Chemotherapy with a platinum-based doublet was associated with a highly significant 36% reduction in mortality, compared with monotherapy, among elderly patients with non–small cell lung cancer in a study published online Aug. 9 by the Lancet.

The combination of carboplatin and paclitaxel was associated with more toxicity than was single-drug vinorelbine or gemcitabine regimens in the phase III trial, but the investigators contended that this was outweighed by the survival benefit.

Median overall survival for patients receiving carboplatin plus paclitaxel was 10.3 months, compared with 6.2 months in those randomized to monotherapy (hazard ratio, 0.64; P less than .0001).

Although several guidelines currently recommend monotherapy for elderly patients, the current finding is "of such magnitude that we believe the treatment paradigm for elderly patients with advanced NSCLC should be reconsidered," wrote Dr. Elisabeth Quoix of the Hôpitaux Universitaires de Strasbourg (France) and colleagues (Lancet 2011 Aug. 9 [doi:10.1016/S0140-6736(11)60780-0]).

The investigators from the IFCT (Intergroupe Francophone de Cancérologie Thoracique) looked at 451 patients aged 70-89 years (median age, 77 years) with unresectable stage IV NSCLC or stage III disease that was "unsuitable" for radical radiation therapy. Patients were followed for a median of 30.3 months. To be included in the study, patients’ scores on the World Health Organization’s performance status scale had to be 2 or lower (indicating severe disease), and patients had to have a life expectancy of at least 12 weeks.

The 225 patients who were randomized to the doublet chemotherapy group received intravenous carboplatin (AUC [area under the curve] = 6) on day 1, plus 90 mg/m² of paclitaxel on days 1, 8, and 15 of 28-day cycles.

The 226-patient monotherapy cohort received 25 mg/m² vinorelbine (62 patients) on days 1 and 8 – or 1,150 mg/m² gemcitabine (164 patients) on days 1 and 8 – of 21-day cycles, with the choice of either vinorelbine or gemcitabine being made by the institution conducting the therapy.

In the doublet group, cycles were repeated every 4 weeks, such that patients received 3 weeks of treatment plus 1 week without, for doublet chemotherapy. For monotherapy, the cycle lasted 3 weeks (2 weeks of treatment plus 1 week without), with a maximum of four cycles for doublet therapy and five cycles for monotherapy.

Survival Rates for Chemotherapy Study Patients

By 1 year, the survival rate was 25.4% in the monotherapy group vs. 44.5% in the doublet therapy group (HR, 0.64; P less than .0001). The trend persisted at 2 years, with the probability of survival being 11.7% in monotherapy recipients and 22.4% in those receiving doublet therapy, wrote the authors.

Median progression-free survival also was significantly longer with the doublet (6 months vs. 2.8 months; P less than .0001).

In 2009, an independent data-monitoring committee recommended stopping recruitment based on the second interim analysis.

"Grade 3-4 neutropenia, febrile neutropenia, thrombopenia, and anemia were significantly more frequent among patients in the doublet chemotherapy group than among those in the monotherapy group, as was grade 3-4 sensory neuropathy," wrote the authors. The protocol did not allow growth factor support in the first cycle, but it was authorized as secondary prophylaxis in patients who developed grade 3 or 4 neutropenia.

In all, 10 deaths in the doublet therapy group (4.4%) and 3 in the monotherapy group (1.3%) were related to treatment: Culprit diagnoses included sepsis, respiratory distress, and diarrhea related to renal insufficiency. But the percentage of deaths in the first 3 months after the start of therapy was "markedly lower" in patients who received carboplatin plus paclitaxel.

Although quality of life scores at week 18 were similar between groups, the authors pointed out that "role functioning and fatigue were worse in the doublet chemotherapy group than in the monotherapy group" (P = .026 and .039, respectively). Full quality of life data will be published separately, they said.

The 2009 American Society of Clinical Oncology guidelines (J. Clin. Oncol. 2009;27:6251-66) recommend that age "not be used as a criterion in the decision-making process about whether to treat a patient" and call for further research devoted to elderly patients, according to Dr. Quoix and colleagues. "Conversely," they noted, "the European Organisation for Research and Treatment of Cancer Elderly Task Force and Lung Cancer Group and International Society of Geriatric Oncology highlighted in 2010 that monotherapy should be given to elderly patients with advanced NSCLC."

"We believe that monthly carboplatin and weekly paclitaxel is a feasible option for first-line therapy of advanced NSCLC in patients older than 70 years with performance status scores of 0-2," the authors wrote.

 

The study was funded by the IFCT and the French National Cancer Institute, with support by grants from Bristol-Myers Squibb, Roche, and Pierre Fabre. Several authors, including Dr. Quoix, disclosed financial relationships with the makers of chemotherapy drugs, including carboplatin (Bristol-Myers Squibb, Roche, and Lilly). Dr. Reckamp disclosed consulting for Amgen, Genentech, and Tragara Pharmaceuticals, as well as serving on speakers bureaus for Lilly Oncology and Genentech.

Chemotherapy with a platinum-based doublet was associated with a highly significant 36% reduction in mortality, compared with monotherapy, among elderly patients with non–small cell lung cancer in a study published online Aug. 9 by the Lancet.

The combination of carboplatin and paclitaxel was associated with more toxicity than was single-drug vinorelbine or gemcitabine regimens in the phase III trial, but the investigators contended that this was outweighed by the survival benefit.

Median overall survival for patients receiving carboplatin plus paclitaxel was 10.3 months, compared with 6.2 months in those randomized to monotherapy (hazard ratio, 0.64; P less than .0001).

Although several guidelines currently recommend monotherapy for elderly patients, the current finding is "of such magnitude that we believe the treatment paradigm for elderly patients with advanced NSCLC should be reconsidered," wrote Dr. Elisabeth Quoix of the Hôpitaux Universitaires de Strasbourg (France) and colleagues (Lancet 2011 Aug. 9 [doi:10.1016/S0140-6736(11)60780-0]).

The investigators from the IFCT (Intergroupe Francophone de Cancérologie Thoracique) looked at 451 patients aged 70-89 years (median age, 77 years) with unresectable stage IV NSCLC or stage III disease that was "unsuitable" for radical radiation therapy. Patients were followed for a median of 30.3 months. To be included in the study, patients’ scores on the World Health Organization’s performance status scale had to be 2 or lower (indicating severe disease), and patients had to have a life expectancy of at least 12 weeks.

The 225 patients who were randomized to the doublet chemotherapy group received intravenous carboplatin (AUC [area under the curve] = 6) on day 1, plus 90 mg/m² of paclitaxel on days 1, 8, and 15 of 28-day cycles.

The 226-patient monotherapy cohort received 25 mg/m² vinorelbine (62 patients) on days 1 and 8 – or 1,150 mg/m² gemcitabine (164 patients) on days 1 and 8 – of 21-day cycles, with the choice of either vinorelbine or gemcitabine being made by the institution conducting the therapy.

In the doublet group, cycles were repeated every 4 weeks, such that patients received 3 weeks of treatment plus 1 week without, for doublet chemotherapy. For monotherapy, the cycle lasted 3 weeks (2 weeks of treatment plus 1 week without), with a maximum of four cycles for doublet therapy and five cycles for monotherapy.

Survival Rates for Chemotherapy Study Patients

By 1 year, the survival rate was 25.4% in the monotherapy group vs. 44.5% in the doublet therapy group (HR, 0.64; P less than .0001). The trend persisted at 2 years, with the probability of survival being 11.7% in monotherapy recipients and 22.4% in those receiving doublet therapy, wrote the authors.

Median progression-free survival also was significantly longer with the doublet (6 months vs. 2.8 months; P less than .0001).

In 2009, an independent data-monitoring committee recommended stopping recruitment based on the second interim analysis.

"Grade 3-4 neutropenia, febrile neutropenia, thrombopenia, and anemia were significantly more frequent among patients in the doublet chemotherapy group than among those in the monotherapy group, as was grade 3-4 sensory neuropathy," wrote the authors. The protocol did not allow growth factor support in the first cycle, but it was authorized as secondary prophylaxis in patients who developed grade 3 or 4 neutropenia.

In all, 10 deaths in the doublet therapy group (4.4%) and 3 in the monotherapy group (1.3%) were related to treatment: Culprit diagnoses included sepsis, respiratory distress, and diarrhea related to renal insufficiency. But the percentage of deaths in the first 3 months after the start of therapy was "markedly lower" in patients who received carboplatin plus paclitaxel.

Although quality of life scores at week 18 were similar between groups, the authors pointed out that "role functioning and fatigue were worse in the doublet chemotherapy group than in the monotherapy group" (P = .026 and .039, respectively). Full quality of life data will be published separately, they said.

The 2009 American Society of Clinical Oncology guidelines (J. Clin. Oncol. 2009;27:6251-66) recommend that age "not be used as a criterion in the decision-making process about whether to treat a patient" and call for further research devoted to elderly patients, according to Dr. Quoix and colleagues. "Conversely," they noted, "the European Organisation for Research and Treatment of Cancer Elderly Task Force and Lung Cancer Group and International Society of Geriatric Oncology highlighted in 2010 that monotherapy should be given to elderly patients with advanced NSCLC."

"We believe that monthly carboplatin and weekly paclitaxel is a feasible option for first-line therapy of advanced NSCLC in patients older than 70 years with performance status scores of 0-2," the authors wrote.

 

The study was funded by the IFCT and the French National Cancer Institute, with support by grants from Bristol-Myers Squibb, Roche, and Pierre Fabre. Several authors, including Dr. Quoix, disclosed financial relationships with the makers of chemotherapy drugs, including carboplatin (Bristol-Myers Squibb, Roche, and Lilly). Dr. Reckamp disclosed consulting for Amgen, Genentech, and Tragara Pharmaceuticals, as well as serving on speakers bureaus for Lilly Oncology and Genentech.

Chemotherapy with a platinum-based doublet was associated with a highly significant 36% reduction in mortality, compared with monotherapy, among elderly patients with non–small cell lung cancer in a study published online Aug. 9 by the Lancet.

