Doctor examines patient

while another looks on

Credit: NCI

A “co-rounding” partnership between medical oncologists and palliative care specialists has shown improvements in health-system and patient-related outcomes.

The first year of the partnership, which was tested in Duke University Hospital’s solid tumor oncology unit, brought significant decreases in the average length of hospital stay and in readmission rates, compared to a previous year in which the partnership did not exist.

There was a decrease in intensive care unit transfers and a trend toward increased hospice referrals as well, although these differences were not significant.

“The integration of palliative care, as a necessary and essential component of cancer care, is one that has been increasingly endorsed," said Richard Riedel, MD, of Duke University Hospital in Durham, North Carolina.

“The benefits of palliative care have been shown in the outpatient and consultative settings, but we didn’t know its impact on daily inpatient care. Now, we have successfully partnered with our palliative care colleagues to bring their unique skill sets and expertise directly to our admitted patients, and have shown it to be beneficial.”

Dr Riedel described this research (abstract 3*) in a presscast prior to the 2014 Palliative Care in Oncology Symposium, which is scheduled to take place October 24-25 at the Westin Boston Waterfront in Boston.

The co-rounding partnership involves 3 formal meetings each day in which members of the team, including both the attending medical oncologist and the attending palliative care physician, discuss all patients in the solid tumor unit.

The team decides which attending physician oversees direct care for a patient depending on his or her needs. For example, patients with higher symptom burden are typically assigned to the palliative care specialists.

The hospital support staff (eg, internal medicine house staff, physician assistants, and pharmacists) round with both attending physicians, and this care model allows for both formal and informal consultation between specialties.

To evaluate the effects of this model, the researchers assessed outcomes among the 731 patients admitted before the intervention began and 783 admitted in the first year of the intervention. About three-quarters of patients in both groups had metastatic cancer.

The team found a significant decrease in the average length of hospital stay from the pre-intervention period to the post-intervention period—4.51 days and 4.16 days, respectively (P=0.02).

Likewise, there was a significant decrease in readmission rates. There was 23% relative reduction in 7-day readmission rates (P<0.0001) and a 12% relative reduction in 30-day readmission rates (P=0.048).

Patient transfers to the intensive care unit decreased by 15% post-intervention, and hospice referrals increased by 17%, but these effects were not statistically significant (P=0.64 and 0.09, respectively).

The researchers said these results emphasize the value of implementing palliative medicine soon after a cancer diagnosis, rather than waiting until later in the disease’s progression.

Due to positive results with the co-rounding partnership, Duke University Hospital has established new outpatient palliative care clinics in oncology and general medicine.

The researchers are planning future studies to assess longer-term effects of the intervention on both patient and health-system outcomes, evaluate patient satisfaction, and explore potential cost savings associated with this intervention.

*Data presented differ from data in the abstract.

Doctor examines patient

while another looks on

Credit: NCI

A “co-rounding” partnership between medical oncologists and palliative care specialists has shown improvements in health-system and patient-related outcomes.

The first year of the partnership, which was tested in Duke University Hospital’s solid tumor oncology unit, brought significant decreases in the average length of hospital stay and in readmission rates, compared to a previous year in which the partnership did not exist.

There was a decrease in intensive care unit transfers and a trend toward increased hospice referrals as well, although these differences were not significant.

“The integration of palliative care, as a necessary and essential component of cancer care, is one that has been increasingly endorsed," said Richard Riedel, MD, of Duke University Hospital in Durham, North Carolina.

“The benefits of palliative care have been shown in the outpatient and consultative settings, but we didn’t know its impact on daily inpatient care. Now, we have successfully partnered with our palliative care colleagues to bring their unique skill sets and expertise directly to our admitted patients, and have shown it to be beneficial.”

Dr Riedel described this research (abstract 3*) in a presscast prior to the 2014 Palliative Care in Oncology Symposium, which is scheduled to take place October 24-25 at the Westin Boston Waterfront in Boston.

The co-rounding partnership involves 3 formal meetings each day in which members of the team, including both the attending medical oncologist and the attending palliative care physician, discuss all patients in the solid tumor unit.

The team decides which attending physician oversees direct care for a patient depending on his or her needs. For example, patients with higher symptom burden are typically assigned to the palliative care specialists.

The hospital support staff (eg, internal medicine house staff, physician assistants, and pharmacists) round with both attending physicians, and this care model allows for both formal and informal consultation between specialties.

To evaluate the effects of this model, the researchers assessed outcomes among the 731 patients admitted before the intervention began and 783 admitted in the first year of the intervention. About three-quarters of patients in both groups had metastatic cancer.

The team found a significant decrease in the average length of hospital stay from the pre-intervention period to the post-intervention period—4.51 days and 4.16 days, respectively (P=0.02).

Likewise, there was a significant decrease in readmission rates. There was 23% relative reduction in 7-day readmission rates (P<0.0001) and a 12% relative reduction in 30-day readmission rates (P=0.048).

Patient transfers to the intensive care unit decreased by 15% post-intervention, and hospice referrals increased by 17%, but these effects were not statistically significant (P=0.64 and 0.09, respectively).

The researchers said these results emphasize the value of implementing palliative medicine soon after a cancer diagnosis, rather than waiting until later in the disease’s progression.

Due to positive results with the co-rounding partnership, Duke University Hospital has established new outpatient palliative care clinics in oncology and general medicine.

The researchers are planning future studies to assess longer-term effects of the intervention on both patient and health-system outcomes, evaluate patient satisfaction, and explore potential cost savings associated with this intervention.

*Data presented differ from data in the abstract.

Doctor examines patient

while another looks on

Credit: NCI

A “co-rounding” partnership between medical oncologists and palliative care specialists has shown improvements in health-system and patient-related outcomes.

The first year of the partnership, which was tested in Duke University Hospital’s solid tumor oncology unit, brought significant decreases in the average length of hospital stay and in readmission rates, compared to a previous year in which the partnership did not exist.

There was a decrease in intensive care unit transfers and a trend toward increased hospice referrals as well, although these differences were not significant.

“The integration of palliative care, as a necessary and essential component of cancer care, is one that has been increasingly endorsed," said Richard Riedel, MD, of Duke University Hospital in Durham, North Carolina.

“The benefits of palliative care have been shown in the outpatient and consultative settings, but we didn’t know its impact on daily inpatient care. Now, we have successfully partnered with our palliative care colleagues to bring their unique skill sets and expertise directly to our admitted patients, and have shown it to be beneficial.”

Dr Riedel described this research (abstract 3*) in a presscast prior to the 2014 Palliative Care in Oncology Symposium, which is scheduled to take place October 24-25 at the Westin Boston Waterfront in Boston.

The co-rounding partnership involves 3 formal meetings each day in which members of the team, including both the attending medical oncologist and the attending palliative care physician, discuss all patients in the solid tumor unit.

The team decides which attending physician oversees direct care for a patient depending on his or her needs. For example, patients with higher symptom burden are typically assigned to the palliative care specialists.

The hospital support staff (eg, internal medicine house staff, physician assistants, and pharmacists) round with both attending physicians, and this care model allows for both formal and informal consultation between specialties.

To evaluate the effects of this model, the researchers assessed outcomes among the 731 patients admitted before the intervention began and 783 admitted in the first year of the intervention. About three-quarters of patients in both groups had metastatic cancer.

The team found a significant decrease in the average length of hospital stay from the pre-intervention period to the post-intervention period—4.51 days and 4.16 days, respectively (P=0.02).

Likewise, there was a significant decrease in readmission rates. There was 23% relative reduction in 7-day readmission rates (P<0.0001) and a 12% relative reduction in 30-day readmission rates (P=0.048).

Patient transfers to the intensive care unit decreased by 15% post-intervention, and hospice referrals increased by 17%, but these effects were not statistically significant (P=0.64 and 0.09, respectively).

The researchers said these results emphasize the value of implementing palliative medicine soon after a cancer diagnosis, rather than waiting until later in the disease’s progression.

Due to positive results with the co-rounding partnership, Duke University Hospital has established new outpatient palliative care clinics in oncology and general medicine.

The researchers are planning future studies to assess longer-term effects of the intervention on both patient and health-system outcomes, evaluate patient satisfaction, and explore potential cost savings associated with this intervention.

*Data presented differ from data in the abstract.

I am what you’d call an unwilling sports fan – and then just barely – in that I reside in a family where everyone else is riveted by sports, and by football in particular. The National Football League is the backdrop to my home life on Sundays, Mondays, and Thursdays, with Saturday reserved for college football, all the more so since both of my children have attended Big 10 universities. With that as a background, I was delighted when the Sept. 19 episode of the NFL’s “A Football Life,” focused on Brandon Marshall, the Chicago Bears wide receiver who has talked publicly about his personal struggles with borderline personality disorder.

While many psychiatric disorders are stigmatized by people who are unfamiliar with them, borderline personality disorder is likely the illness that gets most stigmatized within our profession. “Borderline” or “Cluster B” are sometimes uttered as code, to mean that a patient is difficult to work with, unlikeable, or perhaps even manipulative. We often blame patients for their behaviors in ways that we don’t when a patient is ill with an Axis I disorder, and few psychiatrists relish the opportunity to work with patients who have borderline personality disorder.

The television episode focused on Marshall’s football career, his legal struggles, and his interpersonal relationships both on and off the playing field. There were spotlights on many of the people who were affected by his troubling behavior. Marshall described his relationship with his best friend and quarterback, Jay Cutler, as, “We’re the couple that really love each other but shouldn’t be together.”

Cutler was interviewed. He described Marshall as an emotional man who loved media attention and who would lose his temper and hang on to grudges. They first played together for the Denver Broncos, and now both men play for the Chicago Bears.

Marshall’s agent was interviewed and made the point that Marshall had “…personally destroyed maybe five of my vacations.” Marshall’s former coach; his wife; his mother; and his psychiatrist, Dr. John Gunderson of McLean Hospital in Belmont, Mass., were all interviewed on the show.

The narrator for “A Football Life” described Marshall’s behavior as erratic, both on and off the field. Film clips were shown of Marshall losing his temper, kicking the ball off the field during a penalty, and celebrating excessively. His mother referred to his outbursts as “hissy fits,” and she noted, “We were all under the impression Brandon could control this.”

Despite his talent as a wide receiver – while playing for the Broncos, Marshall caught more than 100 passes in each of three consecutive seasons – the Broncos traded him to the Miami Dolphins. His career with the Broncos had been marked by a brief suspension for charges of drunk driving and domestic violence, and Marshall had had numerous arrests over the years. He finally was required to have a psychiatric assessment, and Marshall flew to Massachusetts for a day-long evaluation with Dr. Gunderson. Dr. Gunderson described Marshall at that meeting as “hostile and nondisclosing.”

