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The stigma tied to mental illness can be particularly difficult to overcome for people of Latin American descent, writes Concepción de León in El Espace, a column in the New York Times focused on news and culture relevant to Latinx communities. Sometimes those seeking help run into familiar mantras. “Let me know if any of these sound familiar: 'Boys don’t cry. We don’t air family business. You have to be strong. Turn to God.' These refrains (all of which I’ve heard at least once...) are just some of the responses that people dealing with mental health challenges in Latino communities have come to know well,” Ms. de León wrote. The unequal access to mental health services and health insurance that is a reality for some Latinos compounds the problem. The result is that mental illness can go untreated. Indeed, according to Ms. de León, Latinos, who are just as likely to suffer from a mental illness as non-Hispanic whites, are half as likely to seek treatment. Adriana Alejandre, a Latina who is a licensed marriage and family therapist in Los Angeles, is seeking to change that statistic. Through her podcast, Latinx Therapy, she seeks to spread the word that seeking therapy for mental illness is a positive step. There’s a long way to go, partly because Latino communities tend to value the group over the individual. “The downfall is that people suffer in silence,” said Ms. Alejandre. Therapy is important for some Latinos, according to Ms. Alejandre, because of intergenerational trauma that “allows the cycle to continue – whether it’s trauma, whether it’s depression, anxiety, domestic violence.” Ms. de León said one strategy she used for more than 1 year while she was in therapy was to set boundaries by not sharing what she was doing with family members. “It is tough when family sees you as ungrateful for healthy behaviors like boundary setting,” Ms. Alejandre said. “But the system will not change if someone does not initiate the change.” The New York Times.

Some state governments are seeking to make mental health services more available. The proposed budget of democratic Gov. Tony Evers of Wisconsin aims to allocate $22 million in mental health funding to school districts in the state to pay for social workers, psychologists, counselors, and nurses. The money would come on top of the $3 million designated by his predecessor and continues the efforts in Wisconsin to give children with mental health problems more access to needed help. The proposed budget also would add $7 million to a state program that works with local health agencies with the goal of providing mental health services for students and would allocate about $2.5 million annually for school staff training. The news is welcome to school districts across Wisconsin. “Schools are struggling to meet all of those [mental health] needs. I think there is an understanding that this is really something we need to be addressing,” said Joanne Juhnke, policy director at Wisconsin Family Ties, which helps families with children who have mental health challenges. Post Crescent, part of the USA Today network.

In Pennsylvania, the state Supreme Court is set to rule on whether those who provide mental health treatment to people addicted to illicit drugs can be free from prosecution. Right now, they are not. As reported in the Legal Intelligence, the case concerns two physicians at a drug addiction treatment facility who treated a man with an opioid addiction. In July 2018, a three-judge Superior Court panel upheld that physicians should not have liability protections under the Mental Health Procedures Act (MHPA). The ruling reversed a lower court decision. The Superior Court judges sympathized with the view that treatment of mental illness in drug treatment facilities be given more legal leeway. Whether that leeway remains in place depends on the Supreme Court. If judges decide no, physicians who recognize signs of mental illness in patients being treated for drug addiction would treat the illness at the risk of subsequent liability. The case has again raised the issue of whether alcoholism and drug dependency should be considered mental illnesses. “We don’t believe it was the intended purpose of the MPHA to include drug addiction. Our concern is we don’t want hospitals or rehab facilities just having patients be seen by psychiatrists in order to invoke the MHPA,” said Patrick Mintzer, the lawyer who will argue the cases before the court. A counter view came from Jack Panella, one of the three Superior Court judges. In his decision, he wrote: “In light of current scientific research, as well as the recent addition of ‘addiction disorders’ to the American Psychiatric Association’s Diagnostic and Statistical Manual–5, we suggest that the Department of Human Services revise this definition.” The Legal Intelligence.

An op-ed in the Des Moines Register applauds republican Gov. Kim Reynolds for introducing two bills that are aimed at expanding mental health services to children and family in Iowa. “After decades of discussion and growing public support, these two bills take a huge step toward establishing a children’s mental health system,” wrote guest columnists Erin Drinnin of the United Way of Central Iowa and Kim Scorza of Seasons Center for Behavioral Health. The two also serve as cochairs of the Coalition to Advance Mental Health in Iowa for Kids (CAMHI4Kids), which includes more than 50 organizations. “Just like building a house requires a sturdy foundation, these bills are an important first step toward creating a structure for children’s mental well-being. In particular, CAMHI4Kids appreciates that these bills establish a voice and a seat for children and families at a regional level, using a system that is already in place,” wrote Ms. Drinnin and Ms. Scorza. The legislation would spell out the core services that would be available regardless of location in Iowa. The services would be geared toward children, rather than adults, reflecting the different mental health needs of children. “These important steps would finally sew together a patchwork of care that families currently must navigate with little direction. If a child is hurt on the playground, a caregiver knows to follow a clear path of care to help that child recover. But for a caregiver who is concerned about a child’s mental health, they often don’t know where to turn for help and must seek out services that might not exist in their community,” wrote Ms. Drinnin and Ms. Scorza. In Iowa, 80,000 children have a diagnosed serious emotional disturbance. About half of children aged 14 years and older with mental illness drop out of high school, and 70% of youth in Iowa’s juvenile justice system have a mental illness. “We are proud that Iowa is working together in a bipartisan way to ensure that our kids have the best start for future success,” wrote Ms. Drinnin and Ms. Scorza. Des Moines Register.

Bill Reilly is the peer support program manager for Bert Nash Community Mental Health Center in Douglas County, Kan. His mental health troubles began in childhood and led to stints in alcohol rehabilitation and mental hospitals, and he tried to end his life several times. But Mr. Reilly now offers his experience to those in trouble. “Those [experiences] can be viewed as a negative until you turn that conversation around and ask, ‘How can this be helpful to another person?’ And to me, that’s where the urgency comes into the work that we’re doing because a clinical relationship is one thing, but a peer support relationship is something different.” He was speaking in support of an initiative that seeks to train and place peer support people in hospital emergency departments in Kansas. The initiative is being spearheaded by Bob Tryanski, Douglas County director of behavioral health projects. “In addition to giving folks the opportunity to have the work experience in an environment where we need peer support, we would wrap around those peers with training, professional development, with coaching and support in an ongoing way,” Mr. Tryanski said, “so that they could become real, robust, huge resources, not just to the emergency department but in our community.” If approved, hiring and training of peers would begin in April, with the goal of having six people in place in emergency rooms by the summer and hiring an additional six people by year end. LJWorld.com.

Wavebreakmedia/iStock/Getty Images

The stigma tied to mental illness can be particularly difficult to overcome for people of Latin American descent, writes Concepción de León in El Espace, a column in the New York Times focused on news and culture relevant to Latinx communities. Sometimes those seeking help run into familiar mantras. “Let me know if any of these sound familiar: 'Boys don’t cry. We don’t air family business. You have to be strong. Turn to God.' These refrains (all of which I’ve heard at least once...) are just some of the responses that people dealing with mental health challenges in Latino communities have come to know well,” Ms. de León wrote. The unequal access to mental health services and health insurance that is a reality for some Latinos compounds the problem. The result is that mental illness can go untreated. Indeed, according to Ms. de León, Latinos, who are just as likely to suffer from a mental illness as non-Hispanic whites, are half as likely to seek treatment. Adriana Alejandre, a Latina who is a licensed marriage and family therapist in Los Angeles, is seeking to change that statistic. Through her podcast, Latinx Therapy, she seeks to spread the word that seeking therapy for mental illness is a positive step. There’s a long way to go, partly because Latino communities tend to value the group over the individual. “The downfall is that people suffer in silence,” said Ms. Alejandre. Therapy is important for some Latinos, according to Ms. Alejandre, because of intergenerational trauma that “allows the cycle to continue – whether it’s trauma, whether it’s depression, anxiety, domestic violence.” Ms. de León said one strategy she used for more than 1 year while she was in therapy was to set boundaries by not sharing what she was doing with family members. “It is tough when family sees you as ungrateful for healthy behaviors like boundary setting,” Ms. Alejandre said. “But the system will not change if someone does not initiate the change.” The New York Times.

Some state governments are seeking to make mental health services more available. The proposed budget of democratic Gov. Tony Evers of Wisconsin aims to allocate $22 million in mental health funding to school districts in the state to pay for social workers, psychologists, counselors, and nurses. The money would come on top of the $3 million designated by his predecessor and continues the efforts in Wisconsin to give children with mental health problems more access to needed help. The proposed budget also would add $7 million to a state program that works with local health agencies with the goal of providing mental health services for students and would allocate about $2.5 million annually for school staff training. The news is welcome to school districts across Wisconsin. “Schools are struggling to meet all of those [mental health] needs. I think there is an understanding that this is really something we need to be addressing,” said Joanne Juhnke, policy director at Wisconsin Family Ties, which helps families with children who have mental health challenges. Post Crescent, part of the USA Today network.

In Pennsylvania, the state Supreme Court is set to rule on whether those who provide mental health treatment to people addicted to illicit drugs can be free from prosecution. Right now, they are not. As reported in the Legal Intelligence, the case concerns two physicians at a drug addiction treatment facility who treated a man with an opioid addiction. In July 2018, a three-judge Superior Court panel upheld that physicians should not have liability protections under the Mental Health Procedures Act (MHPA). The ruling reversed a lower court decision. The Superior Court judges sympathized with the view that treatment of mental illness in drug treatment facilities be given more legal leeway. Whether that leeway remains in place depends on the Supreme Court. If judges decide no, physicians who recognize signs of mental illness in patients being treated for drug addiction would treat the illness at the risk of subsequent liability. The case has again raised the issue of whether alcoholism and drug dependency should be considered mental illnesses. “We don’t believe it was the intended purpose of the MPHA to include drug addiction. Our concern is we don’t want hospitals or rehab facilities just having patients be seen by psychiatrists in order to invoke the MHPA,” said Patrick Mintzer, the lawyer who will argue the cases before the court. A counter view came from Jack Panella, one of the three Superior Court judges. In his decision, he wrote: “In light of current scientific research, as well as the recent addition of ‘addiction disorders’ to the American Psychiatric Association’s Diagnostic and Statistical Manual–5, we suggest that the Department of Human Services revise this definition.” The Legal Intelligence.

