Patrice Wendling

MINNEAPOLIS — Clinicians often hesitate to call a case of pediatric septic shock, even though they may treat the patient appropriately, according to one critical care physician.

Dr. Jerry McLaughlin presented the case of an alert but ill-appearing 1-year-old with 2 days of fever and vomiting, negative chest x-ray, abnormal urine analysis, capillary refill time of 3 seconds, cool extremities, and a normal respiratory rate, blood pressure, and urine output.

When he asked who would call this case septic shock, only one hand rose up among roughly 75 physicians attending the session at the Pediatric Hospital Medicine 2010 meeting.

“We see patients who look like this all the time, and you don't want to say shock – shock is somebody who's clearly obtunded and needs the ICU and is falling apart – that is not this patient, but she meets criteria and she needs to be treated accordingly,” Dr. McLaughlin said. “The thing is that many of you would treat her appropriately in the first hour and her symptoms would reverse, but you just would never call it. I say this because we need to be speaking the same language.”

Recognition Gap

Although the term “shock” carries with it a certain amount of baggage for medical professionals and families, part of the problem lies in recognition, said Dr. McLaughlin of the department of critical care medicine at Seattle Children's Hospital. He cited a study of 91 infants and children who presented to local community hospitals with septic shock that found community physicians achieved shock reversal in just 26% of patients, and used resuscitation practices consistent with American College of Critical Care Medicine–Pediatric Advanced Life Support (ACCM-PALS) septic shock guidelines in 30% (Pediatrics 2003;112:793–9).

A quick quiz about pediatric sepsis facts at the meeting also suggested some knowledge gaps, with Dr. McLaughlin eliciting an audible gasp when he said that 10 times as many infants develop sepsis compared with older children, and that 10% of the 47,000 pediatric sepsis cases reported each year end in death.

Timing, Timing, Timing

International definitions for sepsis and organ dysfunction have been developed by an expert panel, but many attendees seemed unaware of the specific criteria for each diagnosis on the sepsis continuum (Pediatr. Crit. Care Med. 2005;6:2–8). Still others suggested that the panel's broad definition of sepsis – systemic inflammatory response syndrome (SIRS) plus infection – would encompass a disproportionate number of infants and children in the emergency department.

Just as there are “golden hours” in the treatment of stroke and acute MI, early recognition of septic shock and formulation of a goal-directed therapeutic plan is critical, Dr. McLaughlin stressed at the meeting sponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association. In the community hospital study, each additional hour of persistent shock from the time of diagnosis was associated with a doubling of the risk of death.

The good news is that physicians don't have to come up with their own plan, but have the 2007 ACCM guidelines, published last year (Crit. Care Med. 2009;37:666–88) to direct their therapies. The five elements central to early management are oxygen, vascular access, fluids, inotropes, and antibiotics.

“If a patient comes in with septic shock and it's clear, don't delay getting labs to do this stuff,” he said. “You all know how long it can take to get a CBC and blood work. Suddenly 40 minutes has passed and the nurses are saying they can't get blood, and that's 40 minutes lost.”

Oxygen delivery is pretty straightforward, with the method typically dependent on patient preference. Access can be achieved intravenously or via an intraosseous line, which is often quicker to achieve.

Fluid therapy is an entirely different matter, with the optimal amount of fluid debated because of concerns that excess fluid can induce pulmonary edema or heart failure in children with septic shock.

“Some people say 20 mL/kg, some say 60 [mL/kg] because that is what the guidelines say, but I can tell you that by the time some of these kids leave me they've already had 200 mL/kg or more,” he said. “You give as much as the patient needs and don't hold back because of fear. If you hold back on fluid, you push up mortality.”

Tackling the Fluid Therapy Question

An audience member said there may be an exception, as research suggests that pushing fluids may actually increase mortality in children who are severely malnourished. Dr. McLaughlin responded that some of the best literature on fluid resuscitation has been published by Dr. Cláudio Oliveira's group in Brazil, a country that has a significant amount of malnutrition and reports higher survival rates in patients receiving early, adequate fluid therapy (Pediatr. Emerg. Care 2008;24:810–5).

The type of fluid solution does not seem to influence the ability of fluids to improve perfusion, organ function, and outcome. Dr. McLaughlin recommended using normal saline or lactated Ringer's solution instead of 5% albumin, which has not been shown to be decidedly better than saline.

Titrate to Symptoms

The important point to remember is to titrate to effect, he said. This means that the patient's feet and hands should get warmer, his blood pressure should come up, his heart rate should go down, and his capillary refill time should be more normal – although not necessarily faster or slower because some kids have a really brisk capillary refill rate, he said. Clinicians also should titrate to symptoms, which involves feeling a patient's liver.

“If you're giving fluids to the point you're getting hepatomegaly, then you've probably reached your fluid limit for that patient,” Dr. McLaughlin said. “If you're getting more tachycardia as you give more fluids, that should cause you to pause and … shift your therapy.”

Various inotropes can be used for septic shock, and Dr. McLaughlin recommended that clinicians use the one they are most familiar with. In the general pediatric population, that typically means starting out with dopamine and epinephrine, he said, adding that dobutamine and milrinone “could get you into trouble.”

Antibiotic therapy should address the specific epidemiology of the patient population: ceftriaxone for community-acquired pediatric sepsis; ampicillin with gentamicin or cefotaxime, or cefotaxime for neonates; and ceftazidime with or without vancomycin for patients with neutropenia and central venous access.

“What I see too many times is that patients get assessed, plans get started, and then for an hour and a half no one's gone back to look at that kid again,” Dr. McLaughlin said. “That's not okay. You have to stay on top of these kids because time matters. An hour matters.”

He observed that hospitalists are in a unique position to affect sepsis outcomes because they have early access to patients. He also pointed out that 50% of patients with sepsis have chronic disease, SIRS is present in 7% of hospitalized patients, and sepsis is a quality indicator.

MINNEAPOLIS — Clinicians often hesitate to call a case of pediatric septic shock, even though they may treat the patient appropriately, according to one critical care physician.

Dr. Jerry McLaughlin presented the case of an alert but ill-appearing 1-year-old with 2 days of fever and vomiting, negative chest x-ray, abnormal urine analysis, capillary refill time of 3 seconds, cool extremities, and a normal respiratory rate, blood pressure, and urine output.

When he asked who would call this case septic shock, only one hand rose up among roughly 75 physicians attending the session at the Pediatric Hospital Medicine 2010 meeting.

“We see patients who look like this all the time, and you don't want to say shock – shock is somebody who's clearly obtunded and needs the ICU and is falling apart – that is not this patient, but she meets criteria and she needs to be treated accordingly,” Dr. McLaughlin said. “The thing is that many of you would treat her appropriately in the first hour and her symptoms would reverse, but you just would never call it. I say this because we need to be speaking the same language.”

Recognition Gap

Although the term “shock” carries with it a certain amount of baggage for medical professionals and families, part of the problem lies in recognition, said Dr. McLaughlin of the department of critical care medicine at Seattle Children's Hospital. He cited a study of 91 infants and children who presented to local community hospitals with septic shock that found community physicians achieved shock reversal in just 26% of patients, and used resuscitation practices consistent with American College of Critical Care Medicine–Pediatric Advanced Life Support (ACCM-PALS) septic shock guidelines in 30% (Pediatrics 2003;112:793–9).

A quick quiz about pediatric sepsis facts at the meeting also suggested some knowledge gaps, with Dr. McLaughlin eliciting an audible gasp when he said that 10 times as many infants develop sepsis compared with older children, and that 10% of the 47,000 pediatric sepsis cases reported each year end in death.

Timing, Timing, Timing

International definitions for sepsis and organ dysfunction have been developed by an expert panel, but many attendees seemed unaware of the specific criteria for each diagnosis on the sepsis continuum (Pediatr. Crit. Care Med. 2005;6:2–8). Still others suggested that the panel's broad definition of sepsis – systemic inflammatory response syndrome (SIRS) plus infection – would encompass a disproportionate number of infants and children in the emergency department.

Just as there are “golden hours” in the treatment of stroke and acute MI, early recognition of septic shock and formulation of a goal-directed therapeutic plan is critical, Dr. McLaughlin stressed at the meeting sponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association. In the community hospital study, each additional hour of persistent shock from the time of diagnosis was associated with a doubling of the risk of death.

The good news is that physicians don't have to come up with their own plan, but have the 2007 ACCM guidelines, published last year (Crit. Care Med. 2009;37:666–88) to direct their therapies. The five elements central to early management are oxygen, vascular access, fluids, inotropes, and antibiotics.

“If a patient comes in with septic shock and it's clear, don't delay getting labs to do this stuff,” he said. “You all know how long it can take to get a CBC and blood work. Suddenly 40 minutes has passed and the nurses are saying they can't get blood, and that's 40 minutes lost.”

Oxygen delivery is pretty straightforward, with the method typically dependent on patient preference. Access can be achieved intravenously or via an intraosseous line, which is often quicker to achieve.

Fluid therapy is an entirely different matter, with the optimal amount of fluid debated because of concerns that excess fluid can induce pulmonary edema or heart failure in children with septic shock.

“Some people say 20 mL/kg, some say 60 [mL/kg] because that is what the guidelines say, but I can tell you that by the time some of these kids leave me they've already had 200 mL/kg or more,” he said. “You give as much as the patient needs and don't hold back because of fear. If you hold back on fluid, you push up mortality.”

Tackling the Fluid Therapy Question

An audience member said there may be an exception, as research suggests that pushing fluids may actually increase mortality in children who are severely malnourished. Dr. McLaughlin responded that some of the best literature on fluid resuscitation has been published by Dr. Cláudio Oliveira's group in Brazil, a country that has a significant amount of malnutrition and reports higher survival rates in patients receiving early, adequate fluid therapy (Pediatr. Emerg. Care 2008;24:810–5).

The type of fluid solution does not seem to influence the ability of fluids to improve perfusion, organ function, and outcome. Dr. McLaughlin recommended using normal saline or lactated Ringer's solution instead of 5% albumin, which has not been shown to be decidedly better than saline.

Titrate to Symptoms

The important point to remember is to titrate to effect, he said. This means that the patient's feet and hands should get warmer, his blood pressure should come up, his heart rate should go down, and his capillary refill time should be more normal – although not necessarily faster or slower because some kids have a really brisk capillary refill rate, he said. Clinicians also should titrate to symptoms, which involves feeling a patient's liver.

“If you're giving fluids to the point you're getting hepatomegaly, then you've probably reached your fluid limit for that patient,” Dr. McLaughlin said. “If you're getting more tachycardia as you give more fluids, that should cause you to pause and … shift your therapy.”

Various inotropes can be used for septic shock, and Dr. McLaughlin recommended that clinicians use the one they are most familiar with. In the general pediatric population, that typically means starting out with dopamine and epinephrine, he said, adding that dobutamine and milrinone “could get you into trouble.”

Antibiotic therapy should address the specific epidemiology of the patient population: ceftriaxone for community-acquired pediatric sepsis; ampicillin with gentamicin or cefotaxime, or cefotaxime for neonates; and ceftazidime with or without vancomycin for patients with neutropenia and central venous access.

“What I see too many times is that patients get assessed, plans get started, and then for an hour and a half no one's gone back to look at that kid again,” Dr. McLaughlin said. “That's not okay. You have to stay on top of these kids because time matters. An hour matters.”

He observed that hospitalists are in a unique position to affect sepsis outcomes because they have early access to patients. He also pointed out that 50% of patients with sepsis have chronic disease, SIRS is present in 7% of hospitalized patients, and sepsis is a quality indicator.

MINNEAPOLIS — Clinicians often hesitate to call a case of pediatric septic shock, even though they may treat the patient appropriately, according to one critical care physician.

Dr. Jerry McLaughlin presented the case of an alert but ill-appearing 1-year-old with 2 days of fever and vomiting, negative chest x-ray, abnormal urine analysis, capillary refill time of 3 seconds, cool extremities, and a normal respiratory rate, blood pressure, and urine output.

When he asked who would call this case septic shock, only one hand rose up among roughly 75 physicians attending the session at the Pediatric Hospital Medicine 2010 meeting.

“We see patients who look like this all the time, and you don't want to say shock – shock is somebody who's clearly obtunded and needs the ICU and is falling apart – that is not this patient, but she meets criteria and she needs to be treated accordingly,” Dr. McLaughlin said. “The thing is that many of you would treat her appropriately in the first hour and her symptoms would reverse, but you just would never call it. I say this because we need to be speaking the same language.”

Recognition Gap

Although the term “shock” carries with it a certain amount of baggage for medical professionals and families, part of the problem lies in recognition, said Dr. McLaughlin of the department of critical care medicine at Seattle Children's Hospital. He cited a study of 91 infants and children who presented to local community hospitals with septic shock that found community physicians achieved shock reversal in just 26% of patients, and used resuscitation practices consistent with American College of Critical Care Medicine–Pediatric Advanced Life Support (ACCM-PALS) septic shock guidelines in 30% (Pediatrics 2003;112:793–9).