In Miami, Marshall’s behavior continued to be a source of contention. His girlfriend, Michi, described him as remote and withdrawn. After a domestic dispute in which she was charged with stabbing him – charges that both denied and were later dropped – Marshall returned to see Dr. Gunderson and dedicated 3 months of his off-season to getting treatment.

Dr. Gunderson noted that on his return visit, “He was troubled enough by his behaviors and the difficulties they were causing for him.”

With a diagnosis of borderline personality disorder, Marshall became invested in learning about the disorder and devoted his days to intensive treatment, which included group therapy. He discussed the difficulties he has regulating his emotions and noted that he now had strategies to help him maintain control. Cutler noted that Marshall still loses his cool, but he quickly regains his composure, while in the past he could stay angry for days.

The rest of the show went on to document Marshall’s successes. He gained better control of his temper and became less difficult to work with. Coach Tony Sparano was interviewed, and both he and Marshall talked of Sparano’s role in providing emotional support to the football player. He was offered a $30 million contract extension with the Bears. He and Michi married, started the Brandon Marshall Foundation to support mental health education and treatment, and the couple announced in September that they are expecting twins.

Dr. Gunderson noted that Brandon Marshall’s openness about his disorder does a great deal to alleviate the stigma associated with borderline personality disorder.

“He’s an articulate and charismatic male football player,” he said. “This takes it out of the realm of something that’s about weak people.”

The special did not talk about whether Marshall was taking medications – it was implied that he wasn’t – or if he has continued in treatment. We think of borderline personality disorder as being resistant to treatments, and certainly not as a disorder that can be fixed with 3 months of treatment. It was noted that Marshall has some unusual assets in addition to his charismatic personality: He has a vocation he loves and is good at, and he has supportive relationships. A clip was shown of an appearance he and Michi had made on “The View,” where he credited her support as being key to his success.

As psychiatrists, there is a delicate balance when treating patients with personality disorders. On the one hand, we want them to take ownership for their behaviors in the hopes that they will be able to gain some control over them. To balance this, however, personality disorders can be as crippling as any illness we treat in psychiatry, and the prognosis for some people is dismal. While it may be helpful to have a diagnosis and an explanation, it’s not beneficial if the patient sees himself as the victim of an untreatable condition. The television special on Brandon Marshall did a wonderful job of presenting this disorder with a balance – as a problem that happens to people, perhaps because of their difficult childhoods – but one that the individual can learn to take control of in an empowering way.

We might imagine this remains an ongoing struggle for Marshall, not one that was treated and fixed. I, however, enjoyed watching an NFL production with a positive spin on what we think of as being such a devastating psychiatric disorder.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

I am what you’d call an unwilling sports fan – and then just barely – in that I reside in a family where everyone else is riveted by sports, and by football in particular. The National Football League is the backdrop to my home life on Sundays, Mondays, and Thursdays, with Saturday reserved for college football, all the more so since both of my children have attended Big 10 universities. With that as a background, I was delighted when the Sept. 19 episode of the NFL’s “A Football Life,” focused on Brandon Marshall, the Chicago Bears wide receiver who has talked publicly about his personal struggles with borderline personality disorder.

While many psychiatric disorders are stigmatized by people who are unfamiliar with them, borderline personality disorder is likely the illness that gets most stigmatized within our profession. “Borderline” or “Cluster B” are sometimes uttered as code, to mean that a patient is difficult to work with, unlikeable, or perhaps even manipulative. We often blame patients for their behaviors in ways that we don’t when a patient is ill with an Axis I disorder, and few psychiatrists relish the opportunity to work with patients who have borderline personality disorder.

The television episode focused on Marshall’s football career, his legal struggles, and his interpersonal relationships both on and off the playing field. There were spotlights on many of the people who were affected by his troubling behavior. Marshall described his relationship with his best friend and quarterback, Jay Cutler, as, “We’re the couple that really love each other but shouldn’t be together.”

Cutler was interviewed. He described Marshall as an emotional man who loved media attention and who would lose his temper and hang on to grudges. They first played together for the Denver Broncos, and now both men play for the Chicago Bears.

Marshall’s agent was interviewed and made the point that Marshall had “…personally destroyed maybe five of my vacations.” Marshall’s former coach; his wife; his mother; and his psychiatrist, Dr. John Gunderson of McLean Hospital in Belmont, Mass., were all interviewed on the show.

The narrator for “A Football Life” described Marshall’s behavior as erratic, both on and off the field. Film clips were shown of Marshall losing his temper, kicking the ball off the field during a penalty, and celebrating excessively. His mother referred to his outbursts as “hissy fits,” and she noted, “We were all under the impression Brandon could control this.”

Despite his talent as a wide receiver – while playing for the Broncos, Marshall caught more than 100 passes in each of three consecutive seasons – the Broncos traded him to the Miami Dolphins. His career with the Broncos had been marked by a brief suspension for charges of drunk driving and domestic violence, and Marshall had had numerous arrests over the years. He finally was required to have a psychiatric assessment, and Marshall flew to Massachusetts for a day-long evaluation with Dr. Gunderson. Dr. Gunderson described Marshall at that meeting as “hostile and nondisclosing.”

In Miami, Marshall’s behavior continued to be a source of contention. His girlfriend, Michi, described him as remote and withdrawn. After a domestic dispute in which she was charged with stabbing him – charges that both denied and were later dropped – Marshall returned to see Dr. Gunderson and dedicated 3 months of his off-season to getting treatment.

Dr. Gunderson noted that on his return visit, “He was troubled enough by his behaviors and the difficulties they were causing for him.”

With a diagnosis of borderline personality disorder, Marshall became invested in learning about the disorder and devoted his days to intensive treatment, which included group therapy. He discussed the difficulties he has regulating his emotions and noted that he now had strategies to help him maintain control. Cutler noted that Marshall still loses his cool, but he quickly regains his composure, while in the past he could stay angry for days.

The rest of the show went on to document Marshall’s successes. He gained better control of his temper and became less difficult to work with. Coach Tony Sparano was interviewed, and both he and Marshall talked of Sparano’s role in providing emotional support to the football player. He was offered a $30 million contract extension with the Bears. He and Michi married, started the Brandon Marshall Foundation to support mental health education and treatment, and the couple announced in September that they are expecting twins.

Dr. Gunderson noted that Brandon Marshall’s openness about his disorder does a great deal to alleviate the stigma associated with borderline personality disorder.

“He’s an articulate and charismatic male football player,” he said. “This takes it out of the realm of something that’s about weak people.”

The special did not talk about whether Marshall was taking medications – it was implied that he wasn’t – or if he has continued in treatment. We think of borderline personality disorder as being resistant to treatments, and certainly not as a disorder that can be fixed with 3 months of treatment. It was noted that Marshall has some unusual assets in addition to his charismatic personality: He has a vocation he loves and is good at, and he has supportive relationships. A clip was shown of an appearance he and Michi had made on “The View,” where he credited her support as being key to his success.

As psychiatrists, there is a delicate balance when treating patients with personality disorders. On the one hand, we want them to take ownership for their behaviors in the hopes that they will be able to gain some control over them. To balance this, however, personality disorders can be as crippling as any illness we treat in psychiatry, and the prognosis for some people is dismal. While it may be helpful to have a diagnosis and an explanation, it’s not beneficial if the patient sees himself as the victim of an untreatable condition. The television special on Brandon Marshall did a wonderful job of presenting this disorder with a balance – as a problem that happens to people, perhaps because of their difficult childhoods – but one that the individual can learn to take control of in an empowering way.

We might imagine this remains an ongoing struggle for Marshall, not one that was treated and fixed. I, however, enjoyed watching an NFL production with a positive spin on what we think of as being such a devastating psychiatric disorder.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

I am what you’d call an unwilling sports fan – and then just barely – in that I reside in a family where everyone else is riveted by sports, and by football in particular. The National Football League is the backdrop to my home life on Sundays, Mondays, and Thursdays, with Saturday reserved for college football, all the more so since both of my children have attended Big 10 universities. With that as a background, I was delighted when the Sept. 19 episode of the NFL’s “A Football Life,” focused on Brandon Marshall, the Chicago Bears wide receiver who has talked publicly about his personal struggles with borderline personality disorder.

While many psychiatric disorders are stigmatized by people who are unfamiliar with them, borderline personality disorder is likely the illness that gets most stigmatized within our profession. “Borderline” or “Cluster B” are sometimes uttered as code, to mean that a patient is difficult to work with, unlikeable, or perhaps even manipulative. We often blame patients for their behaviors in ways that we don’t when a patient is ill with an Axis I disorder, and few psychiatrists relish the opportunity to work with patients who have borderline personality disorder.

The television episode focused on Marshall’s football career, his legal struggles, and his interpersonal relationships both on and off the playing field. There were spotlights on many of the people who were affected by his troubling behavior. Marshall described his relationship with his best friend and quarterback, Jay Cutler, as, “We’re the couple that really love each other but shouldn’t be together.”

Cutler was interviewed. He described Marshall as an emotional man who loved media attention and who would lose his temper and hang on to grudges. They first played together for the Denver Broncos, and now both men play for the Chicago Bears.

Marshall’s agent was interviewed and made the point that Marshall had “…personally destroyed maybe five of my vacations.” Marshall’s former coach; his wife; his mother; and his psychiatrist, Dr. John Gunderson of McLean Hospital in Belmont, Mass., were all interviewed on the show.

The narrator for “A Football Life” described Marshall’s behavior as erratic, both on and off the field. Film clips were shown of Marshall losing his temper, kicking the ball off the field during a penalty, and celebrating excessively. His mother referred to his outbursts as “hissy fits,” and she noted, “We were all under the impression Brandon could control this.”

Despite his talent as a wide receiver – while playing for the Broncos, Marshall caught more than 100 passes in each of three consecutive seasons – the Broncos traded him to the Miami Dolphins. His career with the Broncos had been marked by a brief suspension for charges of drunk driving and domestic violence, and Marshall had had numerous arrests over the years. He finally was required to have a psychiatric assessment, and Marshall flew to Massachusetts for a day-long evaluation with Dr. Gunderson. Dr. Gunderson described Marshall at that meeting as “hostile and nondisclosing.”

In Miami, Marshall’s behavior continued to be a source of contention. His girlfriend, Michi, described him as remote and withdrawn. After a domestic dispute in which she was charged with stabbing him – charges that both denied and were later dropped – Marshall returned to see Dr. Gunderson and dedicated 3 months of his off-season to getting treatment.

Dr. Gunderson noted that on his return visit, “He was troubled enough by his behaviors and the difficulties they were causing for him.”

With a diagnosis of borderline personality disorder, Marshall became invested in learning about the disorder and devoted his days to intensive treatment, which included group therapy. He discussed the difficulties he has regulating his emotions and noted that he now had strategies to help him maintain control. Cutler noted that Marshall still loses his cool, but he quickly regains his composure, while in the past he could stay angry for days.

