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Cancer in the Future: Looking Into the Crystal Ball

Considering that cancer occurs more commonly in older adults, the aging of America is expected to increase the number of cancer diagnoses substantially. The expected increase in minorities may impact cancer care, particularly since certain minority groups have higher cancer incidence rates and lower disease-specific survival rates than non-minorities. “Compounding the problem is that minorities and older adults can be particularly vulnerable to suboptimal cancer care,” explains Benjamin D. Smith, MD. “Both groups have been under-represented in cancer clinical trials and are also subject to disparities in cancer treatment. Quantifying the likely trajectory of the number of cancer cases in older and minority patients can help clinicians define the expected societal burden of cancer and guide research and health policy priorities.”  Compelling New Data  In the April 29, 2009 Journal of Clinical Oncology, Dr. Smith and colleagues conducted a study designed to project the anticipated number of cancer cases through 2030. Data collected on all cancer sites demonstrated that the total expected cancer incidence in the United States will increase by an additional 45% over the next 20 years, rising from about 1.6 million cases in 2010 to 2.3 million in 2030 (Figure 2). “Between 2010 and 2030, a 67% increase in cancer incidence is anticipated for patients aged 65 and older as compared with only an 11% increase in cancer incidence anticipated for patients younger than 65,” Dr. Smith notes. “Overall, the percent of all cancers diagnosed in older adults is expected to increase from 61% to 70% in the next 20 years.”  According to site-specific data in the study, the leading cancer sites in men in 2030...

Society of Critical Care Medicine 2010 Critical Care Congress

New research presented at the Society of Critical Care Medicine, Critical Care Congress from January 9-13, 2010, in Miami Beach addressed key issues in critical care. The features highlight just some of the studies that emerged from the congress. NRT: Assessing Mortality in Critically Ill Smokers The Particulars: Nicotine replacement therapy (NRT) is often given to smokers admitted to the ICU to prevent withdrawal symptoms, but the safety of NRT in the critically ill has not been well studied. Data Breakdown: A study evaluated 330 active smokers, 174 of whom received NRT upon admission to the ICU. NRT was not associated with increased hospital mortality after adjusting for severity of disease, pack-years of smoking, and do-not-resuscitate status upon ICU admission (odds ratio, 1.6). About 23.0% of NRT patients experienced delirium compared with a 13.1% rate for non-NRT recipients. Take Home Pearls: NRT does not appear to be associated with increased hospital mortality in critically ill active smokers. However, NRT recipients appear to experience more delirium than the non-NRT group. The decision to use NRT in critically ill patients should be balanced individually between risks and benefits for patients. Fresh Blood Better for Transfusing Children in ICUs The Particulars: Transfusion with red blood cells (RBCs) is a common treatment in pediatric intensive care. Past studies conducted with adults have suggested that prolonged length of RBC unit storage is associated with worse clinical outcomes, but data are lacking in children. Data Breakdown: An analysis from a large observational study evaluated 447 children who stayed 48 hours or longer in a pediatric ICU. Results showed an adjusted odds ratio of 1.87 for...

Emerging Drug Options: Adolescent Depression

Approximately 2 million adolescents between the ages 12 and 17 in the United States have suffered a serious bout of depression within the past year. Major depressive disorder (MDD) in adolescents is debilitating; about half of these patients will have continued problems with depression as they enter adulthood. Compounding the problem is the fact that few treatment options have been effective and well-tolerated in this patient group. In March 2009, the FDA approved a supplemental New Drug Application for escitalopram (Lexapro, Forest Laboratories, Inc.) as acute and maintenance treatment for MDD in adolescents aged 12 to 17. The SSRI is only the second antidepressant to be approved for the treatment of MDD in adolescents, the first of which was fluoxetine (Prozac, Eli Lilly and Co.). Encouraging Data After observing improvements in adults with MDD taking escitalopram, investigators more recently undertook several studies to assess efficacy in adolescents with MDD. The FDA’s most recent approval for use in adolescent depression was supported by two placebo-controlled studies, one conducted in adolescents taking the drug and the other conducted in children and adolescents taking citalopram (Celexa, Forest Laboratories, Inc.). In an 8-week flexible-dose, placebo-controlled study that compared escitalopram 10 mg/day or 20 mg/day to placebo in adolescents in 2008, those receiving escitalopram had statistically significant greater improvements from baseline when compared with placebo, based on the Children’s Depression Rating Scale-Revised (CDRS-R). In another 8-week, flexible-dose, placebo-controlled study, children and adolescents aged 7 to 17 treated with racemic citalopram 20 mg/day or 40 mg/day had statistically significant greater improvements from baseline on the CDRS-R when compared with patients treated with placebo. Positive results...

Strategies to Improve Medication Adherence

According to recent estimates, about a third to a half of all patients in the United States fail to comply with their prescribed pharmacotherapy regimens. Failure to adhere to medications can reduce quality of care and increase medical expenses. Costs attributable to non-adherence are about $290 billion each year, and much of this spending stems from complications that result from not taking medications appropriately. “Patients fail to take their medications for many reasons, including difficulty with dosing regimens, costs, side effects, or concerns about drugs in general,” says Walid F. Gellad, MD. “Providers need different strategies and interventions to improve adherence.” To achieve optimal medication adherence, considerations must be made with regard to effective patient-provider communication, coordination among care providers, and active engagement and participation by patients. “All too often, patients are lacking important information or there are gaps in their communication with providers,” Dr. Gellad says. “For these reasons, it’s critical to identify any opportunities to remove barriers that keep patients from adhering to their medications.” New Policy Recommendations On July 15, 2009, several organizations convened more than 40 experts to discuss poor medication adherence in the United States, including GlaxoSmithKline, the National Association of Chain Drug Stores Foundation, the National Consumers League, the Pharmaceutical Research and Manufacturers of America, and the American College of Cardiology. As a result of this meeting, consensus policy recommendations to reduce barriers to adherence were released on October 14, 2009. Using themes that emerged from the July 15, 2009 conference and considering the proposed policies under review by Congress, the resulting recommendations focus on the following key areas: quality improvement strategies, care...