A quick quiz about pediatric sepsis facts at the meeting also suggested some knowledge gaps, with Dr. McLaughlin eliciting an audible gasp when he said that 10 times as many infants develop sepsis compared with older children, and that 10% of the 47,000 pediatric sepsis cases reported each year end in death.

Timing, Timing, Timing

International definitions for sepsis and organ dysfunction have been developed by an expert panel, but many attendees seemed unaware of the specific criteria for each diagnosis on the sepsis continuum (Pediatr. Crit. Care Med. 2005;6:2–8). Still others suggested that the panel's broad definition of sepsis – systemic inflammatory response syndrome (SIRS) plus infection – would encompass a disproportionate number of infants and children in the emergency department.

Just as there are “golden hours” in the treatment of stroke and acute MI, early recognition of septic shock and formulation of a goal-directed therapeutic plan is critical, Dr. McLaughlin stressed at the meeting sponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association. In the community hospital study, each additional hour of persistent shock from the time of diagnosis was associated with a doubling of the risk of death.

The good news is that physicians don't have to come up with their own plan, but have the 2007 ACCM guidelines, published last year (Crit. Care Med. 2009;37:666–88) to direct their therapies. The five elements central to early management are oxygen, vascular access, fluids, inotropes, and antibiotics.

“If a patient comes in with septic shock and it's clear, don't delay getting labs to do this stuff,” he said. “You all know how long it can take to get a CBC and blood work. Suddenly 40 minutes has passed and the nurses are saying they can't get blood, and that's 40 minutes lost.”

Oxygen delivery is pretty straightforward, with the method typically dependent on patient preference. Access can be achieved intravenously or via an intraosseous line, which is often quicker to achieve.

Fluid therapy is an entirely different matter, with the optimal amount of fluid debated because of concerns that excess fluid can induce pulmonary edema or heart failure in children with septic shock.

“Some people say 20 mL/kg, some say 60 [mL/kg] because that is what the guidelines say, but I can tell you that by the time some of these kids leave me they've already had 200 mL/kg or more,” he said. “You give as much as the patient needs and don't hold back because of fear. If you hold back on fluid, you push up mortality.”

Tackling the Fluid Therapy Question

An audience member said there may be an exception, as research suggests that pushing fluids may actually increase mortality in children who are severely malnourished. Dr. McLaughlin responded that some of the best literature on fluid resuscitation has been published by Dr. Cláudio Oliveira's group in Brazil, a country that has a significant amount of malnutrition and reports higher survival rates in patients receiving early, adequate fluid therapy (Pediatr. Emerg. Care 2008;24:810–5).

The type of fluid solution does not seem to influence the ability of fluids to improve perfusion, organ function, and outcome. Dr. McLaughlin recommended using normal saline or lactated Ringer's solution instead of 5% albumin, which has not been shown to be decidedly better than saline.

Titrate to Symptoms

The important point to remember is to titrate to effect, he said. This means that the patient's feet and hands should get warmer, his blood pressure should come up, his heart rate should go down, and his capillary refill time should be more normal – although not necessarily faster or slower because some kids have a really brisk capillary refill rate, he said. Clinicians also should titrate to symptoms, which involves feeling a patient's liver.

“If you're giving fluids to the point you're getting hepatomegaly, then you've probably reached your fluid limit for that patient,” Dr. McLaughlin said. “If you're getting more tachycardia as you give more fluids, that should cause you to pause and … shift your therapy.”

Various inotropes can be used for septic shock, and Dr. McLaughlin recommended that clinicians use the one they are most familiar with. In the general pediatric population, that typically means starting out with dopamine and epinephrine, he said, adding that dobutamine and milrinone “could get you into trouble.”

Antibiotic therapy should address the specific epidemiology of the patient population: ceftriaxone for community-acquired pediatric sepsis; ampicillin with gentamicin or cefotaxime, or cefotaxime for neonates; and ceftazidime with or without vancomycin for patients with neutropenia and central venous access.

“What I see too many times is that patients get assessed, plans get started, and then for an hour and a half no one's gone back to look at that kid again,” Dr. McLaughlin said. “That's not okay. You have to stay on top of these kids because time matters. An hour matters.”

He observed that hospitalists are in a unique position to affect sepsis outcomes because they have early access to patients. He also pointed out that 50% of patients with sepsis have chronic disease, SIRS is present in 7% of hospitalized patients, and sepsis is a quality indicator.

Major Finding: The number of symptom-free days increased from an average of 8 days per 2-week period for all children at baseline to 11.9 days with the intervention vs. 11.2 days with usual care.

Data Source: School-Based Asthma Therapy trial in 530 children with asthma.

Disclosures: SBAT was supported by grants from the National Heart, Lung, and Blood Institute and the Halcyon Hill Foundation. Ms. Fagnano and Dr. Halterman disclosed no financial conflicts.

VANCOUVER, B.C. — A school-based intervention that focused on medication adherence and reducing exposure to tobacco smoke significantly improved outcomes among inner-city children with asthma in a randomized trial.

Children receiving the intervention had almost 1 additional symptom-free day per 2-week period during the peak winter asthma season of November to February.

The number of symptom-free days increased from an average of 8 days for all children at baseline to 11.9 days per 2-week period with the intervention vs. 11.2 days with usual care. “This difference is larger than what has been seen with more intensive and costly interventions,” said Maria Fagnano, M.P.H., of the University of Rochester (N.Y.) Medical Center.

The children receiving the intervention were significantly more likely than controls to have fewer nights with symptoms (mean 1.5 nights vs. 2.0 nights), fewer days with limited activity (1.2 vs. 1.6), and fewer days with rescue medication use (1.59 vs. 2.61), Ms. Fagnano reported at the annual meeting of the Pediatric Academic Societies.

The intervention group also was significantly less likely than controls to have any acute visit for asthma (12% vs. 18%). In addition, the intervention group had fewer days absent from school due to asthma (0.3 days vs. 0.4 days).

Although additional efforts are needed to evaluate costs of the intervention and to develop dissemination strategies, collaborations with schools provide a unique opportunity to reach high-risk children and target those at greatest need for assistance, Ms. Fagnano said.

“This type of intervention is widely applicable for asthma care in the community nationwide, as well as for management of other chronic diseases, and could potentially reduce disparities between poor and nonpoor children,” she said.

The School-Based Asthma Therapy (SBAT) trial, led by colleague Dr. Jill Halterman, was implemented in 2006 in 54 schools and preschools in Rochester, N.Y., to reduce morbidity in poor children aged 3–10 years with physician-diagnosed asthma.

The school nurse was given a canister of preventive medication (fluticasone propionate or fluticasone propionate with salmeterol), with a spacer and mask as appropriate, and asked to give one dose to the child each school day. A supply of preventive asthma medications also was delivered to parents, who were instructed to use the medications on days the child did not attend school.

The intervention also used motivational interviewing to counsel the primary caregiver about how to reduce environmental tobacco smoke (ETS) in the home for smoke-exposed children, Ms. Fagnano said. Overall, 54% of children lived with one or more smokers at baseline. A home-based counseling session was delivered by a trained nurse, with two follow-up telephone calls made at 1 and 3 months after the 30-minute session.

In the usual care group, parents and physicians were notified of the child's asthma severity and encouraged to start on appropriate preventive treatments, but no medication was provided, she said.

At baseline, 69% of children were on preventive medications, 73% received Medicaid, 58% were male, 63% were black, and 28% were Hispanic. Their mean age was 7 years. There were 265 children in each arm.

In a regression analysis, the intervention was associated with 0.92 days per 2 weeks more symptom-free days (P less than .001), Ms. Fagnano said.

A stratified analysis showed a significant intervention effect on the primary outcome of symptom-free days for children with and without ETS exposure in the home. The mean number of symptom-free days among non-ETS exposed children was 11.6 days in the treatment group vs. 10.9 days in the control group; and was 11.6 days vs. 10.0 days, respectively, in smoke-exposed children, she said.

An audience member remarked on the improvement observed, even among controls. Ms. Fagnano said that monthly follow-up calls could have “clued parents in to what the child was experiencing,” and that asthma calendars given to these families may have helped them notice more symptoms.

Major Finding: The number of symptom-free days increased from an average of 8 days per 2-week period for all children at baseline to 11.9 days with the intervention vs. 11.2 days with usual care.

Data Source: School-Based Asthma Therapy trial in 530 children with asthma.

Disclosures: SBAT was supported by grants from the National Heart, Lung, and Blood Institute and the Halcyon Hill Foundation. Ms. Fagnano and Dr. Halterman disclosed no financial conflicts.

VANCOUVER, B.C. — A school-based intervention that focused on medication adherence and reducing exposure to tobacco smoke significantly improved outcomes among inner-city children with asthma in a randomized trial.

Children receiving the intervention had almost 1 additional symptom-free day per 2-week period during the peak winter asthma season of November to February.

The number of symptom-free days increased from an average of 8 days for all children at baseline to 11.9 days per 2-week period with the intervention vs. 11.2 days with usual care. “This difference is larger than what has been seen with more intensive and costly interventions,” said Maria Fagnano, M.P.H., of the University of Rochester (N.Y.) Medical Center.

The children receiving the intervention were significantly more likely than controls to have fewer nights with symptoms (mean 1.5 nights vs. 2.0 nights), fewer days with limited activity (1.2 vs. 1.6), and fewer days with rescue medication use (1.59 vs. 2.61), Ms. Fagnano reported at the annual meeting of the Pediatric Academic Societies.

The intervention group also was significantly less likely than controls to have any acute visit for asthma (12% vs. 18%). In addition, the intervention group had fewer days absent from school due to asthma (0.3 days vs. 0.4 days).

Although additional efforts are needed to evaluate costs of the intervention and to develop dissemination strategies, collaborations with schools provide a unique opportunity to reach high-risk children and target those at greatest need for assistance, Ms. Fagnano said.

“This type of intervention is widely applicable for asthma care in the community nationwide, as well as for management of other chronic diseases, and could potentially reduce disparities between poor and nonpoor children,” she said.

The School-Based Asthma Therapy (SBAT) trial, led by colleague Dr. Jill Halterman, was implemented in 2006 in 54 schools and preschools in Rochester, N.Y., to reduce morbidity in poor children aged 3–10 years with physician-diagnosed asthma.

The school nurse was given a canister of preventive medication (fluticasone propionate or fluticasone propionate with salmeterol), with a spacer and mask as appropriate, and asked to give one dose to the child each school day. A supply of preventive asthma medications also was delivered to parents, who were instructed to use the medications on days the child did not attend school.

The intervention also used motivational interviewing to counsel the primary caregiver about how to reduce environmental tobacco smoke (ETS) in the home for smoke-exposed children, Ms. Fagnano said. Overall, 54% of children lived with one or more smokers at baseline. A home-based counseling session was delivered by a trained nurse, with two follow-up telephone calls made at 1 and 3 months after the 30-minute session.

In the usual care group, parents and physicians were notified of the child's asthma severity and encouraged to start on appropriate preventive treatments, but no medication was provided, she said.

At baseline, 69% of children were on preventive medications, 73% received Medicaid, 58% were male, 63% were black, and 28% were Hispanic. Their mean age was 7 years. There were 265 children in each arm.

In a regression analysis, the intervention was associated with 0.92 days per 2 weeks more symptom-free days (P less than .001), Ms. Fagnano said.

A stratified analysis showed a significant intervention effect on the primary outcome of symptom-free days for children with and without ETS exposure in the home. The mean number of symptom-free days among non-ETS exposed children was 11.6 days in the treatment group vs. 10.9 days in the control group; and was 11.6 days vs. 10.0 days, respectively, in smoke-exposed children, she said.

An audience member remarked on the improvement observed, even among controls. Ms. Fagnano said that monthly follow-up calls could have “clued parents in to what the child was experiencing,” and that asthma calendars given to these families may have helped them notice more symptoms.

Major Finding: The number of symptom-free days increased from an average of 8 days per 2-week period for all children at baseline to 11.9 days with the intervention vs. 11.2 days with usual care.

Data Source: School-Based Asthma Therapy trial in 530 children with asthma.

Disclosures: SBAT was supported by grants from the National Heart, Lung, and Blood Institute and the Halcyon Hill Foundation. Ms. Fagnano and Dr. Halterman disclosed no financial conflicts.

VANCOUVER, B.C. — A school-based intervention that focused on medication adherence and reducing exposure to tobacco smoke significantly improved outcomes among inner-city children with asthma in a randomized trial.

Children receiving the intervention had almost 1 additional symptom-free day per 2-week period during the peak winter asthma season of November to February.