The combination of carboplatin and paclitaxel was associated with more toxicity than was single-drug vinorelbine or gemcitabine regimens in the phase III trial, but the investigators contended that this was outweighed by the survival benefit.

Median overall survival for patients receiving carboplatin plus paclitaxel was 10.3 months, compared with 6.2 months in those randomized to monotherapy (hazard ratio, 0.64; P less than .0001).

Although several guidelines currently recommend monotherapy for elderly patients, the current finding is "of such magnitude that we believe the treatment paradigm for elderly patients with advanced NSCLC should be reconsidered," wrote Dr. Elisabeth Quoix of the Hôpitaux Universitaires de Strasbourg (France) and colleagues (Lancet 2011 Aug. 9 [doi:10.1016/S0140-6736(11)60780-0]).

The investigators from the IFCT (Intergroupe Francophone de Cancérologie Thoracique) looked at 451 patients aged 70-89 years (median age, 77 years) with unresectable stage IV NSCLC or stage III disease that was "unsuitable" for radical radiation therapy. Patients were followed for a median of 30.3 months. To be included in the study, patients’ scores on the World Health Organization’s performance status scale had to be 2 or lower (indicating severe disease), and patients had to have a life expectancy of at least 12 weeks.

The 225 patients who were randomized to the doublet chemotherapy group received intravenous carboplatin (AUC [area under the curve] = 6) on day 1, plus 90 mg/m² of paclitaxel on days 1, 8, and 15 of 28-day cycles.

The 226-patient monotherapy cohort received 25 mg/m² vinorelbine (62 patients) on days 1 and 8 – or 1,150 mg/m² gemcitabine (164 patients) on days 1 and 8 – of 21-day cycles, with the choice of either vinorelbine or gemcitabine being made by the institution conducting the therapy.

In the doublet group, cycles were repeated every 4 weeks, such that patients received 3 weeks of treatment plus 1 week without, for doublet chemotherapy. For monotherapy, the cycle lasted 3 weeks (2 weeks of treatment plus 1 week without), with a maximum of four cycles for doublet therapy and five cycles for monotherapy.

Survival Rates for Chemotherapy Study Patients

By 1 year, the survival rate was 25.4% in the monotherapy group vs. 44.5% in the doublet therapy group (HR, 0.64; P less than .0001). The trend persisted at 2 years, with the probability of survival being 11.7% in monotherapy recipients and 22.4% in those receiving doublet therapy, wrote the authors.

Median progression-free survival also was significantly longer with the doublet (6 months vs. 2.8 months; P less than .0001).

In 2009, an independent data-monitoring committee recommended stopping recruitment based on the second interim analysis.

"Grade 3-4 neutropenia, febrile neutropenia, thrombopenia, and anemia were significantly more frequent among patients in the doublet chemotherapy group than among those in the monotherapy group, as was grade 3-4 sensory neuropathy," wrote the authors. The protocol did not allow growth factor support in the first cycle, but it was authorized as secondary prophylaxis in patients who developed grade 3 or 4 neutropenia.

In all, 10 deaths in the doublet therapy group (4.4%) and 3 in the monotherapy group (1.3%) were related to treatment: Culprit diagnoses included sepsis, respiratory distress, and diarrhea related to renal insufficiency. But the percentage of deaths in the first 3 months after the start of therapy was "markedly lower" in patients who received carboplatin plus paclitaxel.

Although quality of life scores at week 18 were similar between groups, the authors pointed out that "role functioning and fatigue were worse in the doublet chemotherapy group than in the monotherapy group" (P = .026 and .039, respectively). Full quality of life data will be published separately, they said.

The 2009 American Society of Clinical Oncology guidelines (J. Clin. Oncol. 2009;27:6251-66) recommend that age "not be used as a criterion in the decision-making process about whether to treat a patient" and call for further research devoted to elderly patients, according to Dr. Quoix and colleagues. "Conversely," they noted, "the European Organisation for Research and Treatment of Cancer Elderly Task Force and Lung Cancer Group and International Society of Geriatric Oncology highlighted in 2010 that monotherapy should be given to elderly patients with advanced NSCLC."

"We believe that monthly carboplatin and weekly paclitaxel is a feasible option for first-line therapy of advanced NSCLC in patients older than 70 years with performance status scores of 0-2," the authors wrote.

 

The study was funded by the IFCT and the French National Cancer Institute, with support by grants from Bristol-Myers Squibb, Roche, and Pierre Fabre. Several authors, including Dr. Quoix, disclosed financial relationships with the makers of chemotherapy drugs, including carboplatin (Bristol-Myers Squibb, Roche, and Lilly). Dr. Reckamp disclosed consulting for Amgen, Genentech, and Tragara Pharmaceuticals, as well as serving on speakers bureaus for Lilly Oncology and Genentech.

AMSTERDAM – Initial endosonographic assessment of mediastinal lymph node metastases in patients with resectable non–small cell lung cancer surpassed initial surgical staging not just in clinical outcomes but also with lower cost and better quality of life in a controlled, head-to-head comparison of the two staging approaches.

"Given that assessment of lymph nodes by the endoscopic approach was more effective [and] better tolerated by patients, and seems cheaper than the surgical approach, we recommend that endoscopic tests be used, reserving surgical tests as a backup if endoscopy does not show evidence of cancer," Dr. Robert C. Rintoul said in presenting the results of a follow-up analysis at the World Conference on Lung Cancer.

"We think this is the way forward, and that this will change practice globally," said Dr. Rintoul, lead physician for thoracic oncology at Papworth Hospital in Cambridge, England.

He reported new data and addressed implications of the totality of evidence now available from ASTER (Assessment of Surgical Staging vs. Endoscopic Ultrasound in Lung Cancer: A Randomized Clinical Trial) that was conducted in patients with potentially resectable NSCLC.

Although the overall weight of evidence now in from ASTER uniformly favors endosonography first, perhaps the most noteworthy findings from the study were those included in a report in JAMA last November: Endosonography first cut the rate of unnecessary thoracotomies to 7% compared with an 18% rate in patients assessed by mediastinoscopy first (P = .02). In addition, 45% of patients evaluated by endosonography first had positive lymph nodes and so avoided mediastinoscopy (JAMA 2010;304:2245-52).

"A few years ago, people said all these patients need mediastinoscopy. What we’ve learned [from ASTER] is that about half never need mediastinoscopy. That is practice changing," commented Dr. Richard Gralla, chief of hematology oncology at North Shore–Long Island Jewish Health System in New Hyde Park, N.Y. "As a rule, patients find EBUS [endobronchial ultrasound–guided transbronchial needle aspiration] and EUS [transesophageal ultrasound-guided fine-needle aspiration] much simpler procedures," compared with mediastinoscopy, he noted at the meeting, which was sponsored by the International Association for the Study of Lung Cancer.

The ASTER results that were published last year proved so compelling that many surgeons and thoracic oncologists have already switched to endosonography first, noted Dr. Jouke T. Annema, a thoracic surgeon at Leiden (the Netherlands) University and lead ASTER investigator.

"EBUS is the new standard," he said in an interview, noting that earlier this year the Dutch agency responsible for setting medical policy adopted endosonography as the preferred initial method for lymph node assessment in patients with resectable NSCLC. The National Institute for Health and Clinical Excellence (NICE), which sets U.K. health policies, did not name endosonography as the preferred initial staging method for lung cancer in its revised guidelines last April because the cost-effectiveness findings reported at the meeting had not yet been published, Dr. Rintoul said.

ASTER randomized 118 patients to initial mediastinoscopy staging and 123 to initial endosonographic staging at four medical centers in the United Kingdom, the Netherlands, and Belgium. The initial results reported last November also showed that initial endosonography followed by surgical staging in patients who were initially found to be node negative produced 94% sensitivity for finding positive lymph nodes, which was significantly better than the 79% sensitivity rate using mediastinoscopy first (P = .02).

The additional analyses reported by Dr. Rintoul used patient quality of life assessment by the EQ-5D (EuroQol five-domain) instrument at baseline, immediately after staging, and again at 2 and 6 months after staging. Researchers ran EQ-5D assessments on 144 of the study’s 241 patients at baseline, and on 124 patients after 6 months. The results showed similar, average EQ-5D levels at baseline and after 2 and 6 months in the two arms of the trial; however, immediately after staging, the endosonography-first patients had a statistically significant edge in average quality of life of 0.117 EQ-5D units, compared with patients who were staged by mediastinoscopy first (P = .003).

Average medical costs rung up by patients over the 6 months of treatment after baseline were about £746 (about $1,200) less per patient using endosonography first, a difference that was not statistically significant but suggested that initial endosonographic staging produced better cost-effectiveness, Dr. Rintoul said. He also reported that initial endosonography led to an average gain per patient of 0.015 quality-adjusted life-years, an advantage over initial surgical staging that just missed statistical significance (P = .052).

ASTER received no commercial support, and Dr. Rintoul said that he had no disclosures. He said that Papworth Hospital has received unrestricted educational grants and equipment loans from Olympus. Dr. Gralla and Dr. Annema had no disclosures.

AMSTERDAM – Initial endosonographic assessment of mediastinal lymph node metastases in patients with resectable non–small cell lung cancer surpassed initial surgical staging not just in clinical outcomes but also with lower cost and better quality of life in a controlled, head-to-head comparison of the two staging approaches.

"Given that assessment of lymph nodes by the endoscopic approach was more effective [and] better tolerated by patients, and seems cheaper than the surgical approach, we recommend that endoscopic tests be used, reserving surgical tests as a backup if endoscopy does not show evidence of cancer," Dr. Robert C. Rintoul said in presenting the results of a follow-up analysis at the World Conference on Lung Cancer.

"We think this is the way forward, and that this will change practice globally," said Dr. Rintoul, lead physician for thoracic oncology at Papworth Hospital in Cambridge, England.

He reported new data and addressed implications of the totality of evidence now available from ASTER (Assessment of Surgical Staging vs. Endoscopic Ultrasound in Lung Cancer: A Randomized Clinical Trial) that was conducted in patients with potentially resectable NSCLC.

