Military sexual trauma (MST) refers to experiences of sexual assault or repeated, threatening sexual harassment experienced while on federal active duty or active duty for training. About 1 in 4 women and 1 in 100 men have reported MST to their VA doctors. However, these numbers do not account for those who have not sought health care for their MST experience or who have sought care for MST outside the VA.

Military sexual trauma is:

Military sexual trauma is the term VA uses to refer to sexual assault or sexual harassment that occurred while the veteran was in the military. A victim of MST may have been:

• Involved in sexual activity against his or her will, by physical force or nonphysical pressure. Nonphysical pressure includes threats of negative consequences for refusing to be sexually cooperative, or indirect promises of faster promotions or better treatment in exchange for sex.
• Unable to consent to sexual activities. This includes intoxication by alcohol or other substances.

Other experiences include sexual touching or grabbing, threatening or offensive remarks about a person’s body or sexual activities, as well as threatening and unwelcome sexual advances.

How do I know if I’m at risk?

Military sexual trauma can occur on or off base and while a service member—man or woman—is on or off duty. Those who commit sexual assault or sexual harassment can be men or women, military personnel or civilians, commanding officers or subordinates, strangers, friends, spouses, or intimate partners. 

When do I need medical attention?

The VA reports sexual assault is more likely to result in symptoms of PTSD (posttraumatic stress disorder) than are most other types of trauma, including combat. You should seek medical attention from your primary care doctor, a mental health professional, or your VA facility’s MST Coordinator following a MST experience, especially if you experience any of the following symptoms:

• Depression
• Suicidal thoughts
• Feeling angry or irritable most of the time
• Strong emotional reactions
• Feeling emotionally numb
• Trouble falling or staying asleep
• Nightmares
• Trouble focusing
• Difficulty remembering things
• Substance abuse
• Trouble feeling safe or trusting others
• Feeling isolated or disconnected from others
• Headaches
• Gastrointestinal difficulties
• Sexual dysfunction
• Chronic pain
• Chronic fatigue
• Weight or eating problems

Survivors who are not formally diagnosed may still struggle in certain situations with emotional reactions, memories related to their experiences of MST, or other interpersonal issues.

How is MST treated?

Because MST is an experience, not a diagnosis, treatment needs may vary from patient to patient. However, VA provides free, confidential counseling and treatment to male and female veterans for mental and physical health conditions related to experiences of MST. It is important to note that treatment is available even if the MST incident was not reported at the time it happened.

Your doctor may recommend individual therapy, group therapy, or medication, depending on your symptoms. Therapies that may be used to treat MST include:

• Cognitive behavioral therapy. The main goal of this therapy is to help you change your thought patterns, which will help you change the emotions and behavior connected with the MST experience. A counselor might encourage you to reimagine your trauma repeatedly under controlled conditions—an approach called exposure therapy—as a way of learning to cope.
• Stress inoculation (in-ock-you-lay-shun) training. This therapy involves combining stress management strategies with stress-relieving techniques, such as muscle relaxation, breathing retraining, self-dialogue, and thought stopping.
• Group therapy. This therapy enables you to discuss your trauma with others who have had similar experiences.
• Inpatient therapy. Nationwide, there are programs that offer specialized sexual trauma treatment for veterans who need more intense treatment and support, including that for severe depression or substance abuse.
• Medication. If your MST experience resulted in PTSD, your doctor may prescribe medication to help control symptoms of anxiety or to help you sleep. Your doctor will monitor you closely for any possible adverse effects of these medications. It is also possible that an STD (sexually transmitted disease) was passed during the trauma, so your doctor may choose to screen you for an STD. If the test comes back positive, your doctor will prescribe the appropriate drug for treatment.

Services are designed to help veterans at all stages of their recovery, whether that is focusing on strategies for coping with emotions and memories or, for veterans who are ready, talking about their MST experiences in depth.

What can I do to cope?

When trauma survivors take direct action to cope with their stress reactions, they put themselves in a position of power. This is called active coping, which involves accepting the impact the trauma had on your life and taking direct action to make improvements.

It is important to remember that recovery is a process and takes time. Healing from trauma, including MST, does not happen all at once, and healing does not mean that you must forget the experience. Instead, it means you have less pain and fewer bad feelings when you think about the experience, and any associated symptoms will over time bother you less.

Discussing your trauma with other survivors in a controlled setting can help you learn that you are not alone or weak. In addition, surrounding yourself with people you can talk to about your MST experience may help you feel more understood. You may even choose to distract yourself with positive recreational or work activities.

When you experience unwanted or distressing memories, remind yourself that they are just memories, and talk about them with someone you trust. If you feel that the trauma is happening again, which is known as a flashback, keep your eyes open and remind yourself where you presently are and that the trauma happened in the past.

Although VA and DoD are working to put an end to MST, it is an ongoing problem that affects a large percentage of women and men who proudly serve in the armed forces. For information on how to access free VA services and to determine your eligibility in MST benefits, visit http://www.mentalhealth.va.gov/msthome.asp.

Military sexual trauma (MST) refers to experiences of sexual assault or repeated, threatening sexual harassment experienced while on federal active duty or active duty for training. About 1 in 4 women and 1 in 100 men have reported MST to their VA doctors. However, these numbers do not account for those who have not sought health care for their MST experience or who have sought care for MST outside the VA.

Military sexual trauma is:

Military sexual trauma is the term VA uses to refer to sexual assault or sexual harassment that occurred while the veteran was in the military. A victim of MST may have been:

• Involved in sexual activity against his or her will, by physical force or nonphysical pressure. Nonphysical pressure includes threats of negative consequences for refusing to be sexually cooperative, or indirect promises of faster promotions or better treatment in exchange for sex.
• Unable to consent to sexual activities. This includes intoxication by alcohol or other substances.

Other experiences include sexual touching or grabbing, threatening or offensive remarks about a person’s body or sexual activities, as well as threatening and unwelcome sexual advances.

How do I know if I’m at risk?

Military sexual trauma can occur on or off base and while a service member—man or woman—is on or off duty. Those who commit sexual assault or sexual harassment can be men or women, military personnel or civilians, commanding officers or subordinates, strangers, friends, spouses, or intimate partners. 

When do I need medical attention?

The VA reports sexual assault is more likely to result in symptoms of PTSD (posttraumatic stress disorder) than are most other types of trauma, including combat. You should seek medical attention from your primary care doctor, a mental health professional, or your VA facility’s MST Coordinator following a MST experience, especially if you experience any of the following symptoms:

• Depression
• Suicidal thoughts
• Feeling angry or irritable most of the time
• Strong emotional reactions
• Feeling emotionally numb
• Trouble falling or staying asleep
• Nightmares
• Trouble focusing
• Difficulty remembering things
• Substance abuse
• Trouble feeling safe or trusting others
• Feeling isolated or disconnected from others
• Headaches
• Gastrointestinal difficulties
• Sexual dysfunction
• Chronic pain
• Chronic fatigue
• Weight or eating problems

Survivors who are not formally diagnosed may still struggle in certain situations with emotional reactions, memories related to their experiences of MST, or other interpersonal issues.

How is MST treated?

Because MST is an experience, not a diagnosis, treatment needs may vary from patient to patient. However, VA provides free, confidential counseling and treatment to male and female veterans for mental and physical health conditions related to experiences of MST. It is important to note that treatment is available even if the MST incident was not reported at the time it happened.