The number of symptom-free days increased from an average of 8 days for all children at baseline to 11.9 days per 2-week period with the intervention vs. 11.2 days with usual care. “This difference is larger than what has been seen with more intensive and costly interventions,” said Maria Fagnano, M.P.H., of the University of Rochester (N.Y.) Medical Center.

The children receiving the intervention were significantly more likely than controls to have fewer nights with symptoms (mean 1.5 nights vs. 2.0 nights), fewer days with limited activity (1.2 vs. 1.6), and fewer days with rescue medication use (1.59 vs. 2.61), Ms. Fagnano reported at the annual meeting of the Pediatric Academic Societies.

The intervention group also was significantly less likely than controls to have any acute visit for asthma (12% vs. 18%). In addition, the intervention group had fewer days absent from school due to asthma (0.3 days vs. 0.4 days).

Although additional efforts are needed to evaluate costs of the intervention and to develop dissemination strategies, collaborations with schools provide a unique opportunity to reach high-risk children and target those at greatest need for assistance, Ms. Fagnano said.

“This type of intervention is widely applicable for asthma care in the community nationwide, as well as for management of other chronic diseases, and could potentially reduce disparities between poor and nonpoor children,” she said.

The School-Based Asthma Therapy (SBAT) trial, led by colleague Dr. Jill Halterman, was implemented in 2006 in 54 schools and preschools in Rochester, N.Y., to reduce morbidity in poor children aged 3–10 years with physician-diagnosed asthma.

The school nurse was given a canister of preventive medication (fluticasone propionate or fluticasone propionate with salmeterol), with a spacer and mask as appropriate, and asked to give one dose to the child each school day. A supply of preventive asthma medications also was delivered to parents, who were instructed to use the medications on days the child did not attend school.

The intervention also used motivational interviewing to counsel the primary caregiver about how to reduce environmental tobacco smoke (ETS) in the home for smoke-exposed children, Ms. Fagnano said. Overall, 54% of children lived with one or more smokers at baseline. A home-based counseling session was delivered by a trained nurse, with two follow-up telephone calls made at 1 and 3 months after the 30-minute session.

In the usual care group, parents and physicians were notified of the child's asthma severity and encouraged to start on appropriate preventive treatments, but no medication was provided, she said.

At baseline, 69% of children were on preventive medications, 73% received Medicaid, 58% were male, 63% were black, and 28% were Hispanic. Their mean age was 7 years. There were 265 children in each arm.

In a regression analysis, the intervention was associated with 0.92 days per 2 weeks more symptom-free days (P less than .001), Ms. Fagnano said.

A stratified analysis showed a significant intervention effect on the primary outcome of symptom-free days for children with and without ETS exposure in the home. The mean number of symptom-free days among non-ETS exposed children was 11.6 days in the treatment group vs. 10.9 days in the control group; and was 11.6 days vs. 10.0 days, respectively, in smoke-exposed children, she said.

An audience member remarked on the improvement observed, even among controls. Ms. Fagnano said that monthly follow-up calls could have “clued parents in to what the child was experiencing,” and that asthma calendars given to these families may have helped them notice more symptoms.

MINNEAPOLIS – Clinicians consistently undertreat acute pain in hospitalized children, despite parents' expectations that everything possible is being done to relieve their children's suffering.

Data show that with the same procedure, adults are getting many more pain doses than children, Dr. Stefan J. Friedrichsdorf said at the meeting. “Even among children, a 10-year-old is likely to get better analgesia than a 10-day-old for exactly the same procedure,” he added.

Several myths contribute to the abysmal management of acute pain in children, with concern about inducing addiction at the top of the list, said Dr. Friedrichsdorf, a pediatrician and medical director of pain and palliative care at Children's Hospitals and Clinics of Minnesota, Minneapolis.

While there have been reports of opioid use leading to addiction in children with chronic pain, no such cases have been reported in children treated with strong opioids for acute pain, he said.

What's more likely to occur is for staff to confuse tolerance with addiction if children have received opioids for more than 3 days and display signs of withdrawal if the drug is abruptly discontinued instead of carefully titrated down. Still others, out of a belief that the pain is “not that bad” or that pain medications mask the underlying symptoms, will administer such small doses of morphine that the child repeatedly asks the nursing staff for more.

“When you arrive the next day, the nurse says, 'I think he's becoming addicted; shouldn't we switch to codeine?' When, in fact, we are just underdosing,” Dr. Friedrichsdorf said. “This is pseudoaddiction.”

Evidence shows that it is possible to assess symptoms with adequate pain management, with the possible exceptions being compartment syndrome and intracranial injuries, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Respiratory depression is a common concern in pain management, but should not deter providers from using opioid patient-controlled analgesia (PCA) in children.

A recent meta-analysis involving 14 studies and 402 patients indicates that the addition of a continuous infusion to intravenous opioid PCA is associated with a higher incidence of respiratory events, compared with demand intravenous PCA in adults, but not in pediatric patients (J. Opioid Manag. 2010;6:47-54).

Several professional organizations have weighed in on pediatric pain management, with a recent systematic review identifying no less than 25 cancer-related pain management guidelines published between 2000 and May 2006 (Clin. J. Pain 2010;26:449-62).

Dr. Friedrichsdorf advised providers to familiarize themselves with the Principles of Pediatric Acute Pain Management in the 1998 World Health Organization report: “Cancer Pain Relief and Palliative Care in Children” and the WHO's three-step “ladder” for cancer pain relief. The principles address opioid analgesics commonly used for moderate to severe pain, routes of administration, initial pediatric doses, and dosing intervals.

For example, the initial dose for intravenous or subcutaneous morphine ranges from 0.05 mg/kg to 0.1 mg/kg. Because of the wide variability in individual responses to opioids, this should not be interpreted to mean that all patients should start at 0.05 mg/kg, Dr. Friedrichsdorf said.

“For small kids with small pain, use the lower end of the dose range; use a big dose for big kids with big pain,” he said.

As-needed orders for opioids are commonly used to provide flexibility in dosing, but frequently result in the patient receiving nothing or seesawing between under- and oversedation, Dr. Friedrichsdorf said.

“The golden rule is that we must schedule analgesia and then on top of that, of course, use p.r.n. analgesia and titrate to effect,” he said.

Disclosures: Dr. Friedrichsdorf reported having no conflicts of interest.

'The golden rule is that we must schedule analgesia and then … use p.r.n. analgesia and titrate to effect.'

Source DR. FRIEDRICHSDORF

MINNEAPOLIS – Clinicians consistently undertreat acute pain in hospitalized children, despite parents' expectations that everything possible is being done to relieve their children's suffering.

Data show that with the same procedure, adults are getting many more pain doses than children, Dr. Stefan J. Friedrichsdorf said at the meeting. “Even among children, a 10-year-old is likely to get better analgesia than a 10-day-old for exactly the same procedure,” he added.

Several myths contribute to the abysmal management of acute pain in children, with concern about inducing addiction at the top of the list, said Dr. Friedrichsdorf, a pediatrician and medical director of pain and palliative care at Children's Hospitals and Clinics of Minnesota, Minneapolis.

While there have been reports of opioid use leading to addiction in children with chronic pain, no such cases have been reported in children treated with strong opioids for acute pain, he said.

What's more likely to occur is for staff to confuse tolerance with addiction if children have received opioids for more than 3 days and display signs of withdrawal if the drug is abruptly discontinued instead of carefully titrated down. Still others, out of a belief that the pain is “not that bad” or that pain medications mask the underlying symptoms, will administer such small doses of morphine that the child repeatedly asks the nursing staff for more.

“When you arrive the next day, the nurse says, 'I think he's becoming addicted; shouldn't we switch to codeine?' When, in fact, we are just underdosing,” Dr. Friedrichsdorf said. “This is pseudoaddiction.”

Evidence shows that it is possible to assess symptoms with adequate pain management, with the possible exceptions being compartment syndrome and intracranial injuries, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Respiratory depression is a common concern in pain management, but should not deter providers from using opioid patient-controlled analgesia (PCA) in children.

A recent meta-analysis involving 14 studies and 402 patients indicates that the addition of a continuous infusion to intravenous opioid PCA is associated with a higher incidence of respiratory events, compared with demand intravenous PCA in adults, but not in pediatric patients (J. Opioid Manag. 2010;6:47-54).

Several professional organizations have weighed in on pediatric pain management, with a recent systematic review identifying no less than 25 cancer-related pain management guidelines published between 2000 and May 2006 (Clin. J. Pain 2010;26:449-62).

Dr. Friedrichsdorf advised providers to familiarize themselves with the Principles of Pediatric Acute Pain Management in the 1998 World Health Organization report: “Cancer Pain Relief and Palliative Care in Children” and the WHO's three-step “ladder” for cancer pain relief. The principles address opioid analgesics commonly used for moderate to severe pain, routes of administration, initial pediatric doses, and dosing intervals.

For example, the initial dose for intravenous or subcutaneous morphine ranges from 0.05 mg/kg to 0.1 mg/kg. Because of the wide variability in individual responses to opioids, this should not be interpreted to mean that all patients should start at 0.05 mg/kg, Dr. Friedrichsdorf said.

“For small kids with small pain, use the lower end of the dose range; use a big dose for big kids with big pain,” he said.

As-needed orders for opioids are commonly used to provide flexibility in dosing, but frequently result in the patient receiving nothing or seesawing between under- and oversedation, Dr. Friedrichsdorf said.

“The golden rule is that we must schedule analgesia and then on top of that, of course, use p.r.n. analgesia and titrate to effect,” he said.

Disclosures: Dr. Friedrichsdorf reported having no conflicts of interest.

'The golden rule is that we must schedule analgesia and then … use p.r.n. analgesia and titrate to effect.'

Source DR. FRIEDRICHSDORF

MINNEAPOLIS – Clinicians consistently undertreat acute pain in hospitalized children, despite parents' expectations that everything possible is being done to relieve their children's suffering.

Data show that with the same procedure, adults are getting many more pain doses than children, Dr. Stefan J. Friedrichsdorf said at the meeting. “Even among children, a 10-year-old is likely to get better analgesia than a 10-day-old for exactly the same procedure,” he added.

Several myths contribute to the abysmal management of acute pain in children, with concern about inducing addiction at the top of the list, said Dr. Friedrichsdorf, a pediatrician and medical director of pain and palliative care at Children's Hospitals and Clinics of Minnesota, Minneapolis.

While there have been reports of opioid use leading to addiction in children with chronic pain, no such cases have been reported in children treated with strong opioids for acute pain, he said.

What's more likely to occur is for staff to confuse tolerance with addiction if children have received opioids for more than 3 days and display signs of withdrawal if the drug is abruptly discontinued instead of carefully titrated down. Still others, out of a belief that the pain is “not that bad” or that pain medications mask the underlying symptoms, will administer such small doses of morphine that the child repeatedly asks the nursing staff for more.

“When you arrive the next day, the nurse says, 'I think he's becoming addicted; shouldn't we switch to codeine?' When, in fact, we are just underdosing,” Dr. Friedrichsdorf said. “This is pseudoaddiction.”

Evidence shows that it is possible to assess symptoms with adequate pain management, with the possible exceptions being compartment syndrome and intracranial injuries, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Respiratory depression is a common concern in pain management, but should not deter providers from using opioid patient-controlled analgesia (PCA) in children.

A recent meta-analysis involving 14 studies and 402 patients indicates that the addition of a continuous infusion to intravenous opioid PCA is associated with a higher incidence of respiratory events, compared with demand intravenous PCA in adults, but not in pediatric patients (J. Opioid Manag. 2010;6:47-54).

Several professional organizations have weighed in on pediatric pain management, with a recent systematic review identifying no less than 25 cancer-related pain management guidelines published between 2000 and May 2006 (Clin. J. Pain 2010;26:449-62).

Dr. Friedrichsdorf advised providers to familiarize themselves with the Principles of Pediatric Acute Pain Management in the 1998 World Health Organization report: “Cancer Pain Relief and Palliative Care in Children” and the WHO's three-step “ladder” for cancer pain relief. The principles address opioid analgesics commonly used for moderate to severe pain, routes of administration, initial pediatric doses, and dosing intervals.

For example, the initial dose for intravenous or subcutaneous morphine ranges from 0.05 mg/kg to 0.1 mg/kg. Because of the wide variability in individual responses to opioids, this should not be interpreted to mean that all patients should start at 0.05 mg/kg, Dr. Friedrichsdorf said.

“For small kids with small pain, use the lower end of the dose range; use a big dose for big kids with big pain,” he said.

As-needed orders for opioids are commonly used to provide flexibility in dosing, but frequently result in the patient receiving nothing or seesawing between under- and oversedation, Dr. Friedrichsdorf said.

“The golden rule is that we must schedule analgesia and then on top of that, of course, use p.r.n. analgesia and titrate to effect,” he said.

