NASHVILLE, TENN. – Newly reported results from three trials showing “profound” benefit from endovascular embolectomy in selected patients with acute ischemic stroke “will have a major impact on how we treat stroke patients,” Dr. Lee H. Schwamm said during an interview at the International Stroke Conference.

“Many centers already provide this treatment, but this is the first time we have data on which patients to select” for catheter-based embolectomy, said Dr. Schwamm, professor of neurology at Harvard Medical School and director of acute stroke services at Massachusetts General Hospital in Boston. “Because we already have the capability in many centers, the first focus will be to extend the number of centers that can do this,” Dr. Schwamm noted.

An important part of that will be “changing the public health system to route patients to appropriate facilities” that can perform embolectomy, he said at the conference, sponsored by the American Heart Association.

Dr. Schwamm also noted that intravenous, thrombolytic treatment with tissue plasminogen activator (TPA) remains unchanged as the key first treatment for all patients with acute ischemic stroke. Following that, selected patients who do not fully respond to TPA should proceed to embolectomy. However, the new findings “do not suggest that you should avoid TPA and go directly to the catheter,” Dr. Schwamm cautioned.

[email protected]

On Twitter @mitchelzoler

NASHVILLE, TENN. – Newly reported results from three trials showing “profound” benefit from endovascular embolectomy in selected patients with acute ischemic stroke “will have a major impact on how we treat stroke patients,” Dr. Lee H. Schwamm said during an interview at the International Stroke Conference.

“Many centers already provide this treatment, but this is the first time we have data on which patients to select” for catheter-based embolectomy, said Dr. Schwamm, professor of neurology at Harvard Medical School and director of acute stroke services at Massachusetts General Hospital in Boston. “Because we already have the capability in many centers, the first focus will be to extend the number of centers that can do this,” Dr. Schwamm noted.

An important part of that will be “changing the public health system to route patients to appropriate facilities” that can perform embolectomy, he said at the conference, sponsored by the American Heart Association.

Dr. Schwamm also noted that intravenous, thrombolytic treatment with tissue plasminogen activator (TPA) remains unchanged as the key first treatment for all patients with acute ischemic stroke. Following that, selected patients who do not fully respond to TPA should proceed to embolectomy. However, the new findings “do not suggest that you should avoid TPA and go directly to the catheter,” Dr. Schwamm cautioned.

[email protected]

On Twitter @mitchelzoler

NASHVILLE, TENN. – Newly reported results from three trials showing “profound” benefit from endovascular embolectomy in selected patients with acute ischemic stroke “will have a major impact on how we treat stroke patients,” Dr. Lee H. Schwamm said during an interview at the International Stroke Conference.

“Many centers already provide this treatment, but this is the first time we have data on which patients to select” for catheter-based embolectomy, said Dr. Schwamm, professor of neurology at Harvard Medical School and director of acute stroke services at Massachusetts General Hospital in Boston. “Because we already have the capability in many centers, the first focus will be to extend the number of centers that can do this,” Dr. Schwamm noted.

An important part of that will be “changing the public health system to route patients to appropriate facilities” that can perform embolectomy, he said at the conference, sponsored by the American Heart Association.

Dr. Schwamm also noted that intravenous, thrombolytic treatment with tissue plasminogen activator (TPA) remains unchanged as the key first treatment for all patients with acute ischemic stroke. Following that, selected patients who do not fully respond to TPA should proceed to embolectomy. However, the new findings “do not suggest that you should avoid TPA and go directly to the catheter,” Dr. Schwamm cautioned.

[email protected]

On Twitter @mitchelzoler

Recently, bills aimed at allowing for physician-assisted suicide – also referred to as “Death With Dignity” laws – have been introduced in New Jersey, the District of Columbia, Maryland, Colorado, California, and Hawaii. Debates over the issue of end-of-life care are contentious and distressing, often accompanied by the tearful testimony of those who have cared for a family member throughout a long terminal illness. It’s hard to listen to these stories and not be moved personally, and to draw upon one’s own life experience with bereavement after a loved one’s suicide or disease.

For psychiatrists, the challenge is to think about assisted suicide not in terms of what we would want for ourselves, but what is best for our patients and the medical profession. Proponents argue that respect for patient autonomy should take priority, even if by respecting autonomy the end result is death. Opponents believe that by granting a request to die to a few people, many more vulnerable people may be abused or harmed inadvertently.

In my opinion, after extensive review of the bills and the effects of existing laws in Oregon and Washington, there are too many problems with assisted-suicide laws to safeguard or regulate this practice effectively.

The chief issue is that there is no mandate for any mental health evaluation for any qualified patient who requests assisted suicide. The primary physician and consulting physicians who certify competence may refer to a psychiatrist or psychologist, but this is only if there is a suspicion of incapacity. In Oregon, where this has been legal for 18 years, less than 5% of patients are referred for a competency assessment by a mental health professional although as many as 25% of terminally ill individuals may be suffering from clinical depression. In Oregon, individuals with HIV are 18 times more likely to die of assisted suicide than natural illness, which is particularly concerning given that HIV is known to affect the brain, and is associated with an increased risk of clinical depression and mania. The law allows a qualified patient to bar physicians from contacting or notifying family, which would make a psychiatrist’s competency assessment difficult if not impossible when the patient is suffering from a condition like dementia and can’t give a history himself.

The assisted-suicide process contains no mechanism to challenge the adequacy of the nonpsychiatrist’s assessment of capacity and noncoercion. There is no mechanism for judicial oversight, no mechanism to allow an interested party to raise the question of incompetence, and no existing standard of care for the assessment of capacity in this situation. Some bills protect the identity of the physicians and the patient, or bar medical records from subpoena or discovery, which would make any investigation for civil or criminal purposes difficult. In Oregon, 18 physicians were referred for board investigation, but none were sanctioned because the law required no more than “good faith” compliance with procedures – essentially only a requirement that the proper forms be filled out and filed promptly. This level of review is clearly inadequate when the process involves the death of an individual.

Some evidence suggests that having a physician-assisted law on the books may affect suicide rates in the general population. In Oregon, the suicide rate has risen out of proportion to the rest of the country, even excluding assisted-suicide deaths. (All laws require that assisted deaths be reported as a death from natural illness rather than suicide.) No formal study has been made of this issue, but there should be some provision to review and suspend the practice if this turns out to be the case.

All existing assisted-suicide laws recommend but do not require that a death be attended. Thus, despite the intent of the law, there is no way to ensure that the suicide is actually voluntary once the lethal medication is in hand. The law allows a physician to dispense medications to facilitate the ingestion of pentobarbital. This is necessary, because some patients have been unable to ingest the volume of liquid necessary to take the whole dose and have regurgitated the medication. Allowing premedication with an antiemetic is sometimes necessary. In theory, this aspect of the law could allow a health care practitioner to inject the antiemetic – an active involvement that would cross the line into euthanasia.

With regard to institutionalized patients, psychiatrists would be in a particularly challenging position. Presently, all patients admitted to hospitals are offered an opportunity to sign medical advance directives. At our forensic hospital in Maryland, admitting physicians assess the patient’s capacity to sign these directives. In theory, an insanity acquittee or long-term patient with a serious medical illness could request assisted suicide if competent. By law, the primary physician – a ward psychiatrist – would ultimately be required to write the lethal prescription or refer to another physician who would. If the patient were incompetent to request assisted suicide, the ward psychiatrist would be required to treat the mental illness knowing that it could eventually lead to the patient’s death. This situation is analogous to the dilemma of the correctional psychiatrist who treats an incompetent death row inmate.

