Blood samples

Credit: Graham Colm

MIAMI—Results of a small study suggest an experimental agent can decrease the erythrocyte sedimentation rate (ESR) in patients with sickle cell disease (SCD).

Previous research has shown the ESR is elevated in SCD patients during vaso-occlusive crisis.

In the current study, the experimental agent MST-188 decreased elevated ESRs by 50% in blood from SCD patients.

According to researchers, this reflects reduced red blood cell (RBC) aggregation and suggests improved microvascular blood flow.

“The data from this study are consistent with observations in prior studies that MST-188 decreases blood viscosity and RBC aggregation and improves microvascular blood flow, and supportive of the potential for MST-188 to shorten the duration of sickle cell crisis,” said Martin Emanuele, PhD, of Mast Therapeutics, the company developing MST-188.

Dr Emanuele presented the study data at the recent 8th Annual Sickle Cell Disease Research & Educational Symposium.

MST-188 is a non-ionic, linear block copolymer composed of a central chain of hydrophobic polyoxypropylene and 2 flanking chains of hydrophylic polyoxyethylene. In previous studies, the agent has shown hemorheologic properties that result in improved microvascular blood flow.

For the current study, the researchers compared MST-188 to dextrans, evaluating their effects on the ESR in blood collected from SCD patients and healthy controls. Dextrans are branched polysaccharides of 10-70 kDa that have been used as antithrombotic agents and plasma expanders.

The researchers analyzed EDTA-anticoagulated whole blood collected from 8 healthy individuals and 11 SCD patients. The team treated samples with MST-188; dextran 10K, 18K , 40K, and 70K at various concentrations; or saline control.

At baseline, ESRs for SCD patients were significantly higher than for the healthy subjects. The mean ESRs were 26.4 ± 7.1 mm/hr and 14.6 ± 2.1 mm/hr, respectively.

However, adding MST-188 to the SCD patient samples decreased the mean ESR to 14.1 ± 4.6 mm/hr (Δ47%). On the other hand, comparable concentrations of dextrans showed little or no effect on the ESR in SCD samples.

The researchers said MST-188 may reduce the ESR by inhibiting acute-phase-reactant-induced RBC aggregates, and this may result from the effect of MST-188 on RBC membranes or cell-protein interactions.

Regardless of the exact mechanism, the team said lowering the ESR reflects reduced RBC aggregation and suggests improved microvascular blood flow, which indicates that MST-188 may be able to shorten the duration of vaso-occlusive crisis.

“It is widely understood that multiple biological processes contribute to vaso-occlusion and that an effective solution requires a broad, multi-modal approach rather than a single targeted therapy,” Dr Emanuele said.

“In addition to the effects on RBC aggregation, our data suggest that MST-188 addresses cell adhesion and platelet activation, reduces hemolysis, lowers blood viscosity, and limits reperfusion injury following restoration of blood flow.”

He and his colleagues at Mast Therapeutics are planning additional studies of MST-188 in SCD. The agent is currently under investigation in a phase 3 trial.

Blood samples

Credit: Graham Colm

MIAMI—Results of a small study suggest an experimental agent can decrease the erythrocyte sedimentation rate (ESR) in patients with sickle cell disease (SCD).

Previous research has shown the ESR is elevated in SCD patients during vaso-occlusive crisis.

In the current study, the experimental agent MST-188 decreased elevated ESRs by 50% in blood from SCD patients.

According to researchers, this reflects reduced red blood cell (RBC) aggregation and suggests improved microvascular blood flow.

“The data from this study are consistent with observations in prior studies that MST-188 decreases blood viscosity and RBC aggregation and improves microvascular blood flow, and supportive of the potential for MST-188 to shorten the duration of sickle cell crisis,” said Martin Emanuele, PhD, of Mast Therapeutics, the company developing MST-188.

Dr Emanuele presented the study data at the recent 8th Annual Sickle Cell Disease Research & Educational Symposium.

MST-188 is a non-ionic, linear block copolymer composed of a central chain of hydrophobic polyoxypropylene and 2 flanking chains of hydrophylic polyoxyethylene. In previous studies, the agent has shown hemorheologic properties that result in improved microvascular blood flow.

For the current study, the researchers compared MST-188 to dextrans, evaluating their effects on the ESR in blood collected from SCD patients and healthy controls. Dextrans are branched polysaccharides of 10-70 kDa that have been used as antithrombotic agents and plasma expanders.

The researchers analyzed EDTA-anticoagulated whole blood collected from 8 healthy individuals and 11 SCD patients. The team treated samples with MST-188; dextran 10K, 18K , 40K, and 70K at various concentrations; or saline control.

At baseline, ESRs for SCD patients were significantly higher than for the healthy subjects. The mean ESRs were 26.4 ± 7.1 mm/hr and 14.6 ± 2.1 mm/hr, respectively.

However, adding MST-188 to the SCD patient samples decreased the mean ESR to 14.1 ± 4.6 mm/hr (Δ47%). On the other hand, comparable concentrations of dextrans showed little or no effect on the ESR in SCD samples.

The researchers said MST-188 may reduce the ESR by inhibiting acute-phase-reactant-induced RBC aggregates, and this may result from the effect of MST-188 on RBC membranes or cell-protein interactions.

Regardless of the exact mechanism, the team said lowering the ESR reflects reduced RBC aggregation and suggests improved microvascular blood flow, which indicates that MST-188 may be able to shorten the duration of vaso-occlusive crisis.

“It is widely understood that multiple biological processes contribute to vaso-occlusion and that an effective solution requires a broad, multi-modal approach rather than a single targeted therapy,” Dr Emanuele said.

“In addition to the effects on RBC aggregation, our data suggest that MST-188 addresses cell adhesion and platelet activation, reduces hemolysis, lowers blood viscosity, and limits reperfusion injury following restoration of blood flow.”

He and his colleagues at Mast Therapeutics are planning additional studies of MST-188 in SCD. The agent is currently under investigation in a phase 3 trial.

Blood samples

Credit: Graham Colm

MIAMI—Results of a small study suggest an experimental agent can decrease the erythrocyte sedimentation rate (ESR) in patients with sickle cell disease (SCD).

Previous research has shown the ESR is elevated in SCD patients during vaso-occlusive crisis.

In the current study, the experimental agent MST-188 decreased elevated ESRs by 50% in blood from SCD patients.

According to researchers, this reflects reduced red blood cell (RBC) aggregation and suggests improved microvascular blood flow.

“The data from this study are consistent with observations in prior studies that MST-188 decreases blood viscosity and RBC aggregation and improves microvascular blood flow, and supportive of the potential for MST-188 to shorten the duration of sickle cell crisis,” said Martin Emanuele, PhD, of Mast Therapeutics, the company developing MST-188.

Dr Emanuele presented the study data at the recent 8th Annual Sickle Cell Disease Research & Educational Symposium.

MST-188 is a non-ionic, linear block copolymer composed of a central chain of hydrophobic polyoxypropylene and 2 flanking chains of hydrophylic polyoxyethylene. In previous studies, the agent has shown hemorheologic properties that result in improved microvascular blood flow.

For the current study, the researchers compared MST-188 to dextrans, evaluating their effects on the ESR in blood collected from SCD patients and healthy controls. Dextrans are branched polysaccharides of 10-70 kDa that have been used as antithrombotic agents and plasma expanders.

The researchers analyzed EDTA-anticoagulated whole blood collected from 8 healthy individuals and 11 SCD patients. The team treated samples with MST-188; dextran 10K, 18K , 40K, and 70K at various concentrations; or saline control.

At baseline, ESRs for SCD patients were significantly higher than for the healthy subjects. The mean ESRs were 26.4 ± 7.1 mm/hr and 14.6 ± 2.1 mm/hr, respectively.

However, adding MST-188 to the SCD patient samples decreased the mean ESR to 14.1 ± 4.6 mm/hr (Δ47%). On the other hand, comparable concentrations of dextrans showed little or no effect on the ESR in SCD samples.

The researchers said MST-188 may reduce the ESR by inhibiting acute-phase-reactant-induced RBC aggregates, and this may result from the effect of MST-188 on RBC membranes or cell-protein interactions.

Regardless of the exact mechanism, the team said lowering the ESR reflects reduced RBC aggregation and suggests improved microvascular blood flow, which indicates that MST-188 may be able to shorten the duration of vaso-occlusive crisis.

“It is widely understood that multiple biological processes contribute to vaso-occlusion and that an effective solution requires a broad, multi-modal approach rather than a single targeted therapy,” Dr Emanuele said.

“In addition to the effects on RBC aggregation, our data suggest that MST-188 addresses cell adhesion and platelet activation, reduces hemolysis, lowers blood viscosity, and limits reperfusion injury following restoration of blood flow.”

He and his colleagues at Mast Therapeutics are planning additional studies of MST-188 in SCD. The agent is currently under investigation in a phase 3 trial.

On April 17, 2014, the US Food and Drug Administration (FDA) issued a Safety Communication discouraging the use of laparoscopic power morcellation in hysterectomy and myomectomy for uterine fibroids.