Disclosures: Dr. Friedrichsdorf reported having no conflicts of interest.

'The golden rule is that we must schedule analgesia and then … use p.r.n. analgesia and titrate to effect.'

Source DR. FRIEDRICHSDORF

CHICAGO – Depressive symptoms are common in mothers of children with newly diagnosed epilepsy, and they follow four distinct trajectories, new data suggest.

Researchers in Ontario evaluated 339 mothers of children aged 4-12 years with new-onset epilepsy who were enrolled in the national, prospective Health-Related Quality of Life of Children With Epilepsy Study (HERQULES).

About one-third of the mothers were at risk for clinical depression during the first 24 months after diagnosis, Mark Ferro reported in a poster at the Epilepsy and Depressive Disorders Conference.

The prevalence of women with depressive symptoms, as measured using the Center for Epidemiological Studies Depression Scale, was 38% at baseline, 30% at 6 months, 32% at 12 months, and 30% at 24 months.

Previous cross-sectional studies have reported similar rates, but the surprise finding was that maternal depressive symptoms followed four distinct trajectories: high decreasing, moderate increasing, borderline, and low stable, said Mr. Ferro, a doctoral student in epidemiology and biostatistics at the University of Western Ontario, London.

The researchers had anticipated just three trajectories, but found that some women fell in and out of risk for depression. Although the reason for this borderline trajectory is unclear, Mr. Ferro suggests that it may reflect the unpredictable nature of epilepsy, or a family’s search for effective pharmacologic or cognitive-based therapies to manage their child’s illness.

“There’s a big trial-and-error period during the first 2 years after diagnosis,” he said.

At several points during the conference, speakers noted the profound effect that witnessing a seizure and living with epilepsy can have on families. A subsequent unpublished study by the same group found that as a mother’s depressive symptoms increase, a child’s quality of life decreases.

“It’s not just the child suffering the seizures, but the entire family,” Mr. Ferro said. “In terms of putting the patient at the center of care, we’re also asking physicians to put the family at the center of care. We’re hoping that by addressing the mother’s mental health status, clinicians can improve the quality of care for children with epilepsy.”

In the current study, mothers in the low-stable group were significantly more likely to be university educated (63%) than were those in the borderline (46%), moderate-increasing (41%), or high-decreasing groups (21%), and to be older (mean, 39 years) than women in the moderate-increasing group (mean, 34 years).

Child quality of life predicted membership in the high-decreasing group, whereas the presence of cognitive problems in the child predicted membership in the moderate-increasing group. Child cognitive disability was the strongest predictor for any of the variables examined in the model, with an odds ratio of 9.3 in a multinomial regression analysis, Mr. Ferro reported.

Mothers whose depressive symptoms took a low-stable trajectory were significantly more likely than women in the other three groups to have a greater degree of satisfaction with family function, as measured by the APGAR (Adaptability, Partnership, Growth, Affection and Resolve) scale; a greater repertoire of family resources, as measured by the FIRM (Family Inventory of Resources for Management) assessment; and fewer potentially stressful life events, as measured by the FILE (Family Inventory of Life Events and Changes) scale.

The conference was jointly sponsored by the EDDC and the office of continuing medical education of Elsevier. The study was supported by the Canadian Institutes of Health Research. The authors reported no conflicts of interest.

CHICAGO – Depressive symptoms are common in mothers of children with newly diagnosed epilepsy, and they follow four distinct trajectories, new data suggest.

Researchers in Ontario evaluated 339 mothers of children aged 4-12 years with new-onset epilepsy who were enrolled in the national, prospective Health-Related Quality of Life of Children With Epilepsy Study (HERQULES).

About one-third of the mothers were at risk for clinical depression during the first 24 months after diagnosis, Mark Ferro reported in a poster at the Epilepsy and Depressive Disorders Conference.

The prevalence of women with depressive symptoms, as measured using the Center for Epidemiological Studies Depression Scale, was 38% at baseline, 30% at 6 months, 32% at 12 months, and 30% at 24 months.

Previous cross-sectional studies have reported similar rates, but the surprise finding was that maternal depressive symptoms followed four distinct trajectories: high decreasing, moderate increasing, borderline, and low stable, said Mr. Ferro, a doctoral student in epidemiology and biostatistics at the University of Western Ontario, London.

The researchers had anticipated just three trajectories, but found that some women fell in and out of risk for depression. Although the reason for this borderline trajectory is unclear, Mr. Ferro suggests that it may reflect the unpredictable nature of epilepsy, or a family’s search for effective pharmacologic or cognitive-based therapies to manage their child’s illness.

“There’s a big trial-and-error period during the first 2 years after diagnosis,” he said.

At several points during the conference, speakers noted the profound effect that witnessing a seizure and living with epilepsy can have on families. A subsequent unpublished study by the same group found that as a mother’s depressive symptoms increase, a child’s quality of life decreases.

“It’s not just the child suffering the seizures, but the entire family,” Mr. Ferro said. “In terms of putting the patient at the center of care, we’re also asking physicians to put the family at the center of care. We’re hoping that by addressing the mother’s mental health status, clinicians can improve the quality of care for children with epilepsy.”

In the current study, mothers in the low-stable group were significantly more likely to be university educated (63%) than were those in the borderline (46%), moderate-increasing (41%), or high-decreasing groups (21%), and to be older (mean, 39 years) than women in the moderate-increasing group (mean, 34 years).

Child quality of life predicted membership in the high-decreasing group, whereas the presence of cognitive problems in the child predicted membership in the moderate-increasing group. Child cognitive disability was the strongest predictor for any of the variables examined in the model, with an odds ratio of 9.3 in a multinomial regression analysis, Mr. Ferro reported.

Mothers whose depressive symptoms took a low-stable trajectory were significantly more likely than women in the other three groups to have a greater degree of satisfaction with family function, as measured by the APGAR (Adaptability, Partnership, Growth, Affection and Resolve) scale; a greater repertoire of family resources, as measured by the FIRM (Family Inventory of Resources for Management) assessment; and fewer potentially stressful life events, as measured by the FILE (Family Inventory of Life Events and Changes) scale.

The conference was jointly sponsored by the EDDC and the office of continuing medical education of Elsevier. The study was supported by the Canadian Institutes of Health Research. The authors reported no conflicts of interest.

CHICAGO – Depressive symptoms are common in mothers of children with newly diagnosed epilepsy, and they follow four distinct trajectories, new data suggest.

Researchers in Ontario evaluated 339 mothers of children aged 4-12 years with new-onset epilepsy who were enrolled in the national, prospective Health-Related Quality of Life of Children With Epilepsy Study (HERQULES).

About one-third of the mothers were at risk for clinical depression during the first 24 months after diagnosis, Mark Ferro reported in a poster at the Epilepsy and Depressive Disorders Conference.

The prevalence of women with depressive symptoms, as measured using the Center for Epidemiological Studies Depression Scale, was 38% at baseline, 30% at 6 months, 32% at 12 months, and 30% at 24 months.

Previous cross-sectional studies have reported similar rates, but the surprise finding was that maternal depressive symptoms followed four distinct trajectories: high decreasing, moderate increasing, borderline, and low stable, said Mr. Ferro, a doctoral student in epidemiology and biostatistics at the University of Western Ontario, London.

The researchers had anticipated just three trajectories, but found that some women fell in and out of risk for depression. Although the reason for this borderline trajectory is unclear, Mr. Ferro suggests that it may reflect the unpredictable nature of epilepsy, or a family’s search for effective pharmacologic or cognitive-based therapies to manage their child’s illness.

“There’s a big trial-and-error period during the first 2 years after diagnosis,” he said.

At several points during the conference, speakers noted the profound effect that witnessing a seizure and living with epilepsy can have on families. A subsequent unpublished study by the same group found that as a mother’s depressive symptoms increase, a child’s quality of life decreases.

“It’s not just the child suffering the seizures, but the entire family,” Mr. Ferro said. “In terms of putting the patient at the center of care, we’re also asking physicians to put the family at the center of care. We’re hoping that by addressing the mother’s mental health status, clinicians can improve the quality of care for children with epilepsy.”

In the current study, mothers in the low-stable group were significantly more likely to be university educated (63%) than were those in the borderline (46%), moderate-increasing (41%), or high-decreasing groups (21%), and to be older (mean, 39 years) than women in the moderate-increasing group (mean, 34 years).

Child quality of life predicted membership in the high-decreasing group, whereas the presence of cognitive problems in the child predicted membership in the moderate-increasing group. Child cognitive disability was the strongest predictor for any of the variables examined in the model, with an odds ratio of 9.3 in a multinomial regression analysis, Mr. Ferro reported.

Mothers whose depressive symptoms took a low-stable trajectory were significantly more likely than women in the other three groups to have a greater degree of satisfaction with family function, as measured by the APGAR (Adaptability, Partnership, Growth, Affection and Resolve) scale; a greater repertoire of family resources, as measured by the FIRM (Family Inventory of Resources for Management) assessment; and fewer potentially stressful life events, as measured by the FILE (Family Inventory of Life Events and Changes) scale.

The conference was jointly sponsored by the EDDC and the office of continuing medical education of Elsevier. The study was supported by the Canadian Institutes of Health Research. The authors reported no conflicts of interest.

While more common cancers garner the lion’s share of attention, a relatively unfamiliar entity is responsible for a staggering number of cancer deaths.

Cancers of unknown primary (CUP), also known as occult primary tumors, are metastatic malignant tumors whose primary site cannot be identified despite pretreatment evaluation. More than 50% of CUP patients present with multiple site involvement. Median overall survival is about 6-9 months, with the primary tumor being found in fewer than 30% of patients who initially present with CUP.

In the United States, CUP represents about 2% of all cancers, said Dr. David S. Ettinger, who chairs the occult primary clinical practice guidelines for the National Comprehensive Cancer Network (NCCN). This number is based on an estimated 30,680 cases in 2010, although the number of deaths from CUP is likely closer to 44,000, as reports of the underlying cause of cancer deaths are not always specific.

CUP is the fourth most common cause of cancer death in England and Wales, even though it constituted just 3% of cancers registered in England in 2006 and 4% of cancers in Wales between 2002 and 2006, according to a recent assessment by England’s National Institute for Health and Clinical Excellence (NICE).

“We found that one in four cancer deaths was due to cancer of unknown primary, which we were quite surprised at and thought was highly significant,” said Dr. Andy Fowell, chair of the guidance development group for the NICE guidelines on metastatic malignant disease of unknown primary origin, published in July.

While CUP might not be recognized as the underlying cause of death in many cases, both men agree it is garnering increased attention. Dr. Fowell suggests this might reflect frustration felt by oncologists at not being able to treat CUP very well, and growing recognition that the management of these patients has not been particularly efficient or effective.

“They are within hospitals for a long period of time, there are a lot of tests being done, which aren’t in any way coordinated and rational, and you still end up with a patient where you don’t know where the cancer came from,” he said.

Gene Profiling

Dr. Ettinger suggests that efforts by several companies to identify the tissue of origin through gene-based expression profiling might be driving the interest in CUP. These tumors have many chromosomal abnormalities and overexpression of several genes, including Ras, HER2, Bcl2, and p53.

In a study involving 104 patients with CUP, the tissue of origin was identified in 61% using a molecular assay evaluating the expression of 10 specific gene markers by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) (J. Clin. Oncol. 2008;26:4442-8). Results of a prospective trial presented at this year’s American Society of Clinical Oncology annual meeting showed that results of a test measuring the expression of 48 microRNAs by RT-PCR were concordant with clinical presentation in 82% of 46 CUP cases (J. Clin. Oncol. 2010;28:15s).

Although gene profiling looks promising, Dr. Ettinger said the 2010 NCCN occult primary guidelines specifically state that genetic profiling is not recommended for standard management at this time. The guidelines cite the need for prospective trials to confirm whether it can be used in choosing treatment options that would impact prognosis. “It’s like screening in a sense; if you have a screening, it has to [affect] survival and, in some fashion, mortality,” he said.

The NICE guideline panel used similar reasoning in making its recommendation that genetic profiling should only be done as part of a research program.

The phase II UNKPRI 20 trial, sponsored by the Sarah Cannon Cancer Center in Nashville, Tenn., in collaboration with Genentech, is prospectively evaluating molecular profile predictions of the primary site for site-directed therapy in patients with CUP.

A Different Animal

While gene profiling can identify the primary site in about 85% of cases, it will not solve the clinical problem of treatment and prognosis, said Dr. Nicholas Pavlidis, who has written extensively on the subject and is a professor of medical oncology at the University of Ioannina, Greece. Patients with poor-risk tumors, which represent 80% of CUP patients, have dismal outcomes, even when gene profiling assigns a tissue of origin. Overall response rates to chemotherapy range from 25% to 50%. Targeted systemic treatments such as bevacizumab (Avastin), erlotinib (Tarceva), and paclitaxel (Taxol)/carboplatin, have not improved results over previous regimens, he said.