There are many other problems with assisted-suicide legislation. At the very least, states should require a formal certification process to ensure that physicians who provide lethal medication have adequate training and experience to administer and interpret screening tests for psychiatric disorders, to do capacity assessments, and to make prognostic decisions relevant to their board certification and training. In all existing assisted-suicide bills and laws, the only requirement for a physician to provide lethal medication is that he or she must have the “qualifications and experience” to make a diagnosis and prognosis. There is no specific requirement that the attending or consulting physician actually be board certified to treat the illness in question. Thus, in theory, an attending or consulting physician could certify terminal illness without proven competence to do so.

Also, no clear safeguard exists to detect, investigate, and prosecute a hypothetical malicious or unscrupulous physician. In Oregon, three physicians write 20% of lethal prescriptions. It only takes one physician to do a lot of harm.

The American Medical Association has had a position statement on this topic for more than 20 years. The AMA takes the position that physician-assisted suicide is categorically unethical and bars doctors from participation. This, from the standpoint of a state health department, is probably the key issue: Should a legislature have the authority to allow physician behavior that a licensing board and professional organizations already have held to be unethical and not the practice of medicine? One of the core characteristics of a profession is the ability to monitor, police, and ensure the integrity of its members. Legislatures are unwise to undermine this.

Dr. Hanson is a forensic psychiatrist and co-author of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, bills aimed at allowing for physician-assisted suicide – also referred to as “Death With Dignity” laws – have been introduced in New Jersey, the District of Columbia, Maryland, Colorado, California, and Hawaii. Debates over the issue of end-of-life care are contentious and distressing, often accompanied by the tearful testimony of those who have cared for a family member throughout a long terminal illness. It’s hard to listen to these stories and not be moved personally, and to draw upon one’s own life experience with bereavement after a loved one’s suicide or disease.

For psychiatrists, the challenge is to think about assisted suicide not in terms of what we would want for ourselves, but what is best for our patients and the medical profession. Proponents argue that respect for patient autonomy should take priority, even if by respecting autonomy the end result is death. Opponents believe that by granting a request to die to a few people, many more vulnerable people may be abused or harmed inadvertently.

In my opinion, after extensive review of the bills and the effects of existing laws in Oregon and Washington, there are too many problems with assisted-suicide laws to safeguard or regulate this practice effectively.

The chief issue is that there is no mandate for any mental health evaluation for any qualified patient who requests assisted suicide. The primary physician and consulting physicians who certify competence may refer to a psychiatrist or psychologist, but this is only if there is a suspicion of incapacity. In Oregon, where this has been legal for 18 years, less than 5% of patients are referred for a competency assessment by a mental health professional although as many as 25% of terminally ill individuals may be suffering from clinical depression. In Oregon, individuals with HIV are 18 times more likely to die of assisted suicide than natural illness, which is particularly concerning given that HIV is known to affect the brain, and is associated with an increased risk of clinical depression and mania. The law allows a qualified patient to bar physicians from contacting or notifying family, which would make a psychiatrist’s competency assessment difficult if not impossible when the patient is suffering from a condition like dementia and can’t give a history himself.

The assisted-suicide process contains no mechanism to challenge the adequacy of the nonpsychiatrist’s assessment of capacity and noncoercion. There is no mechanism for judicial oversight, no mechanism to allow an interested party to raise the question of incompetence, and no existing standard of care for the assessment of capacity in this situation. Some bills protect the identity of the physicians and the patient, or bar medical records from subpoena or discovery, which would make any investigation for civil or criminal purposes difficult. In Oregon, 18 physicians were referred for board investigation, but none were sanctioned because the law required no more than “good faith” compliance with procedures – essentially only a requirement that the proper forms be filled out and filed promptly. This level of review is clearly inadequate when the process involves the death of an individual.

Some evidence suggests that having a physician-assisted law on the books may affect suicide rates in the general population. In Oregon, the suicide rate has risen out of proportion to the rest of the country, even excluding assisted-suicide deaths. (All laws require that assisted deaths be reported as a death from natural illness rather than suicide.) No formal study has been made of this issue, but there should be some provision to review and suspend the practice if this turns out to be the case.

All existing assisted-suicide laws recommend but do not require that a death be attended. Thus, despite the intent of the law, there is no way to ensure that the suicide is actually voluntary once the lethal medication is in hand. The law allows a physician to dispense medications to facilitate the ingestion of pentobarbital. This is necessary, because some patients have been unable to ingest the volume of liquid necessary to take the whole dose and have regurgitated the medication. Allowing premedication with an antiemetic is sometimes necessary. In theory, this aspect of the law could allow a health care practitioner to inject the antiemetic – an active involvement that would cross the line into euthanasia.

With regard to institutionalized patients, psychiatrists would be in a particularly challenging position. Presently, all patients admitted to hospitals are offered an opportunity to sign medical advance directives. At our forensic hospital in Maryland, admitting physicians assess the patient’s capacity to sign these directives. In theory, an insanity acquittee or long-term patient with a serious medical illness could request assisted suicide if competent. By law, the primary physician – a ward psychiatrist – would ultimately be required to write the lethal prescription or refer to another physician who would. If the patient were incompetent to request assisted suicide, the ward psychiatrist would be required to treat the mental illness knowing that it could eventually lead to the patient’s death. This situation is analogous to the dilemma of the correctional psychiatrist who treats an incompetent death row inmate.

There are many other problems with assisted-suicide legislation. At the very least, states should require a formal certification process to ensure that physicians who provide lethal medication have adequate training and experience to administer and interpret screening tests for psychiatric disorders, to do capacity assessments, and to make prognostic decisions relevant to their board certification and training. In all existing assisted-suicide bills and laws, the only requirement for a physician to provide lethal medication is that he or she must have the “qualifications and experience” to make a diagnosis and prognosis. There is no specific requirement that the attending or consulting physician actually be board certified to treat the illness in question. Thus, in theory, an attending or consulting physician could certify terminal illness without proven competence to do so.

Also, no clear safeguard exists to detect, investigate, and prosecute a hypothetical malicious or unscrupulous physician. In Oregon, three physicians write 20% of lethal prescriptions. It only takes one physician to do a lot of harm.

The American Medical Association has had a position statement on this topic for more than 20 years. The AMA takes the position that physician-assisted suicide is categorically unethical and bars doctors from participation. This, from the standpoint of a state health department, is probably the key issue: Should a legislature have the authority to allow physician behavior that a licensing board and professional organizations already have held to be unethical and not the practice of medicine? One of the core characteristics of a profession is the ability to monitor, police, and ensure the integrity of its members. Legislatures are unwise to undermine this.

Dr. Hanson is a forensic psychiatrist and co-author of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, bills aimed at allowing for physician-assisted suicide – also referred to as “Death With Dignity” laws – have been introduced in New Jersey, the District of Columbia, Maryland, Colorado, California, and Hawaii. Debates over the issue of end-of-life care are contentious and distressing, often accompanied by the tearful testimony of those who have cared for a family member throughout a long terminal illness. It’s hard to listen to these stories and not be moved personally, and to draw upon one’s own life experience with bereavement after a loved one’s suicide or disease.

For psychiatrists, the challenge is to think about assisted suicide not in terms of what we would want for ourselves, but what is best for our patients and the medical profession. Proponents argue that respect for patient autonomy should take priority, even if by respecting autonomy the end result is death. Opponents believe that by granting a request to die to a few people, many more vulnerable people may be abused or harmed inadvertently.

