University Hospitals Case Medical Center Research Articles

Improvement in Patient Performance of Skin Self-examinations After Intervention With Interactive Education and Telecommunication Reminders: A Randomized Controlled Study.

OBJECTIVE To determine if interactive computerized patient education, skin self-examination (SSE) tutorials, and telecommunication reminders could be combined to increase patient performance of SSEs, increase confidence in ability to identify melanoma, and influence individual melanoma risk perception. DESIGN A total of 132 adult participants from our dermatology clinics were enrolled in an interventional study and randomized to a control group or an intervention group. Survey data were collected from all participants on the day of enrollment and 3 months after enrollment. SETTING University Hospitals Case Medical Center outpatient dermatology clinics. PARTICIPANTS English speakers older than 18 years. INTERVENTIONS The intervention group (1) participated in a computer-assisted learning tutorial, (2) took part in a hands-on SSE tutorial, (3) received monthly telecommunication reminders to perform SSEs for 12 weeks, and (4) received a brochure on melanoma detection. The control group received only the brochure on melanoma detection. MAIN OUTCOME MEASURES Self-report of performance of SSEs. Melanoma risk perception and confidence in ability to identify melanoma were secondary considerations. Logistic regressions, controlling for race, age, sex, education, and family history of melanoma, were used to assess the effectiveness of the intervention. RESULTS At the 3-month follow-up, those in the intervention group were more likely to perform SSEs (odds ratio [OR], 2.36; P≤.05). In addition, those who participated in the intervention were more likely to report being confident in their ability to identify melanoma during an SSE (OR,2.72; P≤.05). CONCLUSION Computer-assisted patient education used in conjunction with a hands-on SSE tutorial and telecommunication reminders can increase patient performance of SSEs and confidence in the ability to identify melanoma.

Corrigendum to “Molecular typing and in vitro fluconazole susceptibility of Candida species isolated from diabetic and nondiabetic women with vulvovaginal candidiasis in India” [J Microbiol Immunol Infect 2011;44:166–71

Ali Abdul Lattif*, Gauranga Mukhopadhyay, Uma Banerjee, Ravinder Goswami and Rajendra Prasad Department of Dermatology, School of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA Special Center for Molecular Medicine & School of Life Sciences, Jawaharlal Nehru University, New Delhi, India All India Institute for Medical Sciences, New Delhi, India

Journal-related Activities and Other Special Activities at the 2012 American Society of Anesthesiologists Annual Meeting

Journal-related Activities and Other Special Activities at the 2012 American Society of Anesthesiologists Annual Meeting

Music Therapy Reduces Pain in Palliative Care Patients: A Randomized Controlled Trial

ContextTreatment of pain in palliative care patients is challenging. Adjunctive methods of pain management are desirable. Music therapy offers a nonpharmacologic and safe alternative. ObjectivesTo determine the efficacy of a single music therapy session to reduce pain in palliative care patients. MethodsTwo hundred inpatients at University Hospitals Case Medical Center were enrolled in the study from 2009 to 2011. Patients were randomly assigned to one of two groups: standard care alone (medical and nursing care that included scheduled analgesics) or standard care with music therapy. A clinical nurse specialist administered pre- and post-tests to assess the level of pain using a numeric rating scale as the primary outcome, and the Face, Legs, Activity, Cry, Consolability Scale and the Functional Pain Scale as secondary outcomes. The intervention incorporated music therapist-guided autogenic relaxation and live music. ResultsA significantly greater decrease in numeric rating scale pain scores was seen in the music therapy group (difference in means [95% CI] −1.4 [−2.0, −0.8]; P<0.0001). Mean changes in Face, Legs, Activity, Cry, Consolability scores did not differ between study groups (mean difference −0.3, [95% CI] −0.8, 0.1; P>0.05). Mean change in Functional Pain Scale scores was significantly greater in the music therapy group (difference in means −0.5 ([95% CI] −0.8, 0.3; P<0.0001). ConclusionA single music therapy intervention incorporating therapist-guided autogenic relaxation and live music was effective in lowering pain in palliative care patients.