While the reasons for this are unclear, CUP tumors might represent a distinct clinical entity, said Dr. Pavlidis. “They have a peculiar clinical picture that is not as we know in the primary tumors,” he said. This includes early dissemination, aggressive disease, resistance to chemotherapy, and an unpredictable metastatic pattern. For example, pancreatic cancer presenting as CUPhas a four- to fivefold higher incidence of bone and lung involvement than does primary pancreatic cancer.

Dr. Fowell agrees that CUP tumors behave differently from known primary tumors and said that many CUP patients present late when their performance score is already quite poor. “We saw that as a really important factor that people need to make an early decision as to whether we should be pursuing invasive investigations when at the end of the day they may not be fit for treatment anyway,” he said, noting that data suggests that as few as 8% of CUP patients go to chemotherapy.

The NICE guidelines recommend that investigations be performed only if they affect a treatment decision; and the patient understands why the investigation is being done, the potential benefits and risks of the investigation and treatment, and is prepared to accept treatment.

The NCCN guidelines recommend that chemotherapy for patients with disseminated disease should be limited to symptomatic patients with a performance score of 1-2 or asymptomatic patients with aggressive disease.

NICE, which calls CUP a “neglected disease” contends that patients with CUP are largely denied the medical and other benefits afforded those with site-specific cancers because of a lack of specific, dedicated clinical services, a lack of understanding and information about the disease, and the absence of a formal research structure. The guidelines call on every hospital with a cancer center or unit to establish a CUP team, comprising an oncologist, palliative care physician, and a CUP specialist nurse or key worker as a minimum, said Dr. Fowell, a consultant in palliative medicine at Bangor Hospital in North Wales.

NICE also suggests that a clinical studies group be established for CUP at the National Cancer Research Network level to coordinate and direct clinical trials. There has been a paucity of research, but new studies are in the works. The open-label, phase II UNKPRI 21 trial, also based in Nashville, compares carboplatin/paclitaxel with carboplatin/paclitaxel plus the histone deacetylase inhibitor PXD101 (belinostat) in patients with previously untreated CUP. The United Kingdom’s CUP-ONE trial is prospectively validating three molecular classification techniques and assessing the feasibility of combining the established chemotherapy regimen epirubicin (Ellence), cisplatin and capecitabine (Xeloda) with erlotinib.

Dr. Fowell and Dr. Pavlidis disclosed no conflicts of interest. Dr. Ettinger disclosed relationships with 11 companies including Genentech, which markets bevacizumab and erlotinib.

While more common cancers garner the lion’s share of attention, a relatively unfamiliar entity is responsible for a staggering number of cancer deaths.

Cancers of unknown primary (CUP), also known as occult primary tumors, are metastatic malignant tumors whose primary site cannot be identified despite pretreatment evaluation. More than 50% of CUP patients present with multiple site involvement. Median overall survival is about 6-9 months, with the primary tumor being found in fewer than 30% of patients who initially present with CUP.

In the United States, CUP represents about 2% of all cancers, said Dr. David S. Ettinger, who chairs the occult primary clinical practice guidelines for the National Comprehensive Cancer Network (NCCN). This number is based on an estimated 30,680 cases in 2010, although the number of deaths from CUP is likely closer to 44,000, as reports of the underlying cause of cancer deaths are not always specific.

CUP is the fourth most common cause of cancer death in England and Wales, even though it constituted just 3% of cancers registered in England in 2006 and 4% of cancers in Wales between 2002 and 2006, according to a recent assessment by England’s National Institute for Health and Clinical Excellence (NICE).

“We found that one in four cancer deaths was due to cancer of unknown primary, which we were quite surprised at and thought was highly significant,” said Dr. Andy Fowell, chair of the guidance development group for the NICE guidelines on metastatic malignant disease of unknown primary origin, published in July.

While CUP might not be recognized as the underlying cause of death in many cases, both men agree it is garnering increased attention. Dr. Fowell suggests this might reflect frustration felt by oncologists at not being able to treat CUP very well, and growing recognition that the management of these patients has not been particularly efficient or effective.

“They are within hospitals for a long period of time, there are a lot of tests being done, which aren’t in any way coordinated and rational, and you still end up with a patient where you don’t know where the cancer came from,” he said.

Gene Profiling

Dr. Ettinger suggests that efforts by several companies to identify the tissue of origin through gene-based expression profiling might be driving the interest in CUP. These tumors have many chromosomal abnormalities and overexpression of several genes, including Ras, HER2, Bcl2, and p53.

In a study involving 104 patients with CUP, the tissue of origin was identified in 61% using a molecular assay evaluating the expression of 10 specific gene markers by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) (J. Clin. Oncol. 2008;26:4442-8). Results of a prospective trial presented at this year’s American Society of Clinical Oncology annual meeting showed that results of a test measuring the expression of 48 microRNAs by RT-PCR were concordant with clinical presentation in 82% of 46 CUP cases (J. Clin. Oncol. 2010;28:15s).

Although gene profiling looks promising, Dr. Ettinger said the 2010 NCCN occult primary guidelines specifically state that genetic profiling is not recommended for standard management at this time. The guidelines cite the need for prospective trials to confirm whether it can be used in choosing treatment options that would impact prognosis. “It’s like screening in a sense; if you have a screening, it has to [affect] survival and, in some fashion, mortality,” he said.

The NICE guideline panel used similar reasoning in making its recommendation that genetic profiling should only be done as part of a research program.

The phase II UNKPRI 20 trial, sponsored by the Sarah Cannon Cancer Center in Nashville, Tenn., in collaboration with Genentech, is prospectively evaluating molecular profile predictions of the primary site for site-directed therapy in patients with CUP.

A Different Animal

While gene profiling can identify the primary site in about 85% of cases, it will not solve the clinical problem of treatment and prognosis, said Dr. Nicholas Pavlidis, who has written extensively on the subject and is a professor of medical oncology at the University of Ioannina, Greece. Patients with poor-risk tumors, which represent 80% of CUP patients, have dismal outcomes, even when gene profiling assigns a tissue of origin. Overall response rates to chemotherapy range from 25% to 50%. Targeted systemic treatments such as bevacizumab (Avastin), erlotinib (Tarceva), and paclitaxel (Taxol)/carboplatin, have not improved results over previous regimens, he said.

While the reasons for this are unclear, CUP tumors might represent a distinct clinical entity, said Dr. Pavlidis. “They have a peculiar clinical picture that is not as we know in the primary tumors,” he said. This includes early dissemination, aggressive disease, resistance to chemotherapy, and an unpredictable metastatic pattern. For example, pancreatic cancer presenting as CUPhas a four- to fivefold higher incidence of bone and lung involvement than does primary pancreatic cancer.

Dr. Fowell agrees that CUP tumors behave differently from known primary tumors and said that many CUP patients present late when their performance score is already quite poor. “We saw that as a really important factor that people need to make an early decision as to whether we should be pursuing invasive investigations when at the end of the day they may not be fit for treatment anyway,” he said, noting that data suggests that as few as 8% of CUP patients go to chemotherapy.

The NICE guidelines recommend that investigations be performed only if they affect a treatment decision; and the patient understands why the investigation is being done, the potential benefits and risks of the investigation and treatment, and is prepared to accept treatment.

The NCCN guidelines recommend that chemotherapy for patients with disseminated disease should be limited to symptomatic patients with a performance score of 1-2 or asymptomatic patients with aggressive disease.

NICE, which calls CUP a “neglected disease” contends that patients with CUP are largely denied the medical and other benefits afforded those with site-specific cancers because of a lack of specific, dedicated clinical services, a lack of understanding and information about the disease, and the absence of a formal research structure. The guidelines call on every hospital with a cancer center or unit to establish a CUP team, comprising an oncologist, palliative care physician, and a CUP specialist nurse or key worker as a minimum, said Dr. Fowell, a consultant in palliative medicine at Bangor Hospital in North Wales.

NICE also suggests that a clinical studies group be established for CUP at the National Cancer Research Network level to coordinate and direct clinical trials. There has been a paucity of research, but new studies are in the works. The open-label, phase II UNKPRI 21 trial, also based in Nashville, compares carboplatin/paclitaxel with carboplatin/paclitaxel plus the histone deacetylase inhibitor PXD101 (belinostat) in patients with previously untreated CUP. The United Kingdom’s CUP-ONE trial is prospectively validating three molecular classification techniques and assessing the feasibility of combining the established chemotherapy regimen epirubicin (Ellence), cisplatin and capecitabine (Xeloda) with erlotinib.

Dr. Fowell and Dr. Pavlidis disclosed no conflicts of interest. Dr. Ettinger disclosed relationships with 11 companies including Genentech, which markets bevacizumab and erlotinib.

While more common cancers garner the lion’s share of attention, a relatively unfamiliar entity is responsible for a staggering number of cancer deaths.

Cancers of unknown primary (CUP), also known as occult primary tumors, are metastatic malignant tumors whose primary site cannot be identified despite pretreatment evaluation. More than 50% of CUP patients present with multiple site involvement. Median overall survival is about 6-9 months, with the primary tumor being found in fewer than 30% of patients who initially present with CUP.

In the United States, CUP represents about 2% of all cancers, said Dr. David S. Ettinger, who chairs the occult primary clinical practice guidelines for the National Comprehensive Cancer Network (NCCN). This number is based on an estimated 30,680 cases in 2010, although the number of deaths from CUP is likely closer to 44,000, as reports of the underlying cause of cancer deaths are not always specific.

CUP is the fourth most common cause of cancer death in England and Wales, even though it constituted just 3% of cancers registered in England in 2006 and 4% of cancers in Wales between 2002 and 2006, according to a recent assessment by England’s National Institute for Health and Clinical Excellence (NICE).

“We found that one in four cancer deaths was due to cancer of unknown primary, which we were quite surprised at and thought was highly significant,” said Dr. Andy Fowell, chair of the guidance development group for the NICE guidelines on metastatic malignant disease of unknown primary origin, published in July.

While CUP might not be recognized as the underlying cause of death in many cases, both men agree it is garnering increased attention. Dr. Fowell suggests this might reflect frustration felt by oncologists at not being able to treat CUP very well, and growing recognition that the management of these patients has not been particularly efficient or effective.

“They are within hospitals for a long period of time, there are a lot of tests being done, which aren’t in any way coordinated and rational, and you still end up with a patient where you don’t know where the cancer came from,” he said.

Gene Profiling

Dr. Ettinger suggests that efforts by several companies to identify the tissue of origin through gene-based expression profiling might be driving the interest in CUP. These tumors have many chromosomal abnormalities and overexpression of several genes, including Ras, HER2, Bcl2, and p53.

In a study involving 104 patients with CUP, the tissue of origin was identified in 61% using a molecular assay evaluating the expression of 10 specific gene markers by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) (J. Clin. Oncol. 2008;26:4442-8). Results of a prospective trial presented at this year’s American Society of Clinical Oncology annual meeting showed that results of a test measuring the expression of 48 microRNAs by RT-PCR were concordant with clinical presentation in 82% of 46 CUP cases (J. Clin. Oncol. 2010;28:15s).

Although gene profiling looks promising, Dr. Ettinger said the 2010 NCCN occult primary guidelines specifically state that genetic profiling is not recommended for standard management at this time. The guidelines cite the need for prospective trials to confirm whether it can be used in choosing treatment options that would impact prognosis. “It’s like screening in a sense; if you have a screening, it has to [affect] survival and, in some fashion, mortality,” he said.

The NICE guideline panel used similar reasoning in making its recommendation that genetic profiling should only be done as part of a research program.

The phase II UNKPRI 20 trial, sponsored by the Sarah Cannon Cancer Center in Nashville, Tenn., in collaboration with Genentech, is prospectively evaluating molecular profile predictions of the primary site for site-directed therapy in patients with CUP.

A Different Animal

While gene profiling can identify the primary site in about 85% of cases, it will not solve the clinical problem of treatment and prognosis, said Dr. Nicholas Pavlidis, who has written extensively on the subject and is a professor of medical oncology at the University of Ioannina, Greece. Patients with poor-risk tumors, which represent 80% of CUP patients, have dismal outcomes, even when gene profiling assigns a tissue of origin. Overall response rates to chemotherapy range from 25% to 50%. Targeted systemic treatments such as bevacizumab (Avastin), erlotinib (Tarceva), and paclitaxel (Taxol)/carboplatin, have not improved results over previous regimens, he said.

While the reasons for this are unclear, CUP tumors might represent a distinct clinical entity, said Dr. Pavlidis. “They have a peculiar clinical picture that is not as we know in the primary tumors,” he said. This includes early dissemination, aggressive disease, resistance to chemotherapy, and an unpredictable metastatic pattern. For example, pancreatic cancer presenting as CUPhas a four- to fivefold higher incidence of bone and lung involvement than does primary pancreatic cancer.