Based on an FDA analysis of current data, “… it is estimated that 1 in 350 women undergoing hysterectomy or myomectomy for the treatment of fibroids is found to have an unsuspected uterine sarcoma, a type of uterine cancer that includes leiomyosarcoma. If laparoscopic power morcellation is performed in women with unsuspected uterine sarcoma, there is a risk that the procedure will spread the cancerous tissue within the abdomen and pelvis, significantly worsening the patient’s likelihood of long-term survival.”¹

FDA recommendations
The FDA posted the following recommendations for health-care providers¹:

1. Laparoscopic uterine power morcellation should not be used in women with suspected or known uterine cancer
2. All available treatment options should be considered for women with symptomatic uterine fibroids
3. The benefits and risks of all treatments should be discussed thoroughly with each patient
4. If, after a careful benefit-risk evaluation, laparoscopic power morcellation is considered the best therapeutic option for an individual patient, then:

• Inform the patient that her fibroid(s) may contain unexpected cancerous tissue and that laparoscopic power morcellation may spread the cancer, significantly worsening her prognosis
• Some clinicians and medical institutions now advocate using a specimen “bag” during morcellation in an attempt to contain the uterine tissue and minimize the risk of spread in the abdomen and pelvis.

Although many women choose laparoscopic hysterectomy or myomectomy because of the associated benefits, there are other treatments available, including vaginal or abdominal hysterectomy and myomectomy; laparoscopic hysterectomy or myomectomy without morcellation; minilaparotomy; uterine artery embolization; high-intensity focused ultrasound; and drug therapy.

FDA actions
To reduce the risk of inadvertent spread of unsuspected cancer to the abdomen and pelvis, the FDA has instructed manufacturers of power morcellators used during laparoscopic hysterectomy and myomectomy to immediately review labeling for accurate risk information.

A to-be-convened public meeting of the FDA’s Obstetrics and Gynecological Medical Device Advisory Committee will discuss¹:

• the clinical role of laparoscopic power morcellation in the treatment of uterine fibroids
• whether surgical techniques and/or use of accessories, such as morcellation and/or specimen bags, can enhance the safe and effective use of these devices
• if a boxed warning relating the risk of cancer spread should be required for laparoscopic power morcellators.

The FDA will continue to review adverse event reports and peer-reviewed literature, as well as patient information and evidence from health-care providers, gynecologic and surgical professional societies, and medical device manufacturers.

Adverse events should promptly be reported to the FDA by filing a voluntary report through MedWatch, the FDA Safety Information and Adverse Event Reporting program.

Institution reaction
Brigham and Women's Hospital had banned the use of open power morcellation on March 31, 2014, allowing for the use of power morcellators within a containment system. In light of the FDA notice that discourages the use of power morcellators during hysterectomy or myomectomy for the treatment of uterine fibroids, however, Robert L. Barbieri, MD, chair of obstetrics and gynecology at Brigham and Women’s advised surgical staff to "immediately suspend use of power morcellators in all cases until further notice."    

Massachusetts General, which also had placed restrictions on the use of power morcellators prior to the FDA communication, suspended the use of power morcellation.

“I have asked our doctors to stop the procedure immediately until more information is available,’’ Dr. Isaac Schiff, Massachusetts General’s chief of obstetrics and gynecology, told the Boston Globe.     

On April 17, 2014, the US Food and Drug Administration (FDA) issued a Safety Communication discouraging the use of laparoscopic power morcellation in hysterectomy and myomectomy for uterine fibroids.

Based on an FDA analysis of current data, “… it is estimated that 1 in 350 women undergoing hysterectomy or myomectomy for the treatment of fibroids is found to have an unsuspected uterine sarcoma, a type of uterine cancer that includes leiomyosarcoma. If laparoscopic power morcellation is performed in women with unsuspected uterine sarcoma, there is a risk that the procedure will spread the cancerous tissue within the abdomen and pelvis, significantly worsening the patient’s likelihood of long-term survival.”¹

FDA recommendations
The FDA posted the following recommendations for health-care providers¹:

1. Laparoscopic uterine power morcellation should not be used in women with suspected or known uterine cancer
2. All available treatment options should be considered for women with symptomatic uterine fibroids
3. The benefits and risks of all treatments should be discussed thoroughly with each patient
4. If, after a careful benefit-risk evaluation, laparoscopic power morcellation is considered the best therapeutic option for an individual patient, then:

• Inform the patient that her fibroid(s) may contain unexpected cancerous tissue and that laparoscopic power morcellation may spread the cancer, significantly worsening her prognosis
• Some clinicians and medical institutions now advocate using a specimen “bag” during morcellation in an attempt to contain the uterine tissue and minimize the risk of spread in the abdomen and pelvis.

Although many women choose laparoscopic hysterectomy or myomectomy because of the associated benefits, there are other treatments available, including vaginal or abdominal hysterectomy and myomectomy; laparoscopic hysterectomy or myomectomy without morcellation; minilaparotomy; uterine artery embolization; high-intensity focused ultrasound; and drug therapy.

FDA actions
To reduce the risk of inadvertent spread of unsuspected cancer to the abdomen and pelvis, the FDA has instructed manufacturers of power morcellators used during laparoscopic hysterectomy and myomectomy to immediately review labeling for accurate risk information.

A to-be-convened public meeting of the FDA’s Obstetrics and Gynecological Medical Device Advisory Committee will discuss¹:

• the clinical role of laparoscopic power morcellation in the treatment of uterine fibroids
• whether surgical techniques and/or use of accessories, such as morcellation and/or specimen bags, can enhance the safe and effective use of these devices
• if a boxed warning relating the risk of cancer spread should be required for laparoscopic power morcellators.

The FDA will continue to review adverse event reports and peer-reviewed literature, as well as patient information and evidence from health-care providers, gynecologic and surgical professional societies, and medical device manufacturers.

Adverse events should promptly be reported to the FDA by filing a voluntary report through MedWatch, the FDA Safety Information and Adverse Event Reporting program.

Institution reaction
Brigham and Women's Hospital had banned the use of open power morcellation on March 31, 2014, allowing for the use of power morcellators within a containment system. In light of the FDA notice that discourages the use of power morcellators during hysterectomy or myomectomy for the treatment of uterine fibroids, however, Robert L. Barbieri, MD, chair of obstetrics and gynecology at Brigham and Women’s advised surgical staff to "immediately suspend use of power morcellators in all cases until further notice."    

Massachusetts General, which also had placed restrictions on the use of power morcellators prior to the FDA communication, suspended the use of power morcellation.

“I have asked our doctors to stop the procedure immediately until more information is available,’’ Dr. Isaac Schiff, Massachusetts General’s chief of obstetrics and gynecology, told the Boston Globe.     

On April 17, 2014, the US Food and Drug Administration (FDA) issued a Safety Communication discouraging the use of laparoscopic power morcellation in hysterectomy and myomectomy for uterine fibroids.

Based on an FDA analysis of current data, “… it is estimated that 1 in 350 women undergoing hysterectomy or myomectomy for the treatment of fibroids is found to have an unsuspected uterine sarcoma, a type of uterine cancer that includes leiomyosarcoma. If laparoscopic power morcellation is performed in women with unsuspected uterine sarcoma, there is a risk that the procedure will spread the cancerous tissue within the abdomen and pelvis, significantly worsening the patient’s likelihood of long-term survival.”¹

FDA recommendations
The FDA posted the following recommendations for health-care providers¹:

1. Laparoscopic uterine power morcellation should not be used in women with suspected or known uterine cancer
2. All available treatment options should be considered for women with symptomatic uterine fibroids
3. The benefits and risks of all treatments should be discussed thoroughly with each patient
4. If, after a careful benefit-risk evaluation, laparoscopic power morcellation is considered the best therapeutic option for an individual patient, then:

• Inform the patient that her fibroid(s) may contain unexpected cancerous tissue and that laparoscopic power morcellation may spread the cancer, significantly worsening her prognosis
• Some clinicians and medical institutions now advocate using a specimen “bag” during morcellation in an attempt to contain the uterine tissue and minimize the risk of spread in the abdomen and pelvis.

Although many women choose laparoscopic hysterectomy or myomectomy because of the associated benefits, there are other treatments available, including vaginal or abdominal hysterectomy and myomectomy; laparoscopic hysterectomy or myomectomy without morcellation; minilaparotomy; uterine artery embolization; high-intensity focused ultrasound; and drug therapy.

FDA actions
To reduce the risk of inadvertent spread of unsuspected cancer to the abdomen and pelvis, the FDA has instructed manufacturers of power morcellators used during laparoscopic hysterectomy and myomectomy to immediately review labeling for accurate risk information.

A to-be-convened public meeting of the FDA’s Obstetrics and Gynecological Medical Device Advisory Committee will discuss¹:

• the clinical role of laparoscopic power morcellation in the treatment of uterine fibroids
• whether surgical techniques and/or use of accessories, such as morcellation and/or specimen bags, can enhance the safe and effective use of these devices
• if a boxed warning relating the risk of cancer spread should be required for laparoscopic power morcellators.

The FDA will continue to review adverse event reports and peer-reviewed literature, as well as patient information and evidence from health-care providers, gynecologic and surgical professional societies, and medical device manufacturers.

Adverse events should promptly be reported to the FDA by filing a voluntary report through MedWatch, the FDA Safety Information and Adverse Event Reporting program.

Institution reaction
Brigham and Women's Hospital had banned the use of open power morcellation on March 31, 2014, allowing for the use of power morcellators within a containment system. In light of the FDA notice that discourages the use of power morcellators during hysterectomy or myomectomy for the treatment of uterine fibroids, however, Robert L. Barbieri, MD, chair of obstetrics and gynecology at Brigham and Women’s advised surgical staff to "immediately suspend use of power morcellators in all cases until further notice."    

Massachusetts General, which also had placed restrictions on the use of power morcellators prior to the FDA communication, suspended the use of power morcellation.

“I have asked our doctors to stop the procedure immediately until more information is available,’’ Dr. Isaac Schiff, Massachusetts General’s chief of obstetrics and gynecology, told the Boston Globe.     