The rest of the show went on to document Marshall’s successes. He gained better control of his temper and became less difficult to work with. Coach Tony Sparano was interviewed, and both he and Marshall talked of Sparano’s role in providing emotional support to the football player. He was offered a $30 million contract extension with the Bears. He and Michi married, started the Brandon Marshall Foundation to support mental health education and treatment, and the couple announced in September that they are expecting twins.

Dr. Gunderson noted that Brandon Marshall’s openness about his disorder does a great deal to alleviate the stigma associated with borderline personality disorder.

“He’s an articulate and charismatic male football player,” he said. “This takes it out of the realm of something that’s about weak people.”

The special did not talk about whether Marshall was taking medications – it was implied that he wasn’t – or if he has continued in treatment. We think of borderline personality disorder as being resistant to treatments, and certainly not as a disorder that can be fixed with 3 months of treatment. It was noted that Marshall has some unusual assets in addition to his charismatic personality: He has a vocation he loves and is good at, and he has supportive relationships. A clip was shown of an appearance he and Michi had made on “The View,” where he credited her support as being key to his success.

As psychiatrists, there is a delicate balance when treating patients with personality disorders. On the one hand, we want them to take ownership for their behaviors in the hopes that they will be able to gain some control over them. To balance this, however, personality disorders can be as crippling as any illness we treat in psychiatry, and the prognosis for some people is dismal. While it may be helpful to have a diagnosis and an explanation, it’s not beneficial if the patient sees himself as the victim of an untreatable condition. The television special on Brandon Marshall did a wonderful job of presenting this disorder with a balance – as a problem that happens to people, perhaps because of their difficult childhoods – but one that the individual can learn to take control of in an empowering way.

We might imagine this remains an ongoing struggle for Marshall, not one that was treated and fixed. I, however, enjoyed watching an NFL production with a positive spin on what we think of as being such a devastating psychiatric disorder.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

Ovarian cancer is the most deadly gynecologic malignancy in the United States, with 14,270 deaths expected in 2014 (CA Cancer J. Clin. 2014;64:9-29 ). The 5-year overall survival remains less than 50%. Difficulties in treatment arise due to its aggressive nature, coupled with vague symptomatology and no effective screening test. Advanced-stage disease at the time of diagnosis is an unfortunate hallmark.

Traditional teaching about the pathogenesis of ovarian cancers has been that a metaplastic change in the mesothelial ovarian surface leads to their de novo development. Under this paradigm, 70% of serous tumors were ovarian, 17% peritoneal, and 13% tubal in origin. However, a major change occurred when BRCA carriers began having risk-reducing bilateral salpingo-oophorectomies (BSO). Sequential histologic sections of the adnexa found occult malignancy in 30% of fallopian tubes, but similar lesions were not present within the ovary (Am. J. Surg. Pathol. 1020;34:1407-16). Could these cancers in the fallopian tube be the precursor lesion and then seed or spread to the ovarian surface?

Molecular and genetic analysis of these serous tubal intraepithelial carcinoma (STIC) cells found p53 mutations that were identical to those in concurrent “ovarian” tumors. STICs have been identified in 70% of nonhereditary forms of serous ovarian cancer. Under this paradigm of STIC as tubal in origin, only 28% of serous tumors were ovarian and 64% were of tubal origin (Am. J. Surg. Pathol. 2007;31:161-9).

This paradigm shift elicited new hypotheses about the etiology of endometrioid and clear cell types of ovarian cancer. Rather than metaplasia of the surface epithelium, endometrioid and clear cell tumors may result from retrograde menstruation, with the fallopian tube acting as a conduit for cells to gain access to the peritoneal cavity and the ovarian surface. This hypothesis provides a mechanism for the 34% reduction in ovarian cancer with bilateral tubal ligation (Hum. Reprod. Update 2011;17:55-67). Interestingly, in a large collaborative pooled analysis, the risk reduction of tubal ligation was greatest for endometrioid and clear cell subtypes (Int. J. Epidemiol. 2013;42:579-89).

Given the mounting evidence of fallopian tube involvement in the development of ovarian cancers, there are new primary prevention considerations. After 5 or more years of oral contraceptive use, a 50% reduction in the relative risk of ovarian cancer has been reported (Ann. Epidemiol. 2011;21:188-96). Bilateral salpingo-oophorectomy provides a greater than 50% risk reduction even in the highest-risk BRCA-positive population. However, results from the Nurses’ Health Study suggest that while there are fewer cancers in a low-risk population following BSO, it comes with an increase in all-cause mortality, predominately due to negative cardiovascular effects. With these issues in mind, is it time to consider incorporating prophylactic bilateral salpingectomy in benign gynecologic surgery (Obstet. Gynecol. 2013;121:709-16)?

While salpingectomy at the time of hysterectomy for benign conditions or for sterilization is becoming more common, there are concerns about premature loss of ovarian function secondary to compromise of ovarian blood supply. However, amassing data demonstrates preserved ovarian function. A retrospective study comparing total laparoscopic hysterectomy (TLH) to TLH with bilateral salpingectomy found no difference in markers of ovarian function (anti-Müllerian hormone, FSH, antral follicle count, mean ovarian diameters) up to 3 months postoperatively (Gynecol. Oncol. 2013;129:448-51). In a randomized controlled trial, 30 women were 1:1 randomized to TLH vs. TLH with salpingectomy. There was no change in anti-Müllerian hormone levels (at 3 months), operative time, or estimated blood loss (Fertil. Steril. 2013;100:1704-8). While there are concerns about the paucity of long-term follow-up data, these initial studies are encouraging. Additionally, a large retrospective study of 540 BRCA-negative patients found no difference in surgical outcomes with salpingectomy (estimated blood loss, hospital stay), and furthermore, the study found that removal of the tubes significantly reduces the risk of developing subsequent benign adnexal lesions by nearly 50% (J. Cancer Res. Clin. Oncol. 2014;140:859-65).

Though salpingectomy removes tubal re-anastomosis as an option in cases of “tubal ligation regret,” wisely choosing candidates can minimize this risk. Women less than 30 years old are at highest risk for regret, and the decision for salpingectomy in these patients should be made with caution and extensive counseling. Yet recently, emerging thought leaders in family planning have called for removal to be routinely considered (Obstet. Gynecol. 2014;124:596-9).

Surgical technique involves electrosurgery or suture ligation just inferior to the fallopian tube, ligating the fallopian branches of the ovarian and utero-ovarian arteries while avoiding unnecessary involvement of ovarian branches within the mesosalpinx. Since the fimbria are thought to be the site of origin for many serous carcinomas, removing the fimbrial portion of the tube is crucial.

Ovarian cancer remains the most deadly gynecologic malignancy. Efforts to find effective screening methods have not yet delivered. Pathologic data confirms that over half of “ovarian” cancers are actually of tubal origin, and we should consider risk-reducing salpingectomy in the low-risk population. The Society of Gynecologic Oncology in their November 2013 Clinical Practice Statement stated, “For women at average risk of ovarian cancer, risk-reducing salpingectomy should also be discussed and considered with patients at the time of abdominal or pelvic surgery, hysterectomy or in lieu of tubal ligation [once childbearing is complete].”

Dr. Pierce is a third-year resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology at the university. Dr. Pierce and Dr. Clarke-Pearson said that they had no relevant financial disclosures.

Ovarian cancer is the most deadly gynecologic malignancy in the United States, with 14,270 deaths expected in 2014 (CA Cancer J. Clin. 2014;64:9-29 ). The 5-year overall survival remains less than 50%. Difficulties in treatment arise due to its aggressive nature, coupled with vague symptomatology and no effective screening test. Advanced-stage disease at the time of diagnosis is an unfortunate hallmark.

Traditional teaching about the pathogenesis of ovarian cancers has been that a metaplastic change in the mesothelial ovarian surface leads to their de novo development. Under this paradigm, 70% of serous tumors were ovarian, 17% peritoneal, and 13% tubal in origin. However, a major change occurred when BRCA carriers began having risk-reducing bilateral salpingo-oophorectomies (BSO). Sequential histologic sections of the adnexa found occult malignancy in 30% of fallopian tubes, but similar lesions were not present within the ovary (Am. J. Surg. Pathol. 1020;34:1407-16). Could these cancers in the fallopian tube be the precursor lesion and then seed or spread to the ovarian surface?

Molecular and genetic analysis of these serous tubal intraepithelial carcinoma (STIC) cells found p53 mutations that were identical to those in concurrent “ovarian” tumors. STICs have been identified in 70% of nonhereditary forms of serous ovarian cancer. Under this paradigm of STIC as tubal in origin, only 28% of serous tumors were ovarian and 64% were of tubal origin (Am. J. Surg. Pathol. 2007;31:161-9).

This paradigm shift elicited new hypotheses about the etiology of endometrioid and clear cell types of ovarian cancer. Rather than metaplasia of the surface epithelium, endometrioid and clear cell tumors may result from retrograde menstruation, with the fallopian tube acting as a conduit for cells to gain access to the peritoneal cavity and the ovarian surface. This hypothesis provides a mechanism for the 34% reduction in ovarian cancer with bilateral tubal ligation (Hum. Reprod. Update 2011;17:55-67). Interestingly, in a large collaborative pooled analysis, the risk reduction of tubal ligation was greatest for endometrioid and clear cell subtypes (Int. J. Epidemiol. 2013;42:579-89).

Given the mounting evidence of fallopian tube involvement in the development of ovarian cancers, there are new primary prevention considerations. After 5 or more years of oral contraceptive use, a 50% reduction in the relative risk of ovarian cancer has been reported (Ann. Epidemiol. 2011;21:188-96). Bilateral salpingo-oophorectomy provides a greater than 50% risk reduction even in the highest-risk BRCA-positive population. However, results from the Nurses’ Health Study suggest that while there are fewer cancers in a low-risk population following BSO, it comes with an increase in all-cause mortality, predominately due to negative cardiovascular effects. With these issues in mind, is it time to consider incorporating prophylactic bilateral salpingectomy in benign gynecologic surgery (Obstet. Gynecol. 2013;121:709-16)?

While salpingectomy at the time of hysterectomy for benign conditions or for sterilization is becoming more common, there are concerns about premature loss of ovarian function secondary to compromise of ovarian blood supply. However, amassing data demonstrates preserved ovarian function. A retrospective study comparing total laparoscopic hysterectomy (TLH) to TLH with bilateral salpingectomy found no difference in markers of ovarian function (anti-Müllerian hormone, FSH, antral follicle count, mean ovarian diameters) up to 3 months postoperatively (Gynecol. Oncol. 2013;129:448-51). In a randomized controlled trial, 30 women were 1:1 randomized to TLH vs. TLH with salpingectomy. There was no change in anti-Müllerian hormone levels (at 3 months), operative time, or estimated blood loss (Fertil. Steril. 2013;100:1704-8). While there are concerns about the paucity of long-term follow-up data, these initial studies are encouraging. Additionally, a large retrospective study of 540 BRCA-negative patients found no difference in surgical outcomes with salpingectomy (estimated blood loss, hospital stay), and furthermore, the study found that removal of the tubes significantly reduces the risk of developing subsequent benign adnexal lesions by nearly 50% (J. Cancer Res. Clin. Oncol. 2014;140:859-65).