Dr. Fowell agrees that CUP tumors behave differently from known primary tumors and said that many CUP patients present late when their performance score is already quite poor. “We saw that as a really important factor that people need to make an early decision as to whether we should be pursuing invasive investigations when at the end of the day they may not be fit for treatment anyway,” he said, noting that data suggests that as few as 8% of CUP patients go to chemotherapy.

The NICE guidelines recommend that investigations be performed only if they affect a treatment decision; and the patient understands why the investigation is being done, the potential benefits and risks of the investigation and treatment, and is prepared to accept treatment.

The NCCN guidelines recommend that chemotherapy for patients with disseminated disease should be limited to symptomatic patients with a performance score of 1-2 or asymptomatic patients with aggressive disease.

NICE, which calls CUP a “neglected disease” contends that patients with CUP are largely denied the medical and other benefits afforded those with site-specific cancers because of a lack of specific, dedicated clinical services, a lack of understanding and information about the disease, and the absence of a formal research structure. The guidelines call on every hospital with a cancer center or unit to establish a CUP team, comprising an oncologist, palliative care physician, and a CUP specialist nurse or key worker as a minimum, said Dr. Fowell, a consultant in palliative medicine at Bangor Hospital in North Wales.

NICE also suggests that a clinical studies group be established for CUP at the National Cancer Research Network level to coordinate and direct clinical trials. There has been a paucity of research, but new studies are in the works. The open-label, phase II UNKPRI 21 trial, also based in Nashville, compares carboplatin/paclitaxel with carboplatin/paclitaxel plus the histone deacetylase inhibitor PXD101 (belinostat) in patients with previously untreated CUP. The United Kingdom’s CUP-ONE trial is prospectively validating three molecular classification techniques and assessing the feasibility of combining the established chemotherapy regimen epirubicin (Ellence), cisplatin and capecitabine (Xeloda) with erlotinib.

Dr. Fowell and Dr. Pavlidis disclosed no conflicts of interest. Dr. Ettinger disclosed relationships with 11 companies including Genentech, which markets bevacizumab and erlotinib.

While more common cancers garner the lion’s share of attention, a relatively unfamiliar entity is responsible for a staggering number of cancer deaths.

Cancers of unknown primary (CUP), also known as occult primary tumors, are metastatic malignant tumors whose primary site cannot be identified despite pretreatment evaluation. More than 50% of CUP patients present with multiple site involvement. Median overall survival is about 6-9 months, with the primary tumor being found in fewer than 30% of patients who initially present with CUP.

In the United States, CUP represents about 2% of all cancers, said Dr. David S. Ettinger, who chairs the occult primary clinical practice guidelines for the National Comprehensive Cancer Network (NCCN). This number is based on an estimated 30,680 cases in 2010, although the number of deaths from CUP is likely closer to 44,000, as reports of the underlying cause of cancer deaths are not always specific.

CUP is the fourth most common cause of cancer death in England and Wales, even though it constituted just 3% of cancers registered in England in 2006 and 4% of cancers in Wales between 2002 and 2006, according to a recent assessment by England’s National Institute for Health and Clinical Excellence (NICE).

“We found that one in four cancer deaths was due to cancer of unknown primary, which we were quite surprised at and thought was highly significant,” said Dr. Andy Fowell, chair of the guidance development group for the NICE guidelines on metastatic malignant disease of unknown primary origin, published in July.

While CUP might not be recognized as the underlying cause of death in many cases, both men agree it is garnering increased attention. Dr. Fowell suggests this might reflect frustration felt by oncologists at not being able to treat CUP very well, and growing recognition that the management of these patients has not been particularly efficient or effective.

“They are within hospitals for a long period of time, there are a lot of tests being done, which aren’t in any way coordinated and rational, and you still end up with a patient where you don’t know where the cancer came from,” he said.

Gene Profiling

Dr. Ettinger suggests that efforts by several companies to identify the tissue of origin through gene-based expression profiling might be driving the interest in CUP. These tumors have many chromosomal abnormalities and overexpression of several genes, including Ras, HER2, Bcl2, and p53.

In a study involving 104 patients with CUP, the tissue of origin was identified in 61% using a molecular assay evaluating the expression of 10 specific gene markers by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) (J. Clin. Oncol. 2008;26:4442-8). Results of a prospective trial presented at this year’s American Society of Clinical Oncology annual meeting showed that results of a test measuring the expression of 48 microRNAs by RT-PCR were concordant with clinical presentation in 82% of 46 CUP cases (J. Clin. Oncol. 2010;28:15s).

Although gene profiling looks promising, Dr. Ettinger said the 2010 NCCN occult primary guidelines specifically state that genetic profiling is not recommended for standard management at this time. The guidelines cite the need for prospective trials to confirm whether it can be used in choosing treatment options that would impact prognosis. “It’s like screening in a sense; if you have a screening, it has to [affect] survival and, in some fashion, mortality,” he said.

The NICE guideline panel used similar reasoning in making its recommendation that genetic profiling should only be done as part of a research program.

The phase II UNKPRI 20 trial, sponsored by the Sarah Cannon Cancer Center in Nashville, Tenn., in collaboration with Genentech, is prospectively evaluating molecular profile predictions of the primary site for site-directed therapy in patients with CUP.

A Different Animal

While gene profiling can identify the primary site in about 85% of cases, it will not solve the clinical problem of treatment and prognosis, said Dr. Nicholas Pavlidis, who has written extensively on the subject and is a professor of medical oncology at the University of Ioannina, Greece. Patients with poor-risk tumors, which represent 80% of CUP patients, have dismal outcomes, even when gene profiling assigns a tissue of origin. Overall response rates to chemotherapy range from 25% to 50%. Targeted systemic treatments such as bevacizumab (Avastin), erlotinib (Tarceva), and paclitaxel (Taxol)/carboplatin, have not improved results over previous regimens, he said.

While the reasons for this are unclear, CUP tumors might represent a distinct clinical entity, said Dr. Pavlidis. “They have a peculiar clinical picture that is not as we know in the primary tumors,” he said. This includes early dissemination, aggressive disease, resistance to chemotherapy, and an unpredictable metastatic pattern. For example, pancreatic cancer presenting as CUPhas a four- to fivefold higher incidence of bone and lung involvement than does primary pancreatic cancer.

Dr. Fowell agrees that CUP tumors behave differently from known primary tumors and said that many CUP patients present late when their performance score is already quite poor. “We saw that as a really important factor that people need to make an early decision as to whether we should be pursuing invasive investigations when at the end of the day they may not be fit for treatment anyway,” he said, noting that data suggests that as few as 8% of CUP patients go to chemotherapy.

The NICE guidelines recommend that investigations be performed only if they affect a treatment decision; and the patient understands why the investigation is being done, the potential benefits and risks of the investigation and treatment, and is prepared to accept treatment.

The NCCN guidelines recommend that chemotherapy for patients with disseminated disease should be limited to symptomatic patients with a performance score of 1-2 or asymptomatic patients with aggressive disease.

NICE, which calls CUP a “neglected disease” contends that patients with CUP are largely denied the medical and other benefits afforded those with site-specific cancers because of a lack of specific, dedicated clinical services, a lack of understanding and information about the disease, and the absence of a formal research structure. The guidelines call on every hospital with a cancer center or unit to establish a CUP team, comprising an oncologist, palliative care physician, and a CUP specialist nurse or key worker as a minimum, said Dr. Fowell, a consultant in palliative medicine at Bangor Hospital in North Wales.

NICE also suggests that a clinical studies group be established for CUP at the National Cancer Research Network level to coordinate and direct clinical trials. There has been a paucity of research, but new studies are in the works. The open-label, phase II UNKPRI 21 trial, also based in Nashville, compares carboplatin/paclitaxel with carboplatin/paclitaxel plus the histone deacetylase inhibitor PXD101 (belinostat) in patients with previously untreated CUP. The United Kingdom’s CUP-ONE trial is prospectively validating three molecular classification techniques and assessing the feasibility of combining the established chemotherapy regimen epirubicin (Ellence), cisplatin and capecitabine (Xeloda) with erlotinib.

Dr. Fowell and Dr. Pavlidis disclosed no conflicts of interest. Dr. Ettinger disclosed relationships with 11 companies including Genentech, which markets bevacizumab and erlotinib.

While more common cancers garner the lion’s share of attention, a relatively unfamiliar entity is responsible for a staggering number of cancer deaths.

Cancers of unknown primary (CUP), also known as occult primary tumors, are metastatic malignant tumors whose primary site cannot be identified despite pretreatment evaluation. More than 50% of CUP patients present with multiple site involvement. Median overall survival is about 6-9 months, with the primary tumor being found in fewer than 30% of patients who initially present with CUP.

In the United States, CUP represents about 2% of all cancers, said Dr. David S. Ettinger, who chairs the occult primary clinical practice guidelines for the National Comprehensive Cancer Network (NCCN). This number is based on an estimated 30,680 cases in 2010, although the number of deaths from CUP is likely closer to 44,000, as reports of the underlying cause of cancer deaths are not always specific.

CUP is the fourth most common cause of cancer death in England and Wales, even though it constituted just 3% of cancers registered in England in 2006 and 4% of cancers in Wales between 2002 and 2006, according to a recent assessment by England’s National Institute for Health and Clinical Excellence (NICE).

“We found that one in four cancer deaths was due to cancer of unknown primary, which we were quite surprised at and thought was highly significant,” said Dr. Andy Fowell, chair of the guidance development group for the NICE guidelines on metastatic malignant disease of unknown primary origin, published in July.

While CUP might not be recognized as the underlying cause of death in many cases, both men agree it is garnering increased attention. Dr. Fowell suggests this might reflect frustration felt by oncologists at not being able to treat CUP very well, and growing recognition that the management of these patients has not been particularly efficient or effective.

“They are within hospitals for a long period of time, there are a lot of tests being done, which aren’t in any way coordinated and rational, and you still end up with a patient where you don’t know where the cancer came from,” he said.

Gene Profiling

Dr. Ettinger suggests that efforts by several companies to identify the tissue of origin through gene-based expression profiling might be driving the interest in CUP. These tumors have many chromosomal abnormalities and overexpression of several genes, including Ras, HER2, Bcl2, and p53.

In a study involving 104 patients with CUP, the tissue of origin was identified in 61% using a molecular assay evaluating the expression of 10 specific gene markers by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) (J. Clin. Oncol. 2008;26:4442-8). Results of a prospective trial presented at this year’s American Society of Clinical Oncology annual meeting showed that results of a test measuring the expression of 48 microRNAs by RT-PCR were concordant with clinical presentation in 82% of 46 CUP cases (J. Clin. Oncol. 2010;28:15s).

Although gene profiling looks promising, Dr. Ettinger said the 2010 NCCN occult primary guidelines specifically state that genetic profiling is not recommended for standard management at this time. The guidelines cite the need for prospective trials to confirm whether it can be used in choosing treatment options that would impact prognosis. “It’s like screening in a sense; if you have a screening, it has to [affect] survival and, in some fashion, mortality,” he said.

The NICE guideline panel used similar reasoning in making its recommendation that genetic profiling should only be done as part of a research program.

The phase II UNKPRI 20 trial, sponsored by the Sarah Cannon Cancer Center in Nashville, Tenn., in collaboration with Genentech, is prospectively evaluating molecular profile predictions of the primary site for site-directed therapy in patients with CUP.

A Different Animal

While gene profiling can identify the primary site in about 85% of cases, it will not solve the clinical problem of treatment and prognosis, said Dr. Nicholas Pavlidis, who has written extensively on the subject and is a professor of medical oncology at the University of Ioannina, Greece. Patients with poor-risk tumors, which represent 80% of CUP patients, have dismal outcomes, even when gene profiling assigns a tissue of origin. Overall response rates to chemotherapy range from 25% to 50%. Targeted systemic treatments such as bevacizumab (Avastin), erlotinib (Tarceva), and paclitaxel (Taxol)/carboplatin, have not improved results over previous regimens, he said.

While the reasons for this are unclear, CUP tumors might represent a distinct clinical entity, said Dr. Pavlidis. “They have a peculiar clinical picture that is not as we know in the primary tumors,” he said. This includes early dissemination, aggressive disease, resistance to chemotherapy, and an unpredictable metastatic pattern. For example, pancreatic cancer presenting as CUPhas a four- to fivefold higher incidence of bone and lung involvement than does primary pancreatic cancer.

Dr. Fowell agrees that CUP tumors behave differently from known primary tumors and said that many CUP patients present late when their performance score is already quite poor. “We saw that as a really important factor that people need to make an early decision as to whether we should be pursuing invasive investigations when at the end of the day they may not be fit for treatment anyway,” he said, noting that data suggests that as few as 8% of CUP patients go to chemotherapy.