An op-ed in the Des Moines Register applauds republican Gov. Kim Reynolds for introducing two bills that are aimed at expanding mental health services to children and family in Iowa. “After decades of discussion and growing public support, these two bills take a huge step toward establishing a children’s mental health system,” wrote guest columnists Erin Drinnin of the United Way of Central Iowa and Kim Scorza of Seasons Center for Behavioral Health. The two also serve as cochairs of the Coalition to Advance Mental Health in Iowa for Kids (CAMHI4Kids), which includes more than 50 organizations. “Just like building a house requires a sturdy foundation, these bills are an important first step toward creating a structure for children’s mental well-being. In particular, CAMHI4Kids appreciates that these bills establish a voice and a seat for children and families at a regional level, using a system that is already in place,” wrote Ms. Drinnin and Ms. Scorza. The legislation would spell out the core services that would be available regardless of location in Iowa. The services would be geared toward children, rather than adults, reflecting the different mental health needs of children. “These important steps would finally sew together a patchwork of care that families currently must navigate with little direction. If a child is hurt on the playground, a caregiver knows to follow a clear path of care to help that child recover. But for a caregiver who is concerned about a child’s mental health, they often don’t know where to turn for help and must seek out services that might not exist in their community,” wrote Ms. Drinnin and Ms. Scorza. In Iowa, 80,000 children have a diagnosed serious emotional disturbance. About half of children aged 14 years and older with mental illness drop out of high school, and 70% of youth in Iowa’s juvenile justice system have a mental illness. “We are proud that Iowa is working together in a bipartisan way to ensure that our kids have the best start for future success,” wrote Ms. Drinnin and Ms. Scorza. Des Moines Register.

Bill Reilly is the peer support program manager for Bert Nash Community Mental Health Center in Douglas County, Kan. His mental health troubles began in childhood and led to stints in alcohol rehabilitation and mental hospitals, and he tried to end his life several times. But Mr. Reilly now offers his experience to those in trouble. “Those [experiences] can be viewed as a negative until you turn that conversation around and ask, ‘How can this be helpful to another person?’ And to me, that’s where the urgency comes into the work that we’re doing because a clinical relationship is one thing, but a peer support relationship is something different.” He was speaking in support of an initiative that seeks to train and place peer support people in hospital emergency departments in Kansas. The initiative is being spearheaded by Bob Tryanski, Douglas County director of behavioral health projects. “In addition to giving folks the opportunity to have the work experience in an environment where we need peer support, we would wrap around those peers with training, professional development, with coaching and support in an ongoing way,” Mr. Tryanski said, “so that they could become real, robust, huge resources, not just to the emergency department but in our community.” If approved, hiring and training of peers would begin in April, with the goal of having six people in place in emergency rooms by the summer and hiring an additional six people by year end. LJWorld.com.

Wavebreakmedia/iStock/Getty Images

The stigma tied to mental illness can be particularly difficult to overcome for people of Latin American descent, writes Concepción de León in El Espace, a column in the New York Times focused on news and culture relevant to Latinx communities. Sometimes those seeking help run into familiar mantras. “Let me know if any of these sound familiar: 'Boys don’t cry. We don’t air family business. You have to be strong. Turn to God.' These refrains (all of which I’ve heard at least once...) are just some of the responses that people dealing with mental health challenges in Latino communities have come to know well,” Ms. de León wrote. The unequal access to mental health services and health insurance that is a reality for some Latinos compounds the problem. The result is that mental illness can go untreated. Indeed, according to Ms. de León, Latinos, who are just as likely to suffer from a mental illness as non-Hispanic whites, are half as likely to seek treatment. Adriana Alejandre, a Latina who is a licensed marriage and family therapist in Los Angeles, is seeking to change that statistic. Through her podcast, Latinx Therapy, she seeks to spread the word that seeking therapy for mental illness is a positive step. There’s a long way to go, partly because Latino communities tend to value the group over the individual. “The downfall is that people suffer in silence,” said Ms. Alejandre. Therapy is important for some Latinos, according to Ms. Alejandre, because of intergenerational trauma that “allows the cycle to continue – whether it’s trauma, whether it’s depression, anxiety, domestic violence.” Ms. de León said one strategy she used for more than 1 year while she was in therapy was to set boundaries by not sharing what she was doing with family members. “It is tough when family sees you as ungrateful for healthy behaviors like boundary setting,” Ms. Alejandre said. “But the system will not change if someone does not initiate the change.” The New York Times.

Some state governments are seeking to make mental health services more available. The proposed budget of democratic Gov. Tony Evers of Wisconsin aims to allocate $22 million in mental health funding to school districts in the state to pay for social workers, psychologists, counselors, and nurses. The money would come on top of the $3 million designated by his predecessor and continues the efforts in Wisconsin to give children with mental health problems more access to needed help. The proposed budget also would add $7 million to a state program that works with local health agencies with the goal of providing mental health services for students and would allocate about $2.5 million annually for school staff training. The news is welcome to school districts across Wisconsin. “Schools are struggling to meet all of those [mental health] needs. I think there is an understanding that this is really something we need to be addressing,” said Joanne Juhnke, policy director at Wisconsin Family Ties, which helps families with children who have mental health challenges. Post Crescent, part of the USA Today network.

In Pennsylvania, the state Supreme Court is set to rule on whether those who provide mental health treatment to people addicted to illicit drugs can be free from prosecution. Right now, they are not. As reported in the Legal Intelligence, the case concerns two physicians at a drug addiction treatment facility who treated a man with an opioid addiction. In July 2018, a three-judge Superior Court panel upheld that physicians should not have liability protections under the Mental Health Procedures Act (MHPA). The ruling reversed a lower court decision. The Superior Court judges sympathized with the view that treatment of mental illness in drug treatment facilities be given more legal leeway. Whether that leeway remains in place depends on the Supreme Court. If judges decide no, physicians who recognize signs of mental illness in patients being treated for drug addiction would treat the illness at the risk of subsequent liability. The case has again raised the issue of whether alcoholism and drug dependency should be considered mental illnesses. “We don’t believe it was the intended purpose of the MPHA to include drug addiction. Our concern is we don’t want hospitals or rehab facilities just having patients be seen by psychiatrists in order to invoke the MHPA,” said Patrick Mintzer, the lawyer who will argue the cases before the court. A counter view came from Jack Panella, one of the three Superior Court judges. In his decision, he wrote: “In light of current scientific research, as well as the recent addition of ‘addiction disorders’ to the American Psychiatric Association’s Diagnostic and Statistical Manual–5, we suggest that the Department of Human Services revise this definition.” The Legal Intelligence.

An op-ed in the Des Moines Register applauds republican Gov. Kim Reynolds for introducing two bills that are aimed at expanding mental health services to children and family in Iowa. “After decades of discussion and growing public support, these two bills take a huge step toward establishing a children’s mental health system,” wrote guest columnists Erin Drinnin of the United Way of Central Iowa and Kim Scorza of Seasons Center for Behavioral Health. The two also serve as cochairs of the Coalition to Advance Mental Health in Iowa for Kids (CAMHI4Kids), which includes more than 50 organizations. “Just like building a house requires a sturdy foundation, these bills are an important first step toward creating a structure for children’s mental well-being. In particular, CAMHI4Kids appreciates that these bills establish a voice and a seat for children and families at a regional level, using a system that is already in place,” wrote Ms. Drinnin and Ms. Scorza. The legislation would spell out the core services that would be available regardless of location in Iowa. The services would be geared toward children, rather than adults, reflecting the different mental health needs of children. “These important steps would finally sew together a patchwork of care that families currently must navigate with little direction. If a child is hurt on the playground, a caregiver knows to follow a clear path of care to help that child recover. But for a caregiver who is concerned about a child’s mental health, they often don’t know where to turn for help and must seek out services that might not exist in their community,” wrote Ms. Drinnin and Ms. Scorza. In Iowa, 80,000 children have a diagnosed serious emotional disturbance. About half of children aged 14 years and older with mental illness drop out of high school, and 70% of youth in Iowa’s juvenile justice system have a mental illness. “We are proud that Iowa is working together in a bipartisan way to ensure that our kids have the best start for future success,” wrote Ms. Drinnin and Ms. Scorza. Des Moines Register.

Bill Reilly is the peer support program manager for Bert Nash Community Mental Health Center in Douglas County, Kan. His mental health troubles began in childhood and led to stints in alcohol rehabilitation and mental hospitals, and he tried to end his life several times. But Mr. Reilly now offers his experience to those in trouble. “Those [experiences] can be viewed as a negative until you turn that conversation around and ask, ‘How can this be helpful to another person?’ And to me, that’s where the urgency comes into the work that we’re doing because a clinical relationship is one thing, but a peer support relationship is something different.” He was speaking in support of an initiative that seeks to train and place peer support people in hospital emergency departments in Kansas. The initiative is being spearheaded by Bob Tryanski, Douglas County director of behavioral health projects. “In addition to giving folks the opportunity to have the work experience in an environment where we need peer support, we would wrap around those peers with training, professional development, with coaching and support in an ongoing way,” Mr. Tryanski said, “so that they could become real, robust, huge resources, not just to the emergency department but in our community.” If approved, hiring and training of peers would begin in April, with the goal of having six people in place in emergency rooms by the summer and hiring an additional six people by year end. LJWorld.com.

The combination of neratinib and capecitabine showed positive efficacy outcomes, but also a high degree of toxicity, in patients with progressive HER2-positive breast cancer and brain metastases, according to results from a phase 2 study.

“Neratinib [is] an irreversible pan-HER tyrosine kinase inhibitor that inhibits signal transduction,” wrote Rachel A Freedman, MD, MPH, of the Dana-Farber Cancer Institute in Boston, and her colleagues. Their report is in the Journal of Clinical Oncology. The researchers grouped patients into two cohorts, those without previous lapatinib (n = 37) and those with previous lapatinib exposure (n = 12), which were termed cohort 3A and 3B, respectively. All study participants were given neratinib 240 mg once daily in combination with capecitabine 750 mg/m² twice daily for a total of 14 days, followed by 7 days without capecitabine.

The primary outcome measured was the composite central nervous system (CNS) objective response rate (ORR) of each individual cohort, which was defined as a decrease of at least 50% in the total target CNS lesion volumes, in the absence of other markers of further progression.

After analysis, Dr. Freedman and her colleagues found that the CNS ORR was 49% (95% confidence interval, 32%-66%) and 33% (95% CI, 10%-65%) in cohorts 3A and 3B, respectively. In addition, the team reported that the median progression-free survival was 5.5 and 3.1 months in the same respective cohorts.

With respect to safety, the most frequently seen adverse event was diarrhea, with 29% of study participants having grade 3 toxicity. The researchers reported that no grade 4 adverse events were seen.

“It is possible that selection bias affected toxicity events, because no patients in cohort 3B stopped treatment [due to] toxicity,” they said.

A key limitation of the study was the lack of a comparison group, which could be added in future trials.

“Future studies could examine local therapy versus systemic therapy in CNS disease and additionally explore the role of other neratinib-based combination regimens,” they concluded.