Although the overall weight of evidence now in from ASTER uniformly favors endosonography first, perhaps the most noteworthy findings from the study were those included in a report in JAMA last November: Endosonography first cut the rate of unnecessary thoracotomies to 7% compared with an 18% rate in patients assessed by mediastinoscopy first (P = .02). In addition, 45% of patients evaluated by endosonography first had positive lymph nodes and so avoided mediastinoscopy (JAMA 2010;304:2245-52).

"A few years ago, people said all these patients need mediastinoscopy. What we’ve learned [from ASTER] is that about half never need mediastinoscopy. That is practice changing," commented Dr. Richard Gralla, chief of hematology oncology at North Shore–Long Island Jewish Health System in New Hyde Park, N.Y. "As a rule, patients find EBUS [endobronchial ultrasound–guided transbronchial needle aspiration] and EUS [transesophageal ultrasound-guided fine-needle aspiration] much simpler procedures," compared with mediastinoscopy, he noted at the meeting, which was sponsored by the International Association for the Study of Lung Cancer.

The ASTER results that were published last year proved so compelling that many surgeons and thoracic oncologists have already switched to endosonography first, noted Dr. Jouke T. Annema, a thoracic surgeon at Leiden (the Netherlands) University and lead ASTER investigator.

"EBUS is the new standard," he said in an interview, noting that earlier this year the Dutch agency responsible for setting medical policy adopted endosonography as the preferred initial method for lymph node assessment in patients with resectable NSCLC. The National Institute for Health and Clinical Excellence (NICE), which sets U.K. health policies, did not name endosonography as the preferred initial staging method for lung cancer in its revised guidelines last April because the cost-effectiveness findings reported at the meeting had not yet been published, Dr. Rintoul said.

ASTER randomized 118 patients to initial mediastinoscopy staging and 123 to initial endosonographic staging at four medical centers in the United Kingdom, the Netherlands, and Belgium. The initial results reported last November also showed that initial endosonography followed by surgical staging in patients who were initially found to be node negative produced 94% sensitivity for finding positive lymph nodes, which was significantly better than the 79% sensitivity rate using mediastinoscopy first (P = .02).

The additional analyses reported by Dr. Rintoul used patient quality of life assessment by the EQ-5D (EuroQol five-domain) instrument at baseline, immediately after staging, and again at 2 and 6 months after staging. Researchers ran EQ-5D assessments on 144 of the study’s 241 patients at baseline, and on 124 patients after 6 months. The results showed similar, average EQ-5D levels at baseline and after 2 and 6 months in the two arms of the trial; however, immediately after staging, the endosonography-first patients had a statistically significant edge in average quality of life of 0.117 EQ-5D units, compared with patients who were staged by mediastinoscopy first (P = .003).

Average medical costs rung up by patients over the 6 months of treatment after baseline were about £746 (about $1,200) less per patient using endosonography first, a difference that was not statistically significant but suggested that initial endosonographic staging produced better cost-effectiveness, Dr. Rintoul said. He also reported that initial endosonography led to an average gain per patient of 0.015 quality-adjusted life-years, an advantage over initial surgical staging that just missed statistical significance (P = .052).

ASTER received no commercial support, and Dr. Rintoul said that he had no disclosures. He said that Papworth Hospital has received unrestricted educational grants and equipment loans from Olympus. Dr. Gralla and Dr. Annema had no disclosures.

AMSTERDAM – Initial endosonographic assessment of mediastinal lymph node metastases in patients with resectable non–small cell lung cancer surpassed initial surgical staging not just in clinical outcomes but also with lower cost and better quality of life in a controlled, head-to-head comparison of the two staging approaches.

"Given that assessment of lymph nodes by the endoscopic approach was more effective [and] better tolerated by patients, and seems cheaper than the surgical approach, we recommend that endoscopic tests be used, reserving surgical tests as a backup if endoscopy does not show evidence of cancer," Dr. Robert C. Rintoul said in presenting the results of a follow-up analysis at the World Conference on Lung Cancer.

"We think this is the way forward, and that this will change practice globally," said Dr. Rintoul, lead physician for thoracic oncology at Papworth Hospital in Cambridge, England.

He reported new data and addressed implications of the totality of evidence now available from ASTER (Assessment of Surgical Staging vs. Endoscopic Ultrasound in Lung Cancer: A Randomized Clinical Trial) that was conducted in patients with potentially resectable NSCLC.

Although the overall weight of evidence now in from ASTER uniformly favors endosonography first, perhaps the most noteworthy findings from the study were those included in a report in JAMA last November: Endosonography first cut the rate of unnecessary thoracotomies to 7% compared with an 18% rate in patients assessed by mediastinoscopy first (P = .02). In addition, 45% of patients evaluated by endosonography first had positive lymph nodes and so avoided mediastinoscopy (JAMA 2010;304:2245-52).

"A few years ago, people said all these patients need mediastinoscopy. What we’ve learned [from ASTER] is that about half never need mediastinoscopy. That is practice changing," commented Dr. Richard Gralla, chief of hematology oncology at North Shore–Long Island Jewish Health System in New Hyde Park, N.Y. "As a rule, patients find EBUS [endobronchial ultrasound–guided transbronchial needle aspiration] and EUS [transesophageal ultrasound-guided fine-needle aspiration] much simpler procedures," compared with mediastinoscopy, he noted at the meeting, which was sponsored by the International Association for the Study of Lung Cancer.

The ASTER results that were published last year proved so compelling that many surgeons and thoracic oncologists have already switched to endosonography first, noted Dr. Jouke T. Annema, a thoracic surgeon at Leiden (the Netherlands) University and lead ASTER investigator.

"EBUS is the new standard," he said in an interview, noting that earlier this year the Dutch agency responsible for setting medical policy adopted endosonography as the preferred initial method for lymph node assessment in patients with resectable NSCLC. The National Institute for Health and Clinical Excellence (NICE), which sets U.K. health policies, did not name endosonography as the preferred initial staging method for lung cancer in its revised guidelines last April because the cost-effectiveness findings reported at the meeting had not yet been published, Dr. Rintoul said.

ASTER randomized 118 patients to initial mediastinoscopy staging and 123 to initial endosonographic staging at four medical centers in the United Kingdom, the Netherlands, and Belgium. The initial results reported last November also showed that initial endosonography followed by surgical staging in patients who were initially found to be node negative produced 94% sensitivity for finding positive lymph nodes, which was significantly better than the 79% sensitivity rate using mediastinoscopy first (P = .02).

The additional analyses reported by Dr. Rintoul used patient quality of life assessment by the EQ-5D (EuroQol five-domain) instrument at baseline, immediately after staging, and again at 2 and 6 months after staging. Researchers ran EQ-5D assessments on 144 of the study’s 241 patients at baseline, and on 124 patients after 6 months. The results showed similar, average EQ-5D levels at baseline and after 2 and 6 months in the two arms of the trial; however, immediately after staging, the endosonography-first patients had a statistically significant edge in average quality of life of 0.117 EQ-5D units, compared with patients who were staged by mediastinoscopy first (P = .003).

Average medical costs rung up by patients over the 6 months of treatment after baseline were about £746 (about $1,200) less per patient using endosonography first, a difference that was not statistically significant but suggested that initial endosonographic staging produced better cost-effectiveness, Dr. Rintoul said. He also reported that initial endosonography led to an average gain per patient of 0.015 quality-adjusted life-years, an advantage over initial surgical staging that just missed statistical significance (P = .052).

ASTER received no commercial support, and Dr. Rintoul said that he had no disclosures. He said that Papworth Hospital has received unrestricted educational grants and equipment loans from Olympus. Dr. Gralla and Dr. Annema had no disclosures.

Researchers at Cold Spring Harbor Laboratory (CSHL) and 5 other laboratories may have identified a new drug target for the treatment of acute myeloid leukemia (AML).

They pinpointed a protein called Brd4, which contains a distinct region known as bromodomain and is a member of the BET protein family, known for regulating gene expression.

A new drug candidate that inhibits Brd4 was able to suppress AML in experimental models.

“The drug candidate not only displays remarkable anti-leukemia activity in aggressive disease models and against cells derived from patients with diverse, genetic subtypes of AML, but is also minimally toxic to non-cancerous cells,” said Chris Vakoc, MD, PhD, leader of the study at CSHL.

“The drug is currently being developed for therapeutic use for cancer patients by Tensha Therapeutics and is expected to enter clinical trials within 2 years.”

The team used RNAi screening in an AML murine model. The RNAi screen introduced small hairpin-shaped pieces of RNA (shRNA) that encode epigenetic proteins into mice that harbor leukemia-causing mutations.

The mice in this study carried the oncogene Nras and rearranged forms of the MLL gene, both of which are mutations often found in patients whose leukemia is resistant to standard chemotherapy.

The drinking water for the mice was also supplemented with doxycyline.

“Inducing shRNA that shuts down a gene required for the survival of leukemic cells can lead to complete disease remission,” said Johannes Zuber, MD, former postdoctoral researcher at CSHL. “This ability to use shRNA to simulate the effect of an anti-cancer drug illustrates the power of this approach.”

The team also identified another potential target in AML called Myb. The team found that suppressing the activity of Myb also eliminated AML in mice. The team screened more than 1000 shRNAs targeting 243 known epigenetic regulators of chromatin.

They homed in on Brd4 as a target and found that suppressing the protein led to the most dramatic changes in AML. The cell cycle was arrested, the leukemic cells died, leukemia progression was delayed, and the mice survived longer.

Previously, James Bradner, MD, at Dana-Farber Cancer Institute in Boston, and his research team had developed a small molecule inhibitor of Brd4 called JQ1. The two groups collaborated, reproducing the antileukemic effects in the Brd4 shRNA experiments. They consider JQ1 to be an ideal drug candidate.

Their findings were published online in Nature.

Researchers at Cold Spring Harbor Laboratory (CSHL) and 5 other laboratories may have identified a new drug target for the treatment of acute myeloid leukemia (AML).

They pinpointed a protein called Brd4, which contains a distinct region known as bromodomain and is a member of the BET protein family, known for regulating gene expression.