The NICE guidelines recommend that investigations be performed only if they affect a treatment decision; and the patient understands why the investigation is being done, the potential benefits and risks of the investigation and treatment, and is prepared to accept treatment.

The NCCN guidelines recommend that chemotherapy for patients with disseminated disease should be limited to symptomatic patients with a performance score of 1-2 or asymptomatic patients with aggressive disease.

NICE, which calls CUP a “neglected disease” contends that patients with CUP are largely denied the medical and other benefits afforded those with site-specific cancers because of a lack of specific, dedicated clinical services, a lack of understanding and information about the disease, and the absence of a formal research structure. The guidelines call on every hospital with a cancer center or unit to establish a CUP team, comprising an oncologist, palliative care physician, and a CUP specialist nurse or key worker as a minimum, said Dr. Fowell, a consultant in palliative medicine at Bangor Hospital in North Wales.

NICE also suggests that a clinical studies group be established for CUP at the National Cancer Research Network level to coordinate and direct clinical trials. There has been a paucity of research, but new studies are in the works. The open-label, phase II UNKPRI 21 trial, also based in Nashville, compares carboplatin/paclitaxel with carboplatin/paclitaxel plus the histone deacetylase inhibitor PXD101 (belinostat) in patients with previously untreated CUP. The United Kingdom’s CUP-ONE trial is prospectively validating three molecular classification techniques and assessing the feasibility of combining the established chemotherapy regimen epirubicin (Ellence), cisplatin and capecitabine (Xeloda) with erlotinib.

Dr. Fowell and Dr. Pavlidis disclosed no conflicts of interest. Dr. Ettinger disclosed relationships with 11 companies including Genentech, which markets bevacizumab and erlotinib.

While more common cancers garner the lion’s share of attention, a relatively unfamiliar entity is responsible for a staggering number of cancer deaths.

Cancers of unknown primary (CUP), also known as occult primary tumors, are metastatic malignant tumors whose primary site cannot be identified despite pretreatment evaluation. More than 50% of CUP patients present with multiple site involvement. Median overall survival is about 6-9 months, with the primary tumor being found in fewer than 30% of patients who initially present with CUP.

In the United States, CUP represents about 2% of all cancers, said Dr. David S. Ettinger, who chairs the occult primary clinical practice guidelines for the National Comprehensive Cancer Network (NCCN). This number is based on an estimated 30,680 cases in 2010, although the number of deaths from CUP is likely closer to 44,000, as reports of the underlying cause of cancer deaths are not always specific.

CUP is the fourth most common cause of cancer death in England and Wales, even though it constituted just 3% of cancers registered in England in 2006 and 4% of cancers in Wales between 2002 and 2006, according to a recent assessment by England’s National Institute for Health and Clinical Excellence (NICE).

“We found that one in four cancer deaths was due to cancer of unknown primary, which we were quite surprised at and thought was highly significant,” said Dr. Andy Fowell, chair of the guidance development group for the NICE guidelines on metastatic malignant disease of unknown primary origin, published in July.

While CUP might not be recognized as the underlying cause of death in many cases, both men agree it is garnering increased attention. Dr. Fowell suggests this might reflect frustration felt by oncologists at not being able to treat CUP very well, and growing recognition that the management of these patients has not been particularly efficient or effective.

“They are within hospitals for a long period of time, there are a lot of tests being done, which aren’t in any way coordinated and rational, and you still end up with a patient where you don’t know where the cancer came from,” he said.

Gene Profiling

Dr. Ettinger suggests that efforts by several companies to identify the tissue of origin through gene-based expression profiling might be driving the interest in CUP. These tumors have many chromosomal abnormalities and overexpression of several genes, including Ras, HER2, Bcl2, and p53.

In a study involving 104 patients with CUP, the tissue of origin was identified in 61% using a molecular assay evaluating the expression of 10 specific gene markers by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) (J. Clin. Oncol. 2008;26:4442-8). Results of a prospective trial presented at this year’s American Society of Clinical Oncology annual meeting showed that results of a test measuring the expression of 48 microRNAs by RT-PCR were concordant with clinical presentation in 82% of 46 CUP cases (J. Clin. Oncol. 2010;28:15s).

Although gene profiling looks promising, Dr. Ettinger said the 2010 NCCN occult primary guidelines specifically state that genetic profiling is not recommended for standard management at this time. The guidelines cite the need for prospective trials to confirm whether it can be used in choosing treatment options that would impact prognosis. “It’s like screening in a sense; if you have a screening, it has to [affect] survival and, in some fashion, mortality,” he said.

The NICE guideline panel used similar reasoning in making its recommendation that genetic profiling should only be done as part of a research program.

The phase II UNKPRI 20 trial, sponsored by the Sarah Cannon Cancer Center in Nashville, Tenn., in collaboration with Genentech, is prospectively evaluating molecular profile predictions of the primary site for site-directed therapy in patients with CUP.

A Different Animal

While gene profiling can identify the primary site in about 85% of cases, it will not solve the clinical problem of treatment and prognosis, said Dr. Nicholas Pavlidis, who has written extensively on the subject and is a professor of medical oncology at the University of Ioannina, Greece. Patients with poor-risk tumors, which represent 80% of CUP patients, have dismal outcomes, even when gene profiling assigns a tissue of origin. Overall response rates to chemotherapy range from 25% to 50%. Targeted systemic treatments such as bevacizumab (Avastin), erlotinib (Tarceva), and paclitaxel (Taxol)/carboplatin, have not improved results over previous regimens, he said.

While the reasons for this are unclear, CUP tumors might represent a distinct clinical entity, said Dr. Pavlidis. “They have a peculiar clinical picture that is not as we know in the primary tumors,” he said. This includes early dissemination, aggressive disease, resistance to chemotherapy, and an unpredictable metastatic pattern. For example, pancreatic cancer presenting as CUPhas a four- to fivefold higher incidence of bone and lung involvement than does primary pancreatic cancer.

Dr. Fowell agrees that CUP tumors behave differently from known primary tumors and said that many CUP patients present late when their performance score is already quite poor. “We saw that as a really important factor that people need to make an early decision as to whether we should be pursuing invasive investigations when at the end of the day they may not be fit for treatment anyway,” he said, noting that data suggests that as few as 8% of CUP patients go to chemotherapy.

The NICE guidelines recommend that investigations be performed only if they affect a treatment decision; and the patient understands why the investigation is being done, the potential benefits and risks of the investigation and treatment, and is prepared to accept treatment.

The NCCN guidelines recommend that chemotherapy for patients with disseminated disease should be limited to symptomatic patients with a performance score of 1-2 or asymptomatic patients with aggressive disease.

NICE, which calls CUP a “neglected disease” contends that patients with CUP are largely denied the medical and other benefits afforded those with site-specific cancers because of a lack of specific, dedicated clinical services, a lack of understanding and information about the disease, and the absence of a formal research structure. The guidelines call on every hospital with a cancer center or unit to establish a CUP team, comprising an oncologist, palliative care physician, and a CUP specialist nurse or key worker as a minimum, said Dr. Fowell, a consultant in palliative medicine at Bangor Hospital in North Wales.

NICE also suggests that a clinical studies group be established for CUP at the National Cancer Research Network level to coordinate and direct clinical trials. There has been a paucity of research, but new studies are in the works. The open-label, phase II UNKPRI 21 trial, also based in Nashville, compares carboplatin/paclitaxel with carboplatin/paclitaxel plus the histone deacetylase inhibitor PXD101 (belinostat) in patients with previously untreated CUP. The United Kingdom’s CUP-ONE trial is prospectively validating three molecular classification techniques and assessing the feasibility of combining the established chemotherapy regimen epirubicin (Ellence), cisplatin and capecitabine (Xeloda) with erlotinib.

Dr. Fowell and Dr. Pavlidis disclosed no conflicts of interest. Dr. Ettinger disclosed relationships with 11 companies including Genentech, which markets bevacizumab and erlotinib.

VANCOUVER, B.C. — Roughly 1 in 10 transition-aged adolescents with special health care needs experience some delay in their care, despite high rates of insurance coverage.

A secondary analysis of data from the 2005–2006 National Survey of Children with Special Health Care Needs revealed that 9.8% of 12,385 adolescents, or a weighted total of 2.9 million American adolescents, experienced forgone or delayed health care that year.

Notably, 63% of the cohort (aged 14–17 years) had private insurance, 24% had public insurance, 9% other coverage, and 4% were uninsured, reported Dr. Megumi J. Okumura and her colleagues at the University of California, San Francisco.

While poverty and degree of illness elevated the risk of forgone/delayed health care, receiving transition services appeared to play a protective role in maintaining health care.

“Formal transition planning is a potentially important strategy for preventing forgone care in adolescents with special health care needs,” she said. “Transition planning may help youth and their families better advocate for their own health care services.”

In a multivariate model, the odds of reporting forgone/delayed care increased for adolescents who did not receive transition services (adjusted odds ratio 2.1) or had no medical home (OR 1.6). The same was true for those who lived in a single, mother-only household (OR 1.4) or had an unstable condition (OR 1.4).

Consistent with the previous literature, the odds of forgone care also increased for those with no health insurance (OR 6.1) and an income 200%–400% of the federal poverty line (OR 3.6) or less than 200% of the poverty line (OR 5.6).

Contrary to prior research, however, self-reported black ethnicity was found to decrease the odds of forgone care (OR 0.5), Dr. Okumura said. Data are being analyzed to determine if there is a difference in the utilization of services for physical versus mental health needs.

“It is critical to understand how preparing youth for adult-based health care can ensure continuity as they transition to adult services,” she said.

The majority of the cohort was male (55%), white (69.5%), lived in a two-parent household (61%), had stable medical conditions (66%), and lived at an income level less than 200% of the poverty line (37.5%).

During the discussion of the study, an audience member asked Dr. Okumura to speculate on whether the recently approved Patient Protection and Affordable Care Act will further delay or advance the transition process.

Dr. Okumura said that expanding coverage to more Americans will hopefully improve access to care and that extending coverage to adult dependents up to age 26 may help ease the progression to employer-based health care and other forms of coverage. Still, it's unclear how the new law, even with its provisions for coverage of preexisting conditions, will affect providers transitioning care and whether they will want to “hang on” to their patients.

One audience member observed that it is hard for many adolescents with special health needs to transition to adult services because they have to overcome their loyalty to a pediatrician they feel kept them alive.

Dr. Okumura said limitations of the study included the inability to ascertain causality due to its cross-sectional design, the use of parental self-report, and that foregone care may not be indicative of the quality of care delivered.

Nearly 3 million American teens experienced forgone or delayed health care during 2005–2006.

Source DR. OKUMURA

VANCOUVER, B.C. — Roughly 1 in 10 transition-aged adolescents with special health care needs experience some delay in their care, despite high rates of insurance coverage.

A secondary analysis of data from the 2005–2006 National Survey of Children with Special Health Care Needs revealed that 9.8% of 12,385 adolescents, or a weighted total of 2.9 million American adolescents, experienced forgone or delayed health care that year.

Notably, 63% of the cohort (aged 14–17 years) had private insurance, 24% had public insurance, 9% other coverage, and 4% were uninsured, reported Dr. Megumi J. Okumura and her colleagues at the University of California, San Francisco.

While poverty and degree of illness elevated the risk of forgone/delayed health care, receiving transition services appeared to play a protective role in maintaining health care.

“Formal transition planning is a potentially important strategy for preventing forgone care in adolescents with special health care needs,” she said. “Transition planning may help youth and their families better advocate for their own health care services.”

In a multivariate model, the odds of reporting forgone/delayed care increased for adolescents who did not receive transition services (adjusted odds ratio 2.1) or had no medical home (OR 1.6). The same was true for those who lived in a single, mother-only household (OR 1.4) or had an unstable condition (OR 1.4).

Consistent with the previous literature, the odds of forgone care also increased for those with no health insurance (OR 6.1) and an income 200%–400% of the federal poverty line (OR 3.6) or less than 200% of the poverty line (OR 5.6).

Contrary to prior research, however, self-reported black ethnicity was found to decrease the odds of forgone care (OR 0.5), Dr. Okumura said. Data are being analyzed to determine if there is a difference in the utilization of services for physical versus mental health needs.

“It is critical to understand how preparing youth for adult-based health care can ensure continuity as they transition to adult services,” she said.

The majority of the cohort was male (55%), white (69.5%), lived in a two-parent household (61%), had stable medical conditions (66%), and lived at an income level less than 200% of the poverty line (37.5%).

During the discussion of the study, an audience member asked Dr. Okumura to speculate on whether the recently approved Patient Protection and Affordable Care Act will further delay or advance the transition process.

