivity Technology provides 24/7 remote data tracking that monitors instrument performance while maximizing uptime. Laboratory personnel can log on anytime, anywhere to collaborate on interpreting results in real time.
“With the launch of the ORTHO VISION Analyzer, our goal is to help improve the safety of blood transfusions by reducing the lab’s reliance on manual methods,” said Robert Yates, chief operating officer of Ortho Clinical Diagnostics, the company developing the ORTHO VISION Analyzer.
A version of the ORTHO VISION Analyzer is already commercially available in Europe, Japan, Latin America, Canada, and Australia.
For more information on the system, visit the Ortho Clinical Diagnostics website.
Photo courtesy of
Ortho Clinical Diagnostics
The US Food and Drug Administration (FDA) has granted 510(k) clearance to the ORTHO VISIONTM Analyzer, a system that automates in vitro testing of human blood.
The system is now commercially available in the US and Puerto Rico.
The ORTHO VISION Analyzer automates test processing functions, including liquid pipetting, reagent handling, incubation, centrifugation, reaction grading, and interpretation and data management requirements using ID-MTS Gel Cards and digital image processing.
Tests that can be performed with the system include:
- ABO/Rh/grouping
- ABO/Rh confirmation
- Antibody screen
- Antibody identification
- Selected cell panel
- Rh phenotype (C,c,E,e)
- Donor confirmation
- Crossmatch (AHG)
- Antigen typing
- Serial dilutions for titration studies
- DAT (polyspecific)
- DAT (IGG)
- Cord blood testing
The system can be used as a standalone instrument or interfaced to a laboratory information system.
The ORTHO VISION Analyzer was designed with secure monitoring technologies for safety checks and balances, and it allows transfusion medicine professionals to track steps in the immunohematology testing process.
Through Ortho Clinical Diagnostics’ proprietary Intellicheck Technology, the ORTHO VISION Analyzer verifies and documents diagnostic checks throughout the testing process, while e-Connectivity Technology provides 24/7 remote data tracking that monitors instrument performance while maximizing uptime. Laboratory personnel can log on anytime, anywhere to collaborate on interpreting results in real time.
“With the launch of the ORTHO VISION Analyzer, our goal is to help improve the safety of blood transfusions by reducing the lab’s reliance on manual methods,” said Robert Yates, chief operating officer of Ortho Clinical Diagnostics, the company developing the ORTHO VISION Analyzer.
A version of the ORTHO VISION Analyzer is already commercially available in Europe, Japan, Latin America, Canada, and Australia.
For more information on the system, visit the Ortho Clinical Diagnostics website.
New HMA shows early promise for MDS/AML
Image by Christoph Bock
Investigators say a novel hypomethylating agent (HMA) is safe and clinically active in patients with myelodysplastic syndromes (MDS) or acute myelogenous leukemia (AML) who have failed standard therapy.
The HMA, guadecitabine (SGI-110), reverses aberrant DNA methylation by inhibiting DNA methyltransferase enzymes.
The investigators tested guadecitabine in a phase 1 study of patients with relapsed or refractory AML or MDS.
They reported the results in The Lancet Oncology. The study was sponsored by Astex Pharmaceuticals, the company developing guadecitabine.
“In this study, we observed induced clinical responses in heavily pretreated patients, including prior treatment with current HMAs,” said study author Hagop Kantarjian, MD, of The University of Texas MD Anderson Cancer Center in Houston.
“Together with the results of a large phase 2 study to be published later, these data support further investigation, including the recently commenced global phase 3 study in treatment-naïve AML patients”.
Dr Kantarjian and his colleagues enrolled 93 patients in the phase 1 study, 74 with AML and 19 with MDS. The patients had received 1 to 9 prior treatment regimens, and most had received prior azacitidine or decitabine.
The trial had a 3+3 dose-escalation design. Patients received guadecitabine doses ranging from 3 mg/m2 to 125 mg/m2.