Though salpingectomy removes tubal re-anastomosis as an option in cases of “tubal ligation regret,” wisely choosing candidates can minimize this risk. Women less than 30 years old are at highest risk for regret, and the decision for salpingectomy in these patients should be made with caution and extensive counseling. Yet recently, emerging thought leaders in family planning have called for removal to be routinely considered (Obstet. Gynecol. 2014;124:596-9).

Surgical technique involves electrosurgery or suture ligation just inferior to the fallopian tube, ligating the fallopian branches of the ovarian and utero-ovarian arteries while avoiding unnecessary involvement of ovarian branches within the mesosalpinx. Since the fimbria are thought to be the site of origin for many serous carcinomas, removing the fimbrial portion of the tube is crucial.

Ovarian cancer remains the most deadly gynecologic malignancy. Efforts to find effective screening methods have not yet delivered. Pathologic data confirms that over half of “ovarian” cancers are actually of tubal origin, and we should consider risk-reducing salpingectomy in the low-risk population. The Society of Gynecologic Oncology in their November 2013 Clinical Practice Statement stated, “For women at average risk of ovarian cancer, risk-reducing salpingectomy should also be discussed and considered with patients at the time of abdominal or pelvic surgery, hysterectomy or in lieu of tubal ligation [once childbearing is complete].”

Dr. Pierce is a third-year resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology at the university. Dr. Pierce and Dr. Clarke-Pearson said that they had no relevant financial disclosures.

Ovarian cancer is the most deadly gynecologic malignancy in the United States, with 14,270 deaths expected in 2014 (CA Cancer J. Clin. 2014;64:9-29 ). The 5-year overall survival remains less than 50%. Difficulties in treatment arise due to its aggressive nature, coupled with vague symptomatology and no effective screening test. Advanced-stage disease at the time of diagnosis is an unfortunate hallmark.

Traditional teaching about the pathogenesis of ovarian cancers has been that a metaplastic change in the mesothelial ovarian surface leads to their de novo development. Under this paradigm, 70% of serous tumors were ovarian, 17% peritoneal, and 13% tubal in origin. However, a major change occurred when BRCA carriers began having risk-reducing bilateral salpingo-oophorectomies (BSO). Sequential histologic sections of the adnexa found occult malignancy in 30% of fallopian tubes, but similar lesions were not present within the ovary (Am. J. Surg. Pathol. 1020;34:1407-16). Could these cancers in the fallopian tube be the precursor lesion and then seed or spread to the ovarian surface?

Molecular and genetic analysis of these serous tubal intraepithelial carcinoma (STIC) cells found p53 mutations that were identical to those in concurrent “ovarian” tumors. STICs have been identified in 70% of nonhereditary forms of serous ovarian cancer. Under this paradigm of STIC as tubal in origin, only 28% of serous tumors were ovarian and 64% were of tubal origin (Am. J. Surg. Pathol. 2007;31:161-9).

This paradigm shift elicited new hypotheses about the etiology of endometrioid and clear cell types of ovarian cancer. Rather than metaplasia of the surface epithelium, endometrioid and clear cell tumors may result from retrograde menstruation, with the fallopian tube acting as a conduit for cells to gain access to the peritoneal cavity and the ovarian surface. This hypothesis provides a mechanism for the 34% reduction in ovarian cancer with bilateral tubal ligation (Hum. Reprod. Update 2011;17:55-67). Interestingly, in a large collaborative pooled analysis, the risk reduction of tubal ligation was greatest for endometrioid and clear cell subtypes (Int. J. Epidemiol. 2013;42:579-89).

Given the mounting evidence of fallopian tube involvement in the development of ovarian cancers, there are new primary prevention considerations. After 5 or more years of oral contraceptive use, a 50% reduction in the relative risk of ovarian cancer has been reported (Ann. Epidemiol. 2011;21:188-96). Bilateral salpingo-oophorectomy provides a greater than 50% risk reduction even in the highest-risk BRCA-positive population. However, results from the Nurses’ Health Study suggest that while there are fewer cancers in a low-risk population following BSO, it comes with an increase in all-cause mortality, predominately due to negative cardiovascular effects. With these issues in mind, is it time to consider incorporating prophylactic bilateral salpingectomy in benign gynecologic surgery (Obstet. Gynecol. 2013;121:709-16)?

While salpingectomy at the time of hysterectomy for benign conditions or for sterilization is becoming more common, there are concerns about premature loss of ovarian function secondary to compromise of ovarian blood supply. However, amassing data demonstrates preserved ovarian function. A retrospective study comparing total laparoscopic hysterectomy (TLH) to TLH with bilateral salpingectomy found no difference in markers of ovarian function (anti-Müllerian hormone, FSH, antral follicle count, mean ovarian diameters) up to 3 months postoperatively (Gynecol. Oncol. 2013;129:448-51). In a randomized controlled trial, 30 women were 1:1 randomized to TLH vs. TLH with salpingectomy. There was no change in anti-Müllerian hormone levels (at 3 months), operative time, or estimated blood loss (Fertil. Steril. 2013;100:1704-8). While there are concerns about the paucity of long-term follow-up data, these initial studies are encouraging. Additionally, a large retrospective study of 540 BRCA-negative patients found no difference in surgical outcomes with salpingectomy (estimated blood loss, hospital stay), and furthermore, the study found that removal of the tubes significantly reduces the risk of developing subsequent benign adnexal lesions by nearly 50% (J. Cancer Res. Clin. Oncol. 2014;140:859-65).

Though salpingectomy removes tubal re-anastomosis as an option in cases of “tubal ligation regret,” wisely choosing candidates can minimize this risk. Women less than 30 years old are at highest risk for regret, and the decision for salpingectomy in these patients should be made with caution and extensive counseling. Yet recently, emerging thought leaders in family planning have called for removal to be routinely considered (Obstet. Gynecol. 2014;124:596-9).

Surgical technique involves electrosurgery or suture ligation just inferior to the fallopian tube, ligating the fallopian branches of the ovarian and utero-ovarian arteries while avoiding unnecessary involvement of ovarian branches within the mesosalpinx. Since the fimbria are thought to be the site of origin for many serous carcinomas, removing the fimbrial portion of the tube is crucial.

Ovarian cancer remains the most deadly gynecologic malignancy. Efforts to find effective screening methods have not yet delivered. Pathologic data confirms that over half of “ovarian” cancers are actually of tubal origin, and we should consider risk-reducing salpingectomy in the low-risk population. The Society of Gynecologic Oncology in their November 2013 Clinical Practice Statement stated, “For women at average risk of ovarian cancer, risk-reducing salpingectomy should also be discussed and considered with patients at the time of abdominal or pelvic surgery, hysterectomy or in lieu of tubal ligation [once childbearing is complete].”

Dr. Pierce is a third-year resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology, and a professor in the division of gynecologic oncology at the university. Dr. Pierce and Dr. Clarke-Pearson said that they had no relevant financial disclosures.

Blood samples

Credit: William Weinert

SAN DIEGO—Age-related loss of the Y chromosome (LOY) from blood cells is associated with an elevated risk of cancer and mortality, a new study indicates.

This finding could help explain why men tend to have a shorter life span and higher rates of non-sex-specific cancers than women, said Lars Forsberg, PhD, of Uppsala University in Sweden.

He and his colleagues presented this research at the American Society of Human Genetics 2014 Annual Meeting and described it

in a letter to Nature Genetics.

LOY, which occurs occasionally as a man’s blood cells replicate, was first reported nearly 50 years ago and remains largely unexplained in both its causes and effects. Recent advances have allowed researchers to use a blood test to detect when only a small fraction of a man’s blood cells have undergone LOY.

Dr Forsberg and his colleagues studied the relationship between LOY, cancer, and mortality using blood samples from 1153 men aged 70 to 84 years who were followed for up to 40 years.

In survival analyses, the investigators studied 982 participants who did not have cancer prior to sampling. The team adjusted their analyses for age, hypertension, exercise, smoking, diabetes, body mass index, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and ancestry.

The researchers calculated the degree of LOY for each subject from the median log R ratio values for approximately 2560 probes in the male-specific region of chromosome Y (mLRR-Y).

In a primary analysis, the investigators found that men with a higher degree of LOY had an increased risk of all-cause mortality (hazard ratio [HR]=2.13, P=0.029).

And LOY was a key risk factor for cancer-related mortality (HR=3.76, P=0.022), but it was not significantly associated with non-cancer-related mortality (P=0.245).

The researchers then scored participants on the basis of a defined threshold of mLRR-Y. Men with an mLRR-Y of –0.4 or less were scored as 1, and other subjects were scored as 0.

This analysis confirmed the effect of LOY on the risk of all-cause mortality (HR=1.91, P=0.010). It also showed that median survival times in men with LOY were 5.5 years shorter than for the other subjects, representing half the survival time.

In addition, the analysis confirmed the effect of LOY on the risk of cancer-related mortality (HR=3.29, P=0.003) and death from non-hematologic cancers (HR=3.62, P=0.003).

The investigators could not test the effect of LOY on mortality related to hematologic malignancies, as only one man with an mLRR-Y of –0.4 or less died from a hematologic malignancy.

However, the team did find that the risk of any cancer diagnosis was higher in men with an mLRR-Y of −0.4 or less (HR=2.47, P=0.014). And the same was true for the risk of developing a non-hematologic cancer (HR=2.68, P=0.008).

“Many people think the Y chromosome only contains genes involved in sex determination and sperm production,” said Jan Dumanski, MD, PhD, also of Uppsala University. “In fact, these genes have other important functions, such as possibly playing a role in preventing tumors.”

The researchers noted that LOY in blood cells is associated with many different cancers, and this may be because Y chromosome genes enable blood cells to assist with immunosurveillance.

“Our hypothesis is that LOY disrupts the immunosurveillance normally conducted by blood cells, allowing tumors to grow unchecked and develop into cancer,” Dr Forsberg said.

These findings suggest a new approach to early detection of cancer risk in men: a blood test to assess LOY.

“LOY is not very dangerous in a small fraction of blood cells but becomes increasingly predictive of cancer as more cells lose their Y chromosome,” Dr Forsberg explained. “This takes years, so you’d have a window of time to do something to reduce your risk.”

The investigators are currently exploring LOY in more detail, including the effects of various lifestyle factors and other health conditions on LOY. They are also examining the frequency and consequences of LOY in different types of cells and throughout life.

