Jan Dyer

The only 2 medicines currently approved for young people with type 2 diabetes—long-acting insulin and metformin—do not slow the progression of diabetes in young people, according to a study funded in part by the National Institute of Diabetes and Digestive and Kidney Diseases.

A substudy of the Restoring Insulin Secretion (RISE) study, the RISE Pediatric Medication Study looked at the effects of insulin and metformin in 91 patients aged 10 to 19 years. The participants were randomly assigned to 1 of 2 treatment groups. The first received 3 months of glargine, a long-acting insulin, followed by 9 months of metformin. The second group received only metformin for 12 months. The participants were followed for 3 more months after treatment ended. The pediatric study found that beta-cell function declined in both groups during treatment and worsened after treatment ended.

Researchers also compared the pediatric participants with their adult counterparts in 2 other RISE trials and found the young people had more insulin resistance and other signs of disease progression at the same stage in the disease. Moreover, at baseline, the younger patients responded to the severe insulin resistance with a greater insulin response than did the adults, which the researchers say may be a reason for their more rapid loss of beta-cell function.

However, the study also found modest improvement in blood glucose with metformin in both groups. But metformin alone is not a long-term solution for many youth, said Dr. Kristen Nadeau, principal investigator for the pediatric study. Their findings underscore the “urgent and growing need,” she says, for more options.

The only 2 medicines currently approved for young people with type 2 diabetes—long-acting insulin and metformin—do not slow the progression of diabetes in young people, according to a study funded in part by the National Institute of Diabetes and Digestive and Kidney Diseases.

A substudy of the Restoring Insulin Secretion (RISE) study, the RISE Pediatric Medication Study looked at the effects of insulin and metformin in 91 patients aged 10 to 19 years. The participants were randomly assigned to 1 of 2 treatment groups. The first received 3 months of glargine, a long-acting insulin, followed by 9 months of metformin. The second group received only metformin for 12 months. The participants were followed for 3 more months after treatment ended. The pediatric study found that beta-cell function declined in both groups during treatment and worsened after treatment ended.

Researchers also compared the pediatric participants with their adult counterparts in 2 other RISE trials and found the young people had more insulin resistance and other signs of disease progression at the same stage in the disease. Moreover, at baseline, the younger patients responded to the severe insulin resistance with a greater insulin response than did the adults, which the researchers say may be a reason for their more rapid loss of beta-cell function.

However, the study also found modest improvement in blood glucose with metformin in both groups. But metformin alone is not a long-term solution for many youth, said Dr. Kristen Nadeau, principal investigator for the pediatric study. Their findings underscore the “urgent and growing need,” she says, for more options.

The only 2 medicines currently approved for young people with type 2 diabetes—long-acting insulin and metformin—do not slow the progression of diabetes in young people, according to a study funded in part by the National Institute of Diabetes and Digestive and Kidney Diseases.

A substudy of the Restoring Insulin Secretion (RISE) study, the RISE Pediatric Medication Study looked at the effects of insulin and metformin in 91 patients aged 10 to 19 years. The participants were randomly assigned to 1 of 2 treatment groups. The first received 3 months of glargine, a long-acting insulin, followed by 9 months of metformin. The second group received only metformin for 12 months. The participants were followed for 3 more months after treatment ended. The pediatric study found that beta-cell function declined in both groups during treatment and worsened after treatment ended.

Researchers also compared the pediatric participants with their adult counterparts in 2 other RISE trials and found the young people had more insulin resistance and other signs of disease progression at the same stage in the disease. Moreover, at baseline, the younger patients responded to the severe insulin resistance with a greater insulin response than did the adults, which the researchers say may be a reason for their more rapid loss of beta-cell function.

However, the study also found modest improvement in blood glucose with metformin in both groups. But metformin alone is not a long-term solution for many youth, said Dr. Kristen Nadeau, principal investigator for the pediatric study. Their findings underscore the “urgent and growing need,” she says, for more options.

Many patients with primary central nervous system lymphoma (PCNSL) experience rapid, aggressive progression of CNS malignancy. It is “accepted,” say researchers from Chonnam National University Hwasun Hospital in the Republic of Korea, that salvage therapy is beneficial and significantly improves survival in comparison to palliative care, but therapy options remain limited—mainly because few trials have been done. Several case reports have suggested that bendamustine has modest clinical activity against relapsed PCNSL, the researchers note, but its effect as part of combination salvage therapy in these patients has not been established. The study offers some validation of previous findings and new information about the benefits of a bendamustine-based combination regimen.

The researchers enrolled 10 patients, of whom 7 had refractory disease. All had previously been on high-dose methotrexate. Of the 3 relapsed patients, 1 entered the study at second relapse. The patients received either R-B(O)AD or R-BAD (rituximab, vincristine, bendamustine, cytarabine, dexamethasone) every 4 weeks for up to 4 cycles. Vincristine was omitted in 4 regimens, and dosages of bendamustine and cytarabine were reduced for 4 patients who were over 70.

The overall response rate for R-B(O)AD was 50%. One patient achieved complete response and 4 achieved partial response. The researchers observed “remarkable effects” on imaging in patients who responded. They attribute the activity to the anticipated synergy of bendamustine combined with cytarabine—even though disease in the majority of the patients had progressed despite previous treatment with cytarabine.

However, the synergistic effects also led to significant marrow depression; hematologic toxicity with R-B(O)AD was “considerable,” with grade 3 or 4 neutropenia and thrombocytopenia seen in more than 85% of treatment cycles. Moreover, 3 patients developed severe infection, all with involvement of the lungs. The researchers therefore amended the study protocol to reduce cytarabine dosage. While the toxicity is significant, the researchers say, it is manageable with the dose reduction and supportive care.

Bendamustine cerebrospinal fluid levels were minimal, but corresponded to plasma exposure and response to treatment in deep tumor locations.