Your doctor may recommend individual therapy, group therapy, or medication, depending on your symptoms. Therapies that may be used to treat MST include:

• Cognitive behavioral therapy. The main goal of this therapy is to help you change your thought patterns, which will help you change the emotions and behavior connected with the MST experience. A counselor might encourage you to reimagine your trauma repeatedly under controlled conditions—an approach called exposure therapy—as a way of learning to cope.
• Stress inoculation (in-ock-you-lay-shun) training. This therapy involves combining stress management strategies with stress-relieving techniques, such as muscle relaxation, breathing retraining, self-dialogue, and thought stopping.
• Group therapy. This therapy enables you to discuss your trauma with others who have had similar experiences.
• Inpatient therapy. Nationwide, there are programs that offer specialized sexual trauma treatment for veterans who need more intense treatment and support, including that for severe depression or substance abuse.
• Medication. If your MST experience resulted in PTSD, your doctor may prescribe medication to help control symptoms of anxiety or to help you sleep. Your doctor will monitor you closely for any possible adverse effects of these medications. It is also possible that an STD (sexually transmitted disease) was passed during the trauma, so your doctor may choose to screen you for an STD. If the test comes back positive, your doctor will prescribe the appropriate drug for treatment.

Services are designed to help veterans at all stages of their recovery, whether that is focusing on strategies for coping with emotions and memories or, for veterans who are ready, talking about their MST experiences in depth.

What can I do to cope?

When trauma survivors take direct action to cope with their stress reactions, they put themselves in a position of power. This is called active coping, which involves accepting the impact the trauma had on your life and taking direct action to make improvements.

It is important to remember that recovery is a process and takes time. Healing from trauma, including MST, does not happen all at once, and healing does not mean that you must forget the experience. Instead, it means you have less pain and fewer bad feelings when you think about the experience, and any associated symptoms will over time bother you less.

Discussing your trauma with other survivors in a controlled setting can help you learn that you are not alone or weak. In addition, surrounding yourself with people you can talk to about your MST experience may help you feel more understood. You may even choose to distract yourself with positive recreational or work activities.

When you experience unwanted or distressing memories, remind yourself that they are just memories, and talk about them with someone you trust. If you feel that the trauma is happening again, which is known as a flashback, keep your eyes open and remind yourself where you presently are and that the trauma happened in the past.

Although VA and DoD are working to put an end to MST, it is an ongoing problem that affects a large percentage of women and men who proudly serve in the armed forces. For information on how to access free VA services and to determine your eligibility in MST benefits, visit http://www.mentalhealth.va.gov/msthome.asp.

Military sexual trauma (MST) refers to experiences of sexual assault or repeated, threatening sexual harassment experienced while on federal active duty or active duty for training. About 1 in 4 women and 1 in 100 men have reported MST to their VA doctors. However, these numbers do not account for those who have not sought health care for their MST experience or who have sought care for MST outside the VA.

Military sexual trauma is:

Military sexual trauma is the term VA uses to refer to sexual assault or sexual harassment that occurred while the veteran was in the military. A victim of MST may have been:

• Involved in sexual activity against his or her will, by physical force or nonphysical pressure. Nonphysical pressure includes threats of negative consequences for refusing to be sexually cooperative, or indirect promises of faster promotions or better treatment in exchange for sex.
• Unable to consent to sexual activities. This includes intoxication by alcohol or other substances.

Other experiences include sexual touching or grabbing, threatening or offensive remarks about a person’s body or sexual activities, as well as threatening and unwelcome sexual advances.

How do I know if I’m at risk?

Military sexual trauma can occur on or off base and while a service member—man or woman—is on or off duty. Those who commit sexual assault or sexual harassment can be men or women, military personnel or civilians, commanding officers or subordinates, strangers, friends, spouses, or intimate partners. 

When do I need medical attention?

The VA reports sexual assault is more likely to result in symptoms of PTSD (posttraumatic stress disorder) than are most other types of trauma, including combat. You should seek medical attention from your primary care doctor, a mental health professional, or your VA facility’s MST Coordinator following a MST experience, especially if you experience any of the following symptoms:

• Depression
• Suicidal thoughts
• Feeling angry or irritable most of the time
• Strong emotional reactions
• Feeling emotionally numb
• Trouble falling or staying asleep
• Nightmares
• Trouble focusing
• Difficulty remembering things
• Substance abuse
• Trouble feeling safe or trusting others
• Feeling isolated or disconnected from others
• Headaches
• Gastrointestinal difficulties
• Sexual dysfunction
• Chronic pain
• Chronic fatigue
• Weight or eating problems

Survivors who are not formally diagnosed may still struggle in certain situations with emotional reactions, memories related to their experiences of MST, or other interpersonal issues.

How is MST treated?

Because MST is an experience, not a diagnosis, treatment needs may vary from patient to patient. However, VA provides free, confidential counseling and treatment to male and female veterans for mental and physical health conditions related to experiences of MST. It is important to note that treatment is available even if the MST incident was not reported at the time it happened.

Your doctor may recommend individual therapy, group therapy, or medication, depending on your symptoms. Therapies that may be used to treat MST include:

• Cognitive behavioral therapy. The main goal of this therapy is to help you change your thought patterns, which will help you change the emotions and behavior connected with the MST experience. A counselor might encourage you to reimagine your trauma repeatedly under controlled conditions—an approach called exposure therapy—as a way of learning to cope.
• Stress inoculation (in-ock-you-lay-shun) training. This therapy involves combining stress management strategies with stress-relieving techniques, such as muscle relaxation, breathing retraining, self-dialogue, and thought stopping.
• Group therapy. This therapy enables you to discuss your trauma with others who have had similar experiences.
• Inpatient therapy. Nationwide, there are programs that offer specialized sexual trauma treatment for veterans who need more intense treatment and support, including that for severe depression or substance abuse.
• Medication. If your MST experience resulted in PTSD, your doctor may prescribe medication to help control symptoms of anxiety or to help you sleep. Your doctor will monitor you closely for any possible adverse effects of these medications. It is also possible that an STD (sexually transmitted disease) was passed during the trauma, so your doctor may choose to screen you for an STD. If the test comes back positive, your doctor will prescribe the appropriate drug for treatment.

Services are designed to help veterans at all stages of their recovery, whether that is focusing on strategies for coping with emotions and memories or, for veterans who are ready, talking about their MST experiences in depth.

What can I do to cope?

When trauma survivors take direct action to cope with their stress reactions, they put themselves in a position of power. This is called active coping, which involves accepting the impact the trauma had on your life and taking direct action to make improvements.

It is important to remember that recovery is a process and takes time. Healing from trauma, including MST, does not happen all at once, and healing does not mean that you must forget the experience. Instead, it means you have less pain and fewer bad feelings when you think about the experience, and any associated symptoms will over time bother you less.

Discussing your trauma with other survivors in a controlled setting can help you learn that you are not alone or weak. In addition, surrounding yourself with people you can talk to about your MST experience may help you feel more understood. You may even choose to distract yourself with positive recreational or work activities.

When you experience unwanted or distressing memories, remind yourself that they are just memories, and talk about them with someone you trust. If you feel that the trauma is happening again, which is known as a flashback, keep your eyes open and remind yourself where you presently are and that the trauma happened in the past.

Although VA and DoD are working to put an end to MST, it is an ongoing problem that affects a large percentage of women and men who proudly serve in the armed forces. For information on how to access free VA services and to determine your eligibility in MST benefits, visit http://www.mentalhealth.va.gov/msthome.asp.

Lab mouse

Previous studies have shown that inhibiting the activity of the Malt1 protein can kill lymphoma cells.

Now, research published in Cell Reports has revealed that it also causes the immune system to malfunction.