A new drug candidate that inhibits Brd4 was able to suppress AML in experimental models.

“The drug candidate not only displays remarkable anti-leukemia activity in aggressive disease models and against cells derived from patients with diverse, genetic subtypes of AML, but is also minimally toxic to non-cancerous cells,” said Chris Vakoc, MD, PhD, leader of the study at CSHL.

“The drug is currently being developed for therapeutic use for cancer patients by Tensha Therapeutics and is expected to enter clinical trials within 2 years.”

The team used RNAi screening in an AML murine model. The RNAi screen introduced small hairpin-shaped pieces of RNA (shRNA) that encode epigenetic proteins into mice that harbor leukemia-causing mutations.

The mice in this study carried the oncogene Nras and rearranged forms of the MLL gene, both of which are mutations often found in patients whose leukemia is resistant to standard chemotherapy.

The drinking water for the mice was also supplemented with doxycyline.

“Inducing shRNA that shuts down a gene required for the survival of leukemic cells can lead to complete disease remission,” said Johannes Zuber, MD, former postdoctoral researcher at CSHL. “This ability to use shRNA to simulate the effect of an anti-cancer drug illustrates the power of this approach.”

The team also identified another potential target in AML called Myb. The team found that suppressing the activity of Myb also eliminated AML in mice. The team screened more than 1000 shRNAs targeting 243 known epigenetic regulators of chromatin.

They homed in on Brd4 as a target and found that suppressing the protein led to the most dramatic changes in AML. The cell cycle was arrested, the leukemic cells died, leukemia progression was delayed, and the mice survived longer.

Previously, James Bradner, MD, at Dana-Farber Cancer Institute in Boston, and his research team had developed a small molecule inhibitor of Brd4 called JQ1. The two groups collaborated, reproducing the antileukemic effects in the Brd4 shRNA experiments. They consider JQ1 to be an ideal drug candidate.

Their findings were published online in Nature.

Researchers at Cold Spring Harbor Laboratory (CSHL) and 5 other laboratories may have identified a new drug target for the treatment of acute myeloid leukemia (AML).

They pinpointed a protein called Brd4, which contains a distinct region known as bromodomain and is a member of the BET protein family, known for regulating gene expression.

A new drug candidate that inhibits Brd4 was able to suppress AML in experimental models.

“The drug candidate not only displays remarkable anti-leukemia activity in aggressive disease models and against cells derived from patients with diverse, genetic subtypes of AML, but is also minimally toxic to non-cancerous cells,” said Chris Vakoc, MD, PhD, leader of the study at CSHL.

“The drug is currently being developed for therapeutic use for cancer patients by Tensha Therapeutics and is expected to enter clinical trials within 2 years.”

The team used RNAi screening in an AML murine model. The RNAi screen introduced small hairpin-shaped pieces of RNA (shRNA) that encode epigenetic proteins into mice that harbor leukemia-causing mutations.

The mice in this study carried the oncogene Nras and rearranged forms of the MLL gene, both of which are mutations often found in patients whose leukemia is resistant to standard chemotherapy.

The drinking water for the mice was also supplemented with doxycyline.

“Inducing shRNA that shuts down a gene required for the survival of leukemic cells can lead to complete disease remission,” said Johannes Zuber, MD, former postdoctoral researcher at CSHL. “This ability to use shRNA to simulate the effect of an anti-cancer drug illustrates the power of this approach.”

The team also identified another potential target in AML called Myb. The team found that suppressing the activity of Myb also eliminated AML in mice. The team screened more than 1000 shRNAs targeting 243 known epigenetic regulators of chromatin.

They homed in on Brd4 as a target and found that suppressing the protein led to the most dramatic changes in AML. The cell cycle was arrested, the leukemic cells died, leukemia progression was delayed, and the mice survived longer.

Previously, James Bradner, MD, at Dana-Farber Cancer Institute in Boston, and his research team had developed a small molecule inhibitor of Brd4 called JQ1. The two groups collaborated, reproducing the antileukemic effects in the Brd4 shRNA experiments. They consider JQ1 to be an ideal drug candidate.

Their findings were published online in Nature.

It's 4 p.m. Tired and cranky, you've got three or four hours to go before the end of your shift. What's the best way to ramp up your energy and power through the rest of your workday? Hint: It's not an energy drink (although judicious use of coffee can sometimes help).

Late-afternoon slowdowns are natural, explains Susan Swadener, PhD, RD, dietetic internship director and lecturer in the Food Science and Nutrition Department at California State University San Luis Obispo. "Your enzyme levels go down, which is part of your diurnal pattern to slow down the body's processes to get ready for the evening and sleep," she says.

Common-Sense Nutrition

To fight afternoon fatigue, adopt good nutritional habits throughout your day. It's essential to have a healthy breakfast in the morning, advises Dr. Swadener, who's also a registered dietitian in private practice. Make sure you eat lunch, too, with a balance of protein, carbohydrates, and fats.

Afternoon snacks are a good idea, especially if they incorporate some protein. Foods high in protein can increase norepinephrine and epinephrine production, which helps you stay alert. Some examples of quick and nutritious snacks: string cheese and an apple; sliced cheese or peanut butter on whole-wheat crackers; yogurt; a handful of almonds or walnuts; or trail mix.

And don't forget one of the most common directives to your patients: "Push the fluids." Have a glass of water or nonfat milk with your lunch, and make sure you keep your water bottle handy at your desk.

As for coffee, "you don't want to be drinking it constantly to keep your energy level up, because you'll just crash afterwards," Dr. Swadener says. If you don't abuse caffeine, one cup of coffee in the morning and one in the afternoon is found to be most effective in increasing your alertness.

Change It Up

Desk tasks can make you drowsy. Daniel Markovitz is president of TimeBack Management, which specializes in applying Lean manufacturing principles to increase personal productivity for healthcare workers. He's found—and research such as a 2003 study in Ergonomics and a 2007 National Institute for Occupational Safety and Health study in the American Journal of Industrial Medicine supports these conclusions—that taking mini-breaks and then returning to the task at hand can refresh you and make you more productive.

You also get energy by using it, so a brisk walk around the hospital or walking up and down a couple of flights of stairs can increase circulation and blood flow to the brain. "You don't even have to get up from your desk," Markovitz says. "Just by changing the nature of the work you're doing, it's refreshing to your brain." That might mean switching from dictation to administrative work, or from scheduling to research.

And remember the value of play, Markovitz advises. "We tend to discourage going on Facebook or playing a video game at work. But if you take a 15-minute break to do something that's pleasurable, that causes your brain to fire in different ways, that can be another helpful adaptation."

Gretchen Henkel is a freelance writer based in California.

 

 

 

It's 4 p.m. Tired and cranky, you've got three or four hours to go before the end of your shift. What's the best way to ramp up your energy and power through the rest of your workday? Hint: It's not an energy drink (although judicious use of coffee can sometimes help).

Late-afternoon slowdowns are natural, explains Susan Swadener, PhD, RD, dietetic internship director and lecturer in the Food Science and Nutrition Department at California State University San Luis Obispo. "Your enzyme levels go down, which is part of your diurnal pattern to slow down the body's processes to get ready for the evening and sleep," she says.

Common-Sense Nutrition

To fight afternoon fatigue, adopt good nutritional habits throughout your day. It's essential to have a healthy breakfast in the morning, advises Dr. Swadener, who's also a registered dietitian in private practice. Make sure you eat lunch, too, with a balance of protein, carbohydrates, and fats.

Afternoon snacks are a good idea, especially if they incorporate some protein. Foods high in protein can increase norepinephrine and epinephrine production, which helps you stay alert. Some examples of quick and nutritious snacks: string cheese and an apple; sliced cheese or peanut butter on whole-wheat crackers; yogurt; a handful of almonds or walnuts; or trail mix.

And don't forget one of the most common directives to your patients: "Push the fluids." Have a glass of water or nonfat milk with your lunch, and make sure you keep your water bottle handy at your desk.

As for coffee, "you don't want to be drinking it constantly to keep your energy level up, because you'll just crash afterwards," Dr. Swadener says. If you don't abuse caffeine, one cup of coffee in the morning and one in the afternoon is found to be most effective in increasing your alertness.

Change It Up

Desk tasks can make you drowsy. Daniel Markovitz is president of TimeBack Management, which specializes in applying Lean manufacturing principles to increase personal productivity for healthcare workers. He's found—and research such as a 2003 study in Ergonomics and a 2007 National Institute for Occupational Safety and Health study in the American Journal of Industrial Medicine supports these conclusions—that taking mini-breaks and then returning to the task at hand can refresh you and make you more productive.

You also get energy by using it, so a brisk walk around the hospital or walking up and down a couple of flights of stairs can increase circulation and blood flow to the brain. "You don't even have to get up from your desk," Markovitz says. "Just by changing the nature of the work you're doing, it's refreshing to your brain." That might mean switching from dictation to administrative work, or from scheduling to research.

And remember the value of play, Markovitz advises. "We tend to discourage going on Facebook or playing a video game at work. But if you take a 15-minute break to do something that's pleasurable, that causes your brain to fire in different ways, that can be another helpful adaptation."

Gretchen Henkel is a freelance writer based in California.

 

 

 

It's 4 p.m. Tired and cranky, you've got three or four hours to go before the end of your shift. What's the best way to ramp up your energy and power through the rest of your workday? Hint: It's not an energy drink (although judicious use of coffee can sometimes help).

Late-afternoon slowdowns are natural, explains Susan Swadener, PhD, RD, dietetic internship director and lecturer in the Food Science and Nutrition Department at California State University San Luis Obispo. "Your enzyme levels go down, which is part of your diurnal pattern to slow down the body's processes to get ready for the evening and sleep," she says.

Common-Sense Nutrition

To fight afternoon fatigue, adopt good nutritional habits throughout your day. It's essential to have a healthy breakfast in the morning, advises Dr. Swadener, who's also a registered dietitian in private practice. Make sure you eat lunch, too, with a balance of protein, carbohydrates, and fats.