In my opinion, after extensive review of the bills and the effects of existing laws in Oregon and Washington, there are too many problems with assisted-suicide laws to safeguard or regulate this practice effectively.

The chief issue is that there is no mandate for any mental health evaluation for any qualified patient who requests assisted suicide. The primary physician and consulting physicians who certify competence may refer to a psychiatrist or psychologist, but this is only if there is a suspicion of incapacity. In Oregon, where this has been legal for 18 years, less than 5% of patients are referred for a competency assessment by a mental health professional although as many as 25% of terminally ill individuals may be suffering from clinical depression. In Oregon, individuals with HIV are 18 times more likely to die of assisted suicide than natural illness, which is particularly concerning given that HIV is known to affect the brain, and is associated with an increased risk of clinical depression and mania. The law allows a qualified patient to bar physicians from contacting or notifying family, which would make a psychiatrist’s competency assessment difficult if not impossible when the patient is suffering from a condition like dementia and can’t give a history himself.

The assisted-suicide process contains no mechanism to challenge the adequacy of the nonpsychiatrist’s assessment of capacity and noncoercion. There is no mechanism for judicial oversight, no mechanism to allow an interested party to raise the question of incompetence, and no existing standard of care for the assessment of capacity in this situation. Some bills protect the identity of the physicians and the patient, or bar medical records from subpoena or discovery, which would make any investigation for civil or criminal purposes difficult. In Oregon, 18 physicians were referred for board investigation, but none were sanctioned because the law required no more than “good faith” compliance with procedures – essentially only a requirement that the proper forms be filled out and filed promptly. This level of review is clearly inadequate when the process involves the death of an individual.

Some evidence suggests that having a physician-assisted law on the books may affect suicide rates in the general population. In Oregon, the suicide rate has risen out of proportion to the rest of the country, even excluding assisted-suicide deaths. (All laws require that assisted deaths be reported as a death from natural illness rather than suicide.) No formal study has been made of this issue, but there should be some provision to review and suspend the practice if this turns out to be the case.

All existing assisted-suicide laws recommend but do not require that a death be attended. Thus, despite the intent of the law, there is no way to ensure that the suicide is actually voluntary once the lethal medication is in hand. The law allows a physician to dispense medications to facilitate the ingestion of pentobarbital. This is necessary, because some patients have been unable to ingest the volume of liquid necessary to take the whole dose and have regurgitated the medication. Allowing premedication with an antiemetic is sometimes necessary. In theory, this aspect of the law could allow a health care practitioner to inject the antiemetic – an active involvement that would cross the line into euthanasia.

With regard to institutionalized patients, psychiatrists would be in a particularly challenging position. Presently, all patients admitted to hospitals are offered an opportunity to sign medical advance directives. At our forensic hospital in Maryland, admitting physicians assess the patient’s capacity to sign these directives. In theory, an insanity acquittee or long-term patient with a serious medical illness could request assisted suicide if competent. By law, the primary physician – a ward psychiatrist – would ultimately be required to write the lethal prescription or refer to another physician who would. If the patient were incompetent to request assisted suicide, the ward psychiatrist would be required to treat the mental illness knowing that it could eventually lead to the patient’s death. This situation is analogous to the dilemma of the correctional psychiatrist who treats an incompetent death row inmate.

There are many other problems with assisted-suicide legislation. At the very least, states should require a formal certification process to ensure that physicians who provide lethal medication have adequate training and experience to administer and interpret screening tests for psychiatric disorders, to do capacity assessments, and to make prognostic decisions relevant to their board certification and training. In all existing assisted-suicide bills and laws, the only requirement for a physician to provide lethal medication is that he or she must have the “qualifications and experience” to make a diagnosis and prognosis. There is no specific requirement that the attending or consulting physician actually be board certified to treat the illness in question. Thus, in theory, an attending or consulting physician could certify terminal illness without proven competence to do so.

Also, no clear safeguard exists to detect, investigate, and prosecute a hypothetical malicious or unscrupulous physician. In Oregon, three physicians write 20% of lethal prescriptions. It only takes one physician to do a lot of harm.

The American Medical Association has had a position statement on this topic for more than 20 years. The AMA takes the position that physician-assisted suicide is categorically unethical and bars doctors from participation. This, from the standpoint of a state health department, is probably the key issue: Should a legislature have the authority to allow physician behavior that a licensing board and professional organizations already have held to be unethical and not the practice of medicine? One of the core characteristics of a profession is the ability to monitor, police, and ensure the integrity of its members. Legislatures are unwise to undermine this.

Dr. Hanson is a forensic psychiatrist and co-author of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

This supplement to Pediatric News^® is sponsored by Johnson & Johnson Consumer Companies, Inc.

Click here to view the supplement

Topics

• Introduction
• Prevalence and burden of atopic dermatitis
• Preventing and managing atopic dermatitis with emollients
• Colloidal oatmeal in skin barrier protection
• Clinical efficacy in atopic dermatitis
• Safety of colloidal oatmeal
• Conclusion

Faculty
Adam Friedman, MD
Assistant Professor, Division of Dermatology
Department of Medicine
Montefiore Medical Center
Assistant Professor, Department of Physiology and Biophysics
Albert Einstein College of Medicine
Bronx, NY

Dr. Friedman discloses he is a consultant and serves on the advisory board for Aveeno®, a Johnson & Johnson Consumer Companies, Inc. product line.

This supplement to Pediatric News^® is sponsored by Johnson & Johnson Consumer Companies, Inc.

Click here to view the supplement

Topics

• Introduction
• Prevalence and burden of atopic dermatitis
• Preventing and managing atopic dermatitis with emollients
• Colloidal oatmeal in skin barrier protection
• Clinical efficacy in atopic dermatitis
• Safety of colloidal oatmeal
• Conclusion

Faculty
Adam Friedman, MD
Assistant Professor, Division of Dermatology
Department of Medicine
Montefiore Medical Center
Assistant Professor, Department of Physiology and Biophysics
Albert Einstein College of Medicine
Bronx, NY

Dr. Friedman discloses he is a consultant and serves on the advisory board for Aveeno®, a Johnson & Johnson Consumer Companies, Inc. product line.

This supplement to Pediatric News^® is sponsored by Johnson & Johnson Consumer Companies, Inc.

Click here to view the supplement

Topics

• Introduction
• Prevalence and burden of atopic dermatitis
• Preventing and managing atopic dermatitis with emollients
• Colloidal oatmeal in skin barrier protection
• Clinical efficacy in atopic dermatitis
• Safety of colloidal oatmeal
• Conclusion

Faculty
Adam Friedman, MD
Assistant Professor, Division of Dermatology
Department of Medicine
Montefiore Medical Center
Assistant Professor, Department of Physiology and Biophysics
Albert Einstein College of Medicine
Bronx, NY

Dr. Friedman discloses he is a consultant and serves on the advisory board for Aveeno®, a Johnson & Johnson Consumer Companies, Inc. product line.

[[{"attributes":{},"fields":{}}]]

A supplement to Dermatology News™. This supplement is sponsored by Johnson & Johnson Consumer Companies, Inc.