Malt1 carries out a variety of tasks in lymphocytes, including acting as a protease that breaks down messenger substances and controls their quantity.

Until now, researchers were unsure about the role the protease function plays in immune cell development.

Several years ago, Jürgen Ruland, PhD, of Technische Universität München in Germany, and his colleagues turned their attention to this question.

Via cell culture experiments, the researchers found that blocking the protease function of Malt1 kills lymphoma cells. The team decided to test this strategy in an animal model to shed light on the exact function of Malt1 protease.

“It’s only possible to study complex interactions in the immune system, which comprises a finely orchestrated interplay of various cell types, in an intact organism, not in cell cultures,” Dr Ruland noted. “The processes are too complex to recreate in cells outside the body.”

The mice the researchers used were genetically modified so their Malt1 protein could no longer act as a protease but was still able to carry out all of its other functions.

The team was surprised to find that these mice developed severe signs of inflammation. Moreover, the immune system attacked and destroyed key neurons that coordinate movements.

The researchers were able to explain how this serious malfunction occurred and, in doing so, discovered an unexpected function of Malt1.

They found that, in the absence of the protease function, the mice were unable to produce regulatory T cells, and this caused their immune responses to spin

out of control.

The team also found that normal lymphocytes can be activated without the protease function of Malt1, but they release messenger substances uncontrollably, which causes inflammation.

“Our study showed that Malt1 protease is surprisingly important for the development of regulatory T cells and for damping the immune response in general,” Dr Ruland said. “Since the blockade of the protease function in the organism produces undesirable effects, new alternatives should urgently be sought for the treatment of lymphoma.”

Lab mouse

Previous studies have shown that inhibiting the activity of the Malt1 protein can kill lymphoma cells.

Now, research published in Cell Reports has revealed that it also causes the immune system to malfunction.

Malt1 carries out a variety of tasks in lymphocytes, including acting as a protease that breaks down messenger substances and controls their quantity.

Until now, researchers were unsure about the role the protease function plays in immune cell development.

Several years ago, Jürgen Ruland, PhD, of Technische Universität München in Germany, and his colleagues turned their attention to this question.

Via cell culture experiments, the researchers found that blocking the protease function of Malt1 kills lymphoma cells. The team decided to test this strategy in an animal model to shed light on the exact function of Malt1 protease.

“It’s only possible to study complex interactions in the immune system, which comprises a finely orchestrated interplay of various cell types, in an intact organism, not in cell cultures,” Dr Ruland noted. “The processes are too complex to recreate in cells outside the body.”

The mice the researchers used were genetically modified so their Malt1 protein could no longer act as a protease but was still able to carry out all of its other functions.

The team was surprised to find that these mice developed severe signs of inflammation. Moreover, the immune system attacked and destroyed key neurons that coordinate movements.

The researchers were able to explain how this serious malfunction occurred and, in doing so, discovered an unexpected function of Malt1.

They found that, in the absence of the protease function, the mice were unable to produce regulatory T cells, and this caused their immune responses to spin

out of control.

The team also found that normal lymphocytes can be activated without the protease function of Malt1, but they release messenger substances uncontrollably, which causes inflammation.

“Our study showed that Malt1 protease is surprisingly important for the development of regulatory T cells and for damping the immune response in general,” Dr Ruland said. “Since the blockade of the protease function in the organism produces undesirable effects, new alternatives should urgently be sought for the treatment of lymphoma.”

Lab mouse

Previous studies have shown that inhibiting the activity of the Malt1 protein can kill lymphoma cells.

Now, research published in Cell Reports has revealed that it also causes the immune system to malfunction.

Malt1 carries out a variety of tasks in lymphocytes, including acting as a protease that breaks down messenger substances and controls their quantity.

Until now, researchers were unsure about the role the protease function plays in immune cell development.

Several years ago, Jürgen Ruland, PhD, of Technische Universität München in Germany, and his colleagues turned their attention to this question.

Via cell culture experiments, the researchers found that blocking the protease function of Malt1 kills lymphoma cells. The team decided to test this strategy in an animal model to shed light on the exact function of Malt1 protease.

“It’s only possible to study complex interactions in the immune system, which comprises a finely orchestrated interplay of various cell types, in an intact organism, not in cell cultures,” Dr Ruland noted. “The processes are too complex to recreate in cells outside the body.”

The mice the researchers used were genetically modified so their Malt1 protein could no longer act as a protease but was still able to carry out all of its other functions.

The team was surprised to find that these mice developed severe signs of inflammation. Moreover, the immune system attacked and destroyed key neurons that coordinate movements.

The researchers were able to explain how this serious malfunction occurred and, in doing so, discovered an unexpected function of Malt1.

They found that, in the absence of the protease function, the mice were unable to produce regulatory T cells, and this caused their immune responses to spin

out of control.

The team also found that normal lymphocytes can be activated without the protease function of Malt1, but they release messenger substances uncontrollably, which causes inflammation.

“Our study showed that Malt1 protease is surprisingly important for the development of regulatory T cells and for damping the immune response in general,” Dr Ruland said. “Since the blockade of the protease function in the organism produces undesirable effects, new alternatives should urgently be sought for the treatment of lymphoma.”

Vial of heparin

Two tests used to measure antibodies in patients with a history of heparin-induced thrombocytopenia (HIT) can produce radically different results, new research shows.

The anti-PF4/heparin IgG-specific enzyme-immunoassay can show that HIT antibody levels are high, while the functional platelet serotonin-release assay indicates that levels are low.

And researchers said the functional assay’s results may be the better indicator of a patient’s readiness for re-exposure to heparin.

Theodore Warkentin, MD, of McMaster University in Hamilton, Ontario, Canada, and his colleagues expressed this viewpoint and detailed the research supporting it in Blood.

When patients with a history of HIT require urgent heart surgery, physicians must test for the presence of HIT antibodies to determine whether the patient can be re-exposed to heparin during the procedure.

Hematologists use two types of tests to measure HIT antibodies—a functional platelet serotonin-release assay and an anti-PF4/heparin IgG-specific enzyme-immunoassay. If the more widely used immunoassay indicates the presence of HIT antibodies in a patient, surgery is usually delayed or plasma exchange is performed to lower the antibodies.

Practitioners have historically understood the two assays to provide similar conclusions, but a case report suggested otherwise.

A 76-year-old female with kidney cancer and previous HIT required urgent cardiac surgery to remove a tumor that had spread to her heart. After both her initial functional and immunoassays indicated the presence of HIT antibodies, her doctors deemed her ineligible for surgery.

But after repeated plasma exchange, the researchers performed both the functional and immunoassays on the patient again, and, this time, they observed strikingly different results.

“We were surprised to see that levels of HIT antibodies in this patient fell very quickly according to the functional assay, yet the antibodies detected by the immunoassay remained high,” Dr Warkentin said.

“This suggested to us that, while physicians in many situations may be waiting for the immunoassay to indicate lower antibody levels, patients in urgent need of heart surgery may be ready much earlier than the results suggest.”

To better understand the dissociation between the results of the two tests, Dr Warkentin’s team developed a model comparing functional and immunoassay results among 15 HIT blood samples. The samples were sequentially diluted and tested with both assays to mimic the effects of repeated plasma exchange.

The researchers observed that HIT antibody levels as measured by the functional assay decreased rather quickly, while the immunoassay continued to indicate high levels.

This suggests the sensitivity of the immunoassay may provide an overly conservative estimate of HIT antibody levels and their clinical relevance. The analysis illustrates how quickly platelet-activating properties can decline in a patient, either naturally or by using plasma exchange.