Afternoon snacks are a good idea, especially if they incorporate some protein. Foods high in protein can increase norepinephrine and epinephrine production, which helps you stay alert. Some examples of quick and nutritious snacks: string cheese and an apple; sliced cheese or peanut butter on whole-wheat crackers; yogurt; a handful of almonds or walnuts; or trail mix.

And don't forget one of the most common directives to your patients: "Push the fluids." Have a glass of water or nonfat milk with your lunch, and make sure you keep your water bottle handy at your desk.

As for coffee, "you don't want to be drinking it constantly to keep your energy level up, because you'll just crash afterwards," Dr. Swadener says. If you don't abuse caffeine, one cup of coffee in the morning and one in the afternoon is found to be most effective in increasing your alertness.

Change It Up

Desk tasks can make you drowsy. Daniel Markovitz is president of TimeBack Management, which specializes in applying Lean manufacturing principles to increase personal productivity for healthcare workers. He's found—and research such as a 2003 study in Ergonomics and a 2007 National Institute for Occupational Safety and Health study in the American Journal of Industrial Medicine supports these conclusions—that taking mini-breaks and then returning to the task at hand can refresh you and make you more productive.

You also get energy by using it, so a brisk walk around the hospital or walking up and down a couple of flights of stairs can increase circulation and blood flow to the brain. "You don't even have to get up from your desk," Markovitz says. "Just by changing the nature of the work you're doing, it's refreshing to your brain." That might mean switching from dictation to administrative work, or from scheduling to research.

And remember the value of play, Markovitz advises. "We tend to discourage going on Facebook or playing a video game at work. But if you take a 15-minute break to do something that's pleasurable, that causes your brain to fire in different ways, that can be another helpful adaptation."

Gretchen Henkel is a freelance writer based in California.

 

 

 

The skin may hold the key to differentiating classic pemphigus from the heterogenous autoimmune syndrome known as paraneoplastic autoimmune multiorgan syndrome.

It is a distinction of critical prognostic importance, because paraneoplastic autoimmune multiorgan syndrome (PAMS) typically is rapidly fatal, according to Dr. Sergei A. Grando, professor of dermatology and biologic chemistry at the University of California, Irvine. "The vast majority of patients die within several months of diagnosis, usually due to infections or respiratory failure, often taking the form of multiorgan system failure."

Two-thirds of patients with PAMS have a known internal malignancy at the time of their first mucocutaneous eruption. The most common of these neoplasms are non-Hodgkin’s lymphoma, which is present in more than 40% of PAMS patients; chronic lymphocytic leukemia, present in 30%; Castleman disease, present in 10%; and thymoma, present in 6%.

When a patient meets the diagnostic criteria for PAMS without having a known cancer, it is appropriate to launch a search for hidden malignancy, said Dr. Grando.

A key distinction between the skin lesions of PAMS and classic pemphigus is that PAMS involves inflammatory macules, papules, plaques, and blisters occurring on an inflammatory background over the trunk and extremities, including the palms and soles, but sparing the scalp.

In contrast, the generally more vesicular blisters and crusted erosions of pemphigus vulgaris display little erythema and usually occur on a noninflammatory background on the scalp, trunk, and extremities (but sparing the palms and soles). The most common location for skin lesions in PAMS is the palms; in pemphigus vulgaris, it is the scalp.

Also, Nikolsky's sign is positive in pemphigus vulgaris, but negative in PAMS, added Dr. Grando, who was among the investigators who first described PAMS a decade ago (Arch. Dermatol. 2001;137:193-206).

PAMS is characterized by severe and diffuse oral mucous membrane involvement, with persistent painful stomatitis because of blisters and erosions, and frequent involvement of other mucous membranes, including the eyes and genitalia. Cicatrizing conjunctivitis is particularly common in PAMS. In contrast, oral mucous membrane involvement in pemphigus is more discrete, with the eyes or other nonoral mucosa rarely involved.

Photo courtesy Dr. Rania Abdel Hay

Another key in the differential diagnosis: PAMS is associated with the HLA-DRB1*03 allele, whereas pemphigus vulgaris and foliaceous are strongly associated with the -04 and -14 alleles, respectively.

A hallmark of PAMS is respiratory involvement, with the sloughing of bronchial epithelial cells contributing to small airway occlusion and bronchiolitis obliterans. Classic pemphigus is free of respiratory involvement.

Both the esophagus and colon may be involved in PAMS, whereas only the esophagus is affected in pemphigus vulgaris.

In a published series of 28 PAMS patients, painful and generalized oral stomatitis was present in all 28, respiratory involvement was in 26, death from respiratory failure occurred in 22, and lichenoid skin involvement was present in 19. Only seven patients had no skin lesions (Br. J. Dermatol. 2003;149:1143-51).

At least five different subtypes of PAMS can be distinguished on the basis of the skin disease manifestations they most resemble. These subtypes of pemphiguslike PAMS include paraneoplastic pemphigus, bullous pemphigoid–like, erythema multiforme–like, lichen planus–like, and graft-vs.-host-disease–like versions of PAMS.

Dr. Grando eschews the term "paraneoplastic pemphigus" as too restrictive. After all, true pemphigus doesn’t usually affect the lungs, he noted.

Photo (c) Elsevier Inc.

Whereas most patients with classic pemphigus respond well to high-dose corticosteroids and recalcitrant disease can be effectively treated with cytotoxic agents, cyclosporine, intravenous gamma globulin, and other second-line agents, PAMS is resistant to all conventional forms of therapy.

"What can we offer? Really not much," Dr. Grando said during his presentation at the World Congress of Dermatology in Seoul, South Korea.

The preferred treatment regimen is a combination of prednisone and cyclosporine, with or without cyclophosphamide. Monthly courses of IVIG can buy patients a few extra months, he added.

Dr. Grando declared having no relevant financial interests.

The skin may hold the key to differentiating classic pemphigus from the heterogenous autoimmune syndrome known as paraneoplastic autoimmune multiorgan syndrome.

It is a distinction of critical prognostic importance, because paraneoplastic autoimmune multiorgan syndrome (PAMS) typically is rapidly fatal, according to Dr. Sergei A. Grando, professor of dermatology and biologic chemistry at the University of California, Irvine. "The vast majority of patients die within several months of diagnosis, usually due to infections or respiratory failure, often taking the form of multiorgan system failure."

Two-thirds of patients with PAMS have a known internal malignancy at the time of their first mucocutaneous eruption. The most common of these neoplasms are non-Hodgkin’s lymphoma, which is present in more than 40% of PAMS patients; chronic lymphocytic leukemia, present in 30%; Castleman disease, present in 10%; and thymoma, present in 6%.

When a patient meets the diagnostic criteria for PAMS without having a known cancer, it is appropriate to launch a search for hidden malignancy, said Dr. Grando.

A key distinction between the skin lesions of PAMS and classic pemphigus is that PAMS involves inflammatory macules, papules, plaques, and blisters occurring on an inflammatory background over the trunk and extremities, including the palms and soles, but sparing the scalp.

In contrast, the generally more vesicular blisters and crusted erosions of pemphigus vulgaris display little erythema and usually occur on a noninflammatory background on the scalp, trunk, and extremities (but sparing the palms and soles). The most common location for skin lesions in PAMS is the palms; in pemphigus vulgaris, it is the scalp.

Also, Nikolsky's sign is positive in pemphigus vulgaris, but negative in PAMS, added Dr. Grando, who was among the investigators who first described PAMS a decade ago (Arch. Dermatol. 2001;137:193-206).

PAMS is characterized by severe and diffuse oral mucous membrane involvement, with persistent painful stomatitis because of blisters and erosions, and frequent involvement of other mucous membranes, including the eyes and genitalia. Cicatrizing conjunctivitis is particularly common in PAMS. In contrast, oral mucous membrane involvement in pemphigus is more discrete, with the eyes or other nonoral mucosa rarely involved.

Photo courtesy Dr. Rania Abdel Hay

Another key in the differential diagnosis: PAMS is associated with the HLA-DRB1*03 allele, whereas pemphigus vulgaris and foliaceous are strongly associated with the -04 and -14 alleles, respectively.

A hallmark of PAMS is respiratory involvement, with the sloughing of bronchial epithelial cells contributing to small airway occlusion and bronchiolitis obliterans. Classic pemphigus is free of respiratory involvement.

Both the esophagus and colon may be involved in PAMS, whereas only the esophagus is affected in pemphigus vulgaris.

In a published series of 28 PAMS patients, painful and generalized oral stomatitis was present in all 28, respiratory involvement was in 26, death from respiratory failure occurred in 22, and lichenoid skin involvement was present in 19. Only seven patients had no skin lesions (Br. J. Dermatol. 2003;149:1143-51).

At least five different subtypes of PAMS can be distinguished on the basis of the skin disease manifestations they most resemble. These subtypes of pemphiguslike PAMS include paraneoplastic pemphigus, bullous pemphigoid–like, erythema multiforme–like, lichen planus–like, and graft-vs.-host-disease–like versions of PAMS.

Dr. Grando eschews the term "paraneoplastic pemphigus" as too restrictive. After all, true pemphigus doesn’t usually affect the lungs, he noted.

Photo (c) Elsevier Inc.

Whereas most patients with classic pemphigus respond well to high-dose corticosteroids and recalcitrant disease can be effectively treated with cytotoxic agents, cyclosporine, intravenous gamma globulin, and other second-line agents, PAMS is resistant to all conventional forms of therapy.

"What can we offer? Really not much," Dr. Grando said during his presentation at the World Congress of Dermatology in Seoul, South Korea.

The preferred treatment regimen is a combination of prednisone and cyclosporine, with or without cyclophosphamide. Monthly courses of IVIG can buy patients a few extra months, he added.

Dr. Grando declared having no relevant financial interests.

The skin may hold the key to differentiating classic pemphigus from the heterogenous autoimmune syndrome known as paraneoplastic autoimmune multiorgan syndrome.