Although the study is small, it supports the use of the bendamustine-based regimen as an effective salvage option, the researchers conclude, especially for patients who are no longer responding to methotrexate or have developed cumulative renal or neurotoxicity from treatment.

Source:
Kim T, Choi HY, Lee HS, et al. BMC Cancer. 2018;18(1):729

Many patients with primary central nervous system lymphoma (PCNSL) experience rapid, aggressive progression of CNS malignancy. It is “accepted,” say researchers from Chonnam National University Hwasun Hospital in the Republic of Korea, that salvage therapy is beneficial and significantly improves survival in comparison to palliative care, but therapy options remain limited—mainly because few trials have been done. Several case reports have suggested that bendamustine has modest clinical activity against relapsed PCNSL, the researchers note, but its effect as part of combination salvage therapy in these patients has not been established. The study offers some validation of previous findings and new information about the benefits of a bendamustine-based combination regimen.

The researchers enrolled 10 patients, of whom 7 had refractory disease. All had previously been on high-dose methotrexate. Of the 3 relapsed patients, 1 entered the study at second relapse. The patients received either R-B(O)AD or R-BAD (rituximab, vincristine, bendamustine, cytarabine, dexamethasone) every 4 weeks for up to 4 cycles. Vincristine was omitted in 4 regimens, and dosages of bendamustine and cytarabine were reduced for 4 patients who were over 70.

The overall response rate for R-B(O)AD was 50%. One patient achieved complete response and 4 achieved partial response. The researchers observed “remarkable effects” on imaging in patients who responded. They attribute the activity to the anticipated synergy of bendamustine combined with cytarabine—even though disease in the majority of the patients had progressed despite previous treatment with cytarabine.

However, the synergistic effects also led to significant marrow depression; hematologic toxicity with R-B(O)AD was “considerable,” with grade 3 or 4 neutropenia and thrombocytopenia seen in more than 85% of treatment cycles. Moreover, 3 patients developed severe infection, all with involvement of the lungs. The researchers therefore amended the study protocol to reduce cytarabine dosage. While the toxicity is significant, the researchers say, it is manageable with the dose reduction and supportive care.

Bendamustine cerebrospinal fluid levels were minimal, but corresponded to plasma exposure and response to treatment in deep tumor locations.

Although the study is small, it supports the use of the bendamustine-based regimen as an effective salvage option, the researchers conclude, especially for patients who are no longer responding to methotrexate or have developed cumulative renal or neurotoxicity from treatment.

Source:
Kim T, Choi HY, Lee HS, et al. BMC Cancer. 2018;18(1):729

Many patients with primary central nervous system lymphoma (PCNSL) experience rapid, aggressive progression of CNS malignancy. It is “accepted,” say researchers from Chonnam National University Hwasun Hospital in the Republic of Korea, that salvage therapy is beneficial and significantly improves survival in comparison to palliative care, but therapy options remain limited—mainly because few trials have been done. Several case reports have suggested that bendamustine has modest clinical activity against relapsed PCNSL, the researchers note, but its effect as part of combination salvage therapy in these patients has not been established. The study offers some validation of previous findings and new information about the benefits of a bendamustine-based combination regimen.

The researchers enrolled 10 patients, of whom 7 had refractory disease. All had previously been on high-dose methotrexate. Of the 3 relapsed patients, 1 entered the study at second relapse. The patients received either R-B(O)AD or R-BAD (rituximab, vincristine, bendamustine, cytarabine, dexamethasone) every 4 weeks for up to 4 cycles. Vincristine was omitted in 4 regimens, and dosages of bendamustine and cytarabine were reduced for 4 patients who were over 70.

The overall response rate for R-B(O)AD was 50%. One patient achieved complete response and 4 achieved partial response. The researchers observed “remarkable effects” on imaging in patients who responded. They attribute the activity to the anticipated synergy of bendamustine combined with cytarabine—even though disease in the majority of the patients had progressed despite previous treatment with cytarabine.

However, the synergistic effects also led to significant marrow depression; hematologic toxicity with R-B(O)AD was “considerable,” with grade 3 or 4 neutropenia and thrombocytopenia seen in more than 85% of treatment cycles. Moreover, 3 patients developed severe infection, all with involvement of the lungs. The researchers therefore amended the study protocol to reduce cytarabine dosage. While the toxicity is significant, the researchers say, it is manageable with the dose reduction and supportive care.

Bendamustine cerebrospinal fluid levels were minimal, but corresponded to plasma exposure and response to treatment in deep tumor locations.

Although the study is small, it supports the use of the bendamustine-based regimen as an effective salvage option, the researchers conclude, especially for patients who are no longer responding to methotrexate or have developed cumulative renal or neurotoxicity from treatment.

Source:
Kim T, Choi HY, Lee HS, et al. BMC Cancer. 2018;18(1):729

Indian Health Service (IHS) is taking applications for students to “take part in enriching projects to further the IHS mission of raising the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.” The twist? The students can do it remotely.

The IHS is a new partner with the Virtual Federal Service, the largest virtual internship program in the world, making it the 31st federal agency to participate. Other agencies include the Peace Corps and The National Aeronautics and Space Administration.

The “einterns” spend 10 hours a week from September through May working remotely. The work is unpaid, although they may get course credit. For some, it is the first time they have worked on issues affecting Native people. Those projects have included producing bilingual Navajo and English videos for rural health clinics, developing Navajo-specific health education materials on palliative care, creating a sexual assault locator map, and creating social media strategies and campaigns for health promotion.

IHS welcomed more than 15 interns, both undergraduates and graduate students, for the 2017-2018 academic year.

Indian Health Service (IHS) is taking applications for students to “take part in enriching projects to further the IHS mission of raising the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.” The twist? The students can do it remotely.