Cardiac, Hemorrhagic, and Coagulopathic Oncologic Emergencies

Cardiac, Hemorrhagic, and Coagulopathic Oncologic Emergencies

Frequency of the Metabolic Syndrome and Association with Survival in Newly Diagnosed GBM Patients: A Retrospective Review (P07.106)

Objective: Report the frequency of metabolic syndrome (MS) in newly-diagnosed glioblastoma (NGBM) patients and impact of MS on patient survival. Background The MS is a well-established risk factor for atherosclerotic cardiovascular and cerebrovascular disease. It has been identified as a risk factor for some systemic cancers and as a predictor of worse clinical outcome in systemic cancer. There is limited evidence for obesity and hyperglycemia as predictors of poor outcome in malignant glioma patients (Chambless 2011). The frequency of MS and its impact on survival of NGBM patients has not been determined. Design/Methods: We retrospectively reviewed records of all patients (N = 114) with NGBM at University Hospitals Case Medical Center from 2007-2011. Criteria for MS included > 3 of elevated fasting glucose, hypertension, elevated triglycerides, reduced high density lipoprotein C (or history of these or history of treatment for them), and obesity. The criteria had to be present prior to diagnosis of GBM. Results: MS was identified in 44/114 patients (39%). Mean patient age was 65 years (67 with MS, 64 without MS). The majority received radiation, typically with temozolomide. Median survival by MS status was 7 months for those with MS and 12 months for those without MS (p = 0.0456). After adjustment for other prognostic factors, median survival was shorter for those with MS (8 months) versus those without (10 months), but this did not reach statistical significance (p > 0.05). Conclusions: MS was identified in 39% of NGBM. The presence of MS was associated with an unadjusted lower median survival compared to patients without MS. After adjustment for independent prognostic factors, this survival difference was not significant. Because of potential limitations due to the retrospective design of this study, we will perform a prospective study to determine the impact of MS on survival of NGBM patients. Disclosure: Dr. Rogers has received personal compensation for activities with Sigma Tau Pharmaceuticals as a speaker. Dr. Vengoechea has nothing to disclose. Dr. Ostrom has nothing to disclose. Dr. Chen has nothing to disclose. Dr. Davitkov has nothing to disclose. Dr. Strodtbeck has nothing to disclose. Dr. Selman has nothing to disclose. Dr. Gerson has nothing to disclose. Dr. Nock has nothing to disclose. Dr. Machtay has nothing to disclose. Dr. Lo has nothing to disclose. Dr. Sloan has received personal compensation for activities with RealBio and Nanotech Solutions. Dr. Sloan has received research support from the NIH, Lentigen, RealBio, Nantech, Genentech, the Cristal Chair, and the Kimble Foundation. Dr. Barnholtz-Sloan has nothing to disclose.

Abstract 1279: Proteomics signature of long-term versus short-term survival in glioblastoma