The patients were also randomized to receive guadecitabine either once-daily for 5 consecutive days (35 AML, 9 MDS) or once-weekly (28 AML, 6 MDS) for 3 weeks in a 28-day treatment cycle. A twice-weekly treatment schedule was added to the study after a protocol amendment (11 AML, 4 MDS).
The investigators said the 3 treatment groups were well balanced with regard to baseline characteristics. However, the initial median bone marrow blast percentage in the daily × 5 group was twice that of the once-weekly and twice-weekly groups—42%, 19%, and 20%, respectively.
Safety and efficacy
The investigators said the treatment was well-tolerated. The most common grade 3 or higher adverse events were febrile neutropenia (41%), pneumonia (29%), thrombocytopenia (25%), anemia (25%), and sepsis (17%).
The most common serious adverse events were febrile neutropenia (31%), pneumonia (28%), and sepsis (17%).
There were 2 dose-limiting toxicities in MDS patients at the 125 mg/m2 daily × 5 dose. So the maximum tolerated dose for these patients was 90 mg/m2 daily × 5. The maximum tolerated dose was not reached in patients with AML.
Six patients with AML and 6 with MDS had a clinical response to guadecitabine. The investigators said potent, dose-related DNA demethylation occurred on the daily × 5 regimen, reaching a plateau at 60 mg/m2. So the team recommended this as the phase 2 dose.
A phase 2 study of guadecitabine is ongoing. The study enrolled more than 300 patients with treatment-naïve or relapsed/refractory AML or MDS.
Investigators recently began an 800-patient, phase 3 study (ASTRAL-1), in which guadecitabine is being compared with physician’s choice of decitabine, azacitidine, or low-dose cytarabine in treatment-naïve AML patients who are not candidates for intensive induction chemotherapy.
Image by Christoph Bock
Investigators say a novel hypomethylating agent (HMA) is safe and clinically active in patients with myelodysplastic syndromes (MDS) or acute myelogenous leukemia (AML) who have failed standard therapy.
The HMA, guadecitabine (SGI-110), reverses aberrant DNA methylation by inhibiting DNA methyltransferase enzymes.
The investigators tested guadecitabine in a phase 1 study of patients with relapsed or refractory AML or MDS.
They reported the results in The Lancet Oncology. The study was sponsored by Astex Pharmaceuticals, the company developing guadecitabine.
“In this study, we observed induced clinical responses in heavily pretreated patients, including prior treatment with current HMAs,” said study author Hagop Kantarjian, MD, of The University of Texas MD Anderson Cancer Center in Houston.
“Together with the results of a large phase 2 study to be published later, these data support further investigation, including the recently commenced global phase 3 study in treatment-naïve AML patients”.
Dr Kantarjian and his colleagues enrolled 93 patients in the phase 1 study, 74 with AML and 19 with MDS. The patients had received 1 to 9 prior treatment regimens, and most had received prior azacitidine or decitabine.
The trial had a 3+3 dose-escalation design. Patients received guadecitabine doses ranging from 3 mg/m2 to 125 mg/m2.
The patients were also randomized to receive guadecitabine either once-daily for 5 consecutive days (35 AML, 9 MDS) or once-weekly (28 AML, 6 MDS) for 3 weeks in a 28-day treatment cycle. A twice-weekly treatment schedule was added to the study after a protocol amendment (11 AML, 4 MDS).
The investigators said the 3 treatment groups were well balanced with regard to baseline characteristics. However, the initial median bone marrow blast percentage in the daily × 5 group was twice that of the once-weekly and twice-weekly groups—42%, 19%, and 20%, respectively.
Safety and efficacy
The investigators said the treatment was well-tolerated. The most common grade 3 or higher adverse events were febrile neutropenia (41%), pneumonia (29%), thrombocytopenia (25%), anemia (25%), and sepsis (17%).
The most common serious adverse events were febrile neutropenia (31%), pneumonia (28%), and sepsis (17%).