Secure messaging (SM) is an encrypted, web-based mode of communication within the My HealtheVet (MHV) website. It was developed for the nonurgent, nonemergency communication of test results and other health information as well as for scheduling appointments and renewing medication prescriptions. Secure messaging is asynchronous, which means that communication between parties is not done at the same time. It was designed to address the need for a secure means of communication between patient and provider.¹ Messages can be triaged across teams and saved to the Computerized Patient Record System (CPRS).

The VA patients who use MHV can upgrade their account through an in-person authentication process (IPA), which takes about 10 minutes. Any health care provider (HCP) team or administrator can use SM if set up in the system. Health care providers can only receive messages from patients who have been associated with their triage care group. Patients may only message an HCP with which they are associated. In general, this group would comprise their HCP and 1 or more specialty clinics where they have already been seen. Patients can choose an HCP from a limited drop-down menu.

How Secure Messaging Works

Patients using SM choose a subject, such as appointments, medications, tests, or general. Patients are then able to type a message, and they are also able to see the threads of previous messages. They may access test results or attachments sent to them by the HCPs. Patients are notified of messages through their previously registered e-mail account, which displays a message asking them to log on to MHV.

Health care providers may access MHV either through the CPRS on the tools menu or as a link in an e-mail. Once HCPs log on, they will see their inbox and messages listed by sender and type of inquiry (ie, prescription refill, test question, and so forth). The HCPs can view escalated messages (those that have not been answered within 3 days), drafts, and sent and completed messages. Health care providers can also create special folders to store their messages.

The health care team can personalize how and to whom messages appear. There are 2 main models used by Specialty Care. The first involves a staff member designated to triage messages for the team. This staff member will see all incoming messages and forward them appropriately. For example, in one clinic model, the program assistant reviews all messages and then forwards them to the appropriate provider. The team pharmacist receives prescription requests, the HCP receives general or test inquiries from patients, and the program assistant retains and answers all communication related to appointments and cancellations. Another model involves employing a staff person or administrator as a co-user with each HCP. The HCP can then forward messages that may need administrative action.

The HCPs receive an e-mail notification with a link when a message has been received. Clicking on the link takes them directly to SM within MHV, where they can sign in to see all their messages. Users can also add a signature block, which will appear on all correspondence. They may also designate a surrogate to answer messages when they are unavailable, such as during administrative or personal leave. The HCPs also have the ability to create a SM even if the patient has not yet messaged them. Users can also send copies of messages to other staff members. Providers and staff have the ability to attach a file, which can be a test result, letter, records, etc. Messages can then be saved in the CPRS if desired.

Patients, however, cannot send attachments to their HCP. Only those HCPs who have seen the patient will be available for communication. This system eliminates the possibility of patients self-referring to a specialist and asking questions of HCPs who have never seen them. The HCPs and staff may also forward messages to the appropriate person.

Secure messaging can provide unique opportunities for communication and improvement in outcome measures in certain specialties. For example, in endocrinology patients may be asked to send home blood sugar or blood pressure (BP) readings in between visits, to allow for more rapid medication titration and achievement of treatment goals.  A study by Harris and colleagues showed that the frequent use of electronic SM was associated with improved glycemic control.²

Implementation

At the Atlanta VAMC, SM was implemented in the Primary Care Service Line prior to the Medicine Specialty Care Service Line. The implementation was a natural fit for the organized Primary Care teams. Implementation within the specialties brought forth a new set of issues. Many specialties were not formally organized with a team leader. There were often multiple HCPs in a division, some full time, some part time, in addition to subspecialty pharmacists, physician assistants, and nurse practitioners. Because the Atlanta VAMC is also a training hospital for the Emory University School of Medicine, new residents and fellows are included in the teams each month. It was, therefore, necessary for each specialty to design a message flow that would best fit its needs. Initially, there was concern that SM would add yet another layer of responsibilities to the already stretched HCPs.

The reality has been the opposite. Secure messaging was found to be an additional type of communication, which could be completed more rapidly than a phone call or generating a results letter. The HCPs were also concerned that patients would attempt to use them as primary care providers (PCPs). However, as patients were able to view both their PCP and their specialty care provider in the drop-down menu, they were generally able to direct their questions appropriately.

At the Atlanta VAMC, 60% of the messages were completed by the provider, 29% by a clinical team member, and 11% by the triage staff from 2013 to 2014 (Figure 1). Some HCPs were concerned that once SM was in place, they would be inundated with messages. The reality seems to be that most patients use SM judiciously, and although they are comfortable in the knowledge that they can communicate directly with their HCP, the need is infrequent. The number of messages has slowly increased over the past year as more patients join MHV and SM (Table). Surprisingly, as the number of inbound messages increased, the percentage of escalated messages (messages not answered within 3 days)  declined, indicating a learning curve as HCPs begin using SM.

Challenges

There are 3 steps to patient enrollment in SM. The first is enrollment in MHV, which can be done either online or at the VAMC. The second step requires the patient to go to the VAMC and present identification to complete the IPA. Finally, the enrolled patients must opt-in to the program. Enrollment in MHV has steadily increased through advertising campaigns on the VAMC website, within the VAMC, and through HCPs and staff (Figure 2).

However, barriers still exist. Some patients do not have an Internet connection and are not computer savvy. Other patients express interest but put it off to another visit. Some patients have been confused about the additional step of IPA that is required for SM and stop at enrollment in MHV only.

Therefore the key challenges for implementing SM are facilitating MHV enrollment, IPA, and completion of the opt-in feature. To encourage participation, VISN 7 mailed postcards to all 33,000 patients who had undergone IPA but had not yet opted-in. The number of patients who opted-in quadrupled, demonstrating that this type of promotion is an effective recruitment tool.

Another ongoing challenge is developing a method to easily generate workload credit for the HCPs’ time spent using SM for patient care. This will be an important parameter to track, as the time spent on SM per provider is expected to increase. It has also been suggested that there be an out-of-office response for nonemergent messages and the assignment of a surrogate to handle incoming messages for HCPs who are on leave. An unforeseen example of a nonemergent message occurs when a patient replies “Thank you” to a message from an HCP. That message is then counted as a new message and must be viewed and completed like any other message. It can also become an escalated message, even though there is no important information being transmitted.

Conclusions

Secure messaging provides a simple means of rapid communication and feedback between HCPs and their patients. An e-mail notification is generated, HCPs access SM through the link, the reply is sent, and a CPRS note is automatically generated. That same communication would require a far more time-consuming and complicated process without SM: The patient must contact the service, usually the program assistant, and leave a message; that message would be passed on via voicemail or e-mail to the appropriate HCP; the provider would need to access the CPRS, phone the patient, discuss the issue if the patient is available, and then document the contact with a note in the CPRS. If the patient was unavailable, this process would require multiple phone calls.

With respect to patients, the benefits of SM are significant and include easy access to prescription refills and a quick response to questions about medications, dosages, or tests. Patients are able to change or cancel appointments, thereby avoiding no-shows. Frustration concerning the inability to reach the correct party or to speak with staff directly is reduced with SM, and overall communication between HCP and patient is streamlined.  

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Secure messaging (SM) is an encrypted, web-based mode of communication within the My HealtheVet (MHV) website. It was developed for the nonurgent, nonemergency communication of test results and other health information as well as for scheduling appointments and renewing medication prescriptions. Secure messaging is asynchronous, which means that communication between parties is not done at the same time. It was designed to address the need for a secure means of communication between patient and provider.¹ Messages can be triaged across teams and saved to the Computerized Patient Record System (CPRS).

The VA patients who use MHV can upgrade their account through an in-person authentication process (IPA), which takes about 10 minutes. Any health care provider (HCP) team or administrator can use SM if set up in the system. Health care providers can only receive messages from patients who have been associated with their triage care group. Patients may only message an HCP with which they are associated. In general, this group would comprise their HCP and 1 or more specialty clinics where they have already been seen. Patients can choose an HCP from a limited drop-down menu.

How Secure Messaging Works

Patients using SM choose a subject, such as appointments, medications, tests, or general. Patients are then able to type a message, and they are also able to see the threads of previous messages. They may access test results or attachments sent to them by the HCPs. Patients are notified of messages through their previously registered e-mail account, which displays a message asking them to log on to MHV.

Health care providers may access MHV either through the CPRS on the tools menu or as a link in an e-mail. Once HCPs log on, they will see their inbox and messages listed by sender and type of inquiry (ie, prescription refill, test question, and so forth). The HCPs can view escalated messages (those that have not been answered within 3 days), drafts, and sent and completed messages. Health care providers can also create special folders to store their messages.

The health care team can personalize how and to whom messages appear. There are 2 main models used by Specialty Care. The first involves a staff member designated to triage messages for the team. This staff member will see all incoming messages and forward them appropriately. For example, in one clinic model, the program assistant reviews all messages and then forwards them to the appropriate provider. The team pharmacist receives prescription requests, the HCP receives general or test inquiries from patients, and the program assistant retains and answers all communication related to appointments and cancellations. Another model involves employing a staff person or administrator as a co-user with each HCP. The HCP can then forward messages that may need administrative action.

The HCPs receive an e-mail notification with a link when a message has been received. Clicking on the link takes them directly to SM within MHV, where they can sign in to see all their messages. Users can also add a signature block, which will appear on all correspondence. They may also designate a surrogate to answer messages when they are unavailable, such as during administrative or personal leave. The HCPs also have the ability to create a SM even if the patient has not yet messaged them. Users can also send copies of messages to other staff members. Providers and staff have the ability to attach a file, which can be a test result, letter, records, etc. Messages can then be saved in the CPRS if desired.

Patients, however, cannot send attachments to their HCP. Only those HCPs who have seen the patient will be available for communication. This system eliminates the possibility of patients self-referring to a specialist and asking questions of HCPs who have never seen them. The HCPs and staff may also forward messages to the appropriate person.