Blood samples

Credit: William Weinert

SAN DIEGO—Age-related loss of the Y chromosome (LOY) from blood cells is associated with an elevated risk of cancer and mortality, a new study indicates.

This finding could help explain why men tend to have a shorter life span and higher rates of non-sex-specific cancers than women, said Lars Forsberg, PhD, of Uppsala University in Sweden.

He and his colleagues presented this research at the American Society of Human Genetics 2014 Annual Meeting and described it

in a letter to Nature Genetics.

LOY, which occurs occasionally as a man’s blood cells replicate, was first reported nearly 50 years ago and remains largely unexplained in both its causes and effects. Recent advances have allowed researchers to use a blood test to detect when only a small fraction of a man’s blood cells have undergone LOY.

Dr Forsberg and his colleagues studied the relationship between LOY, cancer, and mortality using blood samples from 1153 men aged 70 to 84 years who were followed for up to 40 years.

In survival analyses, the investigators studied 982 participants who did not have cancer prior to sampling. The team adjusted their analyses for age, hypertension, exercise, smoking, diabetes, body mass index, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and ancestry.

The researchers calculated the degree of LOY for each subject from the median log R ratio values for approximately 2560 probes in the male-specific region of chromosome Y (mLRR-Y).

In a primary analysis, the investigators found that men with a higher degree of LOY had an increased risk of all-cause mortality (hazard ratio [HR]=2.13, P=0.029).

And LOY was a key risk factor for cancer-related mortality (HR=3.76, P=0.022), but it was not significantly associated with non-cancer-related mortality (P=0.245).

The researchers then scored participants on the basis of a defined threshold of mLRR-Y. Men with an mLRR-Y of –0.4 or less were scored as 1, and other subjects were scored as 0.

This analysis confirmed the effect of LOY on the risk of all-cause mortality (HR=1.91, P=0.010). It also showed that median survival times in men with LOY were 5.5 years shorter than for the other subjects, representing half the survival time.

In addition, the analysis confirmed the effect of LOY on the risk of cancer-related mortality (HR=3.29, P=0.003) and death from non-hematologic cancers (HR=3.62, P=0.003).

The investigators could not test the effect of LOY on mortality related to hematologic malignancies, as only one man with an mLRR-Y of –0.4 or less died from a hematologic malignancy.

However, the team did find that the risk of any cancer diagnosis was higher in men with an mLRR-Y of −0.4 or less (HR=2.47, P=0.014). And the same was true for the risk of developing a non-hematologic cancer (HR=2.68, P=0.008).

“Many people think the Y chromosome only contains genes involved in sex determination and sperm production,” said Jan Dumanski, MD, PhD, also of Uppsala University. “In fact, these genes have other important functions, such as possibly playing a role in preventing tumors.”

The researchers noted that LOY in blood cells is associated with many different cancers, and this may be because Y chromosome genes enable blood cells to assist with immunosurveillance.

“Our hypothesis is that LOY disrupts the immunosurveillance normally conducted by blood cells, allowing tumors to grow unchecked and develop into cancer,” Dr Forsberg said.

These findings suggest a new approach to early detection of cancer risk in men: a blood test to assess LOY.

“LOY is not very dangerous in a small fraction of blood cells but becomes increasingly predictive of cancer as more cells lose their Y chromosome,” Dr Forsberg explained. “This takes years, so you’d have a window of time to do something to reduce your risk.”

The investigators are currently exploring LOY in more detail, including the effects of various lifestyle factors and other health conditions on LOY. They are also examining the frequency and consequences of LOY in different types of cells and throughout life.

Blood samples

Credit: William Weinert

SAN DIEGO—Age-related loss of the Y chromosome (LOY) from blood cells is associated with an elevated risk of cancer and mortality, a new study indicates.

This finding could help explain why men tend to have a shorter life span and higher rates of non-sex-specific cancers than women, said Lars Forsberg, PhD, of Uppsala University in Sweden.

He and his colleagues presented this research at the American Society of Human Genetics 2014 Annual Meeting and described it

in a letter to Nature Genetics.

LOY, which occurs occasionally as a man’s blood cells replicate, was first reported nearly 50 years ago and remains largely unexplained in both its causes and effects. Recent advances have allowed researchers to use a blood test to detect when only a small fraction of a man’s blood cells have undergone LOY.

Dr Forsberg and his colleagues studied the relationship between LOY, cancer, and mortality using blood samples from 1153 men aged 70 to 84 years who were followed for up to 40 years.

In survival analyses, the investigators studied 982 participants who did not have cancer prior to sampling. The team adjusted their analyses for age, hypertension, exercise, smoking, diabetes, body mass index, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and ancestry.

The researchers calculated the degree of LOY for each subject from the median log R ratio values for approximately 2560 probes in the male-specific region of chromosome Y (mLRR-Y).

In a primary analysis, the investigators found that men with a higher degree of LOY had an increased risk of all-cause mortality (hazard ratio [HR]=2.13, P=0.029).

And LOY was a key risk factor for cancer-related mortality (HR=3.76, P=0.022), but it was not significantly associated with non-cancer-related mortality (P=0.245).

The researchers then scored participants on the basis of a defined threshold of mLRR-Y. Men with an mLRR-Y of –0.4 or less were scored as 1, and other subjects were scored as 0.

This analysis confirmed the effect of LOY on the risk of all-cause mortality (HR=1.91, P=0.010). It also showed that median survival times in men with LOY were 5.5 years shorter than for the other subjects, representing half the survival time.

In addition, the analysis confirmed the effect of LOY on the risk of cancer-related mortality (HR=3.29, P=0.003) and death from non-hematologic cancers (HR=3.62, P=0.003).

The investigators could not test the effect of LOY on mortality related to hematologic malignancies, as only one man with an mLRR-Y of –0.4 or less died from a hematologic malignancy.

However, the team did find that the risk of any cancer diagnosis was higher in men with an mLRR-Y of −0.4 or less (HR=2.47, P=0.014). And the same was true for the risk of developing a non-hematologic cancer (HR=2.68, P=0.008).

“Many people think the Y chromosome only contains genes involved in sex determination and sperm production,” said Jan Dumanski, MD, PhD, also of Uppsala University. “In fact, these genes have other important functions, such as possibly playing a role in preventing tumors.”

The researchers noted that LOY in blood cells is associated with many different cancers, and this may be because Y chromosome genes enable blood cells to assist with immunosurveillance.

“Our hypothesis is that LOY disrupts the immunosurveillance normally conducted by blood cells, allowing tumors to grow unchecked and develop into cancer,” Dr Forsberg said.

These findings suggest a new approach to early detection of cancer risk in men: a blood test to assess LOY.

“LOY is not very dangerous in a small fraction of blood cells but becomes increasingly predictive of cancer as more cells lose their Y chromosome,” Dr Forsberg explained. “This takes years, so you’d have a window of time to do something to reduce your risk.”

The investigators are currently exploring LOY in more detail, including the effects of various lifestyle factors and other health conditions on LOY. They are also examining the frequency and consequences of LOY in different types of cells and throughout life.

Doctor examines patient

Credit: NCI

The trend of hospitals consolidating medical groups and physician practices is increasing the cost of patient care, new research suggests.

The study was conducted using 4 years of data from nearly 160 medical groups in California.

Results showed that hospital-owned physician organizations incurred higher expenditures than physician-owned organizations for services to patients covered by commercial health maintenance organization (HMO) insurance.

The findings, published in JAMA, come as a growing number of local hospitals and large, multihospital systems in the US are acquiring physician groups and medical practices.

“This consolidation is meant to better coordinate care and to have a stronger bargaining position with insurance plans,” said James Robinson, PhD, of the University of California, Berkeley School of Public Health.

“The movement also aligns with the goals of the Affordable Care Act, since physicians and hospitals working together in ‘accountable care organizations’ can provide care better than the traditional fee-for-service and solo-practice models. The intent of consolidation is to reduce costs and improve quality, but the problem with all this is that hospitals are very expensive and complex organizations, and they are not known for their efficiency and low prices.”

Dr Robinson teamed up with Kelly Miller, of Integrated Healthcare Association in Oakland, California, to analyze data on 158 major medical groups. The data spanned the period from 2009 to 2012.

Of the 158 organizations, 118 (75%) were physician-owned and provided care for 3,065,551 patients, 19 (12%) were owned by local hospitals and provided care for 728,608 patients, and 21 (13%) were owned by multihospital systems and provided care for 693,254 patients.

The patients were covered by commercial HMO insurance. The data did not include patients covered by commercial preferred provider organization (PPO) insurance, Medicare, or Medicaid.

The researchers assessed costs related to physician visits, inpatient hospital admissions, outpatient surgery and diagnostic procedures, drugs, and all other forms of medical care except mental health services.

Results revealed that the average expenditure per patient across all physician organizations increased by 16.5% between 2009 and 2012, from $2954 to $3443.

By 2012, expenditures per patient had increased to an average of $3066 in physician-owned organizations, $4312 in local hospital-owned organizations, and $4776 in multihospital system-owned organizations.

This represents a 40.6% relative difference in expenditures per patient associated with hospital ownership and a 55.8% relative difference associated with ownership by a multihospital system compared with ownership by member physicians.

After adjusting for patient severity and other factors over the period, local hospital-owned physician organizations incurred expenditures per patient 10.3% higher than physician-owned organizations. And organizations owned by multihospital systems incurred expenditures 19.8% higher than physician-owned organizations.

Dr Robinson said these findings might be explained by the fact that, once a medical group has been acquired by a multihospital system, physicians in those groups are expected to admit their patients to the high-priced hospital.

“Hospital-owned medical groups usually are expected to conduct ambulatory surgery and diagnostic procedures in the outpatient departments of their parent hospital, but hospital outpatient departments are much more costly and charge much higher prices than freestanding, non-hospital ambulatory centers,” he said.

Dr Robinson added that public policy should not encourage mergers and acquisitions as a means of promoting collaboration. Instead, policymakers should consider supporting the use of bundled payments for hospitals and physicians to improve the coordination of care.

“Hospitals are an essential part of the healthcare system, but they should not be the center of the delivery system,” he said. “Rather, physician-led organizations based in ambulatory and community settings are likely to be more efficient and provide cheaper care.”

The researchers noted that their findings are limited to California, and further studies should be conducted using data from other states.

“Nevertheless, these findings are important,” Dr Robinson said, “since California is the nation’s leader in terms of having physicians participate in large medical groups that already perform the functions ascribed to ‘accountable care organizations’ by the Obama administration.”

Doctor examines patient

Credit: NCI

The trend of hospitals consolidating medical groups and physician practices is increasing the cost of patient care, new research suggests.

The study was conducted using 4 years of data from nearly 160 medical groups in California.

Results showed that hospital-owned physician organizations incurred higher expenditures than physician-owned organizations for services to patients covered by commercial health maintenance organization (HMO) insurance.