The IHS is a new partner with the Virtual Federal Service, the largest virtual internship program in the world, making it the 31st federal agency to participate. Other agencies include the Peace Corps and The National Aeronautics and Space Administration.

The “einterns” spend 10 hours a week from September through May working remotely. The work is unpaid, although they may get course credit. For some, it is the first time they have worked on issues affecting Native people. Those projects have included producing bilingual Navajo and English videos for rural health clinics, developing Navajo-specific health education materials on palliative care, creating a sexual assault locator map, and creating social media strategies and campaigns for health promotion.

IHS welcomed more than 15 interns, both undergraduates and graduate students, for the 2017-2018 academic year.

Indian Health Service (IHS) is taking applications for students to “take part in enriching projects to further the IHS mission of raising the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.” The twist? The students can do it remotely.

The IHS is a new partner with the Virtual Federal Service, the largest virtual internship program in the world, making it the 31st federal agency to participate. Other agencies include the Peace Corps and The National Aeronautics and Space Administration.

The “einterns” spend 10 hours a week from September through May working remotely. The work is unpaid, although they may get course credit. For some, it is the first time they have worked on issues affecting Native people. Those projects have included producing bilingual Navajo and English videos for rural health clinics, developing Navajo-specific health education materials on palliative care, creating a sexual assault locator map, and creating social media strategies and campaigns for health promotion.

IHS welcomed more than 15 interns, both undergraduates and graduate students, for the 2017-2018 academic year.

The rupture rate for breast implants is about 10% at 10 years after insertion. That means women aged ≥ 70 years have a greater risk of rupture. For women who had breast augmentation or reconstruction before the advent of fifth-generation implants, there are no specific recommendations regarding follow-up and very little guidance in the literature about management for those who have had implants after radiation, say clinicians from Mayo Clinic.

They report on a 74-year-old patient who was treated for breast cancer in 1987 and 1988. She underwent lumpectomy, adjuvant unilateral radiation, a right simple mastectomy, left modified radical mastectomy, and implant-based reconstruction. Nearly 30 years later, she felt an asymmetry in 1 breast. Magnetic resonance imaging and ultrasound revealed that both implants had ruptured.

It is well known, the clinicians say, that complications of postmastectomy radiotherapy include capsular contracture, infection, and loss of prosthesis in implant-based reconstruction. Studies have shown that fibrosis, a hallmark of chronic radiation therapy, can show up even several years after radiotherapy—underscoring the importance of long-term follow-up for these patients. Moreover, the fact that the consequences of silicone on irradiated mastectomy flaps is unknown posed a further challenge.

While the cause of their patient’s implant rupture is unknown, the clinicians say it is “very likely” that delayed-onset fibrosis and capsular contracture secondary to radiation played a role. Such complications, though rare, should be kept in mind, the clinicians advise, when evaluating patients who had radiation and implants.

Source:

Molinar VE, Sabbagh MD, Manrique OJ. BMJ Case Rep. 2018; pii: bcr-2018-224578.
doi: 10.1136/bcr-2018-224578.

The rupture rate for breast implants is about 10% at 10 years after insertion. That means women aged ≥ 70 years have a greater risk of rupture. For women who had breast augmentation or reconstruction before the advent of fifth-generation implants, there are no specific recommendations regarding follow-up and very little guidance in the literature about management for those who have had implants after radiation, say clinicians from Mayo Clinic.

They report on a 74-year-old patient who was treated for breast cancer in 1987 and 1988. She underwent lumpectomy, adjuvant unilateral radiation, a right simple mastectomy, left modified radical mastectomy, and implant-based reconstruction. Nearly 30 years later, she felt an asymmetry in 1 breast. Magnetic resonance imaging and ultrasound revealed that both implants had ruptured.

It is well known, the clinicians say, that complications of postmastectomy radiotherapy include capsular contracture, infection, and loss of prosthesis in implant-based reconstruction. Studies have shown that fibrosis, a hallmark of chronic radiation therapy, can show up even several years after radiotherapy—underscoring the importance of long-term follow-up for these patients. Moreover, the fact that the consequences of silicone on irradiated mastectomy flaps is unknown posed a further challenge.

While the cause of their patient’s implant rupture is unknown, the clinicians say it is “very likely” that delayed-onset fibrosis and capsular contracture secondary to radiation played a role. Such complications, though rare, should be kept in mind, the clinicians advise, when evaluating patients who had radiation and implants.

Source:

Molinar VE, Sabbagh MD, Manrique OJ. BMJ Case Rep. 2018; pii: bcr-2018-224578.
doi: 10.1136/bcr-2018-224578.

The rupture rate for breast implants is about 10% at 10 years after insertion. That means women aged ≥ 70 years have a greater risk of rupture. For women who had breast augmentation or reconstruction before the advent of fifth-generation implants, there are no specific recommendations regarding follow-up and very little guidance in the literature about management for those who have had implants after radiation, say clinicians from Mayo Clinic.

They report on a 74-year-old patient who was treated for breast cancer in 1987 and 1988. She underwent lumpectomy, adjuvant unilateral radiation, a right simple mastectomy, left modified radical mastectomy, and implant-based reconstruction. Nearly 30 years later, she felt an asymmetry in 1 breast. Magnetic resonance imaging and ultrasound revealed that both implants had ruptured.

It is well known, the clinicians say, that complications of postmastectomy radiotherapy include capsular contracture, infection, and loss of prosthesis in implant-based reconstruction. Studies have shown that fibrosis, a hallmark of chronic radiation therapy, can show up even several years after radiotherapy—underscoring the importance of long-term follow-up for these patients. Moreover, the fact that the consequences of silicone on irradiated mastectomy flaps is unknown posed a further challenge.

While the cause of their patient’s implant rupture is unknown, the clinicians say it is “very likely” that delayed-onset fibrosis and capsular contracture secondary to radiation played a role. Such complications, though rare, should be kept in mind, the clinicians advise, when evaluating patients who had radiation and implants.