Secure messaging can provide unique opportunities for communication and improvement in outcome measures in certain specialties. For example, in endocrinology patients may be asked to send home blood sugar or blood pressure (BP) readings in between visits, to allow for more rapid medication titration and achievement of treatment goals.  A study by Harris and colleagues showed that the frequent use of electronic SM was associated with improved glycemic control.²

Implementation

At the Atlanta VAMC, SM was implemented in the Primary Care Service Line prior to the Medicine Specialty Care Service Line. The implementation was a natural fit for the organized Primary Care teams. Implementation within the specialties brought forth a new set of issues. Many specialties were not formally organized with a team leader. There were often multiple HCPs in a division, some full time, some part time, in addition to subspecialty pharmacists, physician assistants, and nurse practitioners. Because the Atlanta VAMC is also a training hospital for the Emory University School of Medicine, new residents and fellows are included in the teams each month. It was, therefore, necessary for each specialty to design a message flow that would best fit its needs. Initially, there was concern that SM would add yet another layer of responsibilities to the already stretched HCPs.

The reality has been the opposite. Secure messaging was found to be an additional type of communication, which could be completed more rapidly than a phone call or generating a results letter. The HCPs were also concerned that patients would attempt to use them as primary care providers (PCPs). However, as patients were able to view both their PCP and their specialty care provider in the drop-down menu, they were generally able to direct their questions appropriately.

At the Atlanta VAMC, 60% of the messages were completed by the provider, 29% by a clinical team member, and 11% by the triage staff from 2013 to 2014 (Figure 1). Some HCPs were concerned that once SM was in place, they would be inundated with messages. The reality seems to be that most patients use SM judiciously, and although they are comfortable in the knowledge that they can communicate directly with their HCP, the need is infrequent. The number of messages has slowly increased over the past year as more patients join MHV and SM (Table). Surprisingly, as the number of inbound messages increased, the percentage of escalated messages (messages not answered within 3 days)  declined, indicating a learning curve as HCPs begin using SM.

Challenges

There are 3 steps to patient enrollment in SM. The first is enrollment in MHV, which can be done either online or at the VAMC. The second step requires the patient to go to the VAMC and present identification to complete the IPA. Finally, the enrolled patients must opt-in to the program. Enrollment in MHV has steadily increased through advertising campaigns on the VAMC website, within the VAMC, and through HCPs and staff (Figure 2).

However, barriers still exist. Some patients do not have an Internet connection and are not computer savvy. Other patients express interest but put it off to another visit. Some patients have been confused about the additional step of IPA that is required for SM and stop at enrollment in MHV only.

Therefore the key challenges for implementing SM are facilitating MHV enrollment, IPA, and completion of the opt-in feature. To encourage participation, VISN 7 mailed postcards to all 33,000 patients who had undergone IPA but had not yet opted-in. The number of patients who opted-in quadrupled, demonstrating that this type of promotion is an effective recruitment tool.

Another ongoing challenge is developing a method to easily generate workload credit for the HCPs’ time spent using SM for patient care. This will be an important parameter to track, as the time spent on SM per provider is expected to increase. It has also been suggested that there be an out-of-office response for nonemergent messages and the assignment of a surrogate to handle incoming messages for HCPs who are on leave. An unforeseen example of a nonemergent message occurs when a patient replies “Thank you” to a message from an HCP. That message is then counted as a new message and must be viewed and completed like any other message. It can also become an escalated message, even though there is no important information being transmitted.

Conclusions

Secure messaging provides a simple means of rapid communication and feedback between HCPs and their patients. An e-mail notification is generated, HCPs access SM through the link, the reply is sent, and a CPRS note is automatically generated. That same communication would require a far more time-consuming and complicated process without SM: The patient must contact the service, usually the program assistant, and leave a message; that message would be passed on via voicemail or e-mail to the appropriate HCP; the provider would need to access the CPRS, phone the patient, discuss the issue if the patient is available, and then document the contact with a note in the CPRS. If the patient was unavailable, this process would require multiple phone calls.

With respect to patients, the benefits of SM are significant and include easy access to prescription refills and a quick response to questions about medications, dosages, or tests. Patients are able to change or cancel appointments, thereby avoiding no-shows. Frustration concerning the inability to reach the correct party or to speak with staff directly is reduced with SM, and overall communication between HCP and patient is streamlined.  

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Secure messaging (SM) is an encrypted, web-based mode of communication within the My HealtheVet (MHV) website. It was developed for the nonurgent, nonemergency communication of test results and other health information as well as for scheduling appointments and renewing medication prescriptions. Secure messaging is asynchronous, which means that communication between parties is not done at the same time. It was designed to address the need for a secure means of communication between patient and provider.¹ Messages can be triaged across teams and saved to the Computerized Patient Record System (CPRS).

The VA patients who use MHV can upgrade their account through an in-person authentication process (IPA), which takes about 10 minutes. Any health care provider (HCP) team or administrator can use SM if set up in the system. Health care providers can only receive messages from patients who have been associated with their triage care group. Patients may only message an HCP with which they are associated. In general, this group would comprise their HCP and 1 or more specialty clinics where they have already been seen. Patients can choose an HCP from a limited drop-down menu.

How Secure Messaging Works

Patients using SM choose a subject, such as appointments, medications, tests, or general. Patients are then able to type a message, and they are also able to see the threads of previous messages. They may access test results or attachments sent to them by the HCPs. Patients are notified of messages through their previously registered e-mail account, which displays a message asking them to log on to MHV.

Health care providers may access MHV either through the CPRS on the tools menu or as a link in an e-mail. Once HCPs log on, they will see their inbox and messages listed by sender and type of inquiry (ie, prescription refill, test question, and so forth). The HCPs can view escalated messages (those that have not been answered within 3 days), drafts, and sent and completed messages. Health care providers can also create special folders to store their messages.

The health care team can personalize how and to whom messages appear. There are 2 main models used by Specialty Care. The first involves a staff member designated to triage messages for the team. This staff member will see all incoming messages and forward them appropriately. For example, in one clinic model, the program assistant reviews all messages and then forwards them to the appropriate provider. The team pharmacist receives prescription requests, the HCP receives general or test inquiries from patients, and the program assistant retains and answers all communication related to appointments and cancellations. Another model involves employing a staff person or administrator as a co-user with each HCP. The HCP can then forward messages that may need administrative action.

The HCPs receive an e-mail notification with a link when a message has been received. Clicking on the link takes them directly to SM within MHV, where they can sign in to see all their messages. Users can also add a signature block, which will appear on all correspondence. They may also designate a surrogate to answer messages when they are unavailable, such as during administrative or personal leave. The HCPs also have the ability to create a SM even if the patient has not yet messaged them. Users can also send copies of messages to other staff members. Providers and staff have the ability to attach a file, which can be a test result, letter, records, etc. Messages can then be saved in the CPRS if desired.

Patients, however, cannot send attachments to their HCP. Only those HCPs who have seen the patient will be available for communication. This system eliminates the possibility of patients self-referring to a specialist and asking questions of HCPs who have never seen them. The HCPs and staff may also forward messages to the appropriate person.

Secure messaging can provide unique opportunities for communication and improvement in outcome measures in certain specialties. For example, in endocrinology patients may be asked to send home blood sugar or blood pressure (BP) readings in between visits, to allow for more rapid medication titration and achievement of treatment goals.  A study by Harris and colleagues showed that the frequent use of electronic SM was associated with improved glycemic control.²

Implementation

At the Atlanta VAMC, SM was implemented in the Primary Care Service Line prior to the Medicine Specialty Care Service Line. The implementation was a natural fit for the organized Primary Care teams. Implementation within the specialties brought forth a new set of issues. Many specialties were not formally organized with a team leader. There were often multiple HCPs in a division, some full time, some part time, in addition to subspecialty pharmacists, physician assistants, and nurse practitioners. Because the Atlanta VAMC is also a training hospital for the Emory University School of Medicine, new residents and fellows are included in the teams each month. It was, therefore, necessary for each specialty to design a message flow that would best fit its needs. Initially, there was concern that SM would add yet another layer of responsibilities to the already stretched HCPs.

The reality has been the opposite. Secure messaging was found to be an additional type of communication, which could be completed more rapidly than a phone call or generating a results letter. The HCPs were also concerned that patients would attempt to use them as primary care providers (PCPs). However, as patients were able to view both their PCP and their specialty care provider in the drop-down menu, they were generally able to direct their questions appropriately.

At the Atlanta VAMC, 60% of the messages were completed by the provider, 29% by a clinical team member, and 11% by the triage staff from 2013 to 2014 (Figure 1). Some HCPs were concerned that once SM was in place, they would be inundated with messages. The reality seems to be that most patients use SM judiciously, and although they are comfortable in the knowledge that they can communicate directly with their HCP, the need is infrequent. The number of messages has slowly increased over the past year as more patients join MHV and SM (Table). Surprisingly, as the number of inbound messages increased, the percentage of escalated messages (messages not answered within 3 days)  declined, indicating a learning curve as HCPs begin using SM.

Challenges

There are 3 steps to patient enrollment in SM. The first is enrollment in MHV, which can be done either online or at the VAMC. The second step requires the patient to go to the VAMC and present identification to complete the IPA. Finally, the enrolled patients must opt-in to the program. Enrollment in MHV has steadily increased through advertising campaigns on the VAMC website, within the VAMC, and through HCPs and staff (Figure 2).

However, barriers still exist. Some patients do not have an Internet connection and are not computer savvy. Other patients express interest but put it off to another visit. Some patients have been confused about the additional step of IPA that is required for SM and stop at enrollment in MHV only.