Abstract Glioblastoma (GB) is the most common malignant primary brain tumor in adults and disproportionately contributes to cancer mortality and morbidity. It has been repeatedly hypothesized that GB patients with varying response to treatment and hence prognosis have differential gene or protein expression profiles. To evaluate proteomic differences between long term and short term survivors with glioblastoma, an unbiased, label-free, unfractionated LC-MS/MS methodology was used on snap-frozen tumor samples from 10 patients with short term survival and 6 patients with long term survival from University Hospitals Case Medical Center. Short term survival was defined as 18 months after diagnosis. Significant protein intensity differences between long and short term survivors were tested using a mixed model. For each protein, the survival group was set as a fixed effect; while the peptide was set as a random effect which allowed for the within-protein correlation of the peptides to be accounted for in the model. In total 1490 proteins were detected in the glioblastoma sample set. One hundred eighty-three (183) proteins were found to be significant between survival groups using an adaptive False Discovery Rate p-value &amp;lt;0.05. Isocitrate Dehydrogenase 1 (IDH1), a mitochondrial energy-production enzyme, which has been implicated in differential response to temozolomide, was among these significant proteins. The top canonical pathways using these top 183 proteins, as generated by Ingenuity Pathway Analysis (IPA), were oxidative phosphorylation and mitochondrial dysfunction. These two pathways were at least twice as statistically significant as compared to any other discovered pathways. Examination of the individual proteins revealed a significant down regulation of oxidative phosphorylation, including subunits of cytochrome-oxidase and the BC1 complex in short term survivors. In addition, matched formalin-fixed paraffin embedded (FFPE) tumor tissue was used in order to verify the protein targets. Using 2 slides of 6 microns each, sufficient protein over 1 microgram of protein was extracted in order to perform an unbiased label-free LC-MS/MS analysis and 930 total proteins were detected. One hundred twenty-six (126) of the 183 significant proteins were successfully identified in the matched FFPE samples; thus FFPE can be used to verify many of the protein targets predicted to be changing. Further validation of the proteomics signature is ongoing in an expanded, independent cohort of glioblastoma patients with targeted validation. Progress in treatment for glioblastoma patients has been slowed by the absence of biomarkers to define treatment response and/or stratify patient sub-groups and help guide physician treatment. Proteomics analysis provides the most direct readout of the functional state of the tumor and thus promises improved functional annotation of patient status. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1279. doi:1538-7445.AM2012-1279

Knowledge Grows About Puzzling Disorder

Although a handful of medications and some nondrug regimens are used to treat fibromyalgia, even more effective treatments may be on the horizon.

Successful Gamma Knife-based stereotactic radiosurgery treatment for medically intractable heterotopia-based seizure disorder

Epilepsy with periventricular nodular heterotopia (PVNH) lacks a conclusive surgical treatment strategy as eloquent cortex and important white matter tracts frequently overlay the deep periventricular nodules. Our goal was to evaluate the safety and efficacy of laser interstitial thermal therapy (LITT) for the treatment of epilepsy in PVNH.Data on demographic characteristics, complications, visual outcomes, Engel classification at last follow-up, antiepileptic drug use, morbidity, and mortality among patients who underwent this procedure were retrospectively reviewed.Between May 2015 and January 2019, 5 patients underwent 6 LITT procedures for epilepsy with PVNH. One patient had residual nodules after their first procedure and underwent a second ablation. The average follow-up time was 12 months. Three patients were Engel class Ia, 1 patient was Engel class II, and 1 patient was Engel class III at last follow-up. Two patients were able to reduce their antiepileptic drugs postoperatively. Three patients had no changes in vision, 1 patient experienced a quadrantanopsia, and 1 patient had subjective blurry vision after their procedures. No patients experienced motor deficits, dysphasia, infection, or mortality.LITT appears to be a safe and promising option to provide seizure relief for patients with refractory epilepsy and PVNH that otherwise may not be surgical candidates. Some appropriately determined patients with refractory epilepsy may benefit from LITT before proceeding with an invasive intracranial evaluation. A larger sample size and long-term follow-up is necessary to further elucidate safety and efficacy.

Social Choice at NIH: the principle of complementarity

The FASEB JournalVolume 25, Issue 11 p. 3763-3764 Life Sciences ForumFree to Read Social Choice at NIH: the principle of complementarity David Kaplan, Corresponding Author David Kaplan david.kaplan@case.edu Case Western Reserve University, Cleveland, Ohio, USACorrespondence: Department of Pathology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA. E-mail: david.kaplan@case.eduSearch for more papers by this author David Kaplan, Corresponding Author David Kaplan david.kaplan@case.edu Case Western Reserve University, Cleveland, Ohio, USACorrespondence: Department of Pathology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA. E-mail: david.kaplan@case.eduSearch for more papers by this author First published: 28 July 2011 https://doi.org/10.1096/fj.11-191015Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume25, Issue11November 2011Pages 3763-3764 RelatedInformation