Source:

Molinar VE, Sabbagh MD, Manrique OJ. BMJ Case Rep. 2018; pii: bcr-2018-224578.
doi: 10.1136/bcr-2018-224578.

Despite “compelling evidence” that medication-assisted treatment (MAT) can help people recover from opioid addiction, methadone, buprenorphine, and naltrexone are woefully underused. A study cofunded by the National Institute on Drug Abuse (NIDA) found that following an overdose, less than one-third of patients were provided any medication for opioid use disorder (OUD).

“A great part of the tragedy of this opioid crisis is that…we now possess effective treatment strategies that could address it and save many lives, yet tens of thousands of people die each year because they have not received these treatments,” said Dr. Nora Volkow, director of NIDA.

The researchers analyzed data from 17,568 adults in Massachusetts who survived an opioid overdose between 2012 and 2014. Opioid overdose deaths declined by 59% among patients who received methadone and 38% for those who received buprenorphine over the 12 months of follow-up, compared with patients who did not receive treatment.

Another disturbing study finding: 34% of people who had an overdose were nonetheless given ≥ 1 prescriptions for opioid painkillers over the next 12 months, and 26% were prescribed benzodiazepines.

Despite “compelling evidence” that medication-assisted treatment (MAT) can help people recover from opioid addiction, methadone, buprenorphine, and naltrexone are woefully underused. A study cofunded by the National Institute on Drug Abuse (NIDA) found that following an overdose, less than one-third of patients were provided any medication for opioid use disorder (OUD).

“A great part of the tragedy of this opioid crisis is that…we now possess effective treatment strategies that could address it and save many lives, yet tens of thousands of people die each year because they have not received these treatments,” said Dr. Nora Volkow, director of NIDA.

The researchers analyzed data from 17,568 adults in Massachusetts who survived an opioid overdose between 2012 and 2014. Opioid overdose deaths declined by 59% among patients who received methadone and 38% for those who received buprenorphine over the 12 months of follow-up, compared with patients who did not receive treatment.

Another disturbing study finding: 34% of people who had an overdose were nonetheless given ≥ 1 prescriptions for opioid painkillers over the next 12 months, and 26% were prescribed benzodiazepines.

Despite “compelling evidence” that medication-assisted treatment (MAT) can help people recover from opioid addiction, methadone, buprenorphine, and naltrexone are woefully underused. A study cofunded by the National Institute on Drug Abuse (NIDA) found that following an overdose, less than one-third of patients were provided any medication for opioid use disorder (OUD).

“A great part of the tragedy of this opioid crisis is that…we now possess effective treatment strategies that could address it and save many lives, yet tens of thousands of people die each year because they have not received these treatments,” said Dr. Nora Volkow, director of NIDA.

The researchers analyzed data from 17,568 adults in Massachusetts who survived an opioid overdose between 2012 and 2014. Opioid overdose deaths declined by 59% among patients who received methadone and 38% for those who received buprenorphine over the 12 months of follow-up, compared with patients who did not receive treatment.

Another disturbing study finding: 34% of people who had an overdose were nonetheless given ≥ 1 prescriptions for opioid painkillers over the next 12 months, and 26% were prescribed benzodiazepines.

Data from a VA report on its nursing homesshow that the VA’s 132 community living centers compare closely with 15,487 private-sector nursing homes even though the VA on average cares for sicker patients, with a higher proportion of conditions such as spinal cord injury, PTSD, and combat injury: 25.6% of VA nursing homes rated 5 stars (the highest rating), as did 28.7% of private-sector facilities.

The VA report notes that VA nursing homes do not refuse service to any eligible veteran. The fact that they often house residents with more complex medical needs than private-sector facilities will accept “makes achieving good quality ratings more challenging,” the VA says. VA nursing homes at times rate lower than private-sector facilities on specific metrics such as pain and type of treatment.

But the VA has a significantly lower percentage of 1-star (lowest rated) facilities. Moreover, 60 of the VA’s nursing homes improved their quality score in the past year. The report also says VA nursing homes have a higher staff-to-resident ratio than private-sector facilities, meaning residents in VA facilities get more direct attention

Data from a VA report on its nursing homesshow that the VA’s 132 community living centers compare closely with 15,487 private-sector nursing homes even though the VA on average cares for sicker patients, with a higher proportion of conditions such as spinal cord injury, PTSD, and combat injury: 25.6% of VA nursing homes rated 5 stars (the highest rating), as did 28.7% of private-sector facilities.

The VA report notes that VA nursing homes do not refuse service to any eligible veteran. The fact that they often house residents with more complex medical needs than private-sector facilities will accept “makes achieving good quality ratings more challenging,” the VA says. VA nursing homes at times rate lower than private-sector facilities on specific metrics such as pain and type of treatment.

But the VA has a significantly lower percentage of 1-star (lowest rated) facilities. Moreover, 60 of the VA’s nursing homes improved their quality score in the past year. The report also says VA nursing homes have a higher staff-to-resident ratio than private-sector facilities, meaning residents in VA facilities get more direct attention

Data from a VA report on its nursing homesshow that the VA’s 132 community living centers compare closely with 15,487 private-sector nursing homes even though the VA on average cares for sicker patients, with a higher proportion of conditions such as spinal cord injury, PTSD, and combat injury: 25.6% of VA nursing homes rated 5 stars (the highest rating), as did 28.7% of private-sector facilities.

The VA report notes that VA nursing homes do not refuse service to any eligible veteran. The fact that they often house residents with more complex medical needs than private-sector facilities will accept “makes achieving good quality ratings more challenging,” the VA says. VA nursing homes at times rate lower than private-sector facilities on specific metrics such as pain and type of treatment.