The study was supported by grant funding from Puma Biotechnology, the Translational Breast Cancer Research Consortium’s foundation partners, the American Cancer Society, Susan G. Komen for the Cure, the Breast Cancer Research Foundation, and the Dana-Farber/Harvard Cancer Center. The authors reported financial affiliations with Puma Biotechnology, Genentech, Eli Lilly, Novartis, Pfizer, and others.

SOURCE: Freedman RA et al. J Clin Oncol. 2019 Mar 12. doi: 10.1200/JCO.18.01511.

The combination of neratinib and capecitabine showed positive efficacy outcomes, but also a high degree of toxicity, in patients with progressive HER2-positive breast cancer and brain metastases, according to results from a phase 2 study.

“Neratinib [is] an irreversible pan-HER tyrosine kinase inhibitor that inhibits signal transduction,” wrote Rachel A Freedman, MD, MPH, of the Dana-Farber Cancer Institute in Boston, and her colleagues. Their report is in the Journal of Clinical Oncology. The researchers grouped patients into two cohorts, those without previous lapatinib (n = 37) and those with previous lapatinib exposure (n = 12), which were termed cohort 3A and 3B, respectively. All study participants were given neratinib 240 mg once daily in combination with capecitabine 750 mg/m² twice daily for a total of 14 days, followed by 7 days without capecitabine.

The primary outcome measured was the composite central nervous system (CNS) objective response rate (ORR) of each individual cohort, which was defined as a decrease of at least 50% in the total target CNS lesion volumes, in the absence of other markers of further progression.

After analysis, Dr. Freedman and her colleagues found that the CNS ORR was 49% (95% confidence interval, 32%-66%) and 33% (95% CI, 10%-65%) in cohorts 3A and 3B, respectively. In addition, the team reported that the median progression-free survival was 5.5 and 3.1 months in the same respective cohorts.

With respect to safety, the most frequently seen adverse event was diarrhea, with 29% of study participants having grade 3 toxicity. The researchers reported that no grade 4 adverse events were seen.

“It is possible that selection bias affected toxicity events, because no patients in cohort 3B stopped treatment [due to] toxicity,” they said.

A key limitation of the study was the lack of a comparison group, which could be added in future trials.

“Future studies could examine local therapy versus systemic therapy in CNS disease and additionally explore the role of other neratinib-based combination regimens,” they concluded.

The study was supported by grant funding from Puma Biotechnology, the Translational Breast Cancer Research Consortium’s foundation partners, the American Cancer Society, Susan G. Komen for the Cure, the Breast Cancer Research Foundation, and the Dana-Farber/Harvard Cancer Center. The authors reported financial affiliations with Puma Biotechnology, Genentech, Eli Lilly, Novartis, Pfizer, and others.

SOURCE: Freedman RA et al. J Clin Oncol. 2019 Mar 12. doi: 10.1200/JCO.18.01511.

The combination of neratinib and capecitabine showed positive efficacy outcomes, but also a high degree of toxicity, in patients with progressive HER2-positive breast cancer and brain metastases, according to results from a phase 2 study.

“Neratinib [is] an irreversible pan-HER tyrosine kinase inhibitor that inhibits signal transduction,” wrote Rachel A Freedman, MD, MPH, of the Dana-Farber Cancer Institute in Boston, and her colleagues. Their report is in the Journal of Clinical Oncology. The researchers grouped patients into two cohorts, those without previous lapatinib (n = 37) and those with previous lapatinib exposure (n = 12), which were termed cohort 3A and 3B, respectively. All study participants were given neratinib 240 mg once daily in combination with capecitabine 750 mg/m² twice daily for a total of 14 days, followed by 7 days without capecitabine.

The primary outcome measured was the composite central nervous system (CNS) objective response rate (ORR) of each individual cohort, which was defined as a decrease of at least 50% in the total target CNS lesion volumes, in the absence of other markers of further progression.

After analysis, Dr. Freedman and her colleagues found that the CNS ORR was 49% (95% confidence interval, 32%-66%) and 33% (95% CI, 10%-65%) in cohorts 3A and 3B, respectively. In addition, the team reported that the median progression-free survival was 5.5 and 3.1 months in the same respective cohorts.

With respect to safety, the most frequently seen adverse event was diarrhea, with 29% of study participants having grade 3 toxicity. The researchers reported that no grade 4 adverse events were seen.

“It is possible that selection bias affected toxicity events, because no patients in cohort 3B stopped treatment [due to] toxicity,” they said.

A key limitation of the study was the lack of a comparison group, which could be added in future trials.

“Future studies could examine local therapy versus systemic therapy in CNS disease and additionally explore the role of other neratinib-based combination regimens,” they concluded.

The study was supported by grant funding from Puma Biotechnology, the Translational Breast Cancer Research Consortium’s foundation partners, the American Cancer Society, Susan G. Komen for the Cure, the Breast Cancer Research Foundation, and the Dana-Farber/Harvard Cancer Center. The authors reported financial affiliations with Puma Biotechnology, Genentech, Eli Lilly, Novartis, Pfizer, and others.

SOURCE: Freedman RA et al. J Clin Oncol. 2019 Mar 12. doi: 10.1200/JCO.18.01511.

The Journal of Hospital Medicine, the official peer-reviewed journal of the Society of Hospital Medicine, has launched its second new series this year, entitled Clinical Guideline Highlights for the Hospitalist. Alongside the new Leadership and Professional Development series, this addition plays a large role in the vision for the future of the journal, spearheaded by new editor in chief, Samir Shah, MD, MSCE, MHM.

“As a new deputy editor for reviews and perspectives, I’m thrilled to help execute Dr. Shah’s vision for a series of articles that aims to facilitate the rapid translation of the latest evidence-based guidelines into hospitalist practice,” said Erin Shaughnessy, MD. “My coeditor, Dr. Read Pierce, and I envision these reviews as tools to enable busy clinicians to quickly understand the latest research and apply it to practice.”

The March issue of JHM features an introduction to the series as well as the first two articles, “The Use of Intravenous Fluids in the Hospitalized Adult” and “Maintenance Intravenous Fluids in Infants and Children.” The introduction provides details on the formatting of the series and discusses a second format that will be introduced in 2019 called Progress Notes, which will be shorter than JHM’s traditional review format. Progress Notes will accept two types or articles, clinical and methodological, and will focus on diagnostics, therapeutics, or risk assessment and prevention of a clinical problem relevant to hospitalists.

“National guidelines and society position statements are important in informing care standards but can be time consuming to read, and only a small portion may be pertinent to the practice of hospital medicine,” Dr. Shah said. “Our Clinical Guideline Highlights for the Hospitalist series, under the leadership of Dr. Shaughnessy and Dr. Pierce, will distill the key elements of national guidelines with a focus on recommendations that are most relevant to the practicing hospitalist. Authors include a brief critique to ensure hospitalists understand the strength of evidence behind the guideline when making decisions.”

Along with this series comes another new feature for the journal, Hospital Medicine: The Year in Review. This annual feature “concisely compiles and critiques the top articles in both adult and pediatric hospital medicine in the past year” and “will serve as a written corollary to the popular ‘Updates in Hospital Medicine’ presentation at the SHM Annual Conference.”

With so many updates, “JHM’s overarching commitment remains unchanged: support clinicians, leaders, and scholars in our field in their pursuit of delivering evidence-based, high-value clinical care.” The journal will continue to accept traditional, long-form review on topics relevant to hospitalists.

Visit www.journalofhospitalmedicine.com for the Clinical Guideline Highlights for the Hospitalist series and additional research.






 

The Journal of Hospital Medicine, the official peer-reviewed journal of the Society of Hospital Medicine, has launched its second new series this year, entitled Clinical Guideline Highlights for the Hospitalist. Alongside the new Leadership and Professional Development series, this addition plays a large role in the vision for the future of the journal, spearheaded by new editor in chief, Samir Shah, MD, MSCE, MHM.

“As a new deputy editor for reviews and perspectives, I’m thrilled to help execute Dr. Shah’s vision for a series of articles that aims to facilitate the rapid translation of the latest evidence-based guidelines into hospitalist practice,” said Erin Shaughnessy, MD. “My coeditor, Dr. Read Pierce, and I envision these reviews as tools to enable busy clinicians to quickly understand the latest research and apply it to practice.”

The March issue of JHM features an introduction to the series as well as the first two articles, “The Use of Intravenous Fluids in the Hospitalized Adult” and “Maintenance Intravenous Fluids in Infants and Children.” The introduction provides details on the formatting of the series and discusses a second format that will be introduced in 2019 called Progress Notes, which will be shorter than JHM’s traditional review format. Progress Notes will accept two types or articles, clinical and methodological, and will focus on diagnostics, therapeutics, or risk assessment and prevention of a clinical problem relevant to hospitalists.

“National guidelines and society position statements are important in informing care standards but can be time consuming to read, and only a small portion may be pertinent to the practice of hospital medicine,” Dr. Shah said. “Our Clinical Guideline Highlights for the Hospitalist series, under the leadership of Dr. Shaughnessy and Dr. Pierce, will distill the key elements of national guidelines with a focus on recommendations that are most relevant to the practicing hospitalist. Authors include a brief critique to ensure hospitalists understand the strength of evidence behind the guideline when making decisions.”

Along with this series comes another new feature for the journal, Hospital Medicine: The Year in Review. This annual feature “concisely compiles and critiques the top articles in both adult and pediatric hospital medicine in the past year” and “will serve as a written corollary to the popular ‘Updates in Hospital Medicine’ presentation at the SHM Annual Conference.”

With so many updates, “JHM’s overarching commitment remains unchanged: support clinicians, leaders, and scholars in our field in their pursuit of delivering evidence-based, high-value clinical care.” The journal will continue to accept traditional, long-form review on topics relevant to hospitalists.

Visit www.journalofhospitalmedicine.com for the Clinical Guideline Highlights for the Hospitalist series and additional research.






 

The Journal of Hospital Medicine, the official peer-reviewed journal of the Society of Hospital Medicine, has launched its second new series this year, entitled Clinical Guideline Highlights for the Hospitalist. Alongside the new Leadership and Professional Development series, this addition plays a large role in the vision for the future of the journal, spearheaded by new editor in chief, Samir Shah, MD, MSCE, MHM.

“As a new deputy editor for reviews and perspectives, I’m thrilled to help execute Dr. Shah’s vision for a series of articles that aims to facilitate the rapid translation of the latest evidence-based guidelines into hospitalist practice,” said Erin Shaughnessy, MD. “My coeditor, Dr. Read Pierce, and I envision these reviews as tools to enable busy clinicians to quickly understand the latest research and apply it to practice.”