The observations also support the use of repeated plasma exchange as a therapeutic strategy prior to planned heparin re-exposure among patients with a recent HIT episode who require urgent cardiac surgery.

“Based on these findings, physicians should consider utilizing both of these tests when preparing a patient with a history of HIT for urgent heart surgery, considering the functional assay result as the stronger indicator of a patient’s readiness,” Dr Warkentin said.

“For these patients, [plasma exchange] can be a useful option to help rapidly reduce their remaining HIT antibody levels, minimize their risk of developing clots, and get them into the operating room sooner.”

Vial of heparin

Two tests used to measure antibodies in patients with a history of heparin-induced thrombocytopenia (HIT) can produce radically different results, new research shows.

The anti-PF4/heparin IgG-specific enzyme-immunoassay can show that HIT antibody levels are high, while the functional platelet serotonin-release assay indicates that levels are low.

And researchers said the functional assay’s results may be the better indicator of a patient’s readiness for re-exposure to heparin.

Theodore Warkentin, MD, of McMaster University in Hamilton, Ontario, Canada, and his colleagues expressed this viewpoint and detailed the research supporting it in Blood.

When patients with a history of HIT require urgent heart surgery, physicians must test for the presence of HIT antibodies to determine whether the patient can be re-exposed to heparin during the procedure.

Hematologists use two types of tests to measure HIT antibodies—a functional platelet serotonin-release assay and an anti-PF4/heparin IgG-specific enzyme-immunoassay. If the more widely used immunoassay indicates the presence of HIT antibodies in a patient, surgery is usually delayed or plasma exchange is performed to lower the antibodies.

Practitioners have historically understood the two assays to provide similar conclusions, but a case report suggested otherwise.

A 76-year-old female with kidney cancer and previous HIT required urgent cardiac surgery to remove a tumor that had spread to her heart. After both her initial functional and immunoassays indicated the presence of HIT antibodies, her doctors deemed her ineligible for surgery.

But after repeated plasma exchange, the researchers performed both the functional and immunoassays on the patient again, and, this time, they observed strikingly different results.

“We were surprised to see that levels of HIT antibodies in this patient fell very quickly according to the functional assay, yet the antibodies detected by the immunoassay remained high,” Dr Warkentin said.

“This suggested to us that, while physicians in many situations may be waiting for the immunoassay to indicate lower antibody levels, patients in urgent need of heart surgery may be ready much earlier than the results suggest.”

To better understand the dissociation between the results of the two tests, Dr Warkentin’s team developed a model comparing functional and immunoassay results among 15 HIT blood samples. The samples were sequentially diluted and tested with both assays to mimic the effects of repeated plasma exchange.

The researchers observed that HIT antibody levels as measured by the functional assay decreased rather quickly, while the immunoassay continued to indicate high levels.

This suggests the sensitivity of the immunoassay may provide an overly conservative estimate of HIT antibody levels and their clinical relevance. The analysis illustrates how quickly platelet-activating properties can decline in a patient, either naturally or by using plasma exchange.

The observations also support the use of repeated plasma exchange as a therapeutic strategy prior to planned heparin re-exposure among patients with a recent HIT episode who require urgent cardiac surgery.

“Based on these findings, physicians should consider utilizing both of these tests when preparing a patient with a history of HIT for urgent heart surgery, considering the functional assay result as the stronger indicator of a patient’s readiness,” Dr Warkentin said.

“For these patients, [plasma exchange] can be a useful option to help rapidly reduce their remaining HIT antibody levels, minimize their risk of developing clots, and get them into the operating room sooner.”

Vial of heparin

Two tests used to measure antibodies in patients with a history of heparin-induced thrombocytopenia (HIT) can produce radically different results, new research shows.

The anti-PF4/heparin IgG-specific enzyme-immunoassay can show that HIT antibody levels are high, while the functional platelet serotonin-release assay indicates that levels are low.

And researchers said the functional assay’s results may be the better indicator of a patient’s readiness for re-exposure to heparin.

Theodore Warkentin, MD, of McMaster University in Hamilton, Ontario, Canada, and his colleagues expressed this viewpoint and detailed the research supporting it in Blood.

When patients with a history of HIT require urgent heart surgery, physicians must test for the presence of HIT antibodies to determine whether the patient can be re-exposed to heparin during the procedure.

Hematologists use two types of tests to measure HIT antibodies—a functional platelet serotonin-release assay and an anti-PF4/heparin IgG-specific enzyme-immunoassay. If the more widely used immunoassay indicates the presence of HIT antibodies in a patient, surgery is usually delayed or plasma exchange is performed to lower the antibodies.

Practitioners have historically understood the two assays to provide similar conclusions, but a case report suggested otherwise.

A 76-year-old female with kidney cancer and previous HIT required urgent cardiac surgery to remove a tumor that had spread to her heart. After both her initial functional and immunoassays indicated the presence of HIT antibodies, her doctors deemed her ineligible for surgery.

But after repeated plasma exchange, the researchers performed both the functional and immunoassays on the patient again, and, this time, they observed strikingly different results.

“We were surprised to see that levels of HIT antibodies in this patient fell very quickly according to the functional assay, yet the antibodies detected by the immunoassay remained high,” Dr Warkentin said.

“This suggested to us that, while physicians in many situations may be waiting for the immunoassay to indicate lower antibody levels, patients in urgent need of heart surgery may be ready much earlier than the results suggest.”

To better understand the dissociation between the results of the two tests, Dr Warkentin’s team developed a model comparing functional and immunoassay results among 15 HIT blood samples. The samples were sequentially diluted and tested with both assays to mimic the effects of repeated plasma exchange.

The researchers observed that HIT antibody levels as measured by the functional assay decreased rather quickly, while the immunoassay continued to indicate high levels.

This suggests the sensitivity of the immunoassay may provide an overly conservative estimate of HIT antibody levels and their clinical relevance. The analysis illustrates how quickly platelet-activating properties can decline in a patient, either naturally or by using plasma exchange.

The observations also support the use of repeated plasma exchange as a therapeutic strategy prior to planned heparin re-exposure among patients with a recent HIT episode who require urgent cardiac surgery.

“Based on these findings, physicians should consider utilizing both of these tests when preparing a patient with a history of HIT for urgent heart surgery, considering the functional assay result as the stronger indicator of a patient’s readiness,” Dr Warkentin said.

“For these patients, [plasma exchange] can be a useful option to help rapidly reduce their remaining HIT antibody levels, minimize their risk of developing clots, and get them into the operating room sooner.”

B-cell ALL

The US Food and Drug Administration (FDA) has granted orphan drug designation for the chimeric antigen receptor (CAR) T-cell therapy JCAR015 to treat acute lymphoblastic leukemia (ALL).

The designation will provide the product’s developer, Juno Therapeutics, with multiple benefits, including the availability of grant money, certain tax credits, and 7 years of market exclusivity, as well as the possibility of an expedited regulatory process.

JCAR015 consists of autologous T cells expressing a CD19-specific, CD28/CD3z CAR. The treatment has shown promise in an ongoing phase 1 trial of patients with B-cell ALL.

Initial results from this study were published in Science Translational Medicine last year and in February. Updated results were presented at the AACR Annual Meeting in April.

At that point, the researchers had enrolled 22 adult patients with relapsed or refractory B-ALL who were minimal residual disease-positive or were in first complete remission at enrollment. Patients in complete remission were monitored and only received JCAR015 if they relapsed.

The remaining patients received re-induction chemotherapy (physician’s choice), followed by an infusion of JCAR015. After treatment, patients could receive allogeneic transplant, a different salvage therapy, or monitoring.