But the VA has a significantly lower percentage of 1-star (lowest rated) facilities. Moreover, 60 of the VA’s nursing homes improved their quality score in the past year. The report also says VA nursing homes have a higher staff-to-resident ratio than private-sector facilities, meaning residents in VA facilities get more direct attention

Physicians from Menoufia University and Cairo University in Egypt, and Al Hada Armed Forces Hospital in Saudi Arabia report on a patient who developed myelodysplasia with excess blasts 1 year after he started on the tumor necrosis factor-alpha blocker etanercept for psoriasis. The patient, a 76-year-old man, arrived at the emergency department (ED) with ecchymosis and recurrent epistaxis. He had a critically low platelet count, anemia, and normal leukocyte count. The reticulocyte index, serum ferritin, and folate levels indicated ineffective erythropoiesis. Bone marrow aspirate and biopsy confirmed a diagnosis of myelodysplastic syndrome.

The physicians stopped the etanercept and administered 2 cycles of azacitidine and folic acid supplementation, but the response was minima,l and the patient platelet count worsened. While waiting for the third cycle, the patient was readmitted to the ED with lower gastrointestinal bleeding, epistaxis, and shock. He died of cardiopulmonary arrest.

The physicians note that immune dysregulation and altered T-cell hemostasis are essential to the development of myelodysplastic syndrome. They also note that nonspecific activation and proliferation of T lymphocytes has been documented as promoting epidermal growth in genetically susceptible psoriasis patients.

Myelodysplastic syndrome has been associated with psoriasis in about 7% of cases, and researchers have found a higher incidence of leukemia and laryngeal cancer in families of psoriasis patients. There also have been reports of leukemia in psoriasis patients on systemic immunosuppressives. Etanercept has various hematologic adverse effects, including pancytopenia and aplastic anemia.

However, only 4 cases (including this one) have been reported of myelodysplastic syndrome in psoriasis patients. Taken together, the cases add to the growing evidence that suggests a link between myelodysplastic syndrome and etanercept treatment for psoriasis. Those patients, the physicians caution, should be considered at dual risk from treatment and disease. The physicians also recommend regular routine blood counts and discontinuing etanercept at onset of any cytopenias.

Source:
Dawoud NM, Ayoub OH, Essa ES, Dawoud DM. Indian J Dermatol Venereol Leprol. 2018;84(4):463-465.
doi: 10.4103/ijdvl.IJDVL_463_17

Physicians from Menoufia University and Cairo University in Egypt, and Al Hada Armed Forces Hospital in Saudi Arabia report on a patient who developed myelodysplasia with excess blasts 1 year after he started on the tumor necrosis factor-alpha blocker etanercept for psoriasis. The patient, a 76-year-old man, arrived at the emergency department (ED) with ecchymosis and recurrent epistaxis. He had a critically low platelet count, anemia, and normal leukocyte count. The reticulocyte index, serum ferritin, and folate levels indicated ineffective erythropoiesis. Bone marrow aspirate and biopsy confirmed a diagnosis of myelodysplastic syndrome.

The physicians stopped the etanercept and administered 2 cycles of azacitidine and folic acid supplementation, but the response was minima,l and the patient platelet count worsened. While waiting for the third cycle, the patient was readmitted to the ED with lower gastrointestinal bleeding, epistaxis, and shock. He died of cardiopulmonary arrest.

The physicians note that immune dysregulation and altered T-cell hemostasis are essential to the development of myelodysplastic syndrome. They also note that nonspecific activation and proliferation of T lymphocytes has been documented as promoting epidermal growth in genetically susceptible psoriasis patients.

Myelodysplastic syndrome has been associated with psoriasis in about 7% of cases, and researchers have found a higher incidence of leukemia and laryngeal cancer in families of psoriasis patients. There also have been reports of leukemia in psoriasis patients on systemic immunosuppressives. Etanercept has various hematologic adverse effects, including pancytopenia and aplastic anemia.

However, only 4 cases (including this one) have been reported of myelodysplastic syndrome in psoriasis patients. Taken together, the cases add to the growing evidence that suggests a link between myelodysplastic syndrome and etanercept treatment for psoriasis. Those patients, the physicians caution, should be considered at dual risk from treatment and disease. The physicians also recommend regular routine blood counts and discontinuing etanercept at onset of any cytopenias.

Source:
Dawoud NM, Ayoub OH, Essa ES, Dawoud DM. Indian J Dermatol Venereol Leprol. 2018;84(4):463-465.
doi: 10.4103/ijdvl.IJDVL_463_17

Physicians from Menoufia University and Cairo University in Egypt, and Al Hada Armed Forces Hospital in Saudi Arabia report on a patient who developed myelodysplasia with excess blasts 1 year after he started on the tumor necrosis factor-alpha blocker etanercept for psoriasis. The patient, a 76-year-old man, arrived at the emergency department (ED) with ecchymosis and recurrent epistaxis. He had a critically low platelet count, anemia, and normal leukocyte count. The reticulocyte index, serum ferritin, and folate levels indicated ineffective erythropoiesis. Bone marrow aspirate and biopsy confirmed a diagnosis of myelodysplastic syndrome.

The physicians stopped the etanercept and administered 2 cycles of azacitidine and folic acid supplementation, but the response was minima,l and the patient platelet count worsened. While waiting for the third cycle, the patient was readmitted to the ED with lower gastrointestinal bleeding, epistaxis, and shock. He died of cardiopulmonary arrest.

The physicians note that immune dysregulation and altered T-cell hemostasis are essential to the development of myelodysplastic syndrome. They also note that nonspecific activation and proliferation of T lymphocytes has been documented as promoting epidermal growth in genetically susceptible psoriasis patients.

Myelodysplastic syndrome has been associated with psoriasis in about 7% of cases, and researchers have found a higher incidence of leukemia and laryngeal cancer in families of psoriasis patients. There also have been reports of leukemia in psoriasis patients on systemic immunosuppressives. Etanercept has various hematologic adverse effects, including pancytopenia and aplastic anemia.