The findings, published in JAMA, come as a growing number of local hospitals and large, multihospital systems in the US are acquiring physician groups and medical practices.

“This consolidation is meant to better coordinate care and to have a stronger bargaining position with insurance plans,” said James Robinson, PhD, of the University of California, Berkeley School of Public Health.

“The movement also aligns with the goals of the Affordable Care Act, since physicians and hospitals working together in ‘accountable care organizations’ can provide care better than the traditional fee-for-service and solo-practice models. The intent of consolidation is to reduce costs and improve quality, but the problem with all this is that hospitals are very expensive and complex organizations, and they are not known for their efficiency and low prices.”

Dr Robinson teamed up with Kelly Miller, of Integrated Healthcare Association in Oakland, California, to analyze data on 158 major medical groups. The data spanned the period from 2009 to 2012.

Of the 158 organizations, 118 (75%) were physician-owned and provided care for 3,065,551 patients, 19 (12%) were owned by local hospitals and provided care for 728,608 patients, and 21 (13%) were owned by multihospital systems and provided care for 693,254 patients.

The patients were covered by commercial HMO insurance. The data did not include patients covered by commercial preferred provider organization (PPO) insurance, Medicare, or Medicaid.

The researchers assessed costs related to physician visits, inpatient hospital admissions, outpatient surgery and diagnostic procedures, drugs, and all other forms of medical care except mental health services.

Results revealed that the average expenditure per patient across all physician organizations increased by 16.5% between 2009 and 2012, from $2954 to $3443.

By 2012, expenditures per patient had increased to an average of $3066 in physician-owned organizations, $4312 in local hospital-owned organizations, and $4776 in multihospital system-owned organizations.

This represents a 40.6% relative difference in expenditures per patient associated with hospital ownership and a 55.8% relative difference associated with ownership by a multihospital system compared with ownership by member physicians.

After adjusting for patient severity and other factors over the period, local hospital-owned physician organizations incurred expenditures per patient 10.3% higher than physician-owned organizations. And organizations owned by multihospital systems incurred expenditures 19.8% higher than physician-owned organizations.

Dr Robinson said these findings might be explained by the fact that, once a medical group has been acquired by a multihospital system, physicians in those groups are expected to admit their patients to the high-priced hospital.

“Hospital-owned medical groups usually are expected to conduct ambulatory surgery and diagnostic procedures in the outpatient departments of their parent hospital, but hospital outpatient departments are much more costly and charge much higher prices than freestanding, non-hospital ambulatory centers,” he said.

Dr Robinson added that public policy should not encourage mergers and acquisitions as a means of promoting collaboration. Instead, policymakers should consider supporting the use of bundled payments for hospitals and physicians to improve the coordination of care.

“Hospitals are an essential part of the healthcare system, but they should not be the center of the delivery system,” he said. “Rather, physician-led organizations based in ambulatory and community settings are likely to be more efficient and provide cheaper care.”

The researchers noted that their findings are limited to California, and further studies should be conducted using data from other states.

“Nevertheless, these findings are important,” Dr Robinson said, “since California is the nation’s leader in terms of having physicians participate in large medical groups that already perform the functions ascribed to ‘accountable care organizations’ by the Obama administration.”

Doctor examines patient

Credit: NCI

The trend of hospitals consolidating medical groups and physician practices is increasing the cost of patient care, new research suggests.

The study was conducted using 4 years of data from nearly 160 medical groups in California.

Results showed that hospital-owned physician organizations incurred higher expenditures than physician-owned organizations for services to patients covered by commercial health maintenance organization (HMO) insurance.

The findings, published in JAMA, come as a growing number of local hospitals and large, multihospital systems in the US are acquiring physician groups and medical practices.

“This consolidation is meant to better coordinate care and to have a stronger bargaining position with insurance plans,” said James Robinson, PhD, of the University of California, Berkeley School of Public Health.

“The movement also aligns with the goals of the Affordable Care Act, since physicians and hospitals working together in ‘accountable care organizations’ can provide care better than the traditional fee-for-service and solo-practice models. The intent of consolidation is to reduce costs and improve quality, but the problem with all this is that hospitals are very expensive and complex organizations, and they are not known for their efficiency and low prices.”

Dr Robinson teamed up with Kelly Miller, of Integrated Healthcare Association in Oakland, California, to analyze data on 158 major medical groups. The data spanned the period from 2009 to 2012.

Of the 158 organizations, 118 (75%) were physician-owned and provided care for 3,065,551 patients, 19 (12%) were owned by local hospitals and provided care for 728,608 patients, and 21 (13%) were owned by multihospital systems and provided care for 693,254 patients.

The patients were covered by commercial HMO insurance. The data did not include patients covered by commercial preferred provider organization (PPO) insurance, Medicare, or Medicaid.

The researchers assessed costs related to physician visits, inpatient hospital admissions, outpatient surgery and diagnostic procedures, drugs, and all other forms of medical care except mental health services.

Results revealed that the average expenditure per patient across all physician organizations increased by 16.5% between 2009 and 2012, from $2954 to $3443.

By 2012, expenditures per patient had increased to an average of $3066 in physician-owned organizations, $4312 in local hospital-owned organizations, and $4776 in multihospital system-owned organizations.

This represents a 40.6% relative difference in expenditures per patient associated with hospital ownership and a 55.8% relative difference associated with ownership by a multihospital system compared with ownership by member physicians.

After adjusting for patient severity and other factors over the period, local hospital-owned physician organizations incurred expenditures per patient 10.3% higher than physician-owned organizations. And organizations owned by multihospital systems incurred expenditures 19.8% higher than physician-owned organizations.

Dr Robinson said these findings might be explained by the fact that, once a medical group has been acquired by a multihospital system, physicians in those groups are expected to admit their patients to the high-priced hospital.

“Hospital-owned medical groups usually are expected to conduct ambulatory surgery and diagnostic procedures in the outpatient departments of their parent hospital, but hospital outpatient departments are much more costly and charge much higher prices than freestanding, non-hospital ambulatory centers,” he said.

Dr Robinson added that public policy should not encourage mergers and acquisitions as a means of promoting collaboration. Instead, policymakers should consider supporting the use of bundled payments for hospitals and physicians to improve the coordination of care.

“Hospitals are an essential part of the healthcare system, but they should not be the center of the delivery system,” he said. “Rather, physician-led organizations based in ambulatory and community settings are likely to be more efficient and provide cheaper care.”

The researchers noted that their findings are limited to California, and further studies should be conducted using data from other states.

“Nevertheless, these findings are important,” Dr Robinson said, “since California is the nation’s leader in terms of having physicians participate in large medical groups that already perform the functions ascribed to ‘accountable care organizations’ by the Obama administration.”

US dollars

Credit: Petr Kratochvil

Medical practices in less competitive markets charge more for their services, according to a study published in JAMA.

The study, based on US healthcare data from 2010, provides new information about the effects of competition on prices for office visits paid by preferred provider organizations (PPOs).

“The research comes out of trying to understand some dramatic changes that have occurred in the healthcare system over a couple of decades,” said Laurence Baker, PhD, of the Stanford University School of Medicine in California.

One such change is the shift from practices with one or two doctors toward larger, more complex organizations with many physicians. An impact of this can be reduced competition among physician practices.

Dr Baker and his colleagues sought to understand how variation in the amount of competition within a region affects the amounts doctors are paid.

The researchers assessed the relationship between competition and prices paid by PPOs for the most commonly billed services within 10 prominent physician specialties—internal medicine, family practice, cardiology, dermatology, gastroenterology, neurology, general surgery, orthopedics, urology, and otolaryngology.

To establish what prices various medical practices were paid for services, the team used Truven Analytics MarketScan Commercial Claims and Encounters database, which contains the prices paid to physicians for more than 49 million privately insured people from all over the US. They obtained the number of claims and the mean price paid for each service in 1058 counties representing all 50 states.

To measure competitiveness, the researchers drew inspiration from the business world. Using Medicare data, they adapted a standard economic competition measure to track physician practice competition for different US regions.

The Hirschman-Herfindahl Index (HHI) uses the relative sizes of practices to measure market concentration. A higher HHI indicates a less competitive market, and a lower HHI indicates higher competition.

Less competition, higher prices

The researchers found that less competition among physician practices was associated with higher prices paid by private PPOs for office visits.

Across 10 types of office visits, the difference in the HHI was associated with average prices for office visits 8.3% to 16.1% higher. In a more conservative model, the difference in the HHI was associated with 3.5% to 5.4% higher average prices.

The researchers pointed out that, in 2011, privately insured individuals in the US spent nearly $250 billion on physician services. In that context, these small percentage increases could translate to tens of billions of dollars in extra spending.

The team also found that, between 2003 and 2010, prices increased more rapidly in areas that were less competitive. Even when there is no change in HHI, practices in less competitive areas could continue to drive up prices.

“These larger organizations might have better processes in place to optimize care,” said Kate Bundorf, PhD, also of the Stanford University School of Medicine.

“But our research also points out [that we] have to think about the effect on prices and try to balance those two things when we think about how to form policy about these organizations.”

Dr Baker echoed that sentiment.

“Sometimes, it can be tempting to say our goals for the healthcare system should be only about taking care of patients and doing it as well as possible,” he said. “We don’t want to worry about the economics. But the truth is, we do have to worry about the prices because the bill does come, even if you wish it wouldn’t.”

US dollars

Credit: Petr Kratochvil

Medical practices in less competitive markets charge more for their services, according to a study published in JAMA.

The study, based on US healthcare data from 2010, provides new information about the effects of competition on prices for office visits paid by preferred provider organizations (PPOs).

“The research comes out of trying to understand some dramatic changes that have occurred in the healthcare system over a couple of decades,” said Laurence Baker, PhD, of the Stanford University School of Medicine in California.

One such change is the shift from practices with one or two doctors toward larger, more complex organizations with many physicians. An impact of this can be reduced competition among physician practices.

Dr Baker and his colleagues sought to understand how variation in the amount of competition within a region affects the amounts doctors are paid.

The researchers assessed the relationship between competition and prices paid by PPOs for the most commonly billed services within 10 prominent physician specialties—internal medicine, family practice, cardiology, dermatology, gastroenterology, neurology, general surgery, orthopedics, urology, and otolaryngology.

To establish what prices various medical practices were paid for services, the team used Truven Analytics MarketScan Commercial Claims and Encounters database, which contains the prices paid to physicians for more than 49 million privately insured people from all over the US. They obtained the number of claims and the mean price paid for each service in 1058 counties representing all 50 states.

To measure competitiveness, the researchers drew inspiration from the business world. Using Medicare data, they adapted a standard economic competition measure to track physician practice competition for different US regions.

The Hirschman-Herfindahl Index (HHI) uses the relative sizes of practices to measure market concentration. A higher HHI indicates a less competitive market, and a lower HHI indicates higher competition.