The March issue of JHM features an introduction to the series as well as the first two articles, “The Use of Intravenous Fluids in the Hospitalized Adult” and “Maintenance Intravenous Fluids in Infants and Children.” The introduction provides details on the formatting of the series and discusses a second format that will be introduced in 2019 called Progress Notes, which will be shorter than JHM’s traditional review format. Progress Notes will accept two types or articles, clinical and methodological, and will focus on diagnostics, therapeutics, or risk assessment and prevention of a clinical problem relevant to hospitalists.

“National guidelines and society position statements are important in informing care standards but can be time consuming to read, and only a small portion may be pertinent to the practice of hospital medicine,” Dr. Shah said. “Our Clinical Guideline Highlights for the Hospitalist series, under the leadership of Dr. Shaughnessy and Dr. Pierce, will distill the key elements of national guidelines with a focus on recommendations that are most relevant to the practicing hospitalist. Authors include a brief critique to ensure hospitalists understand the strength of evidence behind the guideline when making decisions.”

Along with this series comes another new feature for the journal, Hospital Medicine: The Year in Review. This annual feature “concisely compiles and critiques the top articles in both adult and pediatric hospital medicine in the past year” and “will serve as a written corollary to the popular ‘Updates in Hospital Medicine’ presentation at the SHM Annual Conference.”

With so many updates, “JHM’s overarching commitment remains unchanged: support clinicians, leaders, and scholars in our field in their pursuit of delivering evidence-based, high-value clinical care.” The journal will continue to accept traditional, long-form review on topics relevant to hospitalists.

Visit www.journalofhospitalmedicine.com for the Clinical Guideline Highlights for the Hospitalist series and additional research.






 

WASHINGTON – During a session at the annual meeting of the American Academy of Dermatology, Adam Friedman, MD, presented on off-label use of immunomodulators for inflammatory skin diseases, the highlights of which he shared with fellow George Washington University dermatologist, A. Yasmine Kirkorian, MD, in an interview following the session.

Vidyard Video

Dr. Friedman, professor and interim chair of dermatology at George Washington University, Washington, provides his top list of immunomodulators, used off-label, ranging from dapsone and hydroxychloroquine, to pentoxifylline and low-dose naltrexone.

For example, as reflected in PubMed searches, low-dose naltrexone, which has to be compounded, is being used for such diseases as Hailey-Hailey and lichen planopilaris, said Dr. Friedman, who is using it for his mast cell activation syndrome patients. During the interview, he also describes his treatment approach for urticaria.

In his final remarks, Dr. Friedman encourages colleagues to “get creative,” publish, and talk about their experiences with off-label treatments in dermatology, citing the example of an article that mentioned using pioglitazone for lichen planopilaris. This article stimulated interest in using the type 2 diabetes agent pioglitazone to treat this skin disease, he notes.

Dr. Friedman and Dr. Kirkorian, a pediatric dermatologist at George Washington University and interim chief of pediatric dermatology at Children’s National in Washington had no relevant disclosures.

emechcatie@mdedge.com

WASHINGTON – During a session at the annual meeting of the American Academy of Dermatology, Adam Friedman, MD, presented on off-label use of immunomodulators for inflammatory skin diseases, the highlights of which he shared with fellow George Washington University dermatologist, A. Yasmine Kirkorian, MD, in an interview following the session.

Vidyard Video

Dr. Friedman, professor and interim chair of dermatology at George Washington University, Washington, provides his top list of immunomodulators, used off-label, ranging from dapsone and hydroxychloroquine, to pentoxifylline and low-dose naltrexone.

For example, as reflected in PubMed searches, low-dose naltrexone, which has to be compounded, is being used for such diseases as Hailey-Hailey and lichen planopilaris, said Dr. Friedman, who is using it for his mast cell activation syndrome patients. During the interview, he also describes his treatment approach for urticaria.

In his final remarks, Dr. Friedman encourages colleagues to “get creative,” publish, and talk about their experiences with off-label treatments in dermatology, citing the example of an article that mentioned using pioglitazone for lichen planopilaris. This article stimulated interest in using the type 2 diabetes agent pioglitazone to treat this skin disease, he notes.

Dr. Friedman and Dr. Kirkorian, a pediatric dermatologist at George Washington University and interim chief of pediatric dermatology at Children’s National in Washington had no relevant disclosures.

emechcatie@mdedge.com

WASHINGTON – During a session at the annual meeting of the American Academy of Dermatology, Adam Friedman, MD, presented on off-label use of immunomodulators for inflammatory skin diseases, the highlights of which he shared with fellow George Washington University dermatologist, A. Yasmine Kirkorian, MD, in an interview following the session.

Vidyard Video

Dr. Friedman, professor and interim chair of dermatology at George Washington University, Washington, provides his top list of immunomodulators, used off-label, ranging from dapsone and hydroxychloroquine, to pentoxifylline and low-dose naltrexone.

For example, as reflected in PubMed searches, low-dose naltrexone, which has to be compounded, is being used for such diseases as Hailey-Hailey and lichen planopilaris, said Dr. Friedman, who is using it for his mast cell activation syndrome patients. During the interview, he also describes his treatment approach for urticaria.

In his final remarks, Dr. Friedman encourages colleagues to “get creative,” publish, and talk about their experiences with off-label treatments in dermatology, citing the example of an article that mentioned using pioglitazone for lichen planopilaris. This article stimulated interest in using the type 2 diabetes agent pioglitazone to treat this skin disease, he notes.

Dr. Friedman and Dr. Kirkorian, a pediatric dermatologist at George Washington University and interim chief of pediatric dermatology at Children’s National in Washington had no relevant disclosures.

emechcatie@mdedge.com

A telomere-length analysis tool appears to identify reliably which chronic lymphocytic leukemia (CLL) patients will benefit from frontline chemotherapy, according to an analysis of 260 patients across two separate trials.

VashiDonsk/Wikimedia Commons/Creative Commons BY-SA 3.0

The analysis compared the use of high-throughput, single telomere–length analysis (HTSTELA) with other commonly used markers including beta-2 microglobulin, fluorescence-in-situ hybridization (FISH) cytogenetics, CD38 expression, ZAP70 expression, and IGHV mutation status. The researchers looked specifically at whether telomere length could predict response to frontline treatment with fludarabine, cyclophosphamide, rituximab (FCR)–based regimens.

“[T]elomere length is a powerful predictor of both [progression-free survival] and [overall survival] in patients treated with FCR-based therapies. In contrast, CD38 expression and beta-2 microglobulin expression were not predictive, and IGHV mutation status was only predictive of PFS (progression-free survival),” Kevin Norris, PhD, of Cardiff (Wales) University and his colleagues wrote in Leukemia.

Previous studies have shown that telomere-length analysis offers independent prognostic information in all stages of CLL. In the present study, the researchers used HTSTELA to analyze patient samples taken from two concurrent, phase 2 clinical trials of frontline FCR-based treatment – ARCTIC and ADMIRE.

The researchers divided the cohort based on a threshold of telomere dysfunction – the point at which the chromosome end-capping function is lost and there is genomic instability. Shorter telomeres are inside the fusogenic range (TL-IFR) and longer telomeres are outside fusogenic range (TL-OFR).

Patients with TL-IFR had significantly shorter PFS on FCR-based treatment (P less than .0001). They also had reduced overall survival (OS; P = .0002). In the same cohort of patients, IGHV mutation status was predictive of PFS (P = .0016), but it was not predictive for OS (P = .38), while CD38 and beta-2 microglobulin were not predictive of PFS or OS.

The researchers also looked at the value of telomere length in predicting outcomes among IGHV-mutated and -unmutated patients.

Patients with IGHV-mutated disease and TL-IFR had worse PFS and OS than did patients with TL-OFR. TL-IFR patients in this cohort were more likely to progress (hazard ratio, 4.35; P less than .0001) and more likely to die from their disease (HR, 3.81; P = .006).

“Although the number of IGHV-mutated patients with TL-IFR was relatively small (n = 16), our data suggests that telomere length can identify a subset of “bad risk” IGHV-mutated patients who do not respond well to FCR,” the researchers wrote.

Among IGHV unmutated patients, those with short telomeres had worse PFS (HR, 1.48; P = .08) and OS (HR, 2.18; P = .025) than did those with longer telomeres.

In multivariate modeling of all the potential markers, telomere length was the statistically significant dominant covariable for both PFS and OS.

The study was funded by a Bloodwise grant and the Wales Cancer Research Center. Dr. Norris and three coauthors reported that they are coinventors of patents relevant to the study and hold shares in a company set to provide telomere length testing.

mschneider@mdedge.com

SOURCE: Norris K et al. Leukemia. 2019 Jan 30. doi: 10.1038/s41375-019-0389-9.
 

A telomere-length analysis tool appears to identify reliably which chronic lymphocytic leukemia (CLL) patients will benefit from frontline chemotherapy, according to an analysis of 260 patients across two separate trials.

VashiDonsk/Wikimedia Commons/Creative Commons BY-SA 3.0

The analysis compared the use of high-throughput, single telomere–length analysis (HTSTELA) with other commonly used markers including beta-2 microglobulin, fluorescence-in-situ hybridization (FISH) cytogenetics, CD38 expression, ZAP70 expression, and IGHV mutation status. The researchers looked specifically at whether telomere length could predict response to frontline treatment with fludarabine, cyclophosphamide, rituximab (FCR)–based regimens.

“[T]elomere length is a powerful predictor of both [progression-free survival] and [overall survival] in patients treated with FCR-based therapies. In contrast, CD38 expression and beta-2 microglobulin expression were not predictive, and IGHV mutation status was only predictive of PFS (progression-free survival),” Kevin Norris, PhD, of Cardiff (Wales) University and his colleagues wrote in Leukemia.

Previous studies have shown that telomere-length analysis offers independent prognostic information in all stages of CLL. In the present study, the researchers used HTSTELA to analyze patient samples taken from two concurrent, phase 2 clinical trials of frontline FCR-based treatment – ARCTIC and ADMIRE.

The researchers divided the cohort based on a threshold of telomere dysfunction – the point at which the chromosome end-capping function is lost and there is genomic instability. Shorter telomeres are inside the fusogenic range (TL-IFR) and longer telomeres are outside fusogenic range (TL-OFR).

Patients with TL-IFR had significantly shorter PFS on FCR-based treatment (P less than .0001). They also had reduced overall survival (OS; P = .0002). In the same cohort of patients, IGHV mutation status was predictive of PFS (P = .0016), but it was not predictive for OS (P = .38), while CD38 and beta-2 microglobulin were not predictive of PFS or OS.

The researchers also looked at the value of telomere length in predicting outcomes among IGHV-mutated and -unmutated patients.

Patients with IGHV-mutated disease and TL-IFR had worse PFS and OS than did patients with TL-OFR. TL-IFR patients in this cohort were more likely to progress (hazard ratio, 4.35; P less than .0001) and more likely to die from their disease (HR, 3.81; P = .006).