Therefore the key challenges for implementing SM are facilitating MHV enrollment, IPA, and completion of the opt-in feature. To encourage participation, VISN 7 mailed postcards to all 33,000 patients who had undergone IPA but had not yet opted-in. The number of patients who opted-in quadrupled, demonstrating that this type of promotion is an effective recruitment tool.

Another ongoing challenge is developing a method to easily generate workload credit for the HCPs’ time spent using SM for patient care. This will be an important parameter to track, as the time spent on SM per provider is expected to increase. It has also been suggested that there be an out-of-office response for nonemergent messages and the assignment of a surrogate to handle incoming messages for HCPs who are on leave. An unforeseen example of a nonemergent message occurs when a patient replies “Thank you” to a message from an HCP. That message is then counted as a new message and must be viewed and completed like any other message. It can also become an escalated message, even though there is no important information being transmitted.

Conclusions

Secure messaging provides a simple means of rapid communication and feedback between HCPs and their patients. An e-mail notification is generated, HCPs access SM through the link, the reply is sent, and a CPRS note is automatically generated. That same communication would require a far more time-consuming and complicated process without SM: The patient must contact the service, usually the program assistant, and leave a message; that message would be passed on via voicemail or e-mail to the appropriate HCP; the provider would need to access the CPRS, phone the patient, discuss the issue if the patient is available, and then document the contact with a note in the CPRS. If the patient was unavailable, this process would require multiple phone calls.

With respect to patients, the benefits of SM are significant and include easy access to prescription refills and a quick response to questions about medications, dosages, or tests. Patients are able to change or cancel appointments, thereby avoiding no-shows. Frustration concerning the inability to reach the correct party or to speak with staff directly is reduced with SM, and overall communication between HCP and patient is streamlined.  

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

SAN DIEGO—Reovirus can induce cell death in a range of multiple myeloma (MM) cell lines, and it is synergistic with drugs used to treat MM, according to research presented at the AACR Annual Meeting 2014.

Six of the 7 MM cell lines tested were at least moderately sensitive to reovirus, and introducing the virus in combination with the proteasome inhibitor carfilzomib or the Akt inhibitor perifosine increased antimyeloma activity.

Chandini M. Thirukkumaran, PhD, of The University of Calgary in Canada, and her colleagues presented these results at the meeting as abstract 1709. The study was funded by the Cancer Research Society of Canada.

“Our university, about 15 years ago, found that reovirus can infect all cells, but it will specifically kill cancer cells and not harm normal cells,” Dr Thirukkumaran said. “This is because cancer cells have aberrant Ras signaling pathways, and the virus utilizes that aberrant signaling for its replication.”

“Reovirus kills a lot of myeloma cell lines and cells from patients too, but you always find that therapy-resistant population. So we wondered if we could combine reovirus with common myeloma drugs, like carfilzomib and perifosine, and see whether we could get synergy.”

Dr Thirukkumaran and her colleagues first wanted to quantify the effect of reovirus alone on MM cell lines. So they incubated the cell lines RPMI 8226, MM1.S, NCIH929, U266, INA-6, KMS11, and OPM2 with live reovirus or UV-inactivated reovirus and assessed cell death.

They found that RPMI8226 was highly sensitive to reovirus, and OPM2 was resistant to it. The remaining cell lines were somewhat sensitive to the virus.

The researchers chose RPMI8226, KMS-11, and OPM2 to test reovirus in combination with either carfilzomib or perifosine. They tested the drugs at various concentrations to determine effective dose 50% (ED50) values. They combined ED50 values for each drug and reovirus at various concentrations but with consistent ratios and determined toxicity.

The team used software to generate combination index (CI) values and determine synergism per the Chou-Talalay method. A CI equal to 1 suggested an additive effect, a CI greater than 1 suggested an antagonistic effect, and a CI less than 1 suggested a synergistic effect.

Results showed that reovirus synergized with both carfilzomib and perifosine. Furthermore, the greater a cell line’s resistance to reovirus, the greater the synergy.

For instance, with reovirus and carfilzomib in combination, the ED50 was 1.06 + 0.15 in the reovirus-sensitive RPMI8226 cell line, 0.78 + 0.14 in the moderately sensitive KMS11 cell line, and 0.57 + 0.05 in the resistant OPM2 cell line.

When reovirus and perifosine were combined, the ED50 was 0.97 + 0.19 in the RMI8226 cell line, 0.26 + 0.11 in the KMS11 cell line, and 0.88 + 0.22 in the OPM2 cell line.

The researchers said these results highlight the significance of preclinical studies in evaluating reovirus-drug combinations that could be extrapolated to a clinical setting.

Two phase 2 trials evaluating reovirus in combination therapy for MM are now underway. Meanwhile, Dr Thirukkumaran and her colleagues are hoping to gain more insight into how reovirus-drug combinations work by testing them in mouse models of MM.

SAN DIEGO—Reovirus can induce cell death in a range of multiple myeloma (MM) cell lines, and it is synergistic with drugs used to treat MM, according to research presented at the AACR Annual Meeting 2014.

Six of the 7 MM cell lines tested were at least moderately sensitive to reovirus, and introducing the virus in combination with the proteasome inhibitor carfilzomib or the Akt inhibitor perifosine increased antimyeloma activity.

Chandini M. Thirukkumaran, PhD, of The University of Calgary in Canada, and her colleagues presented these results at the meeting as abstract 1709. The study was funded by the Cancer Research Society of Canada.

“Our university, about 15 years ago, found that reovirus can infect all cells, but it will specifically kill cancer cells and not harm normal cells,” Dr Thirukkumaran said. “This is because cancer cells have aberrant Ras signaling pathways, and the virus utilizes that aberrant signaling for its replication.”

“Reovirus kills a lot of myeloma cell lines and cells from patients too, but you always find that therapy-resistant population. So we wondered if we could combine reovirus with common myeloma drugs, like carfilzomib and perifosine, and see whether we could get synergy.”

Dr Thirukkumaran and her colleagues first wanted to quantify the effect of reovirus alone on MM cell lines. So they incubated the cell lines RPMI 8226, MM1.S, NCIH929, U266, INA-6, KMS11, and OPM2 with live reovirus or UV-inactivated reovirus and assessed cell death.

They found that RPMI8226 was highly sensitive to reovirus, and OPM2 was resistant to it. The remaining cell lines were somewhat sensitive to the virus.

The researchers chose RPMI8226, KMS-11, and OPM2 to test reovirus in combination with either carfilzomib or perifosine. They tested the drugs at various concentrations to determine effective dose 50% (ED50) values. They combined ED50 values for each drug and reovirus at various concentrations but with consistent ratios and determined toxicity.

The team used software to generate combination index (CI) values and determine synergism per the Chou-Talalay method. A CI equal to 1 suggested an additive effect, a CI greater than 1 suggested an antagonistic effect, and a CI less than 1 suggested a synergistic effect.

Results showed that reovirus synergized with both carfilzomib and perifosine. Furthermore, the greater a cell line’s resistance to reovirus, the greater the synergy.

For instance, with reovirus and carfilzomib in combination, the ED50 was 1.06 + 0.15 in the reovirus-sensitive RPMI8226 cell line, 0.78 + 0.14 in the moderately sensitive KMS11 cell line, and 0.57 + 0.05 in the resistant OPM2 cell line.

When reovirus and perifosine were combined, the ED50 was 0.97 + 0.19 in the RMI8226 cell line, 0.26 + 0.11 in the KMS11 cell line, and 0.88 + 0.22 in the OPM2 cell line.

The researchers said these results highlight the significance of preclinical studies in evaluating reovirus-drug combinations that could be extrapolated to a clinical setting.

Two phase 2 trials evaluating reovirus in combination therapy for MM are now underway. Meanwhile, Dr Thirukkumaran and her colleagues are hoping to gain more insight into how reovirus-drug combinations work by testing them in mouse models of MM.

SAN DIEGO—Reovirus can induce cell death in a range of multiple myeloma (MM) cell lines, and it is synergistic with drugs used to treat MM, according to research presented at the AACR Annual Meeting 2014.

Six of the 7 MM cell lines tested were at least moderately sensitive to reovirus, and introducing the virus in combination with the proteasome inhibitor carfilzomib or the Akt inhibitor perifosine increased antimyeloma activity.

Chandini M. Thirukkumaran, PhD, of The University of Calgary in Canada, and her colleagues presented these results at the meeting as abstract 1709. The study was funded by the Cancer Research Society of Canada.

“Our university, about 15 years ago, found that reovirus can infect all cells, but it will specifically kill cancer cells and not harm normal cells,” Dr Thirukkumaran said. “This is because cancer cells have aberrant Ras signaling pathways, and the virus utilizes that aberrant signaling for its replication.”

“Reovirus kills a lot of myeloma cell lines and cells from patients too, but you always find that therapy-resistant population. So we wondered if we could combine reovirus with common myeloma drugs, like carfilzomib and perifosine, and see whether we could get synergy.”

Dr Thirukkumaran and her colleagues first wanted to quantify the effect of reovirus alone on MM cell lines. So they incubated the cell lines RPMI 8226, MM1.S, NCIH929, U266, INA-6, KMS11, and OPM2 with live reovirus or UV-inactivated reovirus and assessed cell death.

They found that RPMI8226 was highly sensitive to reovirus, and OPM2 was resistant to it. The remaining cell lines were somewhat sensitive to the virus.

The researchers chose RPMI8226, KMS-11, and OPM2 to test reovirus in combination with either carfilzomib or perifosine. They tested the drugs at various concentrations to determine effective dose 50% (ED50) values. They combined ED50 values for each drug and reovirus at various concentrations but with consistent ratios and determined toxicity.