However, only 4 cases (including this one) have been reported of myelodysplastic syndrome in psoriasis patients. Taken together, the cases add to the growing evidence that suggests a link between myelodysplastic syndrome and etanercept treatment for psoriasis. Those patients, the physicians caution, should be considered at dual risk from treatment and disease. The physicians also recommend regular routine blood counts and discontinuing etanercept at onset of any cytopenias.

Source:
Dawoud NM, Ayoub OH, Essa ES, Dawoud DM. Indian J Dermatol Venereol Leprol. 2018;84(4):463-465.
doi: 10.4103/ijdvl.IJDVL_463_17

In the US, 36% of women and 29% of men have experienced rape, physical violence, or stalking by an intimate partner. Research suggests that veterans may be at greater risk for intimate partner violence than civilian counterparts, given the unique stressors posed by military life, such as military deployments that result in family separation, reintegration issues, and combat-related health issues, including PTSD and TBI. According to the VA’s Domestic Violence Task Force, the overall 12-month prevalence of inmate partner violence (IPV) perpetration among active duty service members was 22%, and victimization was 30%. 

To help address this problem, the VA launched the IPV Assistance Program in 2014 and has since established coordinators at more than 115 facilities. The program coordinators use resources from mental health, primary care, women’s health, veterans’ justice outreach, and employee occupational health and assistance programs. The program also offers intervention through VA and community partnerships that address housing, education, and employment needs.

The program takes a holistic approach, focusing on developing a culture of safety, the VA says, with the goal of understanding, recognizing and responding to the effects of all types of trauma, including physical, sexual, and psychological. “We are giving careful attention to this program,” says Acting VA Secretary Peter O’Rourke, “ensuring it is integrated into clinical care and workplace safety.”

In the US, 36% of women and 29% of men have experienced rape, physical violence, or stalking by an intimate partner. Research suggests that veterans may be at greater risk for intimate partner violence than civilian counterparts, given the unique stressors posed by military life, such as military deployments that result in family separation, reintegration issues, and combat-related health issues, including PTSD and TBI. According to the VA’s Domestic Violence Task Force, the overall 12-month prevalence of inmate partner violence (IPV) perpetration among active duty service members was 22%, and victimization was 30%. 

To help address this problem, the VA launched the IPV Assistance Program in 2014 and has since established coordinators at more than 115 facilities. The program coordinators use resources from mental health, primary care, women’s health, veterans’ justice outreach, and employee occupational health and assistance programs. The program also offers intervention through VA and community partnerships that address housing, education, and employment needs.

The program takes a holistic approach, focusing on developing a culture of safety, the VA says, with the goal of understanding, recognizing and responding to the effects of all types of trauma, including physical, sexual, and psychological. “We are giving careful attention to this program,” says Acting VA Secretary Peter O’Rourke, “ensuring it is integrated into clinical care and workplace safety.”

In the US, 36% of women and 29% of men have experienced rape, physical violence, or stalking by an intimate partner. Research suggests that veterans may be at greater risk for intimate partner violence than civilian counterparts, given the unique stressors posed by military life, such as military deployments that result in family separation, reintegration issues, and combat-related health issues, including PTSD and TBI. According to the VA’s Domestic Violence Task Force, the overall 12-month prevalence of inmate partner violence (IPV) perpetration among active duty service members was 22%, and victimization was 30%. 

To help address this problem, the VA launched the IPV Assistance Program in 2014 and has since established coordinators at more than 115 facilities. The program coordinators use resources from mental health, primary care, women’s health, veterans’ justice outreach, and employee occupational health and assistance programs. The program also offers intervention through VA and community partnerships that address housing, education, and employment needs.

The program takes a holistic approach, focusing on developing a culture of safety, the VA says, with the goal of understanding, recognizing and responding to the effects of all types of trauma, including physical, sexual, and psychological. “We are giving careful attention to this program,” says Acting VA Secretary Peter O’Rourke, “ensuring it is integrated into clinical care and workplace safety.”

When telemental health care (TMH) works, it works well, the research agrees. For rural patients who often do not have easy access to health care TMH can be a lifesaver. The VA uses TMH to deliver care to veterans in rural VA medical centers, community-based outpatient clinics, and residential areas.  However, TMH is still relatively new in many rural communities, say researchers from University of Mississippi in Oxford and Augusta University in Georgia, and few studies have examined the delivery tool from an administrative standpoint. The literature suggests TMH will save money—the exploratory study, however, suggests otherwise.

The researchers interviewed 6 providers selected from the 15 community mental health (MH) centers (CMHCs) in rural Mississippi as well as an independent MH counselor who develops policy for the Mississippi Counselors Association. They asked respondents about the feasibility of TMH in the Mississippi Delta; in particular, the benefits, the costs, and the role of the state in facilitating the service. The researchers also collected data from a grant-funded pilot project conducted in the Mississippi Delta region by the Delta Health Alliance, a nonprofit organization in partnership with the University of Mississippi Medical Center, which ran from 2008 to 2011. Telepsychiatry sessions are not currently being used in the region, but before the project ended, it was responsible for > 1,000 videoconferencing clinical sessions.

The initial counseling sessions were “awkward” for some patients, the interviewees said, and some clients felt the consultation was “less personal.” Getting used to the technology may take some time. Once clients acclimated the feedback was positive.

The health care providers were concerned by not being able to observe in-person nonverbal clues, such as poor hygiene, that would normally help them evaluate the client’s health. The nurse at the CMHC helped fill a gap, the researchers say, created by technology.

The researchers determined that the benefit side was weighty: For instance, patients had better access to well-trained MH professionals and to the state hospital, and family could visit inpatients via videoconferencing. Staff had better access to professional development and training.