“Although the number of IGHV-mutated patients with TL-IFR was relatively small (n = 16), our data suggests that telomere length can identify a subset of “bad risk” IGHV-mutated patients who do not respond well to FCR,” the researchers wrote.

Among IGHV unmutated patients, those with short telomeres had worse PFS (HR, 1.48; P = .08) and OS (HR, 2.18; P = .025) than did those with longer telomeres.

In multivariate modeling of all the potential markers, telomere length was the statistically significant dominant covariable for both PFS and OS.

The study was funded by a Bloodwise grant and the Wales Cancer Research Center. Dr. Norris and three coauthors reported that they are coinventors of patents relevant to the study and hold shares in a company set to provide telomere length testing.

mschneider@mdedge.com

SOURCE: Norris K et al. Leukemia. 2019 Jan 30. doi: 10.1038/s41375-019-0389-9.
 

A telomere-length analysis tool appears to identify reliably which chronic lymphocytic leukemia (CLL) patients will benefit from frontline chemotherapy, according to an analysis of 260 patients across two separate trials.

VashiDonsk/Wikimedia Commons/Creative Commons BY-SA 3.0

The analysis compared the use of high-throughput, single telomere–length analysis (HTSTELA) with other commonly used markers including beta-2 microglobulin, fluorescence-in-situ hybridization (FISH) cytogenetics, CD38 expression, ZAP70 expression, and IGHV mutation status. The researchers looked specifically at whether telomere length could predict response to frontline treatment with fludarabine, cyclophosphamide, rituximab (FCR)–based regimens.

“[T]elomere length is a powerful predictor of both [progression-free survival] and [overall survival] in patients treated with FCR-based therapies. In contrast, CD38 expression and beta-2 microglobulin expression were not predictive, and IGHV mutation status was only predictive of PFS (progression-free survival),” Kevin Norris, PhD, of Cardiff (Wales) University and his colleagues wrote in Leukemia.

Previous studies have shown that telomere-length analysis offers independent prognostic information in all stages of CLL. In the present study, the researchers used HTSTELA to analyze patient samples taken from two concurrent, phase 2 clinical trials of frontline FCR-based treatment – ARCTIC and ADMIRE.

The researchers divided the cohort based on a threshold of telomere dysfunction – the point at which the chromosome end-capping function is lost and there is genomic instability. Shorter telomeres are inside the fusogenic range (TL-IFR) and longer telomeres are outside fusogenic range (TL-OFR).

Patients with TL-IFR had significantly shorter PFS on FCR-based treatment (P less than .0001). They also had reduced overall survival (OS; P = .0002). In the same cohort of patients, IGHV mutation status was predictive of PFS (P = .0016), but it was not predictive for OS (P = .38), while CD38 and beta-2 microglobulin were not predictive of PFS or OS.

The researchers also looked at the value of telomere length in predicting outcomes among IGHV-mutated and -unmutated patients.

Patients with IGHV-mutated disease and TL-IFR had worse PFS and OS than did patients with TL-OFR. TL-IFR patients in this cohort were more likely to progress (hazard ratio, 4.35; P less than .0001) and more likely to die from their disease (HR, 3.81; P = .006).

“Although the number of IGHV-mutated patients with TL-IFR was relatively small (n = 16), our data suggests that telomere length can identify a subset of “bad risk” IGHV-mutated patients who do not respond well to FCR,” the researchers wrote.

Among IGHV unmutated patients, those with short telomeres had worse PFS (HR, 1.48; P = .08) and OS (HR, 2.18; P = .025) than did those with longer telomeres.

In multivariate modeling of all the potential markers, telomere length was the statistically significant dominant covariable for both PFS and OS.

The study was funded by a Bloodwise grant and the Wales Cancer Research Center. Dr. Norris and three coauthors reported that they are coinventors of patents relevant to the study and hold shares in a company set to provide telomere length testing.

mschneider@mdedge.com

SOURCE: Norris K et al. Leukemia. 2019 Jan 30. doi: 10.1038/s41375-019-0389-9.
 

Every year the Society of Hospital Medicine’s Annual Conference Committee examines prior attendee surveys, reviews the content presented the preceding year, and asks itself what new areas of learning are needed by hospitalists, said Dustin Smith, MD, SFHM, hospitalist and associate professor of medicine at Emory University School of Medicine in Atlanta, and HM19 course director.

“The conference’s schedule-at-a-glance of content can be overwhelming, so we have tried to use distinct educational tracks to provide focus and clarity for conference attendees,” he said. “Every year there are a few areas where questions often come up about complex clinical situations where established medical guidelines aren’t much help.”

As a result, for HM19 an educational mini-track called “Between the Guidelines” was developed to gather up several of these areas of clinical complexity where what’s available in established clinical practice guidelines doesn’t offer clear answers, Dr. Smith said. These include controversies around antithrombotic therapy in patients with major bleeds, and a debate on controversial aspects of guidelines to direct inpatient care.

Another planned session, “The History of Hospitals via Arts and Stories,” fits nicely into this mini-track, Dr. Smith noted.

“It’s a history lesson you can’t glean from medical guidelines, which maybe points us toward what to incorporate and what not to repeat from across the history of hospitals,” he said. “That could help us better appreciate the work hospitalists are doing today and into the future.”

Jordan Messler, MD, a hospitalist with the Morton Plant Hospitalist group in Clearwater, Fla., will lead the session and thinks that modern physicians can learn a lot from both the history of medicine and the evolution of hospitals, starting with the ancient Greek physician, Galen (129-200 AD), who directed the celebrated Asclepeion or hospital in Pergamon (present-day Bergama, Turkey). Dr. Messler said this ancient hospital’s treatment of disease also addressed the senses, the emotions, and the spirit – an early prototype for whole-person care – with an emphasis on self-therapy through rest, relaxation, exercise, and the promotion of healthy lifestyles.¹

A different perspective on hospitals

“People used to travel to Pergamon for healing at the Asclepeion, next to the amphitheater, where plays and music were presented, and to be outdoors in the natural elements. Now we’re seeing hospitals being built with healing gardens, and a new emphasis on how artwork and music and environmental design can assist in healing,” Dr. Messler said.

Dr. Messler explained that his “History of Hospitals” presentation will also survey the advent of more recent hospitals in France in the 18th century, pioneering work done at Johns Hopkins Hospital in Baltimore and Bellevue Hospital in New York, and the influence on the modern hospital of nursing pioneer Florence Nightingale (1820-1910). Dr. Messler said she helped improve hospitals in her day, which still influences their modern design, and fundamentally changed the role of nursing in hospitals, introducing professional training standards for nurses.

He also noted that the portico of the beautiful 15th century Hospital of the Innocents in Florence, Italy, the first organic creation of Filippo Brunelleschi (1377-1446), marks the birth of Renaissance architecture in Florence. The Hospital of Santa Maria Nuova, founded in 1288, is the oldest hospital still active in Florence.

Part of the goal for this new annual conference session is to take a break from more clinically focused presentations, and to think about the hospital from a different perspective, Dr. Messler said. His session will emphasize the power of stories and storytelling to inform and inspire medical practice.

“This is not something that can be applied clinically the next day, but lessons from the past can inform the design of hospitals and how we manage patients,” he said. “We need to ask ourselves, ‘How can we analyze hospital history to inform what we do today?’ ”
 

References

“Asclepeion.” Wikipedia. Accessed Jan. 28, 2019: https://en.wikipedia.org/wiki/Asclepeion.

Every year the Society of Hospital Medicine’s Annual Conference Committee examines prior attendee surveys, reviews the content presented the preceding year, and asks itself what new areas of learning are needed by hospitalists, said Dustin Smith, MD, SFHM, hospitalist and associate professor of medicine at Emory University School of Medicine in Atlanta, and HM19 course director.

“The conference’s schedule-at-a-glance of content can be overwhelming, so we have tried to use distinct educational tracks to provide focus and clarity for conference attendees,” he said. “Every year there are a few areas where questions often come up about complex clinical situations where established medical guidelines aren’t much help.”

As a result, for HM19 an educational mini-track called “Between the Guidelines” was developed to gather up several of these areas of clinical complexity where what’s available in established clinical practice guidelines doesn’t offer clear answers, Dr. Smith said. These include controversies around antithrombotic therapy in patients with major bleeds, and a debate on controversial aspects of guidelines to direct inpatient care.

Another planned session, “The History of Hospitals via Arts and Stories,” fits nicely into this mini-track, Dr. Smith noted.

“It’s a history lesson you can’t glean from medical guidelines, which maybe points us toward what to incorporate and what not to repeat from across the history of hospitals,” he said. “That could help us better appreciate the work hospitalists are doing today and into the future.”

Jordan Messler, MD, a hospitalist with the Morton Plant Hospitalist group in Clearwater, Fla., will lead the session and thinks that modern physicians can learn a lot from both the history of medicine and the evolution of hospitals, starting with the ancient Greek physician, Galen (129-200 AD), who directed the celebrated Asclepeion or hospital in Pergamon (present-day Bergama, Turkey). Dr. Messler said this ancient hospital’s treatment of disease also addressed the senses, the emotions, and the spirit – an early prototype for whole-person care – with an emphasis on self-therapy through rest, relaxation, exercise, and the promotion of healthy lifestyles.¹

A different perspective on hospitals

“People used to travel to Pergamon for healing at the Asclepeion, next to the amphitheater, where plays and music were presented, and to be outdoors in the natural elements. Now we’re seeing hospitals being built with healing gardens, and a new emphasis on how artwork and music and environmental design can assist in healing,” Dr. Messler said.

Dr. Messler explained that his “History of Hospitals” presentation will also survey the advent of more recent hospitals in France in the 18th century, pioneering work done at Johns Hopkins Hospital in Baltimore and Bellevue Hospital in New York, and the influence on the modern hospital of nursing pioneer Florence Nightingale (1820-1910). Dr. Messler said she helped improve hospitals in her day, which still influences their modern design, and fundamentally changed the role of nursing in hospitals, introducing professional training standards for nurses.

He also noted that the portico of the beautiful 15th century Hospital of the Innocents in Florence, Italy, the first organic creation of Filippo Brunelleschi (1377-1446), marks the birth of Renaissance architecture in Florence. The Hospital of Santa Maria Nuova, founded in 1288, is the oldest hospital still active in Florence.

Part of the goal for this new annual conference session is to take a break from more clinically focused presentations, and to think about the hospital from a different perspective, Dr. Messler said. His session will emphasize the power of stories and storytelling to inform and inspire medical practice.

“This is not something that can be applied clinically the next day, but lessons from the past can inform the design of hospitals and how we manage patients,” he said. “We need to ask ourselves, ‘How can we analyze hospital history to inform what we do today?’ ”
 

References

“Asclepeion.” Wikipedia. Accessed Jan. 28, 2019: https://en.wikipedia.org/wiki/Asclepeion.