The team used software to generate combination index (CI) values and determine synergism per the Chou-Talalay method. A CI equal to 1 suggested an additive effect, a CI greater than 1 suggested an antagonistic effect, and a CI less than 1 suggested a synergistic effect.

Results showed that reovirus synergized with both carfilzomib and perifosine. Furthermore, the greater a cell line’s resistance to reovirus, the greater the synergy.

For instance, with reovirus and carfilzomib in combination, the ED50 was 1.06 + 0.15 in the reovirus-sensitive RPMI8226 cell line, 0.78 + 0.14 in the moderately sensitive KMS11 cell line, and 0.57 + 0.05 in the resistant OPM2 cell line.

When reovirus and perifosine were combined, the ED50 was 0.97 + 0.19 in the RMI8226 cell line, 0.26 + 0.11 in the KMS11 cell line, and 0.88 + 0.22 in the OPM2 cell line.

The researchers said these results highlight the significance of preclinical studies in evaluating reovirus-drug combinations that could be extrapolated to a clinical setting.

Two phase 2 trials evaluating reovirus in combination therapy for MM are now underway. Meanwhile, Dr Thirukkumaran and her colleagues are hoping to gain more insight into how reovirus-drug combinations work by testing them in mouse models of MM.

Fabienne Mackay, PhD

Credit: Monash University

New research may explain why patients with chronic lymphocytic leukemia (CLL) are vulnerable to severe, recurrent infections.

The study showed that plasmacytoid dendritic cells (pDCs), which orchestrate innate and adaptive immune responses, were eliminated in patients with aggressive CLL.

However, patients with a milder form of CLL appeared to have more pDCs, which suggests some protective effect.

Researchers reported these findings in Leukemia.

“These unprecedented findings reveal that these rare but critical cells can be restored at the experiment level, resulting in re-activated immune functions, including the destruction of cancer cells,” said study author Fabienne Mackay, PhD, of Monash University in Melbourne, Victoria, Australia.

“These results provide supporting evidence that a similar approach might have therapeutic benefits in patients with CLL.”

Dr Mackay and her colleagues noted that CLL patients’ vulnerability to infection is caused by a variety of immunological defects. But the initiating events of immunodeficiency in CLL are unclear.

To gain more insight, the researchers studied samples from CLL patients and conducted experiments in mouse models of the disease.

They found that, in progressive CLL, pDC numbers decreased, and their functionality was impaired. As a result, interferon alpha (IFNα) production decreased.

Additional investigation revealed that the decrease in pDCs and reduction in IFNα production resulted from decreased expression of FLT3 and TLR9.

However, the researchers were able to increase FLT3 expression using inhibitors of TGF-β and TNF. And this reduced the tumor load.

The team said these results offer new insight into mechanisms underpinning the immunodeficiency observed in CLL.

And they hope their discoveries will aid the development of new therapeutic strategies that reactivate the immune system and enhance the long-term survival of those CLL patients who are particularly vulnerable to fatal infectious complications.

Fabienne Mackay, PhD

Credit: Monash University

New research may explain why patients with chronic lymphocytic leukemia (CLL) are vulnerable to severe, recurrent infections.

The study showed that plasmacytoid dendritic cells (pDCs), which orchestrate innate and adaptive immune responses, were eliminated in patients with aggressive CLL.

However, patients with a milder form of CLL appeared to have more pDCs, which suggests some protective effect.

Researchers reported these findings in Leukemia.

“These unprecedented findings reveal that these rare but critical cells can be restored at the experiment level, resulting in re-activated immune functions, including the destruction of cancer cells,” said study author Fabienne Mackay, PhD, of Monash University in Melbourne, Victoria, Australia.

“These results provide supporting evidence that a similar approach might have therapeutic benefits in patients with CLL.”

Dr Mackay and her colleagues noted that CLL patients’ vulnerability to infection is caused by a variety of immunological defects. But the initiating events of immunodeficiency in CLL are unclear.

To gain more insight, the researchers studied samples from CLL patients and conducted experiments in mouse models of the disease.

They found that, in progressive CLL, pDC numbers decreased, and their functionality was impaired. As a result, interferon alpha (IFNα) production decreased.

Additional investigation revealed that the decrease in pDCs and reduction in IFNα production resulted from decreased expression of FLT3 and TLR9.

However, the researchers were able to increase FLT3 expression using inhibitors of TGF-β and TNF. And this reduced the tumor load.

The team said these results offer new insight into mechanisms underpinning the immunodeficiency observed in CLL.

And they hope their discoveries will aid the development of new therapeutic strategies that reactivate the immune system and enhance the long-term survival of those CLL patients who are particularly vulnerable to fatal infectious complications.

Fabienne Mackay, PhD

Credit: Monash University

New research may explain why patients with chronic lymphocytic leukemia (CLL) are vulnerable to severe, recurrent infections.

The study showed that plasmacytoid dendritic cells (pDCs), which orchestrate innate and adaptive immune responses, were eliminated in patients with aggressive CLL.

However, patients with a milder form of CLL appeared to have more pDCs, which suggests some protective effect.

Researchers reported these findings in Leukemia.

“These unprecedented findings reveal that these rare but critical cells can be restored at the experiment level, resulting in re-activated immune functions, including the destruction of cancer cells,” said study author Fabienne Mackay, PhD, of Monash University in Melbourne, Victoria, Australia.

“These results provide supporting evidence that a similar approach might have therapeutic benefits in patients with CLL.”

Dr Mackay and her colleagues noted that CLL patients’ vulnerability to infection is caused by a variety of immunological defects. But the initiating events of immunodeficiency in CLL are unclear.

To gain more insight, the researchers studied samples from CLL patients and conducted experiments in mouse models of the disease.

They found that, in progressive CLL, pDC numbers decreased, and their functionality was impaired. As a result, interferon alpha (IFNα) production decreased.

Additional investigation revealed that the decrease in pDCs and reduction in IFNα production resulted from decreased expression of FLT3 and TLR9.

However, the researchers were able to increase FLT3 expression using inhibitors of TGF-β and TNF. And this reduced the tumor load.

The team said these results offer new insight into mechanisms underpinning the immunodeficiency observed in CLL.

And they hope their discoveries will aid the development of new therapeutic strategies that reactivate the immune system and enhance the long-term survival of those CLL patients who are particularly vulnerable to fatal infectious complications.

Umbilical cord clamping

Credit: Meutia Chaerani

and Indradi Soemardjan

A baby’s position prior to delayed umbilical cord clamping does not affect the volume of placental blood transferred, according to a study published in The Lancet.

Researchers found that placing a baby on the mother’s chest or abdomen before clamping does not decrease the amount of blood transferred when compared to holding the child in the recommended introitus position.

As the chest/abdomen position is more desirable, the researchers believe this discovery could help increase the use of delayed cord clamping, which has been shown to reduce the risk of iron deficiency in infancy.

Current recommendations for delayed cord clamping are based on studies conducted 35 years ago. They suggest that, for effective placental transfusion to occur, a baby must be held at the level of the placenta—the introitus position.

The researchers noted that this position can be uncomfortable for the person holding the baby and interferes with immediate contact between the mother and child. These issues could be contributing to low compliance with delayed cord clamping, ultimately resulting in higher-than-necessary levels of iron deficiency in babies.

So the team decided to examine whether the transfer of blood in delayed cord clamping procedures is affected by the position in which the baby is held immediately after birth.

They conducted the study in 3 university-affiliated hospitals in Argentina, evaluating 197 babies who were held in the introitus position and 194 babies who were immediately placed on the mother’s abdomen or chest.

By measuring the babies’ weights at the point of birth and immediately after the delayed cord clamping procedure, the researchers were able to measure the volume of blood that had transferred from the placenta to the child.

They found no statistically significant difference between the 2 groups in the volume of blood transferred. The mean weight change was 56 g for babies in the introitus group and 53 g for babies in the abdomen/chest group (P=0.45).

“Our study suggests that when umbilical cord clamping is delayed for 2 minutes, holding the baby on the mother’s chest or abdomen is no worse than the currently recommended practice of holding the baby below this level,” said study author Nestor Vain, MD, of the Foundation for Maternal and Child Health (FUNDASAMIN) in Buenos Aires, Argentina.

“Because of the potential of enhanced bonding between mother and baby, increased success of breastfeeding, and the compliance with the procedure, holding the infant by the mother immediately after birth should be strongly recommended.”

Writing in a related comment article, Tonse Raju, MD, of the National Institute of Child Health and Human Development in Bethesda, Maryland, noted that introducing delayed cord clamping into practice has not been easy, and logistical issues might be partly responsible.

“Intuitively, to keep the newborn baby’s position below the level of the placenta in situ should maximize the volume of placental transfusion,” Dr Raju wrote. “However, trying to hold on to a wet, vigorously crying, and wriggling infant at the perineum for 2 minutes, in gloved hands, is awkward and can be risky.”

“[This study] should bring a sigh of relief from those trying to incorporate delayed umbilical cord clamping into practice. The results are convincing and show that gravity did not have an effect on volume of placental transfusion.”

Umbilical cord clamping

Credit: Meutia Chaerani

and Indradi Soemardjan

A baby’s position prior to delayed umbilical cord clamping does not affect the volume of placental blood transferred, according to a study published in The Lancet.

Researchers found that placing a baby on the mother’s chest or abdomen before clamping does not decrease the amount of blood transferred when compared to holding the child in the recommended introitus position.

As the chest/abdomen position is more desirable, the researchers believe this discovery could help increase the use of delayed cord clamping, which has been shown to reduce the risk of iron deficiency in infancy.