It is a distinction of critical prognostic importance, because paraneoplastic autoimmune multiorgan syndrome (PAMS) typically is rapidly fatal, according to Dr. Sergei A. Grando, professor of dermatology and biologic chemistry at the University of California, Irvine. "The vast majority of patients die within several months of diagnosis, usually due to infections or respiratory failure, often taking the form of multiorgan system failure."

Two-thirds of patients with PAMS have a known internal malignancy at the time of their first mucocutaneous eruption. The most common of these neoplasms are non-Hodgkin’s lymphoma, which is present in more than 40% of PAMS patients; chronic lymphocytic leukemia, present in 30%; Castleman disease, present in 10%; and thymoma, present in 6%.

When a patient meets the diagnostic criteria for PAMS without having a known cancer, it is appropriate to launch a search for hidden malignancy, said Dr. Grando.

A key distinction between the skin lesions of PAMS and classic pemphigus is that PAMS involves inflammatory macules, papules, plaques, and blisters occurring on an inflammatory background over the trunk and extremities, including the palms and soles, but sparing the scalp.

In contrast, the generally more vesicular blisters and crusted erosions of pemphigus vulgaris display little erythema and usually occur on a noninflammatory background on the scalp, trunk, and extremities (but sparing the palms and soles). The most common location for skin lesions in PAMS is the palms; in pemphigus vulgaris, it is the scalp.

Also, Nikolsky's sign is positive in pemphigus vulgaris, but negative in PAMS, added Dr. Grando, who was among the investigators who first described PAMS a decade ago (Arch. Dermatol. 2001;137:193-206).

PAMS is characterized by severe and diffuse oral mucous membrane involvement, with persistent painful stomatitis because of blisters and erosions, and frequent involvement of other mucous membranes, including the eyes and genitalia. Cicatrizing conjunctivitis is particularly common in PAMS. In contrast, oral mucous membrane involvement in pemphigus is more discrete, with the eyes or other nonoral mucosa rarely involved.

Photo courtesy Dr. Rania Abdel Hay

Another key in the differential diagnosis: PAMS is associated with the HLA-DRB1*03 allele, whereas pemphigus vulgaris and foliaceous are strongly associated with the -04 and -14 alleles, respectively.

A hallmark of PAMS is respiratory involvement, with the sloughing of bronchial epithelial cells contributing to small airway occlusion and bronchiolitis obliterans. Classic pemphigus is free of respiratory involvement.

Both the esophagus and colon may be involved in PAMS, whereas only the esophagus is affected in pemphigus vulgaris.

In a published series of 28 PAMS patients, painful and generalized oral stomatitis was present in all 28, respiratory involvement was in 26, death from respiratory failure occurred in 22, and lichenoid skin involvement was present in 19. Only seven patients had no skin lesions (Br. J. Dermatol. 2003;149:1143-51).

At least five different subtypes of PAMS can be distinguished on the basis of the skin disease manifestations they most resemble. These subtypes of pemphiguslike PAMS include paraneoplastic pemphigus, bullous pemphigoid–like, erythema multiforme–like, lichen planus–like, and graft-vs.-host-disease–like versions of PAMS.

Dr. Grando eschews the term "paraneoplastic pemphigus" as too restrictive. After all, true pemphigus doesn’t usually affect the lungs, he noted.

Photo (c) Elsevier Inc.

Whereas most patients with classic pemphigus respond well to high-dose corticosteroids and recalcitrant disease can be effectively treated with cytotoxic agents, cyclosporine, intravenous gamma globulin, and other second-line agents, PAMS is resistant to all conventional forms of therapy.

"What can we offer? Really not much," Dr. Grando said during his presentation at the World Congress of Dermatology in Seoul, South Korea.

The preferred treatment regimen is a combination of prednisone and cyclosporine, with or without cyclophosphamide. Monthly courses of IVIG can buy patients a few extra months, he added.

Dr. Grando declared having no relevant financial interests.

A new report that suggests the lower costs and reduced length of stay (LOS) associated with hospitalist care of hospitalized Medicare beneficiaries is offset by higher costs post-discharge highlights progress and opportunities for hospitalists, SHM's president says.

The federally-funded study published Monday in Annals of Internal Medicine showed that while hospitalists clearly reduced LOS and cut in-hospital spending (by $282 per hospital visit), Medicare costs in the 30 days post-discharge were $332 higher than those followed up by primary care physicians. Patients discharged by hospitalists were less likely to be sent straight home and more likely to be admitted to a nursing home.

SHM President Joseph Li, MD, SFHM, associate professor of medicine at Harvard Medical School and director of the hospital medicine division at Beth Israel Deaconess Medical Center in Boston, says the data underscores the need for programs like SHM's Project BOOST, which helps hospitals improve discharge and reduce readmissions.

Dr. Li notes two limitations to the research. First, the patients reviewed were all from 2001-2006, long before the current healthcare debate surrounding cost containment and patient safety. Second, the review does not account for the quality of medical care.

“The study was done at a time which was early in the hospitalist movement,” Dr. Li says. “It’s fair to say at that point we weren’t talking as a field as much about trying to prevent unnecessary readmissions. ... When I look at this study, I think it’s an opportunity for hospitalists to think how we can improve on communications with post-discharge facilities. How we can improve transitions.”

An accompanying editorial agreed, noting that while hospitalists and outpatient care might be viewed in different silos, “patients regularly move back and forth across that divide.”

“It is important to better understand the association between hospitalist care and costs,” editorial co-author Lena Chen, MD, MS, Division of General Medicine, University of Michigan, writes in an email to The Hospitalist. “This paper takes a big step towards addressing this subject with a large study, and will hopefully spur additional related research. That would be a good thing for hospital medicine.”

A new report that suggests the lower costs and reduced length of stay (LOS) associated with hospitalist care of hospitalized Medicare beneficiaries is offset by higher costs post-discharge highlights progress and opportunities for hospitalists, SHM's president says.

The federally-funded study published Monday in Annals of Internal Medicine showed that while hospitalists clearly reduced LOS and cut in-hospital spending (by $282 per hospital visit), Medicare costs in the 30 days post-discharge were $332 higher than those followed up by primary care physicians. Patients discharged by hospitalists were less likely to be sent straight home and more likely to be admitted to a nursing home.

SHM President Joseph Li, MD, SFHM, associate professor of medicine at Harvard Medical School and director of the hospital medicine division at Beth Israel Deaconess Medical Center in Boston, says the data underscores the need for programs like SHM's Project BOOST, which helps hospitals improve discharge and reduce readmissions.

Dr. Li notes two limitations to the research. First, the patients reviewed were all from 2001-2006, long before the current healthcare debate surrounding cost containment and patient safety. Second, the review does not account for the quality of medical care.

“The study was done at a time which was early in the hospitalist movement,” Dr. Li says. “It’s fair to say at that point we weren’t talking as a field as much about trying to prevent unnecessary readmissions. ... When I look at this study, I think it’s an opportunity for hospitalists to think how we can improve on communications with post-discharge facilities. How we can improve transitions.”

An accompanying editorial agreed, noting that while hospitalists and outpatient care might be viewed in different silos, “patients regularly move back and forth across that divide.”

“It is important to better understand the association between hospitalist care and costs,” editorial co-author Lena Chen, MD, MS, Division of General Medicine, University of Michigan, writes in an email to The Hospitalist. “This paper takes a big step towards addressing this subject with a large study, and will hopefully spur additional related research. That would be a good thing for hospital medicine.”

A new report that suggests the lower costs and reduced length of stay (LOS) associated with hospitalist care of hospitalized Medicare beneficiaries is offset by higher costs post-discharge highlights progress and opportunities for hospitalists, SHM's president says.

The federally-funded study published Monday in Annals of Internal Medicine showed that while hospitalists clearly reduced LOS and cut in-hospital spending (by $282 per hospital visit), Medicare costs in the 30 days post-discharge were $332 higher than those followed up by primary care physicians. Patients discharged by hospitalists were less likely to be sent straight home and more likely to be admitted to a nursing home.

SHM President Joseph Li, MD, SFHM, associate professor of medicine at Harvard Medical School and director of the hospital medicine division at Beth Israel Deaconess Medical Center in Boston, says the data underscores the need for programs like SHM's Project BOOST, which helps hospitals improve discharge and reduce readmissions.

Dr. Li notes two limitations to the research. First, the patients reviewed were all from 2001-2006, long before the current healthcare debate surrounding cost containment and patient safety. Second, the review does not account for the quality of medical care.

“The study was done at a time which was early in the hospitalist movement,” Dr. Li says. “It’s fair to say at that point we weren’t talking as a field as much about trying to prevent unnecessary readmissions. ... When I look at this study, I think it’s an opportunity for hospitalists to think how we can improve on communications with post-discharge facilities. How we can improve transitions.”

An accompanying editorial agreed, noting that while hospitalists and outpatient care might be viewed in different silos, “patients regularly move back and forth across that divide.”

“It is important to better understand the association between hospitalist care and costs,” editorial co-author Lena Chen, MD, MS, Division of General Medicine, University of Michigan, writes in an email to The Hospitalist. “This paper takes a big step towards addressing this subject with a large study, and will hopefully spur additional related research. That would be a good thing for hospital medicine.”

Health organizations and providers experienced in providing care across multiple settings have until Aug. 19 to apply for a new accountable care organizations (ACO) program through the Centers for Medicare & Medicaid Services (CMS) that promises to offer a higher level of savings than that offered through a previous initiative.

“Hospital medicine groups in and of themselves won’t be applying for it,” says Ron Greeno, MD, MHM, chief medical officer of Brentwood, Tenn.-based Cogent HMG, and chair of SHM's Public Policy Committee. “But the groups that are looking to participate will have hospitalists working for them.”

The new program, tiled the Pioneer ACO Model, was created to offer potentially higher payments to providers and organizations who have already worked under contracts tied to shared savings or care coordination. A related model, the Medicare Shared Savings Program, does not require any previous experience with such contracts. The latter program has completed accepting public comments, but no application deadline has yet been set. (updated Aug. 15, 2011)

Just how many groups apply for the Pioneer program will be interesting: Initially, CMS will enter participation agreements with up to 30 organizations, and each must serve at least 15,000 beneficiaries (5,000 in rural areas). The capped cohort size didn’t seem to spur additional interest, as CMS originally set an application deadline for July, but pushed it back a month after providers questioned whether they were given enough time.