However, cost issues were a definite concern. The project would not have been feasible without grant funding, the researchers say. Medicaid reimburses for TMH services but not for technology setup costs and maintenance. Moreover, the interviews with administrators, the researchers say, indicated that TMH did not save the organization money. Costs for the equipment, installation, rent, and other supplies were prohibitive.

Although start-up costs are high, overall systematic costs go down, with savings on travel-related costs, including fewer missed appointments. Broadband technology, videoconferencing software, webcams, and education all take money. “If policymakers are serious” about TMH, the researchers conclude, they should allocate appropriate funding and resources.

Source:
Holland J, Hatcher W, Meares WL. J Health Hum Serv Adm. 2018;41(1):52-86.

When telemental health care (TMH) works, it works well, the research agrees. For rural patients who often do not have easy access to health care TMH can be a lifesaver. The VA uses TMH to deliver care to veterans in rural VA medical centers, community-based outpatient clinics, and residential areas.  However, TMH is still relatively new in many rural communities, say researchers from University of Mississippi in Oxford and Augusta University in Georgia, and few studies have examined the delivery tool from an administrative standpoint. The literature suggests TMH will save money—the exploratory study, however, suggests otherwise.

The researchers interviewed 6 providers selected from the 15 community mental health (MH) centers (CMHCs) in rural Mississippi as well as an independent MH counselor who develops policy for the Mississippi Counselors Association. They asked respondents about the feasibility of TMH in the Mississippi Delta; in particular, the benefits, the costs, and the role of the state in facilitating the service. The researchers also collected data from a grant-funded pilot project conducted in the Mississippi Delta region by the Delta Health Alliance, a nonprofit organization in partnership with the University of Mississippi Medical Center, which ran from 2008 to 2011. Telepsychiatry sessions are not currently being used in the region, but before the project ended, it was responsible for > 1,000 videoconferencing clinical sessions.

The initial counseling sessions were “awkward” for some patients, the interviewees said, and some clients felt the consultation was “less personal.” Getting used to the technology may take some time. Once clients acclimated the feedback was positive.

The health care providers were concerned by not being able to observe in-person nonverbal clues, such as poor hygiene, that would normally help them evaluate the client’s health. The nurse at the CMHC helped fill a gap, the researchers say, created by technology.

The researchers determined that the benefit side was weighty: For instance, patients had better access to well-trained MH professionals and to the state hospital, and family could visit inpatients via videoconferencing. Staff had better access to professional development and training.

However, cost issues were a definite concern. The project would not have been feasible without grant funding, the researchers say. Medicaid reimburses for TMH services but not for technology setup costs and maintenance. Moreover, the interviews with administrators, the researchers say, indicated that TMH did not save the organization money. Costs for the equipment, installation, rent, and other supplies were prohibitive.

Although start-up costs are high, overall systematic costs go down, with savings on travel-related costs, including fewer missed appointments. Broadband technology, videoconferencing software, webcams, and education all take money. “If policymakers are serious” about TMH, the researchers conclude, they should allocate appropriate funding and resources.

Source:
Holland J, Hatcher W, Meares WL. J Health Hum Serv Adm. 2018;41(1):52-86.

When telemental health care (TMH) works, it works well, the research agrees. For rural patients who often do not have easy access to health care TMH can be a lifesaver. The VA uses TMH to deliver care to veterans in rural VA medical centers, community-based outpatient clinics, and residential areas.  However, TMH is still relatively new in many rural communities, say researchers from University of Mississippi in Oxford and Augusta University in Georgia, and few studies have examined the delivery tool from an administrative standpoint. The literature suggests TMH will save money—the exploratory study, however, suggests otherwise.

The researchers interviewed 6 providers selected from the 15 community mental health (MH) centers (CMHCs) in rural Mississippi as well as an independent MH counselor who develops policy for the Mississippi Counselors Association. They asked respondents about the feasibility of TMH in the Mississippi Delta; in particular, the benefits, the costs, and the role of the state in facilitating the service. The researchers also collected data from a grant-funded pilot project conducted in the Mississippi Delta region by the Delta Health Alliance, a nonprofit organization in partnership with the University of Mississippi Medical Center, which ran from 2008 to 2011. Telepsychiatry sessions are not currently being used in the region, but before the project ended, it was responsible for > 1,000 videoconferencing clinical sessions.

The initial counseling sessions were “awkward” for some patients, the interviewees said, and some clients felt the consultation was “less personal.” Getting used to the technology may take some time. Once clients acclimated the feedback was positive.

The health care providers were concerned by not being able to observe in-person nonverbal clues, such as poor hygiene, that would normally help them evaluate the client’s health. The nurse at the CMHC helped fill a gap, the researchers say, created by technology.

The researchers determined that the benefit side was weighty: For instance, patients had better access to well-trained MH professionals and to the state hospital, and family could visit inpatients via videoconferencing. Staff had better access to professional development and training.

However, cost issues were a definite concern. The project would not have been feasible without grant funding, the researchers say. Medicaid reimburses for TMH services but not for technology setup costs and maintenance. Moreover, the interviews with administrators, the researchers say, indicated that TMH did not save the organization money. Costs for the equipment, installation, rent, and other supplies were prohibitive.

Although start-up costs are high, overall systematic costs go down, with savings on travel-related costs, including fewer missed appointments. Broadband technology, videoconferencing software, webcams, and education all take money. “If policymakers are serious” about TMH, the researchers conclude, they should allocate appropriate funding and resources.

Source:
Holland J, Hatcher W, Meares WL. J Health Hum Serv Adm. 2018;41(1):52-86.

What’s the best way to encourage patients to get screened for HIV? Money is a time-honored effective incentive, but researchers from University of California say the default option may be even better. They conducted, to their knowledge, the first head-to-head study of 2 types of behavioral economics interventions (cash incentives vs opt-out) in any health behavior context. The working hypothesis was based on “nudge theory,” a concept in behavioral science, political theory, and economics that says using positive reinforcement and indirect suggestions can influence behavior and decision making.