Current recommendations for delayed cord clamping are based on studies conducted 35 years ago. They suggest that, for effective placental transfusion to occur, a baby must be held at the level of the placenta—the introitus position.

The researchers noted that this position can be uncomfortable for the person holding the baby and interferes with immediate contact between the mother and child. These issues could be contributing to low compliance with delayed cord clamping, ultimately resulting in higher-than-necessary levels of iron deficiency in babies.

So the team decided to examine whether the transfer of blood in delayed cord clamping procedures is affected by the position in which the baby is held immediately after birth.

They conducted the study in 3 university-affiliated hospitals in Argentina, evaluating 197 babies who were held in the introitus position and 194 babies who were immediately placed on the mother’s abdomen or chest.

By measuring the babies’ weights at the point of birth and immediately after the delayed cord clamping procedure, the researchers were able to measure the volume of blood that had transferred from the placenta to the child.

They found no statistically significant difference between the 2 groups in the volume of blood transferred. The mean weight change was 56 g for babies in the introitus group and 53 g for babies in the abdomen/chest group (P=0.45).

“Our study suggests that when umbilical cord clamping is delayed for 2 minutes, holding the baby on the mother’s chest or abdomen is no worse than the currently recommended practice of holding the baby below this level,” said study author Nestor Vain, MD, of the Foundation for Maternal and Child Health (FUNDASAMIN) in Buenos Aires, Argentina.

“Because of the potential of enhanced bonding between mother and baby, increased success of breastfeeding, and the compliance with the procedure, holding the infant by the mother immediately after birth should be strongly recommended.”

Writing in a related comment article, Tonse Raju, MD, of the National Institute of Child Health and Human Development in Bethesda, Maryland, noted that introducing delayed cord clamping into practice has not been easy, and logistical issues might be partly responsible.

“Intuitively, to keep the newborn baby’s position below the level of the placenta in situ should maximize the volume of placental transfusion,” Dr Raju wrote. “However, trying to hold on to a wet, vigorously crying, and wriggling infant at the perineum for 2 minutes, in gloved hands, is awkward and can be risky.”

“[This study] should bring a sigh of relief from those trying to incorporate delayed umbilical cord clamping into practice. The results are convincing and show that gravity did not have an effect on volume of placental transfusion.”

Umbilical cord clamping

Credit: Meutia Chaerani

and Indradi Soemardjan

A baby’s position prior to delayed umbilical cord clamping does not affect the volume of placental blood transferred, according to a study published in The Lancet.

Researchers found that placing a baby on the mother’s chest or abdomen before clamping does not decrease the amount of blood transferred when compared to holding the child in the recommended introitus position.

As the chest/abdomen position is more desirable, the researchers believe this discovery could help increase the use of delayed cord clamping, which has been shown to reduce the risk of iron deficiency in infancy.

Current recommendations for delayed cord clamping are based on studies conducted 35 years ago. They suggest that, for effective placental transfusion to occur, a baby must be held at the level of the placenta—the introitus position.

The researchers noted that this position can be uncomfortable for the person holding the baby and interferes with immediate contact between the mother and child. These issues could be contributing to low compliance with delayed cord clamping, ultimately resulting in higher-than-necessary levels of iron deficiency in babies.

So the team decided to examine whether the transfer of blood in delayed cord clamping procedures is affected by the position in which the baby is held immediately after birth.

They conducted the study in 3 university-affiliated hospitals in Argentina, evaluating 197 babies who were held in the introitus position and 194 babies who were immediately placed on the mother’s abdomen or chest.

By measuring the babies’ weights at the point of birth and immediately after the delayed cord clamping procedure, the researchers were able to measure the volume of blood that had transferred from the placenta to the child.

They found no statistically significant difference between the 2 groups in the volume of blood transferred. The mean weight change was 56 g for babies in the introitus group and 53 g for babies in the abdomen/chest group (P=0.45).

“Our study suggests that when umbilical cord clamping is delayed for 2 minutes, holding the baby on the mother’s chest or abdomen is no worse than the currently recommended practice of holding the baby below this level,” said study author Nestor Vain, MD, of the Foundation for Maternal and Child Health (FUNDASAMIN) in Buenos Aires, Argentina.

“Because of the potential of enhanced bonding between mother and baby, increased success of breastfeeding, and the compliance with the procedure, holding the infant by the mother immediately after birth should be strongly recommended.”

Writing in a related comment article, Tonse Raju, MD, of the National Institute of Child Health and Human Development in Bethesda, Maryland, noted that introducing delayed cord clamping into practice has not been easy, and logistical issues might be partly responsible.

“Intuitively, to keep the newborn baby’s position below the level of the placenta in situ should maximize the volume of placental transfusion,” Dr Raju wrote. “However, trying to hold on to a wet, vigorously crying, and wriggling infant at the perineum for 2 minutes, in gloved hands, is awkward and can be risky.”

“[This study] should bring a sigh of relief from those trying to incorporate delayed umbilical cord clamping into practice. The results are convincing and show that gravity did not have an effect on volume of placental transfusion.”

A new study¹ provides the first evidence of a direct effect of maternal metabolism on fetal brain activity, suggesting that insulin resistance, the precursor to type 2 diabetes, begins its formation prenatally.

DETAILS OF THE STUDY

Dr. Katarzyna Linder from the University Hospital Tübingen in Germany and colleagues included in their study 13 healthy pregnant women with normal, singleton pregnancies of between 27 and 36 weeks. All of the women underwent an oral glucose tolerance test, meaning that after a 5-hour overnight fast, each woman drank a solution containing 75 g glucose. The investigators ascertained blood glucose and plasma insulin levels from blood samples taken at 0, 60, and 120 minutes.

At approximately the same time points, but before they drew each blood sample, the authors obtained a fetal magnetoencephalography (fMEG) measurement in an effort to noninvasively record brain activity in utero. During each measurement, they presented an auditory sequence to the fetus. Most (75%) of the time, the sound presented had a frequency of 500 Hz, but 25% of the time the researchers presented a deviant tone with a frequency of 750 Hz to prevent habituation.

The researchers found that maternal insulin sensitivity significantly correlated with response latency of the fetus at the 60-minute time point, so that the higher the insulin sensitivity of the mother, the shorter the response time of the fetus to the sound. The association remained significant even after the investigators controlled for relative maternal weight gain, gestational age, and the child’s birth weight. No significant correlation existed at baseline or at 120 minutes.

The investigators then split the women into 2 groups: those who were insulin-resistant and those who were insulin-sensitive. They found that the fetuses of the insulin-resistant moms were almost 40% slower to respond to the auditory stimuli than those of the insulin-sensitive moms (mean [SD], 283 [79] ms vs 178 [46] ms; P=.03).

INTERPRETING THE FINDINGS

According to the US Centers for Disease Control and Prevention, almost one-third (30.3%) of US adults between the ages of 20 and 39 years—the primary child-bearing years—are obese,² as are 17% of our children and adolescents—triple the rate of 1 generation previous.³ Furthermore, 25.8 million people in the United States have diabetes, including 1 in every 400 children and adolescents.⁴

Experts know that the children of obese or diabetic mothers are at increased risk for obesity and type 2 diabetes as adults, and that the connection is not purely genetic; environmental and epigenetic (environmental elements that affect genetics) factors also play key roles. The latter is the basis for the fetal or developmental origins hypothesis,⁵ which posits that a pregnant woman’s exposure to certain environmental factors can affect the programming of her unborn child and impact adult health.

The authors of the current study demonstrate that the metabolism of a pregnant woman after a sugar load directly affects the response time and brain activity of her developing fetus. They suggest as a mechanism for the effect that “insulin-resistant mothers have higher glucose levels accompanied by increased insulin levels in the postprandial state. As glucose passes the placenta, these postprandially increased glucose levels induce hyperinsulinaemia in the fetus.” The resulting chronic hyperinsulinemia “might induce insulin resistance in the fetal brain.”

A new study¹ provides the first evidence of a direct effect of maternal metabolism on fetal brain activity, suggesting that insulin resistance, the precursor to type 2 diabetes, begins its formation prenatally.

DETAILS OF THE STUDY

Dr. Katarzyna Linder from the University Hospital Tübingen in Germany and colleagues included in their study 13 healthy pregnant women with normal, singleton pregnancies of between 27 and 36 weeks. All of the women underwent an oral glucose tolerance test, meaning that after a 5-hour overnight fast, each woman drank a solution containing 75 g glucose. The investigators ascertained blood glucose and plasma insulin levels from blood samples taken at 0, 60, and 120 minutes.

At approximately the same time points, but before they drew each blood sample, the authors obtained a fetal magnetoencephalography (fMEG) measurement in an effort to noninvasively record brain activity in utero. During each measurement, they presented an auditory sequence to the fetus. Most (75%) of the time, the sound presented had a frequency of 500 Hz, but 25% of the time the researchers presented a deviant tone with a frequency of 750 Hz to prevent habituation.

The researchers found that maternal insulin sensitivity significantly correlated with response latency of the fetus at the 60-minute time point, so that the higher the insulin sensitivity of the mother, the shorter the response time of the fetus to the sound. The association remained significant even after the investigators controlled for relative maternal weight gain, gestational age, and the child’s birth weight. No significant correlation existed at baseline or at 120 minutes.

The investigators then split the women into 2 groups: those who were insulin-resistant and those who were insulin-sensitive. They found that the fetuses of the insulin-resistant moms were almost 40% slower to respond to the auditory stimuli than those of the insulin-sensitive moms (mean [SD], 283 [79] ms vs 178 [46] ms; P=.03).