Conference Highlights: ISET 2010

The International Symposium on Endovascular Therapy, or ISET, held its 2010 annual meeting from January 17-21in Hollywood, Florida. The features below highlight some of the news emerging from the meeting. For more information on these items and other research that was presented, go to www.iset.org. Can A Blood Test Identify Endoleaks? The Particulars: Ruptured abdominal aortic aneurysms (AAAs) kill more than 13,000 Americans every year. Endovascular aneurysm repair (EVAR) is less invasive than open surgical repair of AAAs, but a downside is that about 10% of such repairs result in endoleaks. To monitor for endoleaks, patients undergo CT scans at 3, 6, and 12 months after EVAR and yearly thereafter. Data Breakdown: A study of AAA patients who had an endoleak and a simple blood test found elevated concentrations of a blood protein called matrix metalloproteinase-9 (MMP-9). Researchers determined that MMP-9 concentrations of 55.18 or greater helped to identify endoleaks with both high sensitivity and specificity. Results must be confirmed by a prospective clinical validation trial. Take Home Pearls: A blood test appears to be capable of detecting endoleaks after EVAR for AAAs. Use of this test may help prevent up to 90% of follow-up CT scans. Gender Differences in Treatment of Blocked Leg Arteries The Particulars: Narrowed and blocked leg arteries are a common symptom of peripheral arterial disease (PAD). About 8 million Americans have PAD, which can cause pain while walking. In extreme cases, these blocked leg arteries can lead to gangrene, lower-extremity amputations, or death. Data Breakdown: A retrospective study reviewed the use of endovascular therapy for blocked leg arteries. After 2 years, 46% of treated...

Helpful Guidelines on Hand Hygiene in Healthcare

Throughout the world, surveillance and prevention of healthcare-associated infections (HCAIs) have become a greater priority for institutions committed to making healthcare safer. These infections have been associated with prolonged hospital stays, long-term disability, increased resistance of microorganisms to antimicrobials, massive financial burdens, high costs for patients and their families, and excess deaths. One prominent reason for the spread of HCAIs has been poor hand hygiene. In an effort to address this issue, the World Health Organization (WHO) issued guidelines on hand hygiene in healthcare in May 2009. Available at www.who.int, the guidelines offer a thorough review of evidence as well as specific recommendations to improve hand hygiene practices and reduce transmission of pathogenic microorganisms to patients and healthcare workers (HCWs). “The new WHO guidelines are an extension to recommendations issued by the CDC in 2002,” explains Maryanne McGuckin, ScEd, MT, who was on the task force that created both the WHO and CDC guidelines. “They provide an extensive literature review and inform clinicians on strategies for improvement that have tested successfully.” The WHO guidelines are designed to be used in any setting in which healthcare is delivered. Individual adaptation of the recommendations is encouraged, based on local regulations, settings, needs, and resources. Assessing Practices & Adherence According to the WHO guidelines, understanding hand hygiene practices among HCWs is essential to planning interventions. Adherence by HCWs to recommended procedures has been reported with significant variation, reaching unacceptably poor levels in some cases. Risk factors for poor adherence to hand hygiene recommendations have been well-documented, and there appears to be an inverse relationship between intensity of patient care and adherence to...

Emerging Drug Options: Moderate-to-Severe Pain

More than 25 million Americans experience acute pain each year as a result of injuries or surgery, and it’s the most common reason people seek medical attention. Several classes of medications—particularly opioids—have been historically used to treat moderate-to-severe pain, but the adverse effects of these medications can be difficult for patients to endure. Researchers are continuing to search for new medications and combinations of therapies that limit adverse effects while maximizing efficacy. Two Mechanisms of Action In November 2008, the FDA approved tapentadol (Nucynta, Johnson & Johnson Pharmaceutical R&D, to be marketed by PriCara, Division of Ortho-McNeil-Janssen). This new therapy, available in 50 mg, 75 mg, and 100 mg doses, is an immediate-release tablet indicated for the relief of moderate-to-severe acute pain in adults aged 18 and older. It’s a centrally acting oral analgesic that combines mu-opioid receptor agonist activity and norepinephrine reuptake inhibition. Mu-opioid agonists bind to and activate mu-opioid receptors in the central nervous system. These drugs modify sensory and affective aspects of pain and inhibit pain transmission at the spinal cord. They affect activity at parts of the brain that control how pain is perceived. Norepinephrine reuptake inhibitors, which also affect the central nervous system, are medications that increase the level of norepinephrine in the brain by inhibiting its re-absorption into nerve cells; these compounds have analgesic properties. Tapentadol provides analgesia through both of these mechanisms. Analyzing the Data The approval of tapentadol was based on data from clinical studies involving more than 2,100 patients. At the 2008 annual meeting of the American Pain Society, researchers presented multiple phase III studies demonstrating that tapentadol offered patients...
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