Eighty-two percent of patients achieved a complete response to JCAR015. The average time to complete response was about 24.5 days.

Twelve of the responders were eligible for transplant. Of the 8 patients who ultimately underwent transplant and survived, 1 relapsed, but the rest remained in remission.

Ten patients had died at the time of the AACR presentation. Six deaths were a result of disease relapse or progression, and 2 patients died of complications from stem cell transplant.

The 2 remaining deaths prompted a temporary suspension of enrollment in this trial.

Those deaths were related to complications from cytokine release syndrome. One patient died of cardiovascular disease, and the other died following “persistent seizure activity.”

So researchers at the Memorial Sloan-Kettering Cancer Center, where the trial is being conducted, reviewed these cases.

The results prompted them to amend trial enrollment criteria and dosing recommendations. Now, patients with cardiac disease are ineligible to receive JCAR015.

And the T-cell dose a patient receives will depend on the extent of his or her disease. The hope is that this will reduce the risk of cytokine release syndrome and any resulting seizures.

The researchers also noted that the monoclonal antibody tocilizumab has proven effective in treating cytokine release syndrome.

In addition to this trial, JCAR015 is under investigation in another phase 1 trial of patients with relapsed and refractory non-Hodgkin lymphoma.

B-cell ALL

The US Food and Drug Administration (FDA) has granted orphan drug designation for the chimeric antigen receptor (CAR) T-cell therapy JCAR015 to treat acute lymphoblastic leukemia (ALL).

The designation will provide the product’s developer, Juno Therapeutics, with multiple benefits, including the availability of grant money, certain tax credits, and 7 years of market exclusivity, as well as the possibility of an expedited regulatory process.

JCAR015 consists of autologous T cells expressing a CD19-specific, CD28/CD3z CAR. The treatment has shown promise in an ongoing phase 1 trial of patients with B-cell ALL.

Initial results from this study were published in Science Translational Medicine last year and in February. Updated results were presented at the AACR Annual Meeting in April.

At that point, the researchers had enrolled 22 adult patients with relapsed or refractory B-ALL who were minimal residual disease-positive or were in first complete remission at enrollment. Patients in complete remission were monitored and only received JCAR015 if they relapsed.

The remaining patients received re-induction chemotherapy (physician’s choice), followed by an infusion of JCAR015. After treatment, patients could receive allogeneic transplant, a different salvage therapy, or monitoring.

Eighty-two percent of patients achieved a complete response to JCAR015. The average time to complete response was about 24.5 days.

Twelve of the responders were eligible for transplant. Of the 8 patients who ultimately underwent transplant and survived, 1 relapsed, but the rest remained in remission.

Ten patients had died at the time of the AACR presentation. Six deaths were a result of disease relapse or progression, and 2 patients died of complications from stem cell transplant.

The 2 remaining deaths prompted a temporary suspension of enrollment in this trial.

Those deaths were related to complications from cytokine release syndrome. One patient died of cardiovascular disease, and the other died following “persistent seizure activity.”

So researchers at the Memorial Sloan-Kettering Cancer Center, where the trial is being conducted, reviewed these cases.

The results prompted them to amend trial enrollment criteria and dosing recommendations. Now, patients with cardiac disease are ineligible to receive JCAR015.

And the T-cell dose a patient receives will depend on the extent of his or her disease. The hope is that this will reduce the risk of cytokine release syndrome and any resulting seizures.

The researchers also noted that the monoclonal antibody tocilizumab has proven effective in treating cytokine release syndrome.

In addition to this trial, JCAR015 is under investigation in another phase 1 trial of patients with relapsed and refractory non-Hodgkin lymphoma.

B-cell ALL

The US Food and Drug Administration (FDA) has granted orphan drug designation for the chimeric antigen receptor (CAR) T-cell therapy JCAR015 to treat acute lymphoblastic leukemia (ALL).

The designation will provide the product’s developer, Juno Therapeutics, with multiple benefits, including the availability of grant money, certain tax credits, and 7 years of market exclusivity, as well as the possibility of an expedited regulatory process.

JCAR015 consists of autologous T cells expressing a CD19-specific, CD28/CD3z CAR. The treatment has shown promise in an ongoing phase 1 trial of patients with B-cell ALL.

Initial results from this study were published in Science Translational Medicine last year and in February. Updated results were presented at the AACR Annual Meeting in April.

At that point, the researchers had enrolled 22 adult patients with relapsed or refractory B-ALL who were minimal residual disease-positive or were in first complete remission at enrollment. Patients in complete remission were monitored and only received JCAR015 if they relapsed.

The remaining patients received re-induction chemotherapy (physician’s choice), followed by an infusion of JCAR015. After treatment, patients could receive allogeneic transplant, a different salvage therapy, or monitoring.

Eighty-two percent of patients achieved a complete response to JCAR015. The average time to complete response was about 24.5 days.

Twelve of the responders were eligible for transplant. Of the 8 patients who ultimately underwent transplant and survived, 1 relapsed, but the rest remained in remission.

Ten patients had died at the time of the AACR presentation. Six deaths were a result of disease relapse or progression, and 2 patients died of complications from stem cell transplant.

The 2 remaining deaths prompted a temporary suspension of enrollment in this trial.

Those deaths were related to complications from cytokine release syndrome. One patient died of cardiovascular disease, and the other died following “persistent seizure activity.”

So researchers at the Memorial Sloan-Kettering Cancer Center, where the trial is being conducted, reviewed these cases.

The results prompted them to amend trial enrollment criteria and dosing recommendations. Now, patients with cardiac disease are ineligible to receive JCAR015.

And the T-cell dose a patient receives will depend on the extent of his or her disease. The hope is that this will reduce the risk of cytokine release syndrome and any resulting seizures.

The researchers also noted that the monoclonal antibody tocilizumab has proven effective in treating cytokine release syndrome.

In addition to this trial, JCAR015 is under investigation in another phase 1 trial of patients with relapsed and refractory non-Hodgkin lymphoma.

A recent study published in the Journal of Hospital Medicine reports on an early warning and response system (EWRS) for sepsis used in all three hospitals within the Philadelphia-based University of Pennsylvania Health System (UPHS) for three-month spans in 2012 and 2013. The system integrates laboratory values and vital signs into patients EHRs and establishes a threshold for triggering the alert.

After implementing the EWRS, at-risk patients received faster care for sepsis and/or were transferred to the ICU more quickly, says lead author Craig A. Umscheid, MD, MSCE, director of the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Study authors also note that quicker care suggested reduced mortality from sepsis as well.

"Whenever a patient triggered the alert, their probability of mortality was much higher than patients who didn't trigger the alert," Dr. Umscheid says. "I think what makes our study unique compared to other studies that have tried to predict sepsis is that beyond just creating a prediction rule for sepsis, we actually implemented it into a clinical care setting, alerted providers in real time, and then those providers changed their care based on the prediction."

More than 90% of care teams arrived at the bedside when they received an alert. "Meaning that they saw some value in the alert, and the infrastructure that we put in place was able to mobilize the team and get them to the bedside within 30 minutes," Dr. Umscheid adds. "We saw an increase in sepsis antibiotics used, and we saw an increase in fluid boluses within six hours.”

As many as 3 million cases of severe sepsis occur in the U.S. annually, and 750,000 result in deaths, according to the study. The high number of cases has led to several efforts to create better clinical practices for sepsis patients.

"Sepsis is arguably one of the most, if not the most important, causes of preventable mortality in the inpatient setting," Dr. Umscheid says. "One thing that we thought we could do better was identify sepsis cases earlier so that we could provide early antibiotics and fluids."