INTERPRETING THE FINDINGS

According to the US Centers for Disease Control and Prevention, almost one-third (30.3%) of US adults between the ages of 20 and 39 years—the primary child-bearing years—are obese,² as are 17% of our children and adolescents—triple the rate of 1 generation previous.³ Furthermore, 25.8 million people in the United States have diabetes, including 1 in every 400 children and adolescents.⁴

Experts know that the children of obese or diabetic mothers are at increased risk for obesity and type 2 diabetes as adults, and that the connection is not purely genetic; environmental and epigenetic (environmental elements that affect genetics) factors also play key roles. The latter is the basis for the fetal or developmental origins hypothesis,⁵ which posits that a pregnant woman’s exposure to certain environmental factors can affect the programming of her unborn child and impact adult health.

The authors of the current study demonstrate that the metabolism of a pregnant woman after a sugar load directly affects the response time and brain activity of her developing fetus. They suggest as a mechanism for the effect that “insulin-resistant mothers have higher glucose levels accompanied by increased insulin levels in the postprandial state. As glucose passes the placenta, these postprandially increased glucose levels induce hyperinsulinaemia in the fetus.” The resulting chronic hyperinsulinemia “might induce insulin resistance in the fetal brain.”

A new study¹ provides the first evidence of a direct effect of maternal metabolism on fetal brain activity, suggesting that insulin resistance, the precursor to type 2 diabetes, begins its formation prenatally.

DETAILS OF THE STUDY

Dr. Katarzyna Linder from the University Hospital Tübingen in Germany and colleagues included in their study 13 healthy pregnant women with normal, singleton pregnancies of between 27 and 36 weeks. All of the women underwent an oral glucose tolerance test, meaning that after a 5-hour overnight fast, each woman drank a solution containing 75 g glucose. The investigators ascertained blood glucose and plasma insulin levels from blood samples taken at 0, 60, and 120 minutes.

At approximately the same time points, but before they drew each blood sample, the authors obtained a fetal magnetoencephalography (fMEG) measurement in an effort to noninvasively record brain activity in utero. During each measurement, they presented an auditory sequence to the fetus. Most (75%) of the time, the sound presented had a frequency of 500 Hz, but 25% of the time the researchers presented a deviant tone with a frequency of 750 Hz to prevent habituation.

The researchers found that maternal insulin sensitivity significantly correlated with response latency of the fetus at the 60-minute time point, so that the higher the insulin sensitivity of the mother, the shorter the response time of the fetus to the sound. The association remained significant even after the investigators controlled for relative maternal weight gain, gestational age, and the child’s birth weight. No significant correlation existed at baseline or at 120 minutes.

The investigators then split the women into 2 groups: those who were insulin-resistant and those who were insulin-sensitive. They found that the fetuses of the insulin-resistant moms were almost 40% slower to respond to the auditory stimuli than those of the insulin-sensitive moms (mean [SD], 283 [79] ms vs 178 [46] ms; P=.03).

INTERPRETING THE FINDINGS

According to the US Centers for Disease Control and Prevention, almost one-third (30.3%) of US adults between the ages of 20 and 39 years—the primary child-bearing years—are obese,² as are 17% of our children and adolescents—triple the rate of 1 generation previous.³ Furthermore, 25.8 million people in the United States have diabetes, including 1 in every 400 children and adolescents.⁴

Experts know that the children of obese or diabetic mothers are at increased risk for obesity and type 2 diabetes as adults, and that the connection is not purely genetic; environmental and epigenetic (environmental elements that affect genetics) factors also play key roles. The latter is the basis for the fetal or developmental origins hypothesis,⁵ which posits that a pregnant woman’s exposure to certain environmental factors can affect the programming of her unborn child and impact adult health.

The authors of the current study demonstrate that the metabolism of a pregnant woman after a sugar load directly affects the response time and brain activity of her developing fetus. They suggest as a mechanism for the effect that “insulin-resistant mothers have higher glucose levels accompanied by increased insulin levels in the postprandial state. As glucose passes the placenta, these postprandially increased glucose levels induce hyperinsulinaemia in the fetus.” The resulting chronic hyperinsulinemia “might induce insulin resistance in the fetal brain.”

Congress has once again delayed implementation of draconian Medicare cuts tied to the sustainable growth rate (SGR) formula, but this time, the vote by lawmakers to patch the ailing physician reimbursement program rather than scrap it also pushes back the pending debut of ICD-10.

And that's frustrating some hospitalists.

"For about 12 hours, I felt relief about the ICD-10 and then I just realized, it's still coming, presumably," says John Nelson, MD, MHM, a co-founder and past president of SHM and medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. "[It's] like a patient who needs surgery and finds out it's canceled for the day and he'll have it tomorrow. Well, that's good for right now, but [he] still has to face this eventually."

The SGR extension through year's end means that physicians do not face a 24% cut to physician payments under Medicare. The delay in transitioning healthcare providers from the ICD-9 medical coding classification system to the more complicated ICD-10 could mean the upgraded system may not go into effect until at least Oct. 1, 2015. This comes after the Centers for Medicare & Medicaid Services already pushed back the original implementation date for ICD-10 by one year.

SHM Public Policy Committee member Joshua Lenchus, DO, RPh, SFHM, says he expects the majority of doctors to be content with the delay, particularly in light of some estimates that show only 20% or so of physicians "have actually initiated the ICD-10 transition," but that it's unfair to those health systems that have prepared.

"ICD-9 has a little more than 14,000 diagnostic codes and nearly 4,000 procedural codes. That is to be contrasted to ICD-10, which has more than 68,000 diagnostic codes...and over 72,000 procedural codes," Dr. Lenchus writes in an e-mail to The Hospitalist's eWire. "So, it is not surprising that many take solace in the delay."

"It's distressing and frustrating for hospitalists, but less disruptive than it might be for hospitals," Dr. Nelson says. "And, of course in some places, hospitalists may be the physician leads on ICD-10 efforts, so [they are] very much wrapped up in the problem of 'What do we do now?'"

Visit our website for more information about ICD-10.

Congress has once again delayed implementation of draconian Medicare cuts tied to the sustainable growth rate (SGR) formula, but this time, the vote by lawmakers to patch the ailing physician reimbursement program rather than scrap it also pushes back the pending debut of ICD-10.

And that's frustrating some hospitalists.

"For about 12 hours, I felt relief about the ICD-10 and then I just realized, it's still coming, presumably," says John Nelson, MD, MHM, a co-founder and past president of SHM and medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. "[It's] like a patient who needs surgery and finds out it's canceled for the day and he'll have it tomorrow. Well, that's good for right now, but [he] still has to face this eventually."

The SGR extension through year's end means that physicians do not face a 24% cut to physician payments under Medicare. The delay in transitioning healthcare providers from the ICD-9 medical coding classification system to the more complicated ICD-10 could mean the upgraded system may not go into effect until at least Oct. 1, 2015. This comes after the Centers for Medicare & Medicaid Services already pushed back the original implementation date for ICD-10 by one year.

SHM Public Policy Committee member Joshua Lenchus, DO, RPh, SFHM, says he expects the majority of doctors to be content with the delay, particularly in light of some estimates that show only 20% or so of physicians "have actually initiated the ICD-10 transition," but that it's unfair to those health systems that have prepared.

"ICD-9 has a little more than 14,000 diagnostic codes and nearly 4,000 procedural codes. That is to be contrasted to ICD-10, which has more than 68,000 diagnostic codes...and over 72,000 procedural codes," Dr. Lenchus writes in an e-mail to The Hospitalist's eWire. "So, it is not surprising that many take solace in the delay."

"It's distressing and frustrating for hospitalists, but less disruptive than it might be for hospitals," Dr. Nelson says. "And, of course in some places, hospitalists may be the physician leads on ICD-10 efforts, so [they are] very much wrapped up in the problem of 'What do we do now?'"

Visit our website for more information about ICD-10.

Congress has once again delayed implementation of draconian Medicare cuts tied to the sustainable growth rate (SGR) formula, but this time, the vote by lawmakers to patch the ailing physician reimbursement program rather than scrap it also pushes back the pending debut of ICD-10.

And that's frustrating some hospitalists.

"For about 12 hours, I felt relief about the ICD-10 and then I just realized, it's still coming, presumably," says John Nelson, MD, MHM, a co-founder and past president of SHM and medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. "[It's] like a patient who needs surgery and finds out it's canceled for the day and he'll have it tomorrow. Well, that's good for right now, but [he] still has to face this eventually."

The SGR extension through year's end means that physicians do not face a 24% cut to physician payments under Medicare. The delay in transitioning healthcare providers from the ICD-9 medical coding classification system to the more complicated ICD-10 could mean the upgraded system may not go into effect until at least Oct. 1, 2015. This comes after the Centers for Medicare & Medicaid Services already pushed back the original implementation date for ICD-10 by one year.

SHM Public Policy Committee member Joshua Lenchus, DO, RPh, SFHM, says he expects the majority of doctors to be content with the delay, particularly in light of some estimates that show only 20% or so of physicians "have actually initiated the ICD-10 transition," but that it's unfair to those health systems that have prepared.

"ICD-9 has a little more than 14,000 diagnostic codes and nearly 4,000 procedural codes. That is to be contrasted to ICD-10, which has more than 68,000 diagnostic codes...and over 72,000 procedural codes," Dr. Lenchus writes in an e-mail to The Hospitalist's eWire. "So, it is not surprising that many take solace in the delay."

"It's distressing and frustrating for hospitalists, but less disruptive than it might be for hospitals," Dr. Nelson says. "And, of course in some places, hospitalists may be the physician leads on ICD-10 efforts, so [they are] very much wrapped up in the problem of 'What do we do now?'"

Visit our website for more information about ICD-10.