Every year the Society of Hospital Medicine’s Annual Conference Committee examines prior attendee surveys, reviews the content presented the preceding year, and asks itself what new areas of learning are needed by hospitalists, said Dustin Smith, MD, SFHM, hospitalist and associate professor of medicine at Emory University School of Medicine in Atlanta, and HM19 course director.

“The conference’s schedule-at-a-glance of content can be overwhelming, so we have tried to use distinct educational tracks to provide focus and clarity for conference attendees,” he said. “Every year there are a few areas where questions often come up about complex clinical situations where established medical guidelines aren’t much help.”

As a result, for HM19 an educational mini-track called “Between the Guidelines” was developed to gather up several of these areas of clinical complexity where what’s available in established clinical practice guidelines doesn’t offer clear answers, Dr. Smith said. These include controversies around antithrombotic therapy in patients with major bleeds, and a debate on controversial aspects of guidelines to direct inpatient care.

Another planned session, “The History of Hospitals via Arts and Stories,” fits nicely into this mini-track, Dr. Smith noted.

“It’s a history lesson you can’t glean from medical guidelines, which maybe points us toward what to incorporate and what not to repeat from across the history of hospitals,” he said. “That could help us better appreciate the work hospitalists are doing today and into the future.”

Jordan Messler, MD, a hospitalist with the Morton Plant Hospitalist group in Clearwater, Fla., will lead the session and thinks that modern physicians can learn a lot from both the history of medicine and the evolution of hospitals, starting with the ancient Greek physician, Galen (129-200 AD), who directed the celebrated Asclepeion or hospital in Pergamon (present-day Bergama, Turkey). Dr. Messler said this ancient hospital’s treatment of disease also addressed the senses, the emotions, and the spirit – an early prototype for whole-person care – with an emphasis on self-therapy through rest, relaxation, exercise, and the promotion of healthy lifestyles.¹

A different perspective on hospitals

“People used to travel to Pergamon for healing at the Asclepeion, next to the amphitheater, where plays and music were presented, and to be outdoors in the natural elements. Now we’re seeing hospitals being built with healing gardens, and a new emphasis on how artwork and music and environmental design can assist in healing,” Dr. Messler said.

Dr. Messler explained that his “History of Hospitals” presentation will also survey the advent of more recent hospitals in France in the 18th century, pioneering work done at Johns Hopkins Hospital in Baltimore and Bellevue Hospital in New York, and the influence on the modern hospital of nursing pioneer Florence Nightingale (1820-1910). Dr. Messler said she helped improve hospitals in her day, which still influences their modern design, and fundamentally changed the role of nursing in hospitals, introducing professional training standards for nurses.

He also noted that the portico of the beautiful 15th century Hospital of the Innocents in Florence, Italy, the first organic creation of Filippo Brunelleschi (1377-1446), marks the birth of Renaissance architecture in Florence. The Hospital of Santa Maria Nuova, founded in 1288, is the oldest hospital still active in Florence.

Part of the goal for this new annual conference session is to take a break from more clinically focused presentations, and to think about the hospital from a different perspective, Dr. Messler said. His session will emphasize the power of stories and storytelling to inform and inspire medical practice.

“This is not something that can be applied clinically the next day, but lessons from the past can inform the design of hospitals and how we manage patients,” he said. “We need to ask ourselves, ‘How can we analyze hospital history to inform what we do today?’ ”
 

References

“Asclepeion.” Wikipedia. Accessed Jan. 28, 2019: https://en.wikipedia.org/wiki/Asclepeion.

SEATTLE – The most important thing to know about the apparent HIV cure widely reported in the press recently is that the treatment was worse than the infection, according to John Mellors, MD, chief of the division of infectious diseases at the University of Pittsburgh.

M. Alexander Otto/MDedge News

Dr. Mellors moderated a presentation at the Conference on Retroviruses and Opportunistic Infections about what the cure involved.

An HIV-positive man with advanced Hodgkin’s lymphoma had an allogeneic bone marrow transplant in 2016 after failing first-line chemotherapy and multiple salvage regimens. His donor was homozygous for a gene mutation that prevents HIV from entering new cells. The transplant took; the man’s hematopoietic system was replaced by one with the anti-HIV mutation; and there’s been no trace of active virus in his system since. He’s been off of antiretrovirals for a year and a half. The cancer hasn’t returned.

He’s been dubbed the “London patient.” He joins the “Berlin patient” as the second person who appears to have been freed of infection following a stem cell transplant with the anti-HIV mutation. The Berlin patient recently identified himself as Timothy Ray Brown; he was in the audience at CROI and was applauded for coming forward and sharing his story.

Mr. Brown received a transplant for acute myeloid leukemia and has been off antiretrovirals now for about a decade with no evidence of viral rebound.

M. Alexander Otto/MDedge News

Although it didn’t get much attention at CROI, there was a poster of a similar approach seeming to work in a third patient, also with leukemia. It’s been tried – but failed – in two others: one patient died of their lymphoma and the transplant failed in the other, said lead investigator on the London patient case, Ravindra Gupta, MD, a professor in the division of infection & immunity at University College London.

Dr. Mellors pointed out that “the two people who have been cured had lethal malignancies that were unresponsive to conventional therapy and had the extreme measure of an allogeneic bone marrow transplant. Allogeneic bone marrow transplant is not a walk in the park. It has a mortality of 10%-25%, which is completely unacceptable” when “patients feel great on one pill a day” for HIV remission and pretty much have a normal life span.

The transplant reactivated both cytomegalovirus and Epstein Barr virus in the London patient, and he developed graft-versus-host colitis. He survived all three complications.

The take-home message is that “these cases are inspirational. The work ahead is to find out how to deliver the same results with less-extreme measures,” Dr. Mellors said.

The donors for both the London and Berlin patients were homozygous for a delta 32 deletion in the receptor most commonly used by HIV-1 to enter host cells, CCR5. Cells that carry the mutation don’t express the receptor, preventing infection. The mutation prevalence is about 1% among Europeans.

Of the two failed cases, the person who died of lymphoma had a strain of HIV-1 that used a different receptor – CXCR4 – so it’s doubtful the transplant would have worked even if he had survived his cancer.

The London patient wasn’t what’s called an “elite controller,” one of those rare people who suppress HIV without antiretrovirals. His viral loads bounced right back when we was taken off them prior to transplant.

He’s not interested in an active sex life at the moment, Dr. Gupta said, but he might be soon, so Dr. Gupta plans a discussion with him in the near future. Although the London patient could well be immune to HIV that uses the CCR5 receptor, he might not be immune to CXCR4 virus, and he might still be able to produce infectious CCR5 particles. Time will tell.

There was no industry funding for the work. Dr. Gupta is a consultant for ViiV Healthcare and a speaker for Gilead.

aotto@mdedge.com

SOURCE: Gupta RK et al. CROI 2019, Abstract 29.

SEATTLE – The most important thing to know about the apparent HIV cure widely reported in the press recently is that the treatment was worse than the infection, according to John Mellors, MD, chief of the division of infectious diseases at the University of Pittsburgh.

M. Alexander Otto/MDedge News

Dr. Mellors moderated a presentation at the Conference on Retroviruses and Opportunistic Infections about what the cure involved.

An HIV-positive man with advanced Hodgkin’s lymphoma had an allogeneic bone marrow transplant in 2016 after failing first-line chemotherapy and multiple salvage regimens. His donor was homozygous for a gene mutation that prevents HIV from entering new cells. The transplant took; the man’s hematopoietic system was replaced by one with the anti-HIV mutation; and there’s been no trace of active virus in his system since. He’s been off of antiretrovirals for a year and a half. The cancer hasn’t returned.

He’s been dubbed the “London patient.” He joins the “Berlin patient” as the second person who appears to have been freed of infection following a stem cell transplant with the anti-HIV mutation. The Berlin patient recently identified himself as Timothy Ray Brown; he was in the audience at CROI and was applauded for coming forward and sharing his story.

Mr. Brown received a transplant for acute myeloid leukemia and has been off antiretrovirals now for about a decade with no evidence of viral rebound.

M. Alexander Otto/MDedge News

Although it didn’t get much attention at CROI, there was a poster of a similar approach seeming to work in a third patient, also with leukemia. It’s been tried – but failed – in two others: one patient died of their lymphoma and the transplant failed in the other, said lead investigator on the London patient case, Ravindra Gupta, MD, a professor in the division of infection & immunity at University College London.

Dr. Mellors pointed out that “the two people who have been cured had lethal malignancies that were unresponsive to conventional therapy and had the extreme measure of an allogeneic bone marrow transplant. Allogeneic bone marrow transplant is not a walk in the park. It has a mortality of 10%-25%, which is completely unacceptable” when “patients feel great on one pill a day” for HIV remission and pretty much have a normal life span.

The transplant reactivated both cytomegalovirus and Epstein Barr virus in the London patient, and he developed graft-versus-host colitis. He survived all three complications.

The take-home message is that “these cases are inspirational. The work ahead is to find out how to deliver the same results with less-extreme measures,” Dr. Mellors said.

The donors for both the London and Berlin patients were homozygous for a delta 32 deletion in the receptor most commonly used by HIV-1 to enter host cells, CCR5. Cells that carry the mutation don’t express the receptor, preventing infection. The mutation prevalence is about 1% among Europeans.

Of the two failed cases, the person who died of lymphoma had a strain of HIV-1 that used a different receptor – CXCR4 – so it’s doubtful the transplant would have worked even if he had survived his cancer.

The London patient wasn’t what’s called an “elite controller,” one of those rare people who suppress HIV without antiretrovirals. His viral loads bounced right back when we was taken off them prior to transplant.

He’s not interested in an active sex life at the moment, Dr. Gupta said, but he might be soon, so Dr. Gupta plans a discussion with him in the near future. Although the London patient could well be immune to HIV that uses the CCR5 receptor, he might not be immune to CXCR4 virus, and he might still be able to produce infectious CCR5 particles. Time will tell.

There was no industry funding for the work. Dr. Gupta is a consultant for ViiV Healthcare and a speaker for Gilead.

aotto@mdedge.com

SOURCE: Gupta RK et al. CROI 2019, Abstract 29.

SEATTLE – The most important thing to know about the apparent HIV cure widely reported in the press recently is that the treatment was worse than the infection, according to John Mellors, MD, chief of the division of infectious diseases at the University of Pittsburgh.

M. Alexander Otto/MDedge News

Dr. Mellors moderated a presentation at the Conference on Retroviruses and Opportunistic Infections about what the cure involved.