Visit our website for more information on identifying and treating sepsis.

A recent study published in the Journal of Hospital Medicine reports on an early warning and response system (EWRS) for sepsis used in all three hospitals within the Philadelphia-based University of Pennsylvania Health System (UPHS) for three-month spans in 2012 and 2013. The system integrates laboratory values and vital signs into patients EHRs and establishes a threshold for triggering the alert.

After implementing the EWRS, at-risk patients received faster care for sepsis and/or were transferred to the ICU more quickly, says lead author Craig A. Umscheid, MD, MSCE, director of the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Study authors also note that quicker care suggested reduced mortality from sepsis as well.

"Whenever a patient triggered the alert, their probability of mortality was much higher than patients who didn't trigger the alert," Dr. Umscheid says. "I think what makes our study unique compared to other studies that have tried to predict sepsis is that beyond just creating a prediction rule for sepsis, we actually implemented it into a clinical care setting, alerted providers in real time, and then those providers changed their care based on the prediction."

More than 90% of care teams arrived at the bedside when they received an alert. "Meaning that they saw some value in the alert, and the infrastructure that we put in place was able to mobilize the team and get them to the bedside within 30 minutes," Dr. Umscheid adds. "We saw an increase in sepsis antibiotics used, and we saw an increase in fluid boluses within six hours.”

As many as 3 million cases of severe sepsis occur in the U.S. annually, and 750,000 result in deaths, according to the study. The high number of cases has led to several efforts to create better clinical practices for sepsis patients.

"Sepsis is arguably one of the most, if not the most important, causes of preventable mortality in the inpatient setting," Dr. Umscheid says. "One thing that we thought we could do better was identify sepsis cases earlier so that we could provide early antibiotics and fluids."

Visit our website for more information on identifying and treating sepsis.

A recent study published in the Journal of Hospital Medicine reports on an early warning and response system (EWRS) for sepsis used in all three hospitals within the Philadelphia-based University of Pennsylvania Health System (UPHS) for three-month spans in 2012 and 2013. The system integrates laboratory values and vital signs into patients EHRs and establishes a threshold for triggering the alert.

After implementing the EWRS, at-risk patients received faster care for sepsis and/or were transferred to the ICU more quickly, says lead author Craig A. Umscheid, MD, MSCE, director of the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Study authors also note that quicker care suggested reduced mortality from sepsis as well.

"Whenever a patient triggered the alert, their probability of mortality was much higher than patients who didn't trigger the alert," Dr. Umscheid says. "I think what makes our study unique compared to other studies that have tried to predict sepsis is that beyond just creating a prediction rule for sepsis, we actually implemented it into a clinical care setting, alerted providers in real time, and then those providers changed their care based on the prediction."

More than 90% of care teams arrived at the bedside when they received an alert. "Meaning that they saw some value in the alert, and the infrastructure that we put in place was able to mobilize the team and get them to the bedside within 30 minutes," Dr. Umscheid adds. "We saw an increase in sepsis antibiotics used, and we saw an increase in fluid boluses within six hours.”

As many as 3 million cases of severe sepsis occur in the U.S. annually, and 750,000 result in deaths, according to the study. The high number of cases has led to several efforts to create better clinical practices for sepsis patients.

"Sepsis is arguably one of the most, if not the most important, causes of preventable mortality in the inpatient setting," Dr. Umscheid says. "One thing that we thought we could do better was identify sepsis cases earlier so that we could provide early antibiotics and fluids."

Visit our website for more information on identifying and treating sepsis.

Hospitalists have taken positions in every corner of healthcare: the C-suite, hospital administration, and even nominee for U.S. surgeon general.

Now, add county coroner to the list.

This month, hospitalist Adam Duckett, MD, was elected coroner for Cayuga County, N.Y., whose county seat of Auburn is about 30 miles west of Syracuse. Dr. Duckett, who had never run for public office, is a hospitalist at Auburn Community Hospital and serves as a board member for Hospice of the Finger Lakes.

The Hospitalist spoke with him about his new post, which might make him the only hospitalist/coroner in the country.

Question: HM is a time-consuming job. Why take time out for public service?

Answer: I believe everyone owes a debt of service to their community, and I felt that this was one that I would enjoy.

Q: What skills from HM apply to your new position?

A: The majority of unattended deaths in our county are related to long-standing medical illness. Because of this, I feel that in order to understand how somebody may have died, you must first know how they lived. I believe my role as a hospitalist enables me to review medical records and determine if the medical history provides enough information to determine a cause of death.

Q: What skills from your hospice care experience apply?

A: My role as a hospitalist has given me valuable insight in helping families cope with the loss of a loved one by providing explanations as to why somebody might have passed. It’s very important for a family to understand why a loved one died before they can accept it, and it’s very rewarding to help families through this process.

Get involved in public policy via SHM's advocacy home page. TH

Visit our website for more information about community involvement.

Hospitalists have taken positions in every corner of healthcare: the C-suite, hospital administration, and even nominee for U.S. surgeon general.

Now, add county coroner to the list.

This month, hospitalist Adam Duckett, MD, was elected coroner for Cayuga County, N.Y., whose county seat of Auburn is about 30 miles west of Syracuse. Dr. Duckett, who had never run for public office, is a hospitalist at Auburn Community Hospital and serves as a board member for Hospice of the Finger Lakes.

The Hospitalist spoke with him about his new post, which might make him the only hospitalist/coroner in the country.

Question: HM is a time-consuming job. Why take time out for public service?

Answer: I believe everyone owes a debt of service to their community, and I felt that this was one that I would enjoy.

Q: What skills from HM apply to your new position?

A: The majority of unattended deaths in our county are related to long-standing medical illness. Because of this, I feel that in order to understand how somebody may have died, you must first know how they lived. I believe my role as a hospitalist enables me to review medical records and determine if the medical history provides enough information to determine a cause of death.

Q: What skills from your hospice care experience apply?

A: My role as a hospitalist has given me valuable insight in helping families cope with the loss of a loved one by providing explanations as to why somebody might have passed. It’s very important for a family to understand why a loved one died before they can accept it, and it’s very rewarding to help families through this process.

Get involved in public policy via SHM's advocacy home page. TH

Visit our website for more information about community involvement.

Hospitalists have taken positions in every corner of healthcare: the C-suite, hospital administration, and even nominee for U.S. surgeon general.

Now, add county coroner to the list.

This month, hospitalist Adam Duckett, MD, was elected coroner for Cayuga County, N.Y., whose county seat of Auburn is about 30 miles west of Syracuse. Dr. Duckett, who had never run for public office, is a hospitalist at Auburn Community Hospital and serves as a board member for Hospice of the Finger Lakes.

The Hospitalist spoke with him about his new post, which might make him the only hospitalist/coroner in the country.

Question: HM is a time-consuming job. Why take time out for public service?

Answer: I believe everyone owes a debt of service to their community, and I felt that this was one that I would enjoy.

Q: What skills from HM apply to your new position?

A: The majority of unattended deaths in our county are related to long-standing medical illness. Because of this, I feel that in order to understand how somebody may have died, you must first know how they lived. I believe my role as a hospitalist enables me to review medical records and determine if the medical history provides enough information to determine a cause of death.

Q: What skills from your hospice care experience apply?

A: My role as a hospitalist has given me valuable insight in helping families cope with the loss of a loved one by providing explanations as to why somebody might have passed. It’s very important for a family to understand why a loved one died before they can accept it, and it’s very rewarding to help families through this process.