There were 2 dose-limiting toxicities in MDS patients at the 125 mg/m2 daily × 5 dose. So the maximum tolerated dose for these patients was 90 mg/m2 daily × 5. The maximum tolerated dose was not reached in patients with AML.
Six patients with AML and 6 with MDS had a clinical response to guadecitabine. The investigators said potent, dose-related DNA demethylation occurred on the daily × 5 regimen, reaching a plateau at 60 mg/m2. So the team recommended this as the phase 2 dose.
A phase 2 study of guadecitabine is ongoing. The study enrolled more than 300 patients with treatment-naïve or relapsed/refractory AML or MDS.
Investigators recently began an 800-patient, phase 3 study (ASTRAL-1), in which guadecitabine is being compared with physician’s choice of decitabine, azacitidine, or low-dose cytarabine in treatment-naïve AML patients who are not candidates for intensive induction chemotherapy.
Image by Christoph Bock
Investigators say a novel hypomethylating agent (HMA) is safe and clinically active in patients with myelodysplastic syndromes (MDS) or acute myelogenous leukemia (AML) who have failed standard therapy.
The HMA, guadecitabine (SGI-110), reverses aberrant DNA methylation by inhibiting DNA methyltransferase enzymes.
The investigators tested guadecitabine in a phase 1 study of patients with relapsed or refractory AML or MDS.
They reported the results in The Lancet Oncology. The study was sponsored by Astex Pharmaceuticals, the company developing guadecitabine.
“In this study, we observed induced clinical responses in heavily pretreated patients, including prior treatment with current HMAs,” said study author Hagop Kantarjian, MD, of The University of Texas MD Anderson Cancer Center in Houston.
“Together with the results of a large phase 2 study to be published later, these data support further investigation, including the recently commenced global phase 3 study in treatment-naïve AML patients”.
Dr Kantarjian and his colleagues enrolled 93 patients in the phase 1 study, 74 with AML and 19 with MDS. The patients had received 1 to 9 prior treatment regimens, and most had received prior azacitidine or decitabine.
The trial had a 3+3 dose-escalation design. Patients received guadecitabine doses ranging from 3 mg/m2 to 125 mg/m2.
The patients were also randomized to receive guadecitabine either once-daily for 5 consecutive days (35 AML, 9 MDS) or once-weekly (28 AML, 6 MDS) for 3 weeks in a 28-day treatment cycle. A twice-weekly treatment schedule was added to the study after a protocol amendment (11 AML, 4 MDS).
The investigators said the 3 treatment groups were well balanced with regard to baseline characteristics. However, the initial median bone marrow blast percentage in the daily × 5 group was twice that of the once-weekly and twice-weekly groups—42%, 19%, and 20%, respectively.
Safety and efficacy
The investigators said the treatment was well-tolerated. The most common grade 3 or higher adverse events were febrile neutropenia (41%), pneumonia (29%), thrombocytopenia (25%), anemia (25%), and sepsis (17%).
The most common serious adverse events were febrile neutropenia (31%), pneumonia (28%), and sepsis (17%).
There were 2 dose-limiting toxicities in MDS patients at the 125 mg/m2 daily × 5 dose. So the maximum tolerated dose for these patients was 90 mg/m2 daily × 5. The maximum tolerated dose was not reached in patients with AML.
Six patients with AML and 6 with MDS had a clinical response to guadecitabine. The investigators said potent, dose-related DNA demethylation occurred on the daily × 5 regimen, reaching a plateau at 60 mg/m2. So the team recommended this as the phase 2 dose.
A phase 2 study of guadecitabine is ongoing. The study enrolled more than 300 patients with treatment-naïve or relapsed/refractory AML or MDS.
Investigators recently began an 800-patient, phase 3 study (ASTRAL-1), in which guadecitabine is being compared with physician’s choice of decitabine, azacitidine, or low-dose cytarabine in treatment-naïve AML patients who are not candidates for intensive induction chemotherapy.