An HIV-positive man with advanced Hodgkin’s lymphoma had an allogeneic bone marrow transplant in 2016 after failing first-line chemotherapy and multiple salvage regimens. His donor was homozygous for a gene mutation that prevents HIV from entering new cells. The transplant took; the man’s hematopoietic system was replaced by one with the anti-HIV mutation; and there’s been no trace of active virus in his system since. He’s been off of antiretrovirals for a year and a half. The cancer hasn’t returned.

He’s been dubbed the “London patient.” He joins the “Berlin patient” as the second person who appears to have been freed of infection following a stem cell transplant with the anti-HIV mutation. The Berlin patient recently identified himself as Timothy Ray Brown; he was in the audience at CROI and was applauded for coming forward and sharing his story.

Mr. Brown received a transplant for acute myeloid leukemia and has been off antiretrovirals now for about a decade with no evidence of viral rebound.

M. Alexander Otto/MDedge News

Although it didn’t get much attention at CROI, there was a poster of a similar approach seeming to work in a third patient, also with leukemia. It’s been tried – but failed – in two others: one patient died of their lymphoma and the transplant failed in the other, said lead investigator on the London patient case, Ravindra Gupta, MD, a professor in the division of infection & immunity at University College London.

Dr. Mellors pointed out that “the two people who have been cured had lethal malignancies that were unresponsive to conventional therapy and had the extreme measure of an allogeneic bone marrow transplant. Allogeneic bone marrow transplant is not a walk in the park. It has a mortality of 10%-25%, which is completely unacceptable” when “patients feel great on one pill a day” for HIV remission and pretty much have a normal life span.

The transplant reactivated both cytomegalovirus and Epstein Barr virus in the London patient, and he developed graft-versus-host colitis. He survived all three complications.

The take-home message is that “these cases are inspirational. The work ahead is to find out how to deliver the same results with less-extreme measures,” Dr. Mellors said.

The donors for both the London and Berlin patients were homozygous for a delta 32 deletion in the receptor most commonly used by HIV-1 to enter host cells, CCR5. Cells that carry the mutation don’t express the receptor, preventing infection. The mutation prevalence is about 1% among Europeans.

Of the two failed cases, the person who died of lymphoma had a strain of HIV-1 that used a different receptor – CXCR4 – so it’s doubtful the transplant would have worked even if he had survived his cancer.

The London patient wasn’t what’s called an “elite controller,” one of those rare people who suppress HIV without antiretrovirals. His viral loads bounced right back when we was taken off them prior to transplant.

He’s not interested in an active sex life at the moment, Dr. Gupta said, but he might be soon, so Dr. Gupta plans a discussion with him in the near future. Although the London patient could well be immune to HIV that uses the CCR5 receptor, he might not be immune to CXCR4 virus, and he might still be able to produce infectious CCR5 particles. Time will tell.

There was no industry funding for the work. Dr. Gupta is a consultant for ViiV Healthcare and a speaker for Gilead.

aotto@mdedge.com

SOURCE: Gupta RK et al. CROI 2019, Abstract 29.

At 8:07 am on January 13, 2018, people in Hawaii received an emergency alert advising them to seek shelter from an incoming ballistic missile.

A very long 38 minutes later, the message was retracted via the same systems that had sent it—the Wireless Emergency Alert system, which sends location-based warnings to wireless carrier systems, and the Emergency Alert System, which sends television and radio alerts.

The Federal Communications Commission report that covered the debacle noted that, among other errors, the employee responsible for triggering the false alert believed the missile threat was real. Moreover, the exercise plans did not document a process for disseminating an all-clear message. And on top of that, the established ballistic missile alert checklist did not include a step to notify the Hawaii Emergency Management Agency’s public information officer responsible for communicating with the public, media, other agencies, and other stakeholders during an incident.

Researchers from the CDC and Hawaii Department of Health analyzed tweets sent during 2 periods: early (8:07-8:45 am), the 38 minutes during which the alert circulated; and the late period (8:46-9:24 am), the same amount of elapsed time after the correction had been issued.

They found 4 themes dominated the early period: information processing, information sharing, authentication, and emotional reaction (shock, fear, panic, terror). Information processing was defined as any indication of initial mental processing of the alert. Many of the tweets dealt with coming to terms with the threat.

During the late period, information sharing and emotional reaction persisted, but they were joined by new themes that, according to the researchers, were “fundamentally different” from the early-period themes and reflected reactions to misinformation: denunciation, insufficient knowledge to act, and mistrust of authority. “Insufficient knowledge to act” involved reacting to the lack of a response plan, particularly not knowing how to properly take shelter. Denunciations blamed the emergency warning and response, especially the time it took to correct the mistake. Mistrust of authority involved doubting the emergency alert system or governmental response.

How can a situation like this be better handled? The researchers say public health messaging during an emergency is complicated. For instance, it is influenced by how messages are perceived and interpreted by different people, and by the fact that messages need to be sent over multiple platforms to ensure that the information is disseminated accurately and quickly.

Which is why social media is both a handicap and a boon in public health emergencies. Tweets spread misinformation as fast as information (if not faster), so the first messages are critical. In addition to conveying timely messages, the researchers advise, public health authorities need to address the reactions during each phase of a crisis. They also need to establish credibility to prevent the public from mistrusting the public health message and its issuers.

Most important, perhaps: Alerts should carry clear instructions for persons in the affected area to carry out during an emergency.

At 8:07 am on January 13, 2018, people in Hawaii received an emergency alert advising them to seek shelter from an incoming ballistic missile.

A very long 38 minutes later, the message was retracted via the same systems that had sent it—the Wireless Emergency Alert system, which sends location-based warnings to wireless carrier systems, and the Emergency Alert System, which sends television and radio alerts.

The Federal Communications Commission report that covered the debacle noted that, among other errors, the employee responsible for triggering the false alert believed the missile threat was real. Moreover, the exercise plans did not document a process for disseminating an all-clear message. And on top of that, the established ballistic missile alert checklist did not include a step to notify the Hawaii Emergency Management Agency’s public information officer responsible for communicating with the public, media, other agencies, and other stakeholders during an incident.

Researchers from the CDC and Hawaii Department of Health analyzed tweets sent during 2 periods: early (8:07-8:45 am), the 38 minutes during which the alert circulated; and the late period (8:46-9:24 am), the same amount of elapsed time after the correction had been issued.

They found 4 themes dominated the early period: information processing, information sharing, authentication, and emotional reaction (shock, fear, panic, terror). Information processing was defined as any indication of initial mental processing of the alert. Many of the tweets dealt with coming to terms with the threat.

During the late period, information sharing and emotional reaction persisted, but they were joined by new themes that, according to the researchers, were “fundamentally different” from the early-period themes and reflected reactions to misinformation: denunciation, insufficient knowledge to act, and mistrust of authority. “Insufficient knowledge to act” involved reacting to the lack of a response plan, particularly not knowing how to properly take shelter. Denunciations blamed the emergency warning and response, especially the time it took to correct the mistake. Mistrust of authority involved doubting the emergency alert system or governmental response.

How can a situation like this be better handled? The researchers say public health messaging during an emergency is complicated. For instance, it is influenced by how messages are perceived and interpreted by different people, and by the fact that messages need to be sent over multiple platforms to ensure that the information is disseminated accurately and quickly.

Which is why social media is both a handicap and a boon in public health emergencies. Tweets spread misinformation as fast as information (if not faster), so the first messages are critical. In addition to conveying timely messages, the researchers advise, public health authorities need to address the reactions during each phase of a crisis. They also need to establish credibility to prevent the public from mistrusting the public health message and its issuers.

Most important, perhaps: Alerts should carry clear instructions for persons in the affected area to carry out during an emergency.

At 8:07 am on January 13, 2018, people in Hawaii received an emergency alert advising them to seek shelter from an incoming ballistic missile.

A very long 38 minutes later, the message was retracted via the same systems that had sent it—the Wireless Emergency Alert system, which sends location-based warnings to wireless carrier systems, and the Emergency Alert System, which sends television and radio alerts.

The Federal Communications Commission report that covered the debacle noted that, among other errors, the employee responsible for triggering the false alert believed the missile threat was real. Moreover, the exercise plans did not document a process for disseminating an all-clear message. And on top of that, the established ballistic missile alert checklist did not include a step to notify the Hawaii Emergency Management Agency’s public information officer responsible for communicating with the public, media, other agencies, and other stakeholders during an incident.

Researchers from the CDC and Hawaii Department of Health analyzed tweets sent during 2 periods: early (8:07-8:45 am), the 38 minutes during which the alert circulated; and the late period (8:46-9:24 am), the same amount of elapsed time after the correction had been issued.

They found 4 themes dominated the early period: information processing, information sharing, authentication, and emotional reaction (shock, fear, panic, terror). Information processing was defined as any indication of initial mental processing of the alert. Many of the tweets dealt with coming to terms with the threat.

During the late period, information sharing and emotional reaction persisted, but they were joined by new themes that, according to the researchers, were “fundamentally different” from the early-period themes and reflected reactions to misinformation: denunciation, insufficient knowledge to act, and mistrust of authority. “Insufficient knowledge to act” involved reacting to the lack of a response plan, particularly not knowing how to properly take shelter. Denunciations blamed the emergency warning and response, especially the time it took to correct the mistake. Mistrust of authority involved doubting the emergency alert system or governmental response.

How can a situation like this be better handled? The researchers say public health messaging during an emergency is complicated. For instance, it is influenced by how messages are perceived and interpreted by different people, and by the fact that messages need to be sent over multiple platforms to ensure that the information is disseminated accurately and quickly.

Which is why social media is both a handicap and a boon in public health emergencies. Tweets spread misinformation as fast as information (if not faster), so the first messages are critical. In addition to conveying timely messages, the researchers advise, public health authorities need to address the reactions during each phase of a crisis. They also need to establish credibility to prevent the public from mistrusting the public health message and its issuers.

Most important, perhaps: Alerts should carry clear instructions for persons in the affected area to carry out during an emergency.

SEATTLE – Hepatocellular carcinoma (HCC) is on the rise in HIV-positive individuals, its incidence having quadrupled since 1996, and HIV-positive individuals have about a 300% increase risk of HCC, compared with the general population. However, more than 40% of patients with HIV who develop HCC have a Fibrosis-4 score (FIB-4) suggesting a lack of cirrhosis, according to a new retrospective analysis. By contrast, only about 13% of typical HCC patients have no cirrhosis.

Wavebreakmedia Ltd/ThinkStockPhotos.com

The study also revealed some of the risk factors associated with HCC in this population, including longer duration of HIV viremia and lower CD4 cell counts, as well as markers of metabolic syndrome. “There was some signal that perhaps other markers of metabolic syndrome, obesity and diabetes, were more prevalent in those [who developed HCC] without advanced fibrosis or cirrhosis, suggesting that there may be other underlying etiologies of liver disease that we should be wary of when evaluating somebody for their risk of HCC,” Jessie Torgersen, MD, said in an interview.