Get involved in public policy via SHM's advocacy home page. TH

Visit our website for more information about community involvement.

Postmenopausal women without osteoporosis on their first bone mineral density test are unlikely to fracture before age 65, and are therefore unlikely to benefit from regular or repeated screening before that age, according to an analysis of results from a large cohort study.

“Our data can help inform a BMD testing interval for postmenopausal women who are screened before age 65 years. Using the more conservative time estimates for major osteoporotic fracture, clinicians might allow women aged 50 to 54 years without osteoporosis on their first BMD test to wait 10 years for their next test. Similarly, women aged 60 to 64 years without osteoporosis on their first BMD test might wait until after age 65 years for their next test,” Dr. Margaret Lee Gourlay of the University of North Carolina, Chapel Hill, and her associates wrote in their analysis.

Dr. Gourlay and her coinvestigators on the larger Women’s Health Initiative cohort study looked at data from 4,068 postmenopausal women between the ages of 50 and 64 years. None of the women had prior hip or vertebral fractures or received antifracture treatment; they underwent baseline bone mineral density testing between 1993 and 2005. Fracture follow-up continued through 2012 (Menopause 2014 [doi: 10.1097/gme.0000000000000356]).

Among women with a normal BMD on first screening, the estimated time for 1% of those aged 50-54 years to have a hip or clinical vertebral fracture was 12.8 years. Among women aged 60-64 years, the time to fracture was 7.6 years, Dr. Gourlay and her colleagues found.

For the 8.5% of women in the cohort (all ages) with osteoporosis at baseline (n = 344), the age-adjusted time to hip or vertebral fracture was only 3 years.

Dr. Gourlay and her colleagues also estimated times to major osteoporotic fracture for 3% of the cohort, finding that it took 11.5 years for women aged 50-54 years to sustain a hip, clinical vertebral, proximal humerus, or wrist fracture, compared with 8.6 years for women who were 60-64 years at baseline. For women who had osteoporosis at baseline, the age-adjusted time for 3% to have an osteoporotic fracture was 2.5 years.

The researchers acknowledged as limitations of the study the fact that time estimates were based only on transitions to major fracture; that the full benefits and risks of screening, including cost-effectiveness, were not analyzed; and that the study was not powered to determine fracture risk in subgroups defined by individual risk factors.

Nonetheless, the results suggest that deferred repeat screening can be safe for postmenopausal women aged 50 years and older with normal BMD results at baseline, Dr. Gourlay and her coauthors wrote.

The study was funded by the National Institutes of Health. One of Dr. Gourlay’s coauthors is a consultant for MSD, and another reported receiving recent funding from Bone Ultrasound Finland.

Postmenopausal women without osteoporosis on their first bone mineral density test are unlikely to fracture before age 65, and are therefore unlikely to benefit from regular or repeated screening before that age, according to an analysis of results from a large cohort study.

“Our data can help inform a BMD testing interval for postmenopausal women who are screened before age 65 years. Using the more conservative time estimates for major osteoporotic fracture, clinicians might allow women aged 50 to 54 years without osteoporosis on their first BMD test to wait 10 years for their next test. Similarly, women aged 60 to 64 years without osteoporosis on their first BMD test might wait until after age 65 years for their next test,” Dr. Margaret Lee Gourlay of the University of North Carolina, Chapel Hill, and her associates wrote in their analysis.

Dr. Gourlay and her coinvestigators on the larger Women’s Health Initiative cohort study looked at data from 4,068 postmenopausal women between the ages of 50 and 64 years. None of the women had prior hip or vertebral fractures or received antifracture treatment; they underwent baseline bone mineral density testing between 1993 and 2005. Fracture follow-up continued through 2012 (Menopause 2014 [doi: 10.1097/gme.0000000000000356]).

Among women with a normal BMD on first screening, the estimated time for 1% of those aged 50-54 years to have a hip or clinical vertebral fracture was 12.8 years. Among women aged 60-64 years, the time to fracture was 7.6 years, Dr. Gourlay and her colleagues found.

For the 8.5% of women in the cohort (all ages) with osteoporosis at baseline (n = 344), the age-adjusted time to hip or vertebral fracture was only 3 years.

Dr. Gourlay and her colleagues also estimated times to major osteoporotic fracture for 3% of the cohort, finding that it took 11.5 years for women aged 50-54 years to sustain a hip, clinical vertebral, proximal humerus, or wrist fracture, compared with 8.6 years for women who were 60-64 years at baseline. For women who had osteoporosis at baseline, the age-adjusted time for 3% to have an osteoporotic fracture was 2.5 years.

The researchers acknowledged as limitations of the study the fact that time estimates were based only on transitions to major fracture; that the full benefits and risks of screening, including cost-effectiveness, were not analyzed; and that the study was not powered to determine fracture risk in subgroups defined by individual risk factors.

Nonetheless, the results suggest that deferred repeat screening can be safe for postmenopausal women aged 50 years and older with normal BMD results at baseline, Dr. Gourlay and her coauthors wrote.

The study was funded by the National Institutes of Health. One of Dr. Gourlay’s coauthors is a consultant for MSD, and another reported receiving recent funding from Bone Ultrasound Finland.

Postmenopausal women without osteoporosis on their first bone mineral density test are unlikely to fracture before age 65, and are therefore unlikely to benefit from regular or repeated screening before that age, according to an analysis of results from a large cohort study.

“Our data can help inform a BMD testing interval for postmenopausal women who are screened before age 65 years. Using the more conservative time estimates for major osteoporotic fracture, clinicians might allow women aged 50 to 54 years without osteoporosis on their first BMD test to wait 10 years for their next test. Similarly, women aged 60 to 64 years without osteoporosis on their first BMD test might wait until after age 65 years for their next test,” Dr. Margaret Lee Gourlay of the University of North Carolina, Chapel Hill, and her associates wrote in their analysis.

Dr. Gourlay and her coinvestigators on the larger Women’s Health Initiative cohort study looked at data from 4,068 postmenopausal women between the ages of 50 and 64 years. None of the women had prior hip or vertebral fractures or received antifracture treatment; they underwent baseline bone mineral density testing between 1993 and 2005. Fracture follow-up continued through 2012 (Menopause 2014 [doi: 10.1097/gme.0000000000000356]).

Among women with a normal BMD on first screening, the estimated time for 1% of those aged 50-54 years to have a hip or clinical vertebral fracture was 12.8 years. Among women aged 60-64 years, the time to fracture was 7.6 years, Dr. Gourlay and her colleagues found.

For the 8.5% of women in the cohort (all ages) with osteoporosis at baseline (n = 344), the age-adjusted time to hip or vertebral fracture was only 3 years.

Dr. Gourlay and her colleagues also estimated times to major osteoporotic fracture for 3% of the cohort, finding that it took 11.5 years for women aged 50-54 years to sustain a hip, clinical vertebral, proximal humerus, or wrist fracture, compared with 8.6 years for women who were 60-64 years at baseline. For women who had osteoporosis at baseline, the age-adjusted time for 3% to have an osteoporotic fracture was 2.5 years.

The researchers acknowledged as limitations of the study the fact that time estimates were based only on transitions to major fracture; that the full benefits and risks of screening, including cost-effectiveness, were not analyzed; and that the study was not powered to determine fracture risk in subgroups defined by individual risk factors.

Nonetheless, the results suggest that deferred repeat screening can be safe for postmenopausal women aged 50 years and older with normal BMD results at baseline, Dr. Gourlay and her coauthors wrote.

The study was funded by the National Institutes of Health. One of Dr. Gourlay’s coauthors is a consultant for MSD, and another reported receiving recent funding from Bone Ultrasound Finland.