Prostate-specific Antigen/Solvent Interaction Analysis: A Preliminary Evaluation of a New Assay Concept for Detecting Prostate Cancer Using Urinary Samples

To provide preliminary clinical performance evaluation of a novel prostate cancer (CaP) assay, prostate-specific antigen/solvent interaction analysis (PSA/SIA) that focused on changes to the structure of PSA. Two-hundred twenty-two men undergoing prostate biopsy for accepted clinical criteria at 3 sites (University Hospitals Case Medical Center in Cleveland, Cleveland Clinic, and Veterans Administration Boston Healthcare System) were enrolled in institutional review board-approved study. Before transrectal ultrasound-guided biopsy, patients received digital rectal examination with systematic prostate massage followed by collection of urine. The PSA/SIA assay determined the relative partitioning of heterogeneous PSA isoform populations in urine between 2 aqueous phases. A structural index, K, whose numerical value is defined as the ratio of the concentration of all PSA isoforms, was determined by total PSA enzyme-linked immunosorbent assay and used to set a diagnostic threshold for CaP. Performance was assessed using receiver operating characteristic (ROC) analysis with biopsy as the gold standard. Biopsies were pathologically classified as case (malignant, n=100) or control (benign, n=122). ROC performance demonstrated area under the curve=0.90 for PSA/SIA and 0.58 for serum total PSA. At a cutoff value of k=1.73, PSA/SIA displayed sensitivity=100%, specificity=80.3%, positive predictive value=80.6%, and negative predictive value=100%. No attempt was made in this preliminary study to further control patient population or selection criteria for biopsy, nor did we analytically investigate the type of structural differences in PSA that led to changes in k value. PSA/SIA provides ratiometric information independently of PSA concentration. In this preliminary study, analysis of the overall structurally heterogeneous PSA isoform population using the SIA assay showed promising results to be further evaluated in future studies.

Anticoagulation Should Not Be Used in Most Patients With Stroke With Infective Endocarditis

One of the most worrisome consults to the stroke service is the patient with neurological symptoms in the setting of infective endocarditis (IE). Stroke is the main neurological complication of IE and in 50% to 75% is the presenting feature. The most effective strategy for the prevention of a first or recurrent stroke is the prompt institution of appropriate antibiotic therapy, which reduces the risk to 1% to 3% within the first week.1 Ischemic stroke is 3-fold more common than hemorrhagic stroke. Embolic patterns are seen on diffusion-weighted MR in 92% of patients with stroke or encephalopathy. Initiating anticoagulation may seem reasonable to prevent embolization of infected or bland platelet–fibrin valvular vegetations—perhaps enhanced in the presence of antiphospholipid antibodies—and it is the standard of care for most cardioembolic stroke; however, the stroke risk is similar in the presence or absence of anticoagulants at onset of IE. The most compelling reason to avoid anticoagulation in Staphylococcus aureus IE is the predominance of early …

Left Atrial Mechanical Function and Right Ventricular Apical Pacing: Making the Connections Between the Atrium and Ventricle Clearer

Journal of Cardiovascular ElectrophysiologyVolume 22, Issue 8 p. 875-877 Left Atrial Mechanical Function and Right Ventricular Apical Pacing: Making the Connections Between the Atrium and Ventricle Clearer BRUCE S. STAMBLER M.D., BRUCE S. STAMBLER M.D. University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USASearch for more papers by this author BRUCE S. STAMBLER M.D., BRUCE S. STAMBLER M.D. University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USASearch for more papers by this author First published: 13 April 2011 https://doi.org/10.1111/j.1540-8167.2011.02063.xCitations: 1 Bruce Stambler, M.D., 11100 Euclid Avenue, Cleveland, OH 44106. USA. Fax: 216-844-7116; E-mail: [email protected] J Cardiovasc Electrophysiol, Vol. 22, pp. 875-877, August 2011. Dr. Stambler reports receiving research grants from, serving as consultant to or on the advisory boards of, and receiving honoraria relevant to this topic from Medtronic and Boston Scientific. He has received speaker's fees from Biotronik and serves as consultant to or on the advisory board of St. Jude Medical. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume22, Issue8August 2011Pages 875-877 RelatedInformation

Letter by Varma and Stambler Regarding Article, “Big Brother is Watching You: What Do Patients Think About ICD Home Monitoring?”