Topics

• Introduction
• Prevalence and burden of atopic dermatitis
• Preventing and managing atopic dermatitis with emollients
• Colloidal oatmeal in skin barrier protection
• Clinical efficacy in atopic dermatitis
• Safety of colloidal oatmeal
• Conclusion

Faculty
Adam Friedman, MD
Assistant Professor, Division of Dermatology
Department of Medicine
Montefiore Medical Center
Assistant Professor, Department of Physiology and Biophysics
Albert Einstein College of Medicine
Bronx, NY

Dr. Friedman discloses he is a consultant and serves on the advisory board for Aveeno®, a Johnson & Johnson Consumer Companies, Inc. product line.

Links
Click here to download this supplement.

[[{"attributes":{},"fields":{}}]]

A supplement to Dermatology News™. This supplement is sponsored by Johnson & Johnson Consumer Companies, Inc.

Topics

• Introduction
• Prevalence and burden of atopic dermatitis
• Preventing and managing atopic dermatitis with emollients
• Colloidal oatmeal in skin barrier protection
• Clinical efficacy in atopic dermatitis
• Safety of colloidal oatmeal
• Conclusion

Faculty
Adam Friedman, MD
Assistant Professor, Division of Dermatology
Department of Medicine
Montefiore Medical Center
Assistant Professor, Department of Physiology and Biophysics
Albert Einstein College of Medicine
Bronx, NY

Dr. Friedman discloses he is a consultant and serves on the advisory board for Aveeno®, a Johnson & Johnson Consumer Companies, Inc. product line.

Links
Click here to download this supplement.

[[{"attributes":{},"fields":{}}]]

A supplement to Dermatology News™. This supplement is sponsored by Johnson & Johnson Consumer Companies, Inc.

Topics

• Introduction
• Prevalence and burden of atopic dermatitis
• Preventing and managing atopic dermatitis with emollients
• Colloidal oatmeal in skin barrier protection
• Clinical efficacy in atopic dermatitis
• Safety of colloidal oatmeal
• Conclusion

Faculty
Adam Friedman, MD
Assistant Professor, Division of Dermatology
Department of Medicine
Montefiore Medical Center
Assistant Professor, Department of Physiology and Biophysics
Albert Einstein College of Medicine
Bronx, NY

Dr. Friedman discloses he is a consultant and serves on the advisory board for Aveeno®, a Johnson & Johnson Consumer Companies, Inc. product line.

Links
Click here to download this supplement.

Projections for the number of new melanoma cases in 2015 give Texas the lowest estimated incidence and Oregon the highest, according to a report from the American Cancer Society.

Texas is expected to have 2,410 new cases of melanoma this year, for an incidence of 8.9 cases per 100,000 people. Oregon’s projected 1,480 melanoma cases for 2015 results in an incidence of 37.3 cases per 100,000 population. (The ACS projected the number of new cases, so incidences here are calculated via recent Census Bureau population estimates.)

After Texas, Louisiana should have the lowest melanoma rate at 11.6 per 100,000, followed by Arkansas and the District of Columbia, both at 12.1 per 100,000. On the upper end of the scale, Oregon will likely be followed by Washington, where the incidence for 2015 is expected to be 34.8 per 100,000, the ACS data show.

Using incidences (1995-2011) reported by the North American Association of Central Cancer Registries, the ACS projected that 73,870 new cases of melanoma will be diagnosed in the United States this year – meaning an overall incidence of 23.2 per 100,000, based on the same Census Bureau figures.

The ACS estimated that there will be 9,940 deaths from melanoma in 2015 – an incidence of 3.1 per 100,000 population – as well as 3,400 deaths from other forms of skin cancer, not including basal cell and squamous cell carcinomas.

[email protected]

Projections for the number of new melanoma cases in 2015 give Texas the lowest estimated incidence and Oregon the highest, according to a report from the American Cancer Society.

Texas is expected to have 2,410 new cases of melanoma this year, for an incidence of 8.9 cases per 100,000 people. Oregon’s projected 1,480 melanoma cases for 2015 results in an incidence of 37.3 cases per 100,000 population. (The ACS projected the number of new cases, so incidences here are calculated via recent Census Bureau population estimates.)

After Texas, Louisiana should have the lowest melanoma rate at 11.6 per 100,000, followed by Arkansas and the District of Columbia, both at 12.1 per 100,000. On the upper end of the scale, Oregon will likely be followed by Washington, where the incidence for 2015 is expected to be 34.8 per 100,000, the ACS data show.

Using incidences (1995-2011) reported by the North American Association of Central Cancer Registries, the ACS projected that 73,870 new cases of melanoma will be diagnosed in the United States this year – meaning an overall incidence of 23.2 per 100,000, based on the same Census Bureau figures.

The ACS estimated that there will be 9,940 deaths from melanoma in 2015 – an incidence of 3.1 per 100,000 population – as well as 3,400 deaths from other forms of skin cancer, not including basal cell and squamous cell carcinomas.

[email protected]

Projections for the number of new melanoma cases in 2015 give Texas the lowest estimated incidence and Oregon the highest, according to a report from the American Cancer Society.

Texas is expected to have 2,410 new cases of melanoma this year, for an incidence of 8.9 cases per 100,000 people. Oregon’s projected 1,480 melanoma cases for 2015 results in an incidence of 37.3 cases per 100,000 population. (The ACS projected the number of new cases, so incidences here are calculated via recent Census Bureau population estimates.)

After Texas, Louisiana should have the lowest melanoma rate at 11.6 per 100,000, followed by Arkansas and the District of Columbia, both at 12.1 per 100,000. On the upper end of the scale, Oregon will likely be followed by Washington, where the incidence for 2015 is expected to be 34.8 per 100,000, the ACS data show.

Using incidences (1995-2011) reported by the North American Association of Central Cancer Registries, the ACS projected that 73,870 new cases of melanoma will be diagnosed in the United States this year – meaning an overall incidence of 23.2 per 100,000, based on the same Census Bureau figures.

The ACS estimated that there will be 9,940 deaths from melanoma in 2015 – an incidence of 3.1 per 100,000 population – as well as 3,400 deaths from other forms of skin cancer, not including basal cell and squamous cell carcinomas.

[email protected]

Doctor consults with a cancer

patient and her father

Photo by Rhoda Baer

Results of 2 new studies indicate that young adults (ages 18 to 39) who have survived leukemia or lymphoma are more likely to report high distress than older survivors (age 65 and older).

Specifically, 45% of younger survivors reported moderate-to-high distress, whereas only 18% of older survivors reported similarly elevated levels.

In both groups, this distress was not affected by the amount of time since a patient received treatment. Distress was just as likely to be high in survivors who had completed treatment 4 years prior as in survivors who were 3 months out of treatment.

Whitney Jones, PhD, of the University of Colorado Denver, and her colleagues reported these findings in the Journal of Psychosocial Oncology.

In the first study, Dr Jones and her colleagues surveyed 477 cancer survivors, using a widely used measure of distress after trauma and several items from a measure of quality of life in cancer survivors.

These measures allowed the researchers to ask which factors of a cancer survivor’s life after treatment are the best predictors of persistent distress after treatment completion.

And results showed that survivors younger than 40 had the highest prevalence of distress.

Dr Jones explained the effect of age on distress using a framework called the Lifespan Perspective. Because there is an expected social, cultural, and developmental course of a person’s life, an event that is highly disruptive in one lifespan stage may be less disruptive in another.

“For younger survivors, cancer is out of context,” Dr Jones said. “When you’re under 40, you’re finishing your education, entering the workforce, starting a family, and cancer may be interpreted as disruptive and unexpected in that phase.”