In the study, patients aged 13 to 64 years were told the emergency department was offering rapid screening HIV tests, with results available within 2 hours. Then each patient was given a test offer: opt-in (“You can let me, your nurse, or your doctor know if you’d like a test today”); active choice (“Would you like a test today?”); or opt-out (“You will be tested unless you decline.”) Patients assigned to a positive monetary incentive were told “To encourage testing today we are offering a $1 (or $5 or $10) cash incentive.”

Of 8,715 patients, 4,831 (55%) accepted an HIV test. Those offered no monetary incentive accepted 52% of test offers. The $1 offer did not increase test acceptance, but the $5 and $10 offers increased acceptance rates by 10.5 and 15 percentage points, respectively. Active-choice increased acceptance by 11.5 percentage points compared with that of opt-in offers.

However, opt-out testing—essentially a default option—had the largest effect, increasing acceptance by 24 percentage points. The next most effective was the $10 incentive.

The researchers say the effects were consistent across all levels of patient risk of infection, although the effects were somewhat attenuated when defaults and incentives were used together. In general, higher risk patients tested at higher rates than did lower risk patients.

Defaults have been “understudied in medicine,” the researchers say. The study not only reaffirms that behavioral economics “nudges” work, but also that “small interventions can have significant effects.” Moreover, the finding that moving from opt-in to opt-out testing influenced behavior more than even the largest incentive reinforces the notion that “medicine is not just a transaction, and what we say to patients matters.”

Source:
Montoy JCC, Dow WH, Kaplan BC. PLoS One. 2018;13(7):e0199833.
doi: 10.1371/journal.pone.0199833.

What’s the best way to encourage patients to get screened for HIV? Money is a time-honored effective incentive, but researchers from University of California say the default option may be even better. They conducted, to their knowledge, the first head-to-head study of 2 types of behavioral economics interventions (cash incentives vs opt-out) in any health behavior context. The working hypothesis was based on “nudge theory,” a concept in behavioral science, political theory, and economics that says using positive reinforcement and indirect suggestions can influence behavior and decision making.

In the study, patients aged 13 to 64 years were told the emergency department was offering rapid screening HIV tests, with results available within 2 hours. Then each patient was given a test offer: opt-in (“You can let me, your nurse, or your doctor know if you’d like a test today”); active choice (“Would you like a test today?”); or opt-out (“You will be tested unless you decline.”) Patients assigned to a positive monetary incentive were told “To encourage testing today we are offering a $1 (or $5 or $10) cash incentive.”

Of 8,715 patients, 4,831 (55%) accepted an HIV test. Those offered no monetary incentive accepted 52% of test offers. The $1 offer did not increase test acceptance, but the $5 and $10 offers increased acceptance rates by 10.5 and 15 percentage points, respectively. Active-choice increased acceptance by 11.5 percentage points compared with that of opt-in offers.

However, opt-out testing—essentially a default option—had the largest effect, increasing acceptance by 24 percentage points. The next most effective was the $10 incentive.

The researchers say the effects were consistent across all levels of patient risk of infection, although the effects were somewhat attenuated when defaults and incentives were used together. In general, higher risk patients tested at higher rates than did lower risk patients.

Defaults have been “understudied in medicine,” the researchers say. The study not only reaffirms that behavioral economics “nudges” work, but also that “small interventions can have significant effects.” Moreover, the finding that moving from opt-in to opt-out testing influenced behavior more than even the largest incentive reinforces the notion that “medicine is not just a transaction, and what we say to patients matters.”

Source:
Montoy JCC, Dow WH, Kaplan BC. PLoS One. 2018;13(7):e0199833.
doi: 10.1371/journal.pone.0199833.

What’s the best way to encourage patients to get screened for HIV? Money is a time-honored effective incentive, but researchers from University of California say the default option may be even better. They conducted, to their knowledge, the first head-to-head study of 2 types of behavioral economics interventions (cash incentives vs opt-out) in any health behavior context. The working hypothesis was based on “nudge theory,” a concept in behavioral science, political theory, and economics that says using positive reinforcement and indirect suggestions can influence behavior and decision making.

In the study, patients aged 13 to 64 years were told the emergency department was offering rapid screening HIV tests, with results available within 2 hours. Then each patient was given a test offer: opt-in (“You can let me, your nurse, or your doctor know if you’d like a test today”); active choice (“Would you like a test today?”); or opt-out (“You will be tested unless you decline.”) Patients assigned to a positive monetary incentive were told “To encourage testing today we are offering a $1 (or $5 or $10) cash incentive.”

Of 8,715 patients, 4,831 (55%) accepted an HIV test. Those offered no monetary incentive accepted 52% of test offers. The $1 offer did not increase test acceptance, but the $5 and $10 offers increased acceptance rates by 10.5 and 15 percentage points, respectively. Active-choice increased acceptance by 11.5 percentage points compared with that of opt-in offers.

However, opt-out testing—essentially a default option—had the largest effect, increasing acceptance by 24 percentage points. The next most effective was the $10 incentive.

The researchers say the effects were consistent across all levels of patient risk of infection, although the effects were somewhat attenuated when defaults and incentives were used together. In general, higher risk patients tested at higher rates than did lower risk patients.

Defaults have been “understudied in medicine,” the researchers say. The study not only reaffirms that behavioral economics “nudges” work, but also that “small interventions can have significant effects.” Moreover, the finding that moving from opt-in to opt-out testing influenced behavior more than even the largest incentive reinforces the notion that “medicine is not just a transaction, and what we say to patients matters.”

Source:
Montoy JCC, Dow WH, Kaplan BC. PLoS One. 2018;13(7):e0199833.
doi: 10.1371/journal.pone.0199833.