Dr. Torgersen is an instructor of medicine at the University of Pennsylvania, Philadelphia. She presented the study at the Conference on Retroviruses & Opportunistic Infections.

The results of the study are tantalizing, but not yet practice changing. “I don’t think we have enough information from this study to recommend a dramatic overhaul of the current HCC screening guidelines, but with the anticipated elimination of hepatitis C, I think the emergence of [metabolic factors and their] contributions to our HIV-positive population’s risk of HCC needs to be better understood. Hopefully this will serve as a first step in further understanding those risks,” Dr. Torgersen said.

She also hopes to get a better handle on the biological mechanisms that might drive HCC in the absence of cirrhosis. “While the mechanisms are unclear as to why HCC would develop in HIV-positive patients without cirrhosis, there are a lot of biologically plausible mechanisms that seem to make [sense],” said Dr. Torgersen. The team hopes to get a better understanding of those mechanisms in order to information evaluation and screening for HCC.

The researchers analyzed data from the Veterans Affairs Cancer Registry as well as EMRs for HIV-positive veterans across the United States. The study included 2,497 participants with a FIB-4 score greater than 3.25, and 29,836 with an FIB-4 score less than or equal to 3.25. At baseline, subjects with FIB-4 greater than 3.25 were more likely to have an alcohol-related diagnosis (47% vs. 29%), be positive for hepatitis C virus RNA (59% vs. 30%), be positive for the hepatitis B surface antigen (10% versus 5%), have HIV RNA greater than or equal to 500 copies/mL (63% vs. 56%), and to have a CD4+ cell count less than 200 cells/m³ (39% vs. 26%).

A total of 278 subjects were diagnosed with HCC; 43% had an FIB-4 less than or equal to 3.25. Among those 43%, more patients had a body mass index of 30 or higher (16% vs. 12%), had diabetes (31% vs. 25%), and tested positive for the hepatitis B surface antigen (26% vs. 17%).

Among subjects with FIB-4 less than or equal to 3.25, factors associated with greater HCC risk included higher HIV RNA level (hazard ratio, 1.24 per 1.0 log¹⁰ copies/mL), CD4+ cell count less than 200 cells/m³ (HR, 1.78), hepatitis C virus infection (HR, 6.32), and positive hepatitis B surface antigen (HR, 4.93).

Among subjects with FIB-4 greater than 3.25, increased HCC risk was associated with HCV infection (HR, 6.18) and positive hepatitis B surface antigen (HR, 2.12).

The study was funded by the National Institutes of Health. Dr. Torgersen reported no financial disclosures.

SOURCE: Torgersen J et al. CROI 2019, Abstract 90.

SEATTLE – Hepatocellular carcinoma (HCC) is on the rise in HIV-positive individuals, its incidence having quadrupled since 1996, and HIV-positive individuals have about a 300% increase risk of HCC, compared with the general population. However, more than 40% of patients with HIV who develop HCC have a Fibrosis-4 score (FIB-4) suggesting a lack of cirrhosis, according to a new retrospective analysis. By contrast, only about 13% of typical HCC patients have no cirrhosis.

Wavebreakmedia Ltd/ThinkStockPhotos.com

The study also revealed some of the risk factors associated with HCC in this population, including longer duration of HIV viremia and lower CD4 cell counts, as well as markers of metabolic syndrome. “There was some signal that perhaps other markers of metabolic syndrome, obesity and diabetes, were more prevalent in those [who developed HCC] without advanced fibrosis or cirrhosis, suggesting that there may be other underlying etiologies of liver disease that we should be wary of when evaluating somebody for their risk of HCC,” Jessie Torgersen, MD, said in an interview.

Dr. Torgersen is an instructor of medicine at the University of Pennsylvania, Philadelphia. She presented the study at the Conference on Retroviruses & Opportunistic Infections.

The results of the study are tantalizing, but not yet practice changing. “I don’t think we have enough information from this study to recommend a dramatic overhaul of the current HCC screening guidelines, but with the anticipated elimination of hepatitis C, I think the emergence of [metabolic factors and their] contributions to our HIV-positive population’s risk of HCC needs to be better understood. Hopefully this will serve as a first step in further understanding those risks,” Dr. Torgersen said.

She also hopes to get a better handle on the biological mechanisms that might drive HCC in the absence of cirrhosis. “While the mechanisms are unclear as to why HCC would develop in HIV-positive patients without cirrhosis, there are a lot of biologically plausible mechanisms that seem to make [sense],” said Dr. Torgersen. The team hopes to get a better understanding of those mechanisms in order to information evaluation and screening for HCC.

The researchers analyzed data from the Veterans Affairs Cancer Registry as well as EMRs for HIV-positive veterans across the United States. The study included 2,497 participants with a FIB-4 score greater than 3.25, and 29,836 with an FIB-4 score less than or equal to 3.25. At baseline, subjects with FIB-4 greater than 3.25 were more likely to have an alcohol-related diagnosis (47% vs. 29%), be positive for hepatitis C virus RNA (59% vs. 30%), be positive for the hepatitis B surface antigen (10% versus 5%), have HIV RNA greater than or equal to 500 copies/mL (63% vs. 56%), and to have a CD4+ cell count less than 200 cells/m³ (39% vs. 26%).

A total of 278 subjects were diagnosed with HCC; 43% had an FIB-4 less than or equal to 3.25. Among those 43%, more patients had a body mass index of 30 or higher (16% vs. 12%), had diabetes (31% vs. 25%), and tested positive for the hepatitis B surface antigen (26% vs. 17%).

Among subjects with FIB-4 less than or equal to 3.25, factors associated with greater HCC risk included higher HIV RNA level (hazard ratio, 1.24 per 1.0 log¹⁰ copies/mL), CD4+ cell count less than 200 cells/m³ (HR, 1.78), hepatitis C virus infection (HR, 6.32), and positive hepatitis B surface antigen (HR, 4.93).

Among subjects with FIB-4 greater than 3.25, increased HCC risk was associated with HCV infection (HR, 6.18) and positive hepatitis B surface antigen (HR, 2.12).

The study was funded by the National Institutes of Health. Dr. Torgersen reported no financial disclosures.

SOURCE: Torgersen J et al. CROI 2019, Abstract 90.

SEATTLE – Hepatocellular carcinoma (HCC) is on the rise in HIV-positive individuals, its incidence having quadrupled since 1996, and HIV-positive individuals have about a 300% increase risk of HCC, compared with the general population. However, more than 40% of patients with HIV who develop HCC have a Fibrosis-4 score (FIB-4) suggesting a lack of cirrhosis, according to a new retrospective analysis. By contrast, only about 13% of typical HCC patients have no cirrhosis.

Wavebreakmedia Ltd/ThinkStockPhotos.com

The study also revealed some of the risk factors associated with HCC in this population, including longer duration of HIV viremia and lower CD4 cell counts, as well as markers of metabolic syndrome. “There was some signal that perhaps other markers of metabolic syndrome, obesity and diabetes, were more prevalent in those [who developed HCC] without advanced fibrosis or cirrhosis, suggesting that there may be other underlying etiologies of liver disease that we should be wary of when evaluating somebody for their risk of HCC,” Jessie Torgersen, MD, said in an interview.

Dr. Torgersen is an instructor of medicine at the University of Pennsylvania, Philadelphia. She presented the study at the Conference on Retroviruses & Opportunistic Infections.

The results of the study are tantalizing, but not yet practice changing. “I don’t think we have enough information from this study to recommend a dramatic overhaul of the current HCC screening guidelines, but with the anticipated elimination of hepatitis C, I think the emergence of [metabolic factors and their] contributions to our HIV-positive population’s risk of HCC needs to be better understood. Hopefully this will serve as a first step in further understanding those risks,” Dr. Torgersen said.

She also hopes to get a better handle on the biological mechanisms that might drive HCC in the absence of cirrhosis. “While the mechanisms are unclear as to why HCC would develop in HIV-positive patients without cirrhosis, there are a lot of biologically plausible mechanisms that seem to make [sense],” said Dr. Torgersen. The team hopes to get a better understanding of those mechanisms in order to information evaluation and screening for HCC.

The researchers analyzed data from the Veterans Affairs Cancer Registry as well as EMRs for HIV-positive veterans across the United States. The study included 2,497 participants with a FIB-4 score greater than 3.25, and 29,836 with an FIB-4 score less than or equal to 3.25. At baseline, subjects with FIB-4 greater than 3.25 were more likely to have an alcohol-related diagnosis (47% vs. 29%), be positive for hepatitis C virus RNA (59% vs. 30%), be positive for the hepatitis B surface antigen (10% versus 5%), have HIV RNA greater than or equal to 500 copies/mL (63% vs. 56%), and to have a CD4+ cell count less than 200 cells/m³ (39% vs. 26%).

A total of 278 subjects were diagnosed with HCC; 43% had an FIB-4 less than or equal to 3.25. Among those 43%, more patients had a body mass index of 30 or higher (16% vs. 12%), had diabetes (31% vs. 25%), and tested positive for the hepatitis B surface antigen (26% vs. 17%).

Among subjects with FIB-4 less than or equal to 3.25, factors associated with greater HCC risk included higher HIV RNA level (hazard ratio, 1.24 per 1.0 log¹⁰ copies/mL), CD4+ cell count less than 200 cells/m³ (HR, 1.78), hepatitis C virus infection (HR, 6.32), and positive hepatitis B surface antigen (HR, 4.93).

Among subjects with FIB-4 greater than 3.25, increased HCC risk was associated with HCV infection (HR, 6.18) and positive hepatitis B surface antigen (HR, 2.12).

The study was funded by the National Institutes of Health. Dr. Torgersen reported no financial disclosures.

SOURCE: Torgersen J et al. CROI 2019, Abstract 90.

This week in MDedge Cardiocast: A novel drug lowers LDL in on top of maximums statins, invasive cardiology is a top money maker for hospitals, a meta-analysis parses the heart and kidney benefits of new diabetes drugs, and the AHA warns that heart-harming toxins may hurt hookah smokers.
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TuneIn

This week in MDedge Cardiocast: A novel drug lowers LDL in on top of maximums statins, invasive cardiology is a top money maker for hospitals, a meta-analysis parses the heart and kidney benefits of new diabetes drugs, and the AHA warns that heart-harming toxins may hurt hookah smokers.
Amazon Alexa
Apple Podcasts
Google Podcasts
TuneIn

This week in MDedge Cardiocast: A novel drug lowers LDL in on top of maximums statins, invasive cardiology is a top money maker for hospitals, a meta-analysis parses the heart and kidney benefits of new diabetes drugs, and the AHA warns that heart-harming toxins may hurt hookah smokers.
Amazon Alexa
Apple Podcasts
Google Podcasts
TuneIn