Still, Dr. Greeno, for one, is anxious to see the first round of applications. “It won’t interest me in terms of who jumps in,” he says. “The robustness of the response is what I’m interested in…It’s not going to do (CMS) any good to build a program nobody participates in.”

Health organizations and providers experienced in providing care across multiple settings have until Aug. 19 to apply for a new accountable care organizations (ACO) program through the Centers for Medicare & Medicaid Services (CMS) that promises to offer a higher level of savings than that offered through a previous initiative.

“Hospital medicine groups in and of themselves won’t be applying for it,” says Ron Greeno, MD, MHM, chief medical officer of Brentwood, Tenn.-based Cogent HMG, and chair of SHM's Public Policy Committee. “But the groups that are looking to participate will have hospitalists working for them.”

The new program, tiled the Pioneer ACO Model, was created to offer potentially higher payments to providers and organizations who have already worked under contracts tied to shared savings or care coordination. A related model, the Medicare Shared Savings Program, does not require any previous experience with such contracts. The latter program has completed accepting public comments, but no application deadline has yet been set. (updated Aug. 15, 2011)

Just how many groups apply for the Pioneer program will be interesting: Initially, CMS will enter participation agreements with up to 30 organizations, and each must serve at least 15,000 beneficiaries (5,000 in rural areas). The capped cohort size didn’t seem to spur additional interest, as CMS originally set an application deadline for July, but pushed it back a month after providers questioned whether they were given enough time.

Still, Dr. Greeno, for one, is anxious to see the first round of applications. “It won’t interest me in terms of who jumps in,” he says. “The robustness of the response is what I’m interested in…It’s not going to do (CMS) any good to build a program nobody participates in.”

Health organizations and providers experienced in providing care across multiple settings have until Aug. 19 to apply for a new accountable care organizations (ACO) program through the Centers for Medicare & Medicaid Services (CMS) that promises to offer a higher level of savings than that offered through a previous initiative.

“Hospital medicine groups in and of themselves won’t be applying for it,” says Ron Greeno, MD, MHM, chief medical officer of Brentwood, Tenn.-based Cogent HMG, and chair of SHM's Public Policy Committee. “But the groups that are looking to participate will have hospitalists working for them.”

The new program, tiled the Pioneer ACO Model, was created to offer potentially higher payments to providers and organizations who have already worked under contracts tied to shared savings or care coordination. A related model, the Medicare Shared Savings Program, does not require any previous experience with such contracts. The latter program has completed accepting public comments, but no application deadline has yet been set. (updated Aug. 15, 2011)

Just how many groups apply for the Pioneer program will be interesting: Initially, CMS will enter participation agreements with up to 30 organizations, and each must serve at least 15,000 beneficiaries (5,000 in rural areas). The capped cohort size didn’t seem to spur additional interest, as CMS originally set an application deadline for July, but pushed it back a month after providers questioned whether they were given enough time.

Still, Dr. Greeno, for one, is anxious to see the first round of applications. “It won’t interest me in terms of who jumps in,” he says. “The robustness of the response is what I’m interested in…It’s not going to do (CMS) any good to build a program nobody participates in.”

AMSTERDAM – Video-assisted thoracoscopic surgery worked as well as open lobectomy for 5-year survival in early-stage lung cancer, based on a secondary analysis of nonrandomized patients who underwent surgery as part of a multicenter trial.

"These data demonstrate that VATS, when properly done, can achieve long-term survival that is similar to open lobectomy," Dr. Walter J. Scott said at the World Conference on Lung Cancer. He stressed that study included only patients with early-stage lung cancer that was either node negative or had nonhilar N1 disease, and hence the finding is specific for only these patients. Until now, questions existed about the oncologic efficacy of VATS, noted Dr. Scott, chief of the division of thoracic surgery at Fox Chase Cancer Center in Philadelphia.But "VATS lobectomy provides comparable oncologic outcomes" for this group of patients, he said.

His analysis used data collected from 964 lung cancer patients who participated in a multicenter study during 1999-2004 that compared two different strategies for lymph node assessment in early-stage lung cancer (Ann. Thorac. Surg. 2006;81:1013-20). Although most surgeons did not perform VATS during this time, a few surgeons did, and 5-year outcome results were available for 66 patients in the study underwent VATS. Five-year data also existed for 898 of the patients who underwent open lobectomy.

To adjust for baseline differences among the patients, Dr. Scott and his associates ran a propensity score analysis that took into account age, sex, performance status, tumor histology, location, and tumor size and invasion. The analysis excluded about a fifth of the open lobectomy patients because their propensity scores fell outside the range of the VATS patients, so the final survival comparison included 66 VATS and 686 open lobectomy patients.

With propensity adjustment, the results showed no significant differences between the VATS and open lobectomy patients in their 5-year rates of overall survival, disease-free survival, local disease-free survival, or freedom from new primary tumors (see table), Dr. Scott reported at the meeting, which was sponsored by the International Association for the Study of Lung Cancer.

Dr. Scott said that he is a shareholder in Biogen Idec, Celgene, and Johnson & Johnson.

AMSTERDAM – Video-assisted thoracoscopic surgery worked as well as open lobectomy for 5-year survival in early-stage lung cancer, based on a secondary analysis of nonrandomized patients who underwent surgery as part of a multicenter trial.

"These data demonstrate that VATS, when properly done, can achieve long-term survival that is similar to open lobectomy," Dr. Walter J. Scott said at the World Conference on Lung Cancer. He stressed that study included only patients with early-stage lung cancer that was either node negative or had nonhilar N1 disease, and hence the finding is specific for only these patients. Until now, questions existed about the oncologic efficacy of VATS, noted Dr. Scott, chief of the division of thoracic surgery at Fox Chase Cancer Center in Philadelphia.But "VATS lobectomy provides comparable oncologic outcomes" for this group of patients, he said.

His analysis used data collected from 964 lung cancer patients who participated in a multicenter study during 1999-2004 that compared two different strategies for lymph node assessment in early-stage lung cancer (Ann. Thorac. Surg. 2006;81:1013-20). Although most surgeons did not perform VATS during this time, a few surgeons did, and 5-year outcome results were available for 66 patients in the study underwent VATS. Five-year data also existed for 898 of the patients who underwent open lobectomy.

To adjust for baseline differences among the patients, Dr. Scott and his associates ran a propensity score analysis that took into account age, sex, performance status, tumor histology, location, and tumor size and invasion. The analysis excluded about a fifth of the open lobectomy patients because their propensity scores fell outside the range of the VATS patients, so the final survival comparison included 66 VATS and 686 open lobectomy patients.

With propensity adjustment, the results showed no significant differences between the VATS and open lobectomy patients in their 5-year rates of overall survival, disease-free survival, local disease-free survival, or freedom from new primary tumors (see table), Dr. Scott reported at the meeting, which was sponsored by the International Association for the Study of Lung Cancer.

Dr. Scott said that he is a shareholder in Biogen Idec, Celgene, and Johnson & Johnson.

AMSTERDAM – Video-assisted thoracoscopic surgery worked as well as open lobectomy for 5-year survival in early-stage lung cancer, based on a secondary analysis of nonrandomized patients who underwent surgery as part of a multicenter trial.

"These data demonstrate that VATS, when properly done, can achieve long-term survival that is similar to open lobectomy," Dr. Walter J. Scott said at the World Conference on Lung Cancer. He stressed that study included only patients with early-stage lung cancer that was either node negative or had nonhilar N1 disease, and hence the finding is specific for only these patients. Until now, questions existed about the oncologic efficacy of VATS, noted Dr. Scott, chief of the division of thoracic surgery at Fox Chase Cancer Center in Philadelphia.But "VATS lobectomy provides comparable oncologic outcomes" for this group of patients, he said.

His analysis used data collected from 964 lung cancer patients who participated in a multicenter study during 1999-2004 that compared two different strategies for lymph node assessment in early-stage lung cancer (Ann. Thorac. Surg. 2006;81:1013-20). Although most surgeons did not perform VATS during this time, a few surgeons did, and 5-year outcome results were available for 66 patients in the study underwent VATS. Five-year data also existed for 898 of the patients who underwent open lobectomy.

To adjust for baseline differences among the patients, Dr. Scott and his associates ran a propensity score analysis that took into account age, sex, performance status, tumor histology, location, and tumor size and invasion. The analysis excluded about a fifth of the open lobectomy patients because their propensity scores fell outside the range of the VATS patients, so the final survival comparison included 66 VATS and 686 open lobectomy patients.

With propensity adjustment, the results showed no significant differences between the VATS and open lobectomy patients in their 5-year rates of overall survival, disease-free survival, local disease-free survival, or freedom from new primary tumors (see table), Dr. Scott reported at the meeting, which was sponsored by the International Association for the Study of Lung Cancer.

Dr. Scott said that he is a shareholder in Biogen Idec, Celgene, and Johnson & Johnson.

John Krisa, MD, medical director of the hospitalist group at Albany Memorial Hospital in New York, pictures his HM group as an organic whole when he draws up the schedule. He tries to avoid a strict 50-50 parceling out of night and day shifts. The hospitalist group makes liberal use of per-diem hospitalists and moonlighters, and has a few nocturnists.

“The vast majority of the work at night is processing new admissions, so these tend to be single encounters. You want your full-time people there multiple consecutive days for continuity and to represent the face of your program,” he says.

But for the required, ’round-the-clock coverage, he and other group members are expected to pull their share of nights as well. “I was always more of a nighttime person, in terms of my body clock,” Dr. Krisa says, “but now that I have more daytime nonclinical duties [as regional site director for Cogent HMG], it’s been more of a challenge to juggle home responsibilities, night shifts, and multiple administrative meetings.”