BOSTON – Nearly all hospitalizations of people who were discharged with a primary diagnosis of gout were likely preventable, based on the results of a retrospective analysis of 79 cases at a single institution.

Because most of these patients presented to the emergency department rather than their doctor’s office, and were in pain and had other comorbidities, admission seemed the correct medical care decision, said Dr. Thomas Olenginski of the Geisinger Health System and one of the study’s lead authors. If the ED had gotten a rheumatology consult during the patients’ observation periods, however, the diagnosis could have been confirmed and most of these admissions would likely have been avoided, with a potential savings of over $200,000 in total hospitalization-related costs, Dr. Olenginski said at the annual meeting of the American College of Rheumatology.

Mary Jo Dales/Frontline Medical Media

Further, most of these patients were not adherent to their prescribed gout medications. Better clinical care and compliance with gout therapy might prevent most gout flareups that result in hospitalization, he added.

As a result of these findings, Geisinger has reassessed its approach to gout patients, especially those who present to the ED. For identified gout patients, they have ramped up efforts to make sure patients are adhering to therapy and are at goal, as well as educating them about their disease and how it can worsen without adherence. Rheumatologists are available to the ED by pager, encouraging arthrocentesis and crystal confirmation, thereby allowing the ED to focus on treating any associated skin infections and comorbidities, Dr. Olenginski said.

Of 56 gout-related admissions to their hospital, the Geisinger researchers found that 50 (89%) met the study’s definition of a preventable admission. A preventable admission was defined as one with a primary admitting diagnosis of mono- or polyarthritis subsequently diagnosed as gout and without any concomitant illness warranting admission on presentation.

The clinical diagnoses included 76% septic arthritis, 14% inflammatory polyarthritis, and 8% cellulitis.

Of the 50 preventable admissions, 33 patients underwent arthrocentesis, 24 of which were performed in the ED where the diagnosis could have been made based on crystal-confirmed diagnosis, he said.

Among the 35 patients with a prior history of gout, there were 23 patients whose serum uric acid levels were recorded within 1 year of their hospitalization, and 18 (78%) did not reach the goal of less than 6 mg/dL. Of 15 patients on long-term gout treatment, 5 (33%) were noncompliant with their treatment plans.

The total additive length of stay for the preventable gout admissions was 171 days with a mean stay of 3.42 days. Total hospitalization-related costs of these admissions were $208,000, with an average cost per admission of $4,160.

The study was performed as a quality initiative at Geisinger Health System. Dr. Olenginski had no relevant financial disclosures.

[email protected]

BOSTON – Nearly all hospitalizations of people who were discharged with a primary diagnosis of gout were likely preventable, based on the results of a retrospective analysis of 79 cases at a single institution.

Because most of these patients presented to the emergency department rather than their doctor’s office, and were in pain and had other comorbidities, admission seemed the correct medical care decision, said Dr. Thomas Olenginski of the Geisinger Health System and one of the study’s lead authors. If the ED had gotten a rheumatology consult during the patients’ observation periods, however, the diagnosis could have been confirmed and most of these admissions would likely have been avoided, with a potential savings of over $200,000 in total hospitalization-related costs, Dr. Olenginski said at the annual meeting of the American College of Rheumatology.

Mary Jo Dales/Frontline Medical Media

Further, most of these patients were not adherent to their prescribed gout medications. Better clinical care and compliance with gout therapy might prevent most gout flareups that result in hospitalization, he added.

As a result of these findings, Geisinger has reassessed its approach to gout patients, especially those who present to the ED. For identified gout patients, they have ramped up efforts to make sure patients are adhering to therapy and are at goal, as well as educating them about their disease and how it can worsen without adherence. Rheumatologists are available to the ED by pager, encouraging arthrocentesis and crystal confirmation, thereby allowing the ED to focus on treating any associated skin infections and comorbidities, Dr. Olenginski said.

Of 56 gout-related admissions to their hospital, the Geisinger researchers found that 50 (89%) met the study’s definition of a preventable admission. A preventable admission was defined as one with a primary admitting diagnosis of mono- or polyarthritis subsequently diagnosed as gout and without any concomitant illness warranting admission on presentation.

The clinical diagnoses included 76% septic arthritis, 14% inflammatory polyarthritis, and 8% cellulitis.

Of the 50 preventable admissions, 33 patients underwent arthrocentesis, 24 of which were performed in the ED where the diagnosis could have been made based on crystal-confirmed diagnosis, he said.

Among the 35 patients with a prior history of gout, there were 23 patients whose serum uric acid levels were recorded within 1 year of their hospitalization, and 18 (78%) did not reach the goal of less than 6 mg/dL. Of 15 patients on long-term gout treatment, 5 (33%) were noncompliant with their treatment plans.

The total additive length of stay for the preventable gout admissions was 171 days with a mean stay of 3.42 days. Total hospitalization-related costs of these admissions were $208,000, with an average cost per admission of $4,160.

The study was performed as a quality initiative at Geisinger Health System. Dr. Olenginski had no relevant financial disclosures.

[email protected]

BOSTON – Nearly all hospitalizations of people who were discharged with a primary diagnosis of gout were likely preventable, based on the results of a retrospective analysis of 79 cases at a single institution.

Because most of these patients presented to the emergency department rather than their doctor’s office, and were in pain and had other comorbidities, admission seemed the correct medical care decision, said Dr. Thomas Olenginski of the Geisinger Health System and one of the study’s lead authors. If the ED had gotten a rheumatology consult during the patients’ observation periods, however, the diagnosis could have been confirmed and most of these admissions would likely have been avoided, with a potential savings of over $200,000 in total hospitalization-related costs, Dr. Olenginski said at the annual meeting of the American College of Rheumatology.

Mary Jo Dales/Frontline Medical Media

Further, most of these patients were not adherent to their prescribed gout medications. Better clinical care and compliance with gout therapy might prevent most gout flareups that result in hospitalization, he added.

As a result of these findings, Geisinger has reassessed its approach to gout patients, especially those who present to the ED. For identified gout patients, they have ramped up efforts to make sure patients are adhering to therapy and are at goal, as well as educating them about their disease and how it can worsen without adherence. Rheumatologists are available to the ED by pager, encouraging arthrocentesis and crystal confirmation, thereby allowing the ED to focus on treating any associated skin infections and comorbidities, Dr. Olenginski said.

Of 56 gout-related admissions to their hospital, the Geisinger researchers found that 50 (89%) met the study’s definition of a preventable admission. A preventable admission was defined as one with a primary admitting diagnosis of mono- or polyarthritis subsequently diagnosed as gout and without any concomitant illness warranting admission on presentation.

The clinical diagnoses included 76% septic arthritis, 14% inflammatory polyarthritis, and 8% cellulitis.

Of the 50 preventable admissions, 33 patients underwent arthrocentesis, 24 of which were performed in the ED where the diagnosis could have been made based on crystal-confirmed diagnosis, he said.

Among the 35 patients with a prior history of gout, there were 23 patients whose serum uric acid levels were recorded within 1 year of their hospitalization, and 18 (78%) did not reach the goal of less than 6 mg/dL. Of 15 patients on long-term gout treatment, 5 (33%) were noncompliant with their treatment plans.

The total additive length of stay for the preventable gout admissions was 171 days with a mean stay of 3.42 days. Total hospitalization-related costs of these admissions were $208,000, with an average cost per admission of $4,160.

The study was performed as a quality initiative at Geisinger Health System. Dr. Olenginski had no relevant financial disclosures.

[email protected]