Less competition, higher prices

The researchers found that less competition among physician practices was associated with higher prices paid by private PPOs for office visits.

Across 10 types of office visits, the difference in the HHI was associated with average prices for office visits 8.3% to 16.1% higher. In a more conservative model, the difference in the HHI was associated with 3.5% to 5.4% higher average prices.

The researchers pointed out that, in 2011, privately insured individuals in the US spent nearly $250 billion on physician services. In that context, these small percentage increases could translate to tens of billions of dollars in extra spending.

The team also found that, between 2003 and 2010, prices increased more rapidly in areas that were less competitive. Even when there is no change in HHI, practices in less competitive areas could continue to drive up prices.

“These larger organizations might have better processes in place to optimize care,” said Kate Bundorf, PhD, also of the Stanford University School of Medicine.

“But our research also points out [that we] have to think about the effect on prices and try to balance those two things when we think about how to form policy about these organizations.”

Dr Baker echoed that sentiment.

“Sometimes, it can be tempting to say our goals for the healthcare system should be only about taking care of patients and doing it as well as possible,” he said. “We don’t want to worry about the economics. But the truth is, we do have to worry about the prices because the bill does come, even if you wish it wouldn’t.”

US dollars

Credit: Petr Kratochvil

Medical practices in less competitive markets charge more for their services, according to a study published in JAMA.

The study, based on US healthcare data from 2010, provides new information about the effects of competition on prices for office visits paid by preferred provider organizations (PPOs).

“The research comes out of trying to understand some dramatic changes that have occurred in the healthcare system over a couple of decades,” said Laurence Baker, PhD, of the Stanford University School of Medicine in California.

One such change is the shift from practices with one or two doctors toward larger, more complex organizations with many physicians. An impact of this can be reduced competition among physician practices.

Dr Baker and his colleagues sought to understand how variation in the amount of competition within a region affects the amounts doctors are paid.

The researchers assessed the relationship between competition and prices paid by PPOs for the most commonly billed services within 10 prominent physician specialties—internal medicine, family practice, cardiology, dermatology, gastroenterology, neurology, general surgery, orthopedics, urology, and otolaryngology.

To establish what prices various medical practices were paid for services, the team used Truven Analytics MarketScan Commercial Claims and Encounters database, which contains the prices paid to physicians for more than 49 million privately insured people from all over the US. They obtained the number of claims and the mean price paid for each service in 1058 counties representing all 50 states.

To measure competitiveness, the researchers drew inspiration from the business world. Using Medicare data, they adapted a standard economic competition measure to track physician practice competition for different US regions.

The Hirschman-Herfindahl Index (HHI) uses the relative sizes of practices to measure market concentration. A higher HHI indicates a less competitive market, and a lower HHI indicates higher competition.

Less competition, higher prices

The researchers found that less competition among physician practices was associated with higher prices paid by private PPOs for office visits.

Across 10 types of office visits, the difference in the HHI was associated with average prices for office visits 8.3% to 16.1% higher. In a more conservative model, the difference in the HHI was associated with 3.5% to 5.4% higher average prices.

The researchers pointed out that, in 2011, privately insured individuals in the US spent nearly $250 billion on physician services. In that context, these small percentage increases could translate to tens of billions of dollars in extra spending.

The team also found that, between 2003 and 2010, prices increased more rapidly in areas that were less competitive. Even when there is no change in HHI, practices in less competitive areas could continue to drive up prices.

“These larger organizations might have better processes in place to optimize care,” said Kate Bundorf, PhD, also of the Stanford University School of Medicine.

“But our research also points out [that we] have to think about the effect on prices and try to balance those two things when we think about how to form policy about these organizations.”

Dr Baker echoed that sentiment.

“Sometimes, it can be tempting to say our goals for the healthcare system should be only about taking care of patients and doing it as well as possible,” he said. “We don’t want to worry about the economics. But the truth is, we do have to worry about the prices because the bill does come, even if you wish it wouldn’t.”

CVC equipment

A multicenter study showed that roughly 1 in 5 physicians did not know when a hospitalized patient had a central venous catheter (CVC) in place.

Hospitalists were the least likely to know of a CVC’s presence, followed by general medicine teaching attendings, interns, and residents.

These findings raise questions about patient safety, as CVCs pose a risk of bloodstream infection and thrombosis, both of which can be prevented by removing catheters that are no longer necessary.

“We know that central venous catheters are invaluable for the safe and comprehensive care of some hospitalized patients, but just as they are helpful, they can be harmful,” said study author Vineet Chopra, MD, of the University of Michigan Health System in Ann Arbor.

“The key to preventing complications is to remove devices when they are no longer necessary, but that requires knowing they are there in the first place. Our findings suggest that patient safety may be jeopardized if medical providers don’t improve their practices regarding device awareness.”

Dr Chopra and his colleagues reported their findings in the Annals of Internal Medicine.

The study included 990 patients and 1881 clinical assessments at 3 academic medical centers in the US. Responses from interns (n=454), residents and physician extenders (n=513), general medicine teaching attendings (n=245), subspecialty attendings (n=176), intensivists (n=95), and hospitalists (n=398) were included.

The overall prevalence of CVCs was 21.1%, 60.3% of which were peripherally inserted central catheters (PICCs). The remaining CVCs were triple-lumen catheters inserted in the neck (19.6%), chest (11.5%), or groin (8.6%).

In all, 21.2% of clinicians interviewed did not know when a patient had a CVC in place. And 5.6% of clinicians said a patient had a CVC when there was no device in place.

Hospitalists were most likely to be unaware of a CVC (30.5%), followed by general medicine teaching attendings (25.8%), interns (19.1%), and residents (13.8%).

When assessed by service, critical care physicians were the least likely to be unaware of a CVC (12.6%), compared to general medicine teaching attendings/hospitalists (26.2%) and clinicians in other subspecialties (22.5%). Awareness was best among specialties that used CVCs often, such as cardiology and oncology.

Lack of awareness was greatest for PICCs; 25.1% of clinicians were unaware of a PICC’s presence, and 15.6% were unaware of a triple lumen catheter’s presence.

“These findings have important patient safety and policy implications for health systems nationwide,” Dr Chopra said, “because they suggest that removal of clinically unnecessary catheters may be limited by lack of awareness by providers, especially in non-intensive care settings.”

CVC equipment

A multicenter study showed that roughly 1 in 5 physicians did not know when a hospitalized patient had a central venous catheter (CVC) in place.

Hospitalists were the least likely to know of a CVC’s presence, followed by general medicine teaching attendings, interns, and residents.

These findings raise questions about patient safety, as CVCs pose a risk of bloodstream infection and thrombosis, both of which can be prevented by removing catheters that are no longer necessary.

“We know that central venous catheters are invaluable for the safe and comprehensive care of some hospitalized patients, but just as they are helpful, they can be harmful,” said study author Vineet Chopra, MD, of the University of Michigan Health System in Ann Arbor.

“The key to preventing complications is to remove devices when they are no longer necessary, but that requires knowing they are there in the first place. Our findings suggest that patient safety may be jeopardized if medical providers don’t improve their practices regarding device awareness.”

Dr Chopra and his colleagues reported their findings in the Annals of Internal Medicine.

The study included 990 patients and 1881 clinical assessments at 3 academic medical centers in the US. Responses from interns (n=454), residents and physician extenders (n=513), general medicine teaching attendings (n=245), subspecialty attendings (n=176), intensivists (n=95), and hospitalists (n=398) were included.

The overall prevalence of CVCs was 21.1%, 60.3% of which were peripherally inserted central catheters (PICCs). The remaining CVCs were triple-lumen catheters inserted in the neck (19.6%), chest (11.5%), or groin (8.6%).

In all, 21.2% of clinicians interviewed did not know when a patient had a CVC in place. And 5.6% of clinicians said a patient had a CVC when there was no device in place.

Hospitalists were most likely to be unaware of a CVC (30.5%), followed by general medicine teaching attendings (25.8%), interns (19.1%), and residents (13.8%).

When assessed by service, critical care physicians were the least likely to be unaware of a CVC (12.6%), compared to general medicine teaching attendings/hospitalists (26.2%) and clinicians in other subspecialties (22.5%). Awareness was best among specialties that used CVCs often, such as cardiology and oncology.

Lack of awareness was greatest for PICCs; 25.1% of clinicians were unaware of a PICC’s presence, and 15.6% were unaware of a triple lumen catheter’s presence.

“These findings have important patient safety and policy implications for health systems nationwide,” Dr Chopra said, “because they suggest that removal of clinically unnecessary catheters may be limited by lack of awareness by providers, especially in non-intensive care settings.”

CVC equipment

A multicenter study showed that roughly 1 in 5 physicians did not know when a hospitalized patient had a central venous catheter (CVC) in place.

Hospitalists were the least likely to know of a CVC’s presence, followed by general medicine teaching attendings, interns, and residents.

These findings raise questions about patient safety, as CVCs pose a risk of bloodstream infection and thrombosis, both of which can be prevented by removing catheters that are no longer necessary.

“We know that central venous catheters are invaluable for the safe and comprehensive care of some hospitalized patients, but just as they are helpful, they can be harmful,” said study author Vineet Chopra, MD, of the University of Michigan Health System in Ann Arbor.

“The key to preventing complications is to remove devices when they are no longer necessary, but that requires knowing they are there in the first place. Our findings suggest that patient safety may be jeopardized if medical providers don’t improve their practices regarding device awareness.”

Dr Chopra and his colleagues reported their findings in the Annals of Internal Medicine.

The study included 990 patients and 1881 clinical assessments at 3 academic medical centers in the US. Responses from interns (n=454), residents and physician extenders (n=513), general medicine teaching attendings (n=245), subspecialty attendings (n=176), intensivists (n=95), and hospitalists (n=398) were included.

The overall prevalence of CVCs was 21.1%, 60.3% of which were peripherally inserted central catheters (PICCs). The remaining CVCs were triple-lumen catheters inserted in the neck (19.6%), chest (11.5%), or groin (8.6%).

In all, 21.2% of clinicians interviewed did not know when a patient had a CVC in place. And 5.6% of clinicians said a patient had a CVC when there was no device in place.

Hospitalists were most likely to be unaware of a CVC (30.5%), followed by general medicine teaching attendings (25.8%), interns (19.1%), and residents (13.8%).

When assessed by service, critical care physicians were the least likely to be unaware of a CVC (12.6%), compared to general medicine teaching attendings/hospitalists (26.2%) and clinicians in other subspecialties (22.5%). Awareness was best among specialties that used CVCs often, such as cardiology and oncology.

Lack of awareness was greatest for PICCs; 25.1% of clinicians were unaware of a PICC’s presence, and 15.6% were unaware of a triple lumen catheter’s presence.

“These findings have important patient safety and policy implications for health systems nationwide,” Dr Chopra said, “because they suggest that removal of clinically unnecessary catheters may be limited by lack of awareness by providers, especially in non-intensive care settings.”