“On the other hand, some of our older survivors said things like, ‘Cancer isn’t the most difficult thing I’ve experienced in life.’ And they knew friends and family members who had dealt with similar cancer experiences.”

The study also showed that people who feared recurrence were most likely to report high overall distress levels. And high financial burden due to cancer treatment predicted distress.

In the second study, the researchers used interviews with 51 leukemia and lymphoma survivors to explore the human side of these numbers and better understand the sources of distress as articulated by survivors themselves.

“For example, this was before the Affordable Care Act, and we had one survivor who talked about having only the basic college student insurance when he was diagnosed,” Dr Jones said. “After treatment, he discovered he had substantial medical debt and was uninsurable.”

“It helped to hear survivors talk about their experiences in their own words. To hear them articulate it helped us understand the real struggles behind our data.”

The interviews also helped to explain why distress lingers even years after treatment ends.

“A patient told us that, after lymphoma treatment, her doctor said that it would take 2 years to recover physically and mentally, and that almost all the gains would be in these 2 years,” Dr Jones said.

“She said something like, ‘I was really patient for 2 years, then after those 2 years passed, I didn’t feel any better and realized this is what I was going to be living with.’”

Distress detection and treatment is increasingly being seen as part of the standard of care for cancer patients and post-treatment survivors, the researchers noted.

For example, organizations like the National Comprehensive Cancer Network and the American College of Surgeons Commission on Cancer mandate distress screening and treatment in order to earn accreditation from these institutions.

“Understanding which individuals are most likely to experience elevated distress can be useful in targeting interventions to potential participants,” Dr Jones said.

Doctor consults with a cancer

patient and her father

Photo by Rhoda Baer

Results of 2 new studies indicate that young adults (ages 18 to 39) who have survived leukemia or lymphoma are more likely to report high distress than older survivors (age 65 and older).

Specifically, 45% of younger survivors reported moderate-to-high distress, whereas only 18% of older survivors reported similarly elevated levels.

In both groups, this distress was not affected by the amount of time since a patient received treatment. Distress was just as likely to be high in survivors who had completed treatment 4 years prior as in survivors who were 3 months out of treatment.

Whitney Jones, PhD, of the University of Colorado Denver, and her colleagues reported these findings in the Journal of Psychosocial Oncology.

In the first study, Dr Jones and her colleagues surveyed 477 cancer survivors, using a widely used measure of distress after trauma and several items from a measure of quality of life in cancer survivors.

These measures allowed the researchers to ask which factors of a cancer survivor’s life after treatment are the best predictors of persistent distress after treatment completion.

And results showed that survivors younger than 40 had the highest prevalence of distress.

Dr Jones explained the effect of age on distress using a framework called the Lifespan Perspective. Because there is an expected social, cultural, and developmental course of a person’s life, an event that is highly disruptive in one lifespan stage may be less disruptive in another.

“For younger survivors, cancer is out of context,” Dr Jones said. “When you’re under 40, you’re finishing your education, entering the workforce, starting a family, and cancer may be interpreted as disruptive and unexpected in that phase.”

“On the other hand, some of our older survivors said things like, ‘Cancer isn’t the most difficult thing I’ve experienced in life.’ And they knew friends and family members who had dealt with similar cancer experiences.”

The study also showed that people who feared recurrence were most likely to report high overall distress levels. And high financial burden due to cancer treatment predicted distress.

In the second study, the researchers used interviews with 51 leukemia and lymphoma survivors to explore the human side of these numbers and better understand the sources of distress as articulated by survivors themselves.

“For example, this was before the Affordable Care Act, and we had one survivor who talked about having only the basic college student insurance when he was diagnosed,” Dr Jones said. “After treatment, he discovered he had substantial medical debt and was uninsurable.”

“It helped to hear survivors talk about their experiences in their own words. To hear them articulate it helped us understand the real struggles behind our data.”

The interviews also helped to explain why distress lingers even years after treatment ends.

“A patient told us that, after lymphoma treatment, her doctor said that it would take 2 years to recover physically and mentally, and that almost all the gains would be in these 2 years,” Dr Jones said.

“She said something like, ‘I was really patient for 2 years, then after those 2 years passed, I didn’t feel any better and realized this is what I was going to be living with.’”

Distress detection and treatment is increasingly being seen as part of the standard of care for cancer patients and post-treatment survivors, the researchers noted.

For example, organizations like the National Comprehensive Cancer Network and the American College of Surgeons Commission on Cancer mandate distress screening and treatment in order to earn accreditation from these institutions.

“Understanding which individuals are most likely to experience elevated distress can be useful in targeting interventions to potential participants,” Dr Jones said.

Doctor consults with a cancer

patient and her father

Photo by Rhoda Baer

Results of 2 new studies indicate that young adults (ages 18 to 39) who have survived leukemia or lymphoma are more likely to report high distress than older survivors (age 65 and older).

Specifically, 45% of younger survivors reported moderate-to-high distress, whereas only 18% of older survivors reported similarly elevated levels.

In both groups, this distress was not affected by the amount of time since a patient received treatment. Distress was just as likely to be high in survivors who had completed treatment 4 years prior as in survivors who were 3 months out of treatment.

Whitney Jones, PhD, of the University of Colorado Denver, and her colleagues reported these findings in the Journal of Psychosocial Oncology.

In the first study, Dr Jones and her colleagues surveyed 477 cancer survivors, using a widely used measure of distress after trauma and several items from a measure of quality of life in cancer survivors.

These measures allowed the researchers to ask which factors of a cancer survivor’s life after treatment are the best predictors of persistent distress after treatment completion.

And results showed that survivors younger than 40 had the highest prevalence of distress.

Dr Jones explained the effect of age on distress using a framework called the Lifespan Perspective. Because there is an expected social, cultural, and developmental course of a person’s life, an event that is highly disruptive in one lifespan stage may be less disruptive in another.

“For younger survivors, cancer is out of context,” Dr Jones said. “When you’re under 40, you’re finishing your education, entering the workforce, starting a family, and cancer may be interpreted as disruptive and unexpected in that phase.”

“On the other hand, some of our older survivors said things like, ‘Cancer isn’t the most difficult thing I’ve experienced in life.’ And they knew friends and family members who had dealt with similar cancer experiences.”

The study also showed that people who feared recurrence were most likely to report high overall distress levels. And high financial burden due to cancer treatment predicted distress.

In the second study, the researchers used interviews with 51 leukemia and lymphoma survivors to explore the human side of these numbers and better understand the sources of distress as articulated by survivors themselves.

“For example, this was before the Affordable Care Act, and we had one survivor who talked about having only the basic college student insurance when he was diagnosed,” Dr Jones said. “After treatment, he discovered he had substantial medical debt and was uninsurable.”

“It helped to hear survivors talk about their experiences in their own words. To hear them articulate it helped us understand the real struggles behind our data.”

The interviews also helped to explain why distress lingers even years after treatment ends.

“A patient told us that, after lymphoma treatment, her doctor said that it would take 2 years to recover physically and mentally, and that almost all the gains would be in these 2 years,” Dr Jones said.

“She said something like, ‘I was really patient for 2 years, then after those 2 years passed, I didn’t feel any better and realized this is what I was going to be living with.’”

Distress detection and treatment is increasingly being seen as part of the standard of care for cancer patients and post-treatment survivors, the researchers noted.

For example, organizations like the National Comprehensive Cancer Network and the American College of Surgeons Commission on Cancer mandate distress screening and treatment in order to earn accreditation from these institutions.