HomeCirculationVol. 123, No. 7Letter by Varma and Stambler Regarding Article, “Big Brother is Watching You: What Do Patients Think About ICD Home Monitoring?” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Varma and Stambler Regarding Article, “Big Brother is Watching You: What Do Patients Think About ICD Home Monitoring?” Niraj Varma Bruce S. Stambler Niraj VarmaNiraj Varma Cardiac Pacing and Electrophysiology Cleveland Clinic Cleveland, OH (Varma) Search for more papers by this author Bruce S. StamblerBruce S. Stambler University Hospitals Case Medical Center Case Western Reserve University Cleveland, OH (Stambler) Search for more papers by this author Originally published22 Feb 2011https://doi.org/10.1161/CIRCULATIONAHA.110.983148Circulation. 2011;123:e247To the Editor:We thank Dr Matlock for recognizing the Lumos-T Safely RedUceS RouTine Office Device Follow-up (TRUST) trial's quality.1 Some points raised merit further comment.We acknowledge the importance of patient perspective. TRUST was initiated in 2005, preceding the call from the Heart Rhythm Society to develop remote technologies, and coincided with well-publicized recalls which heightened patients' awareness for monitoring. The remote technology used in TRUST Home Monitoring (HM) has demonstrated excellent levels (>95%) of patient acceptance and satisfaction.2 It is likely then that patients' motivation propelled TRUST to rapid enrollment and early completion. No TRUST patients assigned to HM crossed over during the study, and 98% elected to retain this follow-up mode on trial conclusion, representing the outcome of the shared decision. In contrast, conventional care was characterized by follow up attrition, indicating how onerous patients find scheduled clinic visits.It is possible that patient notification of detection of asymptomatic problems (eg, a broken lead) or nonsustained events is anxiety-provoking. However, inaction is more hazardous. Monitoring hardware performance is a physician responsibility embodied in recent Heart Rhythm Society position statements and often demanded by post-2005 patients.3 Conventional monitoring significantly underreports these events compared to HM.4 Nonsustained arrhythmia notifications which may also be triggered by, for example, lead noise/T wave oversensing, may cause battery depletion and presage shock delivery causing patient morbidity. Shock burden reduction, especially if inappropriate, is a major current concern. HM's early detection of such asymptomatic problems provides an opportunity for early preventative action.4Adjudication of actionability of patient data is the cornerstone of clinical management. HM may facilitate this decision making process for system function as well as patient condition. Automatic longitudinal databasing generates baseline trends with automatic notification of parameter deviation. This lays a foundation for future clinical outcomes studies (not in TRUST's purview) especially for heart failure for which a variety of implantable sensors are under development. The success of these depends on continuous monitoring, accessibility of collected data, and notification of asymptomatic deviation from individually established trends, to permit preemptive clinical intervention. The threat that such event notifications needlessly increase unscheduled visits was tested in TRUST. Notifications occurred infrequently (median <2 per patient per year) yet were valuable since face-to-face encounters triggered were highly actionable (>50%).5 Problem discovery and clinical response (ie, the aims of monitoring) are therefore improved by utilizing this exception-based care model with HM. Importantly, TRUST supported continued face-to-face to follow up with heart failure physicians.We question the validity of Dr Matlock's comparison to prostate-specific antigen screening. HM purpose is to provide near-continuous surveillance for early detection of changes in patients with already declared disease, considered at high risk for subsequent problems, and to monitor a therapy with established efficacy (ie, implantable device performance). TRUST illustrates a mechanism for improved execution of this necessary responsibility.3 This philosophy is separate to population screening for disease in which value will be determined by disease prevalence, the test's predictive value, and the efficacy of treatment available.TRUST illustrates how the rich diagnostic resources of implantable devices may be accessed in an efficient and timely manner to enhance patient care.Niraj Varma, MA, DM, FRCP Cardiac Pacing and Electrophysiology Cleveland Clinic Cleveland, OHBruce S. Stambler, MD University Hospitals Case Medical Center Case Western Reserve University Cleveland, OHDisclosuresDr Varma has received research grants and honoraria from Biotronik. Dr Stambler has received honoraria from Biotronik.