There are some basic principles of sleep hygiene and lessons learned from industrial settings that are good to keep in mind, says Christopher P. Landrigan, MD, SFHM, MPH, associate professor of medicine and pediatrics at Harvard Medical School and director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital in Boston. “It’s really incumbent upon hospitalist group leaders to recognize the hazards of scheduling people for too many nights in a row, which conveys a risk both to the patients and to the hospitalists themselves,” Dr. Landrigan says. “We know that if hospitalists are driving home after night shifts, particularly multiple night shifts, that they’re at risk for motor vehicle crashes and at risk of sticking themselves with needles and scalpels toward the tail end of their shifts. None of us want that.”

Dr. Landrigan advises hospitalist groups to be cognizant of the hazards and think about the schedule “proactively.”

John Krisa, MD, medical director of the hospitalist group at Albany Memorial Hospital in New York, pictures his HM group as an organic whole when he draws up the schedule. He tries to avoid a strict 50-50 parceling out of night and day shifts. The hospitalist group makes liberal use of per-diem hospitalists and moonlighters, and has a few nocturnists.

“The vast majority of the work at night is processing new admissions, so these tend to be single encounters. You want your full-time people there multiple consecutive days for continuity and to represent the face of your program,” he says.

But for the required, ’round-the-clock coverage, he and other group members are expected to pull their share of nights as well. “I was always more of a nighttime person, in terms of my body clock,” Dr. Krisa says, “but now that I have more daytime nonclinical duties [as regional site director for Cogent HMG], it’s been more of a challenge to juggle home responsibilities, night shifts, and multiple administrative meetings.”

There are some basic principles of sleep hygiene and lessons learned from industrial settings that are good to keep in mind, says Christopher P. Landrigan, MD, SFHM, MPH, associate professor of medicine and pediatrics at Harvard Medical School and director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital in Boston. “It’s really incumbent upon hospitalist group leaders to recognize the hazards of scheduling people for too many nights in a row, which conveys a risk both to the patients and to the hospitalists themselves,” Dr. Landrigan says. “We know that if hospitalists are driving home after night shifts, particularly multiple night shifts, that they’re at risk for motor vehicle crashes and at risk of sticking themselves with needles and scalpels toward the tail end of their shifts. None of us want that.”

Dr. Landrigan advises hospitalist groups to be cognizant of the hazards and think about the schedule “proactively.”

John Krisa, MD, medical director of the hospitalist group at Albany Memorial Hospital in New York, pictures his HM group as an organic whole when he draws up the schedule. He tries to avoid a strict 50-50 parceling out of night and day shifts. The hospitalist group makes liberal use of per-diem hospitalists and moonlighters, and has a few nocturnists.

“The vast majority of the work at night is processing new admissions, so these tend to be single encounters. You want your full-time people there multiple consecutive days for continuity and to represent the face of your program,” he says.

But for the required, ’round-the-clock coverage, he and other group members are expected to pull their share of nights as well. “I was always more of a nighttime person, in terms of my body clock,” Dr. Krisa says, “but now that I have more daytime nonclinical duties [as regional site director for Cogent HMG], it’s been more of a challenge to juggle home responsibilities, night shifts, and multiple administrative meetings.”

There are some basic principles of sleep hygiene and lessons learned from industrial settings that are good to keep in mind, says Christopher P. Landrigan, MD, SFHM, MPH, associate professor of medicine and pediatrics at Harvard Medical School and director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital in Boston. “It’s really incumbent upon hospitalist group leaders to recognize the hazards of scheduling people for too many nights in a row, which conveys a risk both to the patients and to the hospitalists themselves,” Dr. Landrigan says. “We know that if hospitalists are driving home after night shifts, particularly multiple night shifts, that they’re at risk for motor vehicle crashes and at risk of sticking themselves with needles and scalpels toward the tail end of their shifts. None of us want that.”

Dr. Landrigan advises hospitalist groups to be cognizant of the hazards and think about the schedule “proactively.”

Increased handoffs are often viewed as a byproduct of the growth in hospital medicine, with heightened scrutiny on the quality of communication that accompanies these transfers of care. As research suggests, though, finding and fixing the weak links can require persistence.

A study led by Siddhartha Singh, MD, MS, associate chief medical officer of Medical College Physicians, the adult practice for Medical College of Wisconsin in Milwaukee, compared a traditional, resident-based model of care to one involving a hospitalist-physician assistant team. Initially, his study found a 6% higher length of stay (LOS) for the hospitalist-physician assistant teams, with no differences in costs or readmission rates.1

But when the researchers pored over their results, they discovered that the increased LOS was limited to patients admitted overnight. Those patients, Dr. Singh says, were admitted by other providers—a night-float resident or faculty hospitalist—and then transferred to the hospitalist-physician assistant teams when they arrived in the morning. These “overflow patients” also were admitted only during busy periods, when limits on the number of admissions by house staff required other arrangements.

To make a direct comparison, Dr. Singh focused on a window from 11 a.m. to 4 p.m., when patients would have an equal probability of being admitted by a resident team or a hospitalist-physician assistant team. From a pool of about 3,000 admitted patients, the study found no significant difference in LOS, cost, readmission rates, or mortality. Instead of highlighting significant differences in models of care, then, Dr. Singh says, his study highlighted a potential weak link in the “treacherous” overnight-to-morning handoffs during busy periods that should be addressed.

“There have been a lot of studies implicating poor communication as a cause of patient-safety issues,” notes Sunil Kripalani, MD, MSc, FHM, chief of the section of hospital medicine and an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. But fewer studies, he says, have shown how to effectively improve communication in a way that improves patient safety.

One focal point is the often incomplete and inadequate nature of discharge summaries. Several models are emerging on how to build a better discharge summary, Dr. Kripalani says, with researchers offering solid recommendations (as multiple presentations at SHM’s annual meeting suggest). The trick is ensuring that those plans can be implemented into practice on a consistent and timely basis.

Dr. Kripalani says at least one straightforward strategy might help improve handoffs, however: building time into the schedule for them, such as 15-minute overlaps between shifts.—BN

Increased handoffs are often viewed as a byproduct of the growth in hospital medicine, with heightened scrutiny on the quality of communication that accompanies these transfers of care. As research suggests, though, finding and fixing the weak links can require persistence.

A study led by Siddhartha Singh, MD, MS, associate chief medical officer of Medical College Physicians, the adult practice for Medical College of Wisconsin in Milwaukee, compared a traditional, resident-based model of care to one involving a hospitalist-physician assistant team. Initially, his study found a 6% higher length of stay (LOS) for the hospitalist-physician assistant teams, with no differences in costs or readmission rates.1

But when the researchers pored over their results, they discovered that the increased LOS was limited to patients admitted overnight. Those patients, Dr. Singh says, were admitted by other providers—a night-float resident or faculty hospitalist—and then transferred to the hospitalist-physician assistant teams when they arrived in the morning. These “overflow patients” also were admitted only during busy periods, when limits on the number of admissions by house staff required other arrangements.

To make a direct comparison, Dr. Singh focused on a window from 11 a.m. to 4 p.m., when patients would have an equal probability of being admitted by a resident team or a hospitalist-physician assistant team. From a pool of about 3,000 admitted patients, the study found no significant difference in LOS, cost, readmission rates, or mortality. Instead of highlighting significant differences in models of care, then, Dr. Singh says, his study highlighted a potential weak link in the “treacherous” overnight-to-morning handoffs during busy periods that should be addressed.

“There have been a lot of studies implicating poor communication as a cause of patient-safety issues,” notes Sunil Kripalani, MD, MSc, FHM, chief of the section of hospital medicine and an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. But fewer studies, he says, have shown how to effectively improve communication in a way that improves patient safety.

One focal point is the often incomplete and inadequate nature of discharge summaries. Several models are emerging on how to build a better discharge summary, Dr. Kripalani says, with researchers offering solid recommendations (as multiple presentations at SHM’s annual meeting suggest). The trick is ensuring that those plans can be implemented into practice on a consistent and timely basis.

Dr. Kripalani says at least one straightforward strategy might help improve handoffs, however: building time into the schedule for them, such as 15-minute overlaps between shifts.—BN

Increased handoffs are often viewed as a byproduct of the growth in hospital medicine, with heightened scrutiny on the quality of communication that accompanies these transfers of care. As research suggests, though, finding and fixing the weak links can require persistence.

A study led by Siddhartha Singh, MD, MS, associate chief medical officer of Medical College Physicians, the adult practice for Medical College of Wisconsin in Milwaukee, compared a traditional, resident-based model of care to one involving a hospitalist-physician assistant team. Initially, his study found a 6% higher length of stay (LOS) for the hospitalist-physician assistant teams, with no differences in costs or readmission rates.1

But when the researchers pored over their results, they discovered that the increased LOS was limited to patients admitted overnight. Those patients, Dr. Singh says, were admitted by other providers—a night-float resident or faculty hospitalist—and then transferred to the hospitalist-physician assistant teams when they arrived in the morning. These “overflow patients” also were admitted only during busy periods, when limits on the number of admissions by house staff required other arrangements.

To make a direct comparison, Dr. Singh focused on a window from 11 a.m. to 4 p.m., when patients would have an equal probability of being admitted by a resident team or a hospitalist-physician assistant team. From a pool of about 3,000 admitted patients, the study found no significant difference in LOS, cost, readmission rates, or mortality. Instead of highlighting significant differences in models of care, then, Dr. Singh says, his study highlighted a potential weak link in the “treacherous” overnight-to-morning handoffs during busy periods that should be addressed.

“There have been a lot of studies implicating poor communication as a cause of patient-safety issues,” notes Sunil Kripalani, MD, MSc, FHM, chief of the section of hospital medicine and an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn. But fewer studies, he says, have shown how to effectively improve communication in a way that improves patient safety.

One focal point is the often incomplete and inadequate nature of discharge summaries. Several models are emerging on how to build a better discharge summary, Dr. Kripalani says, with researchers offering solid recommendations (as multiple presentations at SHM’s annual meeting suggest). The trick is ensuring that those plans can be implemented into practice on a consistent and timely basis.

Dr. Kripalani says at least one straightforward strategy might help improve handoffs, however: building time into the schedule for them, such as 15-minute overlaps between shifts.—BN