“Understanding which individuals are most likely to experience elevated distress can be useful in targeting interventions to potential participants,” Dr Jones said.

Cancer patient receives therapy

Photo by Rhoda Baer

A survey of cancer patients has shown that when physicians make treatment decisions alone, patients tend to rate the quality of care lower than when physicians include patients in the decision-making process.

Researchers found this to be the case even among patients who said they preferred it when physicians made treatment decisions alone.

Kenneth L. Kehl, MD, of MD Anderson Cancer Center in Houston, Texas, and his colleagues reported these findings in JAMA Oncology.

The researchers surveyed 5315 cancer patients who reported decision roles for 10,817 treatment decisions. The team assessed the association between patients’ roles in decisions with their reports on quality of care and physician communication.

Most of the patients (58%) said they preferred shared roles in decision-making, 36% preferred patient-controlled decisions, and 6% preferred physician-controlled decisions.

The patients reported that their actual decision-making process was patient-controlled in 39% of decisions, shared in 44%, and physician-controlled in 17%. Of the treatment decisions made by patients, 42% were regarding surgery, 36% were regarding chemotherapy, and 22% were regarding radiation.

The researchers found that patients’ preferred role in decision-making was not associated with how they rated the quality of care. But when they reported that treatment decisions were controlled by physicians, the patients were less likely to rate the quality of care as excellent, as compared to shared-decision making situations.

Patients said physician care was excellent in 67.8% of cases. And 55.8% of patients gave their physicians the highest possible rating of communication.

However, patients who preferred physician-controlled decisions to shared decision-making were less likely to give top ratings to their physicians, as were patients who reported actually experiencing physician-controlled vs shared decisions.

The researchers said these results highlight the benefits of promoting shared decision-making among all patients with cancer, even those who seem to prefer less active roles in the process.

In a related commentary, Sarah T. Hawley, PhD, and Reshma Jagsi, MD, DPhil, of the University of Michigan in Ann Arbor, said they were intrigued by the fact that the association between shared decision-making and patient appraisal of care quality remained even when controlling for a patient’s preferred role in the decision-making process.

“Kehl and colleagues conclude from this finding that it is important to promote [shared decision-making], even among patients who may seek less active roles,” Drs Hawley and Jagsi wrote.

“Yet . . . prior work . . . has suggested that it is the match between patients’ preferred and actual involvement that contributes to greater satisfaction with care. These conflicting results underscore the need for further work to better quantify and link measures of [shared decision-making] to patient appraisal of care.”

Cancer patient receives therapy

Photo by Rhoda Baer

A survey of cancer patients has shown that when physicians make treatment decisions alone, patients tend to rate the quality of care lower than when physicians include patients in the decision-making process.

Researchers found this to be the case even among patients who said they preferred it when physicians made treatment decisions alone.

Kenneth L. Kehl, MD, of MD Anderson Cancer Center in Houston, Texas, and his colleagues reported these findings in JAMA Oncology.

The researchers surveyed 5315 cancer patients who reported decision roles for 10,817 treatment decisions. The team assessed the association between patients’ roles in decisions with their reports on quality of care and physician communication.

Most of the patients (58%) said they preferred shared roles in decision-making, 36% preferred patient-controlled decisions, and 6% preferred physician-controlled decisions.

The patients reported that their actual decision-making process was patient-controlled in 39% of decisions, shared in 44%, and physician-controlled in 17%. Of the treatment decisions made by patients, 42% were regarding surgery, 36% were regarding chemotherapy, and 22% were regarding radiation.

The researchers found that patients’ preferred role in decision-making was not associated with how they rated the quality of care. But when they reported that treatment decisions were controlled by physicians, the patients were less likely to rate the quality of care as excellent, as compared to shared-decision making situations.

Patients said physician care was excellent in 67.8% of cases. And 55.8% of patients gave their physicians the highest possible rating of communication.

However, patients who preferred physician-controlled decisions to shared decision-making were less likely to give top ratings to their physicians, as were patients who reported actually experiencing physician-controlled vs shared decisions.

The researchers said these results highlight the benefits of promoting shared decision-making among all patients with cancer, even those who seem to prefer less active roles in the process.

In a related commentary, Sarah T. Hawley, PhD, and Reshma Jagsi, MD, DPhil, of the University of Michigan in Ann Arbor, said they were intrigued by the fact that the association between shared decision-making and patient appraisal of care quality remained even when controlling for a patient’s preferred role in the decision-making process.

“Kehl and colleagues conclude from this finding that it is important to promote [shared decision-making], even among patients who may seek less active roles,” Drs Hawley and Jagsi wrote.

“Yet . . . prior work . . . has suggested that it is the match between patients’ preferred and actual involvement that contributes to greater satisfaction with care. These conflicting results underscore the need for further work to better quantify and link measures of [shared decision-making] to patient appraisal of care.”

Cancer patient receives therapy

Photo by Rhoda Baer

A survey of cancer patients has shown that when physicians make treatment decisions alone, patients tend to rate the quality of care lower than when physicians include patients in the decision-making process.

Researchers found this to be the case even among patients who said they preferred it when physicians made treatment decisions alone.

Kenneth L. Kehl, MD, of MD Anderson Cancer Center in Houston, Texas, and his colleagues reported these findings in JAMA Oncology.

The researchers surveyed 5315 cancer patients who reported decision roles for 10,817 treatment decisions. The team assessed the association between patients’ roles in decisions with their reports on quality of care and physician communication.

Most of the patients (58%) said they preferred shared roles in decision-making, 36% preferred patient-controlled decisions, and 6% preferred physician-controlled decisions.

The patients reported that their actual decision-making process was patient-controlled in 39% of decisions, shared in 44%, and physician-controlled in 17%. Of the treatment decisions made by patients, 42% were regarding surgery, 36% were regarding chemotherapy, and 22% were regarding radiation.

The researchers found that patients’ preferred role in decision-making was not associated with how they rated the quality of care. But when they reported that treatment decisions were controlled by physicians, the patients were less likely to rate the quality of care as excellent, as compared to shared-decision making situations.

Patients said physician care was excellent in 67.8% of cases. And 55.8% of patients gave their physicians the highest possible rating of communication.

However, patients who preferred physician-controlled decisions to shared decision-making were less likely to give top ratings to their physicians, as were patients who reported actually experiencing physician-controlled vs shared decisions.

The researchers said these results highlight the benefits of promoting shared decision-making among all patients with cancer, even those who seem to prefer less active roles in the process.

In a related commentary, Sarah T. Hawley, PhD, and Reshma Jagsi, MD, DPhil, of the University of Michigan in Ann Arbor, said they were intrigued by the fact that the association between shared decision-making and patient appraisal of care quality remained even when controlling for a patient’s preferred role in the decision-making process.

“Kehl and colleagues conclude from this finding that it is important to promote [shared decision-making], even among patients who may seek less active roles,” Drs Hawley and Jagsi wrote.

“Yet . . . prior work . . . has suggested that it is the match between patients’ preferred and actual involvement that contributes to greater satisfaction with care. These conflicting results underscore the need for further work to better quantify and link measures of [shared decision-making] to patient appraisal of care.”

Doctor consults with a patient

Photo courtesy of NIH

Although it makes sense that patient requests might drive physicians to practice defensive medicine, new research suggests that may not be the case with cancer patients.

The study, conducted at outpatient oncology centers, showed that patients rarely made clinically inappropriate requests.

Only 1% of more than 5000 patient-clinician encounters resulted in a clinically inappropriate request. And physicians rarely complied with these requests.