A Traveler to Africa With Fever and a Rash

From the *Division of Infectious Diseases, Akron General Medical Center, Akron; †Northeastern Ohio Universities College of Medicine, Rootstown; and ‡Division of Infectious Diseases and HIV Medicine, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH. Correspondence to: Richard R. Watkins, MD, MS, Suite 290, 224 West Exchange St, Akron, OH 44302. E-mail: [email protected]. The authors have no funding or conflicts of interest to disclose.

Development of the Neurological Institute: a strategic, improvement, and systems approach

The Neurological Institute at University Hospitals Case Medical Center is designed to be responsive to the ever-changing healthcare environment, aligning clinical services and goals in response to internal and external...

“Secondary MGUS” After High-Dose Melphalan and Autologous Hematopoietic Progenitor Cell Transplantation In Multiple Myeloma: A Matter of Undetermined Significance.

AbstractAbstract 1296New monoclonal gammopathies (secondary MGUS) sometimes appear after autologous hematopoietic progenitor cell transplantation (AHPCT) for multiple myeloma (MM). While the pathophysiology and prognostic significance of this phenomenon is incompletely defined, previously published series hypothesize that this phenomenon is due to recapitulation of early B-cell ontogeny, and suggest that it confers a more favorable prognosis.[1-3] We retrospectively reviewed immunoelectrophoretic data on MM patients who underwent AHPCT at University Hospitals Case Medical Center from January 2000 - May 2009, searching for development of secondary MGUS after AHPCT. Secondary MGUS was defined as the occurrence of a monoclonal gammopathy of a different isotype (i.e. change in either the heavy chain, light chain, or both) than the patient's previously identified MM-associated monoclonal gammopathy at any time point after AHPCT.We identified 89 MM patients who underwent AHPCT during that period. All patients received pre-transplant conditioning with melphalan 200 mg/m2 +/− TBI. Eighteen patients (20%) subsequently developed one or more secondary MGUS. There was no significant difference in age, gender, and stage of disease between patients who developed a secondary MGUS and those who did not (p=0.88). No patients who developed secondary MGUS had light-chain only disease at diagnosis. Nine patients developed a single new isotype, nine patients developed two or more new isotypes. The maximum number of new isotypes of monoclonal gammopathy in a single patient was six. Time to development of a secondary MGUS (latency) was highly variable, from 1.9 to 63.9 months, with a median of 10.5 months. One-third (33.3%) of patients who developed secondary MGUS developed their new isotype or isotypes more than a year after AHPCT. Amongst patients with secondary MGUS, the number of secondary isotypes was predictive of overall survival (OS). The hazard of death was 2.04 times higher with one increase of isotype (p = 0.016). There was a statistically significant association between latency to developing secondary MGUS and OS; for patients with latency ≤10 months, the median OS was 38 months, compared to 74 months for those with latency > 10 months (p = 0.023).Secondary MGUS is a phenomenon observed in a substantial subset of patients undergoing AHPCT for MM. Our study demonstrates that this phenomenon cannot be entirely attributed to immune reconstitution, as previously postulated, as one-third of patients developed secondary MGUS a year or more after AHPCT. While selection bias may explain why patients who have longer latency to secondary MGUS have significantly better overall survival, further study is needed to clarify predictors of developing secondary MGUS and the pathophysiology underlying this phenomenon. [Display omitted] 1. Maisnar, V., et al., Isotype class switching after transplantation in multiple myeloma. Neoplasma, 2007. 54(3): p.225-8.2. Zent, C.S., et al., Oligoclonal protein bands and Ig isotype switching in multiple myeloma treated with high-dose therapy and hematopoietic cell transplantation. Blood, 1998. 91(9): p.3518-23.3. Mitus, A.J., et al., Monoclonal and oligoclonal gammopathy after bone marrow transplantation. Blood, 1989. 74(8): p. 2764-8. Disclosures:No relevant conflicts of interest to declare.