Most practitioners know that the flu vaccine has been proven to reduce the frequency of middle ear infections, sinusitis, and pneumonia. However, how that happens is not as clear. My group has been studying the details of the interaction between flu virus and pneumococci to unravel the steps in the dance between the flu virus and the pneumococcus in the nasopharynx that results in significant respiratory diseases. Pneumococci live in the posterior part of the nose and upper pharynx as commensal bacteria in all of us, harmlessly present in relatively low numbers. The bacteria are so common that studies to detect pneumococci in the nasopharynx discover their presence in up to 80% of infants and young children, and about 20% of adults at any one time. The bacteria are harmless in patients that have a competent immune system unless an intercurrent viral upper respiratory infection (URI) occurs.

The trigger in pathogenesis of pneumococcal infections is a viral URI, and particularly influenza infection. The combination of pneumococci and flu in the nose can cause compromise in all four aspects of host defense: 1) structural change, 2) physiologic change, 3) innate immunity change, and 4) adaptive immunity change. Structural change is swelling of the nasal passageways, Eustachian tube, osteomeatal sinus pathway, and tracheobronchial tree. Physiologic change is increased mucus production and reduced cilia beat, resulting in stasis of thickened mucus in the respiratory tree. Thus the stage is set for compromise in the immune response.

Innate immunity basically translates to the response of neutrophils, macrophages, and lymphocytes that are resident in the respiratory pathways or migrate there in response to signals from the site of infection that a problem is brewing. To start the process of innate immunity, chemicals are released from resident epithelial cells, lymphocytes, and neutrophils/macrophages. The chemicals are called cytokines and chemokines. The viruses enter the epithelial cells of the nasopharynx and tracheobronchial tree, and leave a change on the surface of the epithelial cells that alerts lymphocytes to kill and destroy those cells harboring virus. Neutrophils and macrophages ingest the bacteria by recognizing surface proteins on the bacteria that are foreign. Sometimes that is all that is needed, and the host clears the infection. But sometimes the innate response is not enough.

The innate response is good and bad. The bad part is that the release of the cytokines and chemokines and the migration of immune cells to the site of infection results in the release of even more cytokines and chemokines that cause increased inflammation. Microbes love inflammation. The inflammation caused by the virus, such as flu virus, creates a very favorable environment for the pneumococci. So the pneumococci start to reproduce in abundance. Then when the secretions of the nose are swept into the Eustachian tube and middle ear or the sinus drainage pathways and then to the sinuses or into the trachea and bronchi and then the lungs, we see the clinical manifestations of acute otitis media, sinusitis, or pneumonia. The innate response failed.

The adaptive response – as the word implies – is when the immune cells recognize and adapt to the presence of foreign microbes by recognizing their presence, migrating to lymph nodes and spleen, communicating with each other, and consequently multiplying into great numbers. The interaction between the immune cells – T cells and B cells – in the lymph node and migration back to the site of infection takes a few days to occur (3-5 days) if the host has prior immunity from prior infections or vaccination. If there is no prior immunity and no vaccination, then it takes 10-14 days for the adaptive immunity response to kick in and clear the infection. During that extra time, the pneumococci are gaining in numbers, causing more inflammation, and we see those clinical signs of fever, redness, and swelling at the site of infection, and pain.

So influenza can cause all of the events above by itself, but when the virus dances with the pneumococci, and the pneumococci benefit from the partnership, that is the most frequent cause of acute otitis media, sinusitis, and pneumonia. And all of that could have been prevented in most of our patients if they only got their annual flu vaccine.

Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. The study was supported by a National Institutes of Health grant. Dr. Pichichero said he had no relevant financial disclosures. Email him at [email protected].

Most practitioners know that the flu vaccine has been proven to reduce the frequency of middle ear infections, sinusitis, and pneumonia. However, how that happens is not as clear. My group has been studying the details of the interaction between flu virus and pneumococci to unravel the steps in the dance between the flu virus and the pneumococcus in the nasopharynx that results in significant respiratory diseases. Pneumococci live in the posterior part of the nose and upper pharynx as commensal bacteria in all of us, harmlessly present in relatively low numbers. The bacteria are so common that studies to detect pneumococci in the nasopharynx discover their presence in up to 80% of infants and young children, and about 20% of adults at any one time. The bacteria are harmless in patients that have a competent immune system unless an intercurrent viral upper respiratory infection (URI) occurs.

The trigger in pathogenesis of pneumococcal infections is a viral URI, and particularly influenza infection. The combination of pneumococci and flu in the nose can cause compromise in all four aspects of host defense: 1) structural change, 2) physiologic change, 3) innate immunity change, and 4) adaptive immunity change. Structural change is swelling of the nasal passageways, Eustachian tube, osteomeatal sinus pathway, and tracheobronchial tree. Physiologic change is increased mucus production and reduced cilia beat, resulting in stasis of thickened mucus in the respiratory tree. Thus the stage is set for compromise in the immune response.

Innate immunity basically translates to the response of neutrophils, macrophages, and lymphocytes that are resident in the respiratory pathways or migrate there in response to signals from the site of infection that a problem is brewing. To start the process of innate immunity, chemicals are released from resident epithelial cells, lymphocytes, and neutrophils/macrophages. The chemicals are called cytokines and chemokines. The viruses enter the epithelial cells of the nasopharynx and tracheobronchial tree, and leave a change on the surface of the epithelial cells that alerts lymphocytes to kill and destroy those cells harboring virus. Neutrophils and macrophages ingest the bacteria by recognizing surface proteins on the bacteria that are foreign. Sometimes that is all that is needed, and the host clears the infection. But sometimes the innate response is not enough.

The innate response is good and bad. The bad part is that the release of the cytokines and chemokines and the migration of immune cells to the site of infection results in the release of even more cytokines and chemokines that cause increased inflammation. Microbes love inflammation. The inflammation caused by the virus, such as flu virus, creates a very favorable environment for the pneumococci. So the pneumococci start to reproduce in abundance. Then when the secretions of the nose are swept into the Eustachian tube and middle ear or the sinus drainage pathways and then to the sinuses or into the trachea and bronchi and then the lungs, we see the clinical manifestations of acute otitis media, sinusitis, or pneumonia. The innate response failed.

The adaptive response – as the word implies – is when the immune cells recognize and adapt to the presence of foreign microbes by recognizing their presence, migrating to lymph nodes and spleen, communicating with each other, and consequently multiplying into great numbers. The interaction between the immune cells – T cells and B cells – in the lymph node and migration back to the site of infection takes a few days to occur (3-5 days) if the host has prior immunity from prior infections or vaccination. If there is no prior immunity and no vaccination, then it takes 10-14 days for the adaptive immunity response to kick in and clear the infection. During that extra time, the pneumococci are gaining in numbers, causing more inflammation, and we see those clinical signs of fever, redness, and swelling at the site of infection, and pain.

So influenza can cause all of the events above by itself, but when the virus dances with the pneumococci, and the pneumococci benefit from the partnership, that is the most frequent cause of acute otitis media, sinusitis, and pneumonia. And all of that could have been prevented in most of our patients if they only got their annual flu vaccine.

Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. The study was supported by a National Institutes of Health grant. Dr. Pichichero said he had no relevant financial disclosures. Email him at [email protected].

Most practitioners know that the flu vaccine has been proven to reduce the frequency of middle ear infections, sinusitis, and pneumonia. However, how that happens is not as clear. My group has been studying the details of the interaction between flu virus and pneumococci to unravel the steps in the dance between the flu virus and the pneumococcus in the nasopharynx that results in significant respiratory diseases. Pneumococci live in the posterior part of the nose and upper pharynx as commensal bacteria in all of us, harmlessly present in relatively low numbers. The bacteria are so common that studies to detect pneumococci in the nasopharynx discover their presence in up to 80% of infants and young children, and about 20% of adults at any one time. The bacteria are harmless in patients that have a competent immune system unless an intercurrent viral upper respiratory infection (URI) occurs.

The trigger in pathogenesis of pneumococcal infections is a viral URI, and particularly influenza infection. The combination of pneumococci and flu in the nose can cause compromise in all four aspects of host defense: 1) structural change, 2) physiologic change, 3) innate immunity change, and 4) adaptive immunity change. Structural change is swelling of the nasal passageways, Eustachian tube, osteomeatal sinus pathway, and tracheobronchial tree. Physiologic change is increased mucus production and reduced cilia beat, resulting in stasis of thickened mucus in the respiratory tree. Thus the stage is set for compromise in the immune response.

Innate immunity basically translates to the response of neutrophils, macrophages, and lymphocytes that are resident in the respiratory pathways or migrate there in response to signals from the site of infection that a problem is brewing. To start the process of innate immunity, chemicals are released from resident epithelial cells, lymphocytes, and neutrophils/macrophages. The chemicals are called cytokines and chemokines. The viruses enter the epithelial cells of the nasopharynx and tracheobronchial tree, and leave a change on the surface of the epithelial cells that alerts lymphocytes to kill and destroy those cells harboring virus. Neutrophils and macrophages ingest the bacteria by recognizing surface proteins on the bacteria that are foreign. Sometimes that is all that is needed, and the host clears the infection. But sometimes the innate response is not enough.

The innate response is good and bad. The bad part is that the release of the cytokines and chemokines and the migration of immune cells to the site of infection results in the release of even more cytokines and chemokines that cause increased inflammation. Microbes love inflammation. The inflammation caused by the virus, such as flu virus, creates a very favorable environment for the pneumococci. So the pneumococci start to reproduce in abundance. Then when the secretions of the nose are swept into the Eustachian tube and middle ear or the sinus drainage pathways and then to the sinuses or into the trachea and bronchi and then the lungs, we see the clinical manifestations of acute otitis media, sinusitis, or pneumonia. The innate response failed.

The adaptive response – as the word implies – is when the immune cells recognize and adapt to the presence of foreign microbes by recognizing their presence, migrating to lymph nodes and spleen, communicating with each other, and consequently multiplying into great numbers. The interaction between the immune cells – T cells and B cells – in the lymph node and migration back to the site of infection takes a few days to occur (3-5 days) if the host has prior immunity from prior infections or vaccination. If there is no prior immunity and no vaccination, then it takes 10-14 days for the adaptive immunity response to kick in and clear the infection. During that extra time, the pneumococci are gaining in numbers, causing more inflammation, and we see those clinical signs of fever, redness, and swelling at the site of infection, and pain.

So influenza can cause all of the events above by itself, but when the virus dances with the pneumococci, and the pneumococci benefit from the partnership, that is the most frequent cause of acute otitis media, sinusitis, and pneumonia. And all of that could have been prevented in most of our patients if they only got their annual flu vaccine.

Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. The study was supported by a National Institutes of Health grant. Dr. Pichichero said he had no relevant financial disclosures. Email him at [email protected].