Keerthi Gogineni, MD, of the Hospital of the University of Pennsylvania in Philadelphia, and colleagues  reported these findings in JAMA Oncology.

The researchers analyzed interviews with clinicians immediately after they visited with patients to assess whether a patient had made a request, the type of request made, and the clinical appropriateness of it.

The interviews were conducted at outpatient oncology facilities at 3 Philadelphia-area hospitals between October 2013 and June 2014.

The authors evaluated 5050 patient-clinician encounters involving 3624 patients and 60 clinicians. Most of the patients were women, and the most common cancer was hematologic.

Overall, 440 (8.7%) of the encounters included a patient demand or request, such as for imaging studies, treatments, or tests. And physicians complied with 365 (83%) of them.

Of all the patient-clinician encounters, 50 (1%) included a clinically inappropriate request. Clinicians complied with 7 of them. So, in 0.14% of encounters, clinicians ordered a test or treatment based on a clinically inappropriate request.

“At least in oncology, ‘demanding patients’ seem infrequent and may not account for a significant proportion of costs,” the researchers concluded.

In a related editorial, Anthony L. Back, MD, of the Seattle Cancer Care Alliance in Washington, wrote that inappropriate patient demands appear to be “more mythical than real.”

“[W]e have to stop blaming patients for being demanding,” he wrote. “In reality, it is hardly happening. The myth of the demanding patient is more about our own responses and how lackluster communication skills can contribute to difficult situations that stick in our throats and in our memories. And when we have calmed down enough to look up, we see that what is really happening between patients and physicians these days is something quite different.”

“It is possible that what the study by Gogineni et al documents is a point in the evolution of the patient-physician relationship when both sides recognize the complexity of cancer care belies a simple fix. Perhaps this ‘negative’ study is pointing to an important truth: that we need to redirect our attention from the myths that are distracting us.”

Doctor consults with a patient

Photo courtesy of NIH

Although it makes sense that patient requests might drive physicians to practice defensive medicine, new research suggests that may not be the case with cancer patients.

The study, conducted at outpatient oncology centers, showed that patients rarely made clinically inappropriate requests.

Only 1% of more than 5000 patient-clinician encounters resulted in a clinically inappropriate request. And physicians rarely complied with these requests.

Keerthi Gogineni, MD, of the Hospital of the University of Pennsylvania in Philadelphia, and colleagues  reported these findings in JAMA Oncology.

The researchers analyzed interviews with clinicians immediately after they visited with patients to assess whether a patient had made a request, the type of request made, and the clinical appropriateness of it.

The interviews were conducted at outpatient oncology facilities at 3 Philadelphia-area hospitals between October 2013 and June 2014.

The authors evaluated 5050 patient-clinician encounters involving 3624 patients and 60 clinicians. Most of the patients were women, and the most common cancer was hematologic.

Overall, 440 (8.7%) of the encounters included a patient demand or request, such as for imaging studies, treatments, or tests. And physicians complied with 365 (83%) of them.

Of all the patient-clinician encounters, 50 (1%) included a clinically inappropriate request. Clinicians complied with 7 of them. So, in 0.14% of encounters, clinicians ordered a test or treatment based on a clinically inappropriate request.

“At least in oncology, ‘demanding patients’ seem infrequent and may not account for a significant proportion of costs,” the researchers concluded.

In a related editorial, Anthony L. Back, MD, of the Seattle Cancer Care Alliance in Washington, wrote that inappropriate patient demands appear to be “more mythical than real.”

“[W]e have to stop blaming patients for being demanding,” he wrote. “In reality, it is hardly happening. The myth of the demanding patient is more about our own responses and how lackluster communication skills can contribute to difficult situations that stick in our throats and in our memories. And when we have calmed down enough to look up, we see that what is really happening between patients and physicians these days is something quite different.”

“It is possible that what the study by Gogineni et al documents is a point in the evolution of the patient-physician relationship when both sides recognize the complexity of cancer care belies a simple fix. Perhaps this ‘negative’ study is pointing to an important truth: that we need to redirect our attention from the myths that are distracting us.”

Doctor consults with a patient

Photo courtesy of NIH

Although it makes sense that patient requests might drive physicians to practice defensive medicine, new research suggests that may not be the case with cancer patients.

The study, conducted at outpatient oncology centers, showed that patients rarely made clinically inappropriate requests.

Only 1% of more than 5000 patient-clinician encounters resulted in a clinically inappropriate request. And physicians rarely complied with these requests.

Keerthi Gogineni, MD, of the Hospital of the University of Pennsylvania in Philadelphia, and colleagues  reported these findings in JAMA Oncology.

The researchers analyzed interviews with clinicians immediately after they visited with patients to assess whether a patient had made a request, the type of request made, and the clinical appropriateness of it.

The interviews were conducted at outpatient oncology facilities at 3 Philadelphia-area hospitals between October 2013 and June 2014.

The authors evaluated 5050 patient-clinician encounters involving 3624 patients and 60 clinicians. Most of the patients were women, and the most common cancer was hematologic.

Overall, 440 (8.7%) of the encounters included a patient demand or request, such as for imaging studies, treatments, or tests. And physicians complied with 365 (83%) of them.

Of all the patient-clinician encounters, 50 (1%) included a clinically inappropriate request. Clinicians complied with 7 of them. So, in 0.14% of encounters, clinicians ordered a test or treatment based on a clinically inappropriate request.

“At least in oncology, ‘demanding patients’ seem infrequent and may not account for a significant proportion of costs,” the researchers concluded.

In a related editorial, Anthony L. Back, MD, of the Seattle Cancer Care Alliance in Washington, wrote that inappropriate patient demands appear to be “more mythical than real.”

“[W]e have to stop blaming patients for being demanding,” he wrote. “In reality, it is hardly happening. The myth of the demanding patient is more about our own responses and how lackluster communication skills can contribute to difficult situations that stick in our throats and in our memories. And when we have calmed down enough to look up, we see that what is really happening between patients and physicians these days is something quite different.”

“It is possible that what the study by Gogineni et al documents is a point in the evolution of the patient-physician relationship when both sides recognize the complexity of cancer care belies a simple fix. Perhaps this ‘negative’ study is pointing to an important truth: that we need to redirect our attention from the myths that are distracting us.”

Blood for transfusion

Photo by Elise Amendola

In-flight red blood cell (RBC) transfusions can improve outcomes in trauma patients, according to a study published in the Journal of the American College of Surgeons.

The research showed that air-lifted trauma victims who received blood transfusions in the helicopter had higher one-day survival rates and a lower risk of shock than air-lifted patients who did not receive transfusions until they arrived at the trauma unit.

Patients who received in-flight transfusions also required fewer RBCs once they arrived at the hospital.

Joshua Brown, MD, and his colleagues at the University of Pittsburgh Medical Center (UPMC) conducted this research, evaluating the air medical evacuation strategy at UPMC, which has a network of 18 helicopter bases in Pennsylvania, Ohio, and Maryland.

The STAT MedEvac helicopter teams have been carrying blood for transfusion on their flights for about 2 decades, but this is the first study that evaluated the use of transfused blood in civilian trauma victims air-evacuated directly from the injury scene and compared them with air-evacuated trauma victims who did not receive transfused blood.

It is also the largest study to date of a civilian in-flight trauma resuscitation protocol that has been used by the military in Iraq and Afghanistan.

The researchers evaluated 240 patients who received in-flight RBC transfusions and 480 patients who were not transfused until they reached the trauma center.