ACO Tests May Start Next Year

Just about the only thing that experts can agree on about accountable care organizations right now is that the idea behind them is still in its infancy.“It's not exactly clear that, when people are talking about ACOs, [everyone] has the same thing in mind,” said Dr. Francis J. Crosson, senior fellow in the Kaiser Permanente Institute for Health Policy in Oakland, Calif., and a member of a task force on ACOs that was recently convened by the National Committee for Quality Assurance (NCQA).In general, ACOs would allow primary care physicians, specialists, and hospitals to form a partnership to provide care to a group of patients. The idea is that all the providers would work together to improve quality and manage costs and that they would share in any savings that were produced as a result. Participating in an ACO will mean shifting a system's focus from an acute, episodic care model to a prevention and wellness model, according to Dr. Eric Bieber, chief medical officer at University Hospitals Case Medical Center in Northeast Ohio.The Medicare shared-savings ACO program is set to launch in January 2012. ACOs may also end up being part of testing performed by the Center for Medicare and Medicaid Innovation, a new office created under the law, beginning in January 2011.In the near term, there is likely to be a range of ACO models, Dr. Crosson predicted. Some will be tightly constructed around integrated delivery systems in which physicians and hospitals are part of the same economic entity. Others will be looser models that bring together a group of physicians and hospitals that are financially separate from one another, he said. Just about the only thing that experts can agree on about accountable care organizations right now is that the idea behind them is still in its infancy. “It's not exactly clear that, when people are talking about ACOs, [everyone] has the same thing in mind,” said Dr. Francis J. Crosson, senior fellow in the Kaiser Permanente Institute for Health Policy in Oakland, Calif., and a member of a task force on ACOs that was recently convened by the National Committee for Quality Assurance (NCQA). In general, ACOs would allow primary care physicians, specialists, and hospitals to form a partnership to provide care to a group of patients. The idea is that all the providers would work together to improve quality and manage costs and that they would share in any savings that were produced as a result. Participating in an ACO will mean shifting a system's focus from an acute, episodic care model to a prevention and wellness model, according to Dr. Eric Bieber, chief medical officer at University Hospitals Case Medical Center in Northeast Ohio. The Medicare shared-savings ACO program is set to launch in January 2012. ACOs may also end up being part of testing performed by the Center for Medicare and Medicaid Innovation, a new office created under the law, beginning in January 2011. In the near term, there is likely to be a range of ACO models, Dr. Crosson predicted. Some will be tightly constructed around integrated delivery systems in which physicians and hospitals are part of the same economic entity. Others will be looser models that bring together a group of physicians and hospitals that are financially separate from one another, he said.

Late manifestations of tricho‐rhino‐pharangeal syndrome in a patient: Expanded skeletal phenotype in adulthood

Late manifestations of tricho‐rhino‐pharangeal syndrome in a patient: Expanded skeletal phenotype in adulthood

Postresection CA 19-9 Value as a Prognostic Factor

University Hospitals Case Medical Center, Department of Radiation Oncology, Cleveland, Ohio (Seo) Stony Brook University Cancer Center, Stony Brook, New York (Kinsella)