Receiving an in-flight transfusion was associated with better odds of 24-hour survival (adjusted odds ratio=4.92, P=0.01), decreased odds of shock (adjusted odds ratio=0.28, P=0.03), and lower 24-hour RBC requirement (coef -3.6 RBC units, P=0.04).

Based on these data, the UPMC may modify its protocol, Dr Brown said.

“It used to be the paramedics had to give the patient 2 liters of saline before giving them blood, and we dropped that down to only 1 liter of saline,” he noted. “Now, based on this study, we’re actually looking at giving patients blood without any saline who meet the criteria of low blood pressure and elevated heart rate and are clearly in shock.”

The UPMC protocol involves giving guidelines on when to administer transfusions to the paramedics and nurses onboard flights. All the STAT MedEvac flights at the institution carry 2 units of RBCs for transfusion.

Helicopter staff can communicate with the medical command doctor at the trauma center to get the go-ahead order to give blood to patients who may not meet the guidelines for transfusion but still may benefit from receiving it.

However, there are regulatory issues that may prevent such a protocol from being adopted universally, Dr Brown noted. In Pennsylvania, paramedics who have had additional training are allowed to start a blood transfusion without a physician present, but not all states allow this.

Dr Brown also explained the logistics and challenges of storing blood away from the blood bank.

“The blood needs to be refrigerated, the helicopter base must have a freezer, and the helicopters must have coolers when they’re actually out on a mission to keep the blood at an appropriate temperature,” he said.

Meeting these requirements involves close coordination with the blood bank and having a way to return unused blood after it expires in 30 days. The University of Pittsburgh has registered all of its helicopter bases as satellite blood banks to comply with the regulations.

Blood for transfusion

Photo by Elise Amendola

In-flight red blood cell (RBC) transfusions can improve outcomes in trauma patients, according to a study published in the Journal of the American College of Surgeons.

The research showed that air-lifted trauma victims who received blood transfusions in the helicopter had higher one-day survival rates and a lower risk of shock than air-lifted patients who did not receive transfusions until they arrived at the trauma unit.

Patients who received in-flight transfusions also required fewer RBCs once they arrived at the hospital.

Joshua Brown, MD, and his colleagues at the University of Pittsburgh Medical Center (UPMC) conducted this research, evaluating the air medical evacuation strategy at UPMC, which has a network of 18 helicopter bases in Pennsylvania, Ohio, and Maryland.

The STAT MedEvac helicopter teams have been carrying blood for transfusion on their flights for about 2 decades, but this is the first study that evaluated the use of transfused blood in civilian trauma victims air-evacuated directly from the injury scene and compared them with air-evacuated trauma victims who did not receive transfused blood.

It is also the largest study to date of a civilian in-flight trauma resuscitation protocol that has been used by the military in Iraq and Afghanistan.

The researchers evaluated 240 patients who received in-flight RBC transfusions and 480 patients who were not transfused until they reached the trauma center.

Receiving an in-flight transfusion was associated with better odds of 24-hour survival (adjusted odds ratio=4.92, P=0.01), decreased odds of shock (adjusted odds ratio=0.28, P=0.03), and lower 24-hour RBC requirement (coef -3.6 RBC units, P=0.04).

Based on these data, the UPMC may modify its protocol, Dr Brown said.

“It used to be the paramedics had to give the patient 2 liters of saline before giving them blood, and we dropped that down to only 1 liter of saline,” he noted. “Now, based on this study, we’re actually looking at giving patients blood without any saline who meet the criteria of low blood pressure and elevated heart rate and are clearly in shock.”

The UPMC protocol involves giving guidelines on when to administer transfusions to the paramedics and nurses onboard flights. All the STAT MedEvac flights at the institution carry 2 units of RBCs for transfusion.

Helicopter staff can communicate with the medical command doctor at the trauma center to get the go-ahead order to give blood to patients who may not meet the guidelines for transfusion but still may benefit from receiving it.

However, there are regulatory issues that may prevent such a protocol from being adopted universally, Dr Brown noted. In Pennsylvania, paramedics who have had additional training are allowed to start a blood transfusion without a physician present, but not all states allow this.

Dr Brown also explained the logistics and challenges of storing blood away from the blood bank.

“The blood needs to be refrigerated, the helicopter base must have a freezer, and the helicopters must have coolers when they’re actually out on a mission to keep the blood at an appropriate temperature,” he said.

Meeting these requirements involves close coordination with the blood bank and having a way to return unused blood after it expires in 30 days. The University of Pittsburgh has registered all of its helicopter bases as satellite blood banks to comply with the regulations.

Blood for transfusion

Photo by Elise Amendola

In-flight red blood cell (RBC) transfusions can improve outcomes in trauma patients, according to a study published in the Journal of the American College of Surgeons.

The research showed that air-lifted trauma victims who received blood transfusions in the helicopter had higher one-day survival rates and a lower risk of shock than air-lifted patients who did not receive transfusions until they arrived at the trauma unit.

Patients who received in-flight transfusions also required fewer RBCs once they arrived at the hospital.

Joshua Brown, MD, and his colleagues at the University of Pittsburgh Medical Center (UPMC) conducted this research, evaluating the air medical evacuation strategy at UPMC, which has a network of 18 helicopter bases in Pennsylvania, Ohio, and Maryland.

The STAT MedEvac helicopter teams have been carrying blood for transfusion on their flights for about 2 decades, but this is the first study that evaluated the use of transfused blood in civilian trauma victims air-evacuated directly from the injury scene and compared them with air-evacuated trauma victims who did not receive transfused blood.

It is also the largest study to date of a civilian in-flight trauma resuscitation protocol that has been used by the military in Iraq and Afghanistan.

The researchers evaluated 240 patients who received in-flight RBC transfusions and 480 patients who were not transfused until they reached the trauma center.

Receiving an in-flight transfusion was associated with better odds of 24-hour survival (adjusted odds ratio=4.92, P=0.01), decreased odds of shock (adjusted odds ratio=0.28, P=0.03), and lower 24-hour RBC requirement (coef -3.6 RBC units, P=0.04).

Based on these data, the UPMC may modify its protocol, Dr Brown said.

“It used to be the paramedics had to give the patient 2 liters of saline before giving them blood, and we dropped that down to only 1 liter of saline,” he noted. “Now, based on this study, we’re actually looking at giving patients blood without any saline who meet the criteria of low blood pressure and elevated heart rate and are clearly in shock.”

The UPMC protocol involves giving guidelines on when to administer transfusions to the paramedics and nurses onboard flights. All the STAT MedEvac flights at the institution carry 2 units of RBCs for transfusion.

Helicopter staff can communicate with the medical command doctor at the trauma center to get the go-ahead order to give blood to patients who may not meet the guidelines for transfusion but still may benefit from receiving it.

However, there are regulatory issues that may prevent such a protocol from being adopted universally, Dr Brown noted. In Pennsylvania, paramedics who have had additional training are allowed to start a blood transfusion without a physician present, but not all states allow this.

Dr Brown also explained the logistics and challenges of storing blood away from the blood bank.

“The blood needs to be refrigerated, the helicopter base must have a freezer, and the helicopters must have coolers when they’re actually out on a mission to keep the blood at an appropriate temperature,” he said.

Meeting these requirements involves close coordination with the blood bank and having a way to return unused blood after it expires in 30 days. The University of Pittsburgh has registered all of its helicopter bases as satellite blood banks to comply with the regulations.