Dr. Okumura said that expanding coverage to more Americans will hopefully improve access to care and that extending coverage to adult dependents up to age 26 may help ease the progression to employer-based health care and other forms of coverage. Still, it's unclear how the new law, even with its provisions for coverage of preexisting conditions, will affect providers transitioning care and whether they will want to “hang on” to their patients.

One audience member observed that it is hard for many adolescents with special health needs to transition to adult services because they have to overcome their loyalty to a pediatrician they feel kept them alive.

Dr. Okumura said limitations of the study included the inability to ascertain causality due to its cross-sectional design, the use of parental self-report, and that foregone care may not be indicative of the quality of care delivered.

Nearly 3 million American teens experienced forgone or delayed health care during 2005–2006.

Source DR. OKUMURA

VANCOUVER, B.C. — Roughly 1 in 10 transition-aged adolescents with special health care needs experience some delay in their care, despite high rates of insurance coverage.

A secondary analysis of data from the 2005–2006 National Survey of Children with Special Health Care Needs revealed that 9.8% of 12,385 adolescents, or a weighted total of 2.9 million American adolescents, experienced forgone or delayed health care that year.

Notably, 63% of the cohort (aged 14–17 years) had private insurance, 24% had public insurance, 9% other coverage, and 4% were uninsured, reported Dr. Megumi J. Okumura and her colleagues at the University of California, San Francisco.

While poverty and degree of illness elevated the risk of forgone/delayed health care, receiving transition services appeared to play a protective role in maintaining health care.

“Formal transition planning is a potentially important strategy for preventing forgone care in adolescents with special health care needs,” she said. “Transition planning may help youth and their families better advocate for their own health care services.”

In a multivariate model, the odds of reporting forgone/delayed care increased for adolescents who did not receive transition services (adjusted odds ratio 2.1) or had no medical home (OR 1.6). The same was true for those who lived in a single, mother-only household (OR 1.4) or had an unstable condition (OR 1.4).

Consistent with the previous literature, the odds of forgone care also increased for those with no health insurance (OR 6.1) and an income 200%–400% of the federal poverty line (OR 3.6) or less than 200% of the poverty line (OR 5.6).

Contrary to prior research, however, self-reported black ethnicity was found to decrease the odds of forgone care (OR 0.5), Dr. Okumura said. Data are being analyzed to determine if there is a difference in the utilization of services for physical versus mental health needs.

“It is critical to understand how preparing youth for adult-based health care can ensure continuity as they transition to adult services,” she said.

The majority of the cohort was male (55%), white (69.5%), lived in a two-parent household (61%), had stable medical conditions (66%), and lived at an income level less than 200% of the poverty line (37.5%).

During the discussion of the study, an audience member asked Dr. Okumura to speculate on whether the recently approved Patient Protection and Affordable Care Act will further delay or advance the transition process.

Dr. Okumura said that expanding coverage to more Americans will hopefully improve access to care and that extending coverage to adult dependents up to age 26 may help ease the progression to employer-based health care and other forms of coverage. Still, it's unclear how the new law, even with its provisions for coverage of preexisting conditions, will affect providers transitioning care and whether they will want to “hang on” to their patients.

One audience member observed that it is hard for many adolescents with special health needs to transition to adult services because they have to overcome their loyalty to a pediatrician they feel kept them alive.

Dr. Okumura said limitations of the study included the inability to ascertain causality due to its cross-sectional design, the use of parental self-report, and that foregone care may not be indicative of the quality of care delivered.

Nearly 3 million American teens experienced forgone or delayed health care during 2005–2006.

Source DR. OKUMURA

VANCOUVER, B.C. — Adolescents are seldom screened for health-related social problems, and opportunities for referral are missed, research suggests.

Among 362 patients, aged 15–25 years surveyed in an urban, adolescent/young adult medicine clinic, the rate of screening in the previous year by any health care provider averaged 40% per health-related social domain.

Adolescents experience a broad range of social problems that can deleteriously affect their health, Dr. Eric W. Fleegler said at the meeting. “We need to implement universal screening for health-related social problems, and we need to develop the systems that will provide our patients with the needed referrals.”

Yet office visits during adolescence are often limited by insurance protocols, even though these young people may need more frequent visits during certain times of transition and major life changes, he said.

He added that context is important, as screening may not be appropriate in the setting of an acute illness, but better suited to a well-child visit.

Among the nine domains (housing problems, food insecurity, nutrition and fitness, education, substance abuse, interpersonal violence, safety equipment, income security, and health care access), 9% of patients were screened for all and 15% were screened for none.

Screening rates were lowest for housing problems and food insecurity at 29% each.

The top three screening rates were for nutrition and fitness at 66%, education at 56%, and substance abuse at 52%.

Without screening, adolescents may miss opportunities for referral. Currently, there are no data available on actual referral needs for social problems among adolescents, said Dr. Fleegler, a pediatric emergency physician at Children's Hospital Boston and a pediatrics instructor at Harvard Medical School, also in Boston.

In the current analysis, the majority or 62% of adolescents required one referral for a health-related social problem. In addition, 38% of patients had at least one unmet referral need in the previous 12 months, he said.

Referrals were lowest for interpersonal violence at 11% and for safety equipment and substance abuse at 14% each. The highest domains for referrals were nutrition and fitness at 46%, income security at 35%, and education at 31%.

The analysis was part of a larger study evaluating the efficacy of the Online Advocate, a self-administered, Web-based screening and referral tool for health-related social problems.

The cohort was mostly female (69%), and aged 18–25 years (57%). The ethnic groups were black (56%), Hispanic (28%), white (9%), and multiracial or not identified (7%).

Significantly more 18- to 25-year-olds than 15- to 17-year-olds were screened for income security (47% vs. 25%) and for problems with interpersonal violence (44% vs. 27%).

Males were significantly more likely than females to be screened within the past 12 months for housing problems (41% vs. 24%), income security (49% vs. 32%), and violence (47% vs. 32%).

Whites were significantly more likely to be screened for substance abuse (64%) than were blacks (52%) or Hispanics (43%).

Referrals were significantly more likely to be given to 15- to 17-year-olds than 18- to 25-year-olds for health care access (71% vs. 49%) and for housing problems (68% vs. 44%), he said.

Disclosures: Dr. Fleegler reported no relevant disclosures.

'We need to develop the systems that will provide our patients with the needed referrals.'

Source DR. FLEEGLER

VANCOUVER, B.C. — Adolescents are seldom screened for health-related social problems, and opportunities for referral are missed, research suggests.

Among 362 patients, aged 15–25 years surveyed in an urban, adolescent/young adult medicine clinic, the rate of screening in the previous year by any health care provider averaged 40% per health-related social domain.

Adolescents experience a broad range of social problems that can deleteriously affect their health, Dr. Eric W. Fleegler said at the meeting. “We need to implement universal screening for health-related social problems, and we need to develop the systems that will provide our patients with the needed referrals.”

Yet office visits during adolescence are often limited by insurance protocols, even though these young people may need more frequent visits during certain times of transition and major life changes, he said.

He added that context is important, as screening may not be appropriate in the setting of an acute illness, but better suited to a well-child visit.

Among the nine domains (housing problems, food insecurity, nutrition and fitness, education, substance abuse, interpersonal violence, safety equipment, income security, and health care access), 9% of patients were screened for all and 15% were screened for none.

Screening rates were lowest for housing problems and food insecurity at 29% each.

The top three screening rates were for nutrition and fitness at 66%, education at 56%, and substance abuse at 52%.

Without screening, adolescents may miss opportunities for referral. Currently, there are no data available on actual referral needs for social problems among adolescents, said Dr. Fleegler, a pediatric emergency physician at Children's Hospital Boston and a pediatrics instructor at Harvard Medical School, also in Boston.

In the current analysis, the majority or 62% of adolescents required one referral for a health-related social problem. In addition, 38% of patients had at least one unmet referral need in the previous 12 months, he said.

Referrals were lowest for interpersonal violence at 11% and for safety equipment and substance abuse at 14% each. The highest domains for referrals were nutrition and fitness at 46%, income security at 35%, and education at 31%.

The analysis was part of a larger study evaluating the efficacy of the Online Advocate, a self-administered, Web-based screening and referral tool for health-related social problems.

The cohort was mostly female (69%), and aged 18–25 years (57%). The ethnic groups were black (56%), Hispanic (28%), white (9%), and multiracial or not identified (7%).

Significantly more 18- to 25-year-olds than 15- to 17-year-olds were screened for income security (47% vs. 25%) and for problems with interpersonal violence (44% vs. 27%).

Males were significantly more likely than females to be screened within the past 12 months for housing problems (41% vs. 24%), income security (49% vs. 32%), and violence (47% vs. 32%).

Whites were significantly more likely to be screened for substance abuse (64%) than were blacks (52%) or Hispanics (43%).

Referrals were significantly more likely to be given to 15- to 17-year-olds than 18- to 25-year-olds for health care access (71% vs. 49%) and for housing problems (68% vs. 44%), he said.

Disclosures: Dr. Fleegler reported no relevant disclosures.

'We need to develop the systems that will provide our patients with the needed referrals.'

Source DR. FLEEGLER

VANCOUVER, B.C. — Adolescents are seldom screened for health-related social problems, and opportunities for referral are missed, research suggests.

Among 362 patients, aged 15–25 years surveyed in an urban, adolescent/young adult medicine clinic, the rate of screening in the previous year by any health care provider averaged 40% per health-related social domain.

Adolescents experience a broad range of social problems that can deleteriously affect their health, Dr. Eric W. Fleegler said at the meeting. “We need to implement universal screening for health-related social problems, and we need to develop the systems that will provide our patients with the needed referrals.”

Yet office visits during adolescence are often limited by insurance protocols, even though these young people may need more frequent visits during certain times of transition and major life changes, he said.

He added that context is important, as screening may not be appropriate in the setting of an acute illness, but better suited to a well-child visit.

Among the nine domains (housing problems, food insecurity, nutrition and fitness, education, substance abuse, interpersonal violence, safety equipment, income security, and health care access), 9% of patients were screened for all and 15% were screened for none.

Screening rates were lowest for housing problems and food insecurity at 29% each.

The top three screening rates were for nutrition and fitness at 66%, education at 56%, and substance abuse at 52%.

Without screening, adolescents may miss opportunities for referral. Currently, there are no data available on actual referral needs for social problems among adolescents, said Dr. Fleegler, a pediatric emergency physician at Children's Hospital Boston and a pediatrics instructor at Harvard Medical School, also in Boston.

In the current analysis, the majority or 62% of adolescents required one referral for a health-related social problem. In addition, 38% of patients had at least one unmet referral need in the previous 12 months, he said.

Referrals were lowest for interpersonal violence at 11% and for safety equipment and substance abuse at 14% each. The highest domains for referrals were nutrition and fitness at 46%, income security at 35%, and education at 31%.

The analysis was part of a larger study evaluating the efficacy of the Online Advocate, a self-administered, Web-based screening and referral tool for health-related social problems.

The cohort was mostly female (69%), and aged 18–25 years (57%). The ethnic groups were black (56%), Hispanic (28%), white (9%), and multiracial or not identified (7%).

Significantly more 18- to 25-year-olds than 15- to 17-year-olds were screened for income security (47% vs. 25%) and for problems with interpersonal violence (44% vs. 27%).

Males were significantly more likely than females to be screened within the past 12 months for housing problems (41% vs. 24%), income security (49% vs. 32%), and violence (47% vs. 32%).

Whites were significantly more likely to be screened for substance abuse (64%) than were blacks (52%) or Hispanics (43%).

Referrals were significantly more likely to be given to 15- to 17-year-olds than 18- to 25-year-olds for health care access (71% vs. 49%) and for housing problems (68% vs. 44%), he said.

Disclosures: Dr. Fleegler reported no relevant disclosures.

'We need to develop the systems that will provide our patients with the needed referrals.'

Source DR. FLEEGLER

Major Finding: The average rate of screening for a single health-related social problem was 40%.

Data Source: Analysis of screening for health-related social problems in 362 adolescents.

Disclosures: Dr. Fleegler reported no relevant disclosures.

VANCOUVER, B.C. – Adolescents are seldom screened for health-related social problems, research suggests.

Among 362 patients, aged 15-25 years surveyed in an urban, adolescent/young adult medicine clinic, the rate of screening in the previous year by any health care provider averaged 40% per health-related social domain.

Adolescents experience a broad range of social problems that can deleteriously affect their health, Dr. Eric W. Fleegler said at the meeting. “We need to implement universal screening for health-related social problems, and we need to develop the systems that will provide our patients with the needed referrals,” he said.

Yet, office visits during adolescence are often limited by insurance protocols, even though these young people may need more frequent visits during certain times of transition and major life changes, he said.

Among the nine domains (housing problems, food insecurity, nutrition and fitness, education, substance abuse, interpersonal violence, safety equipment, income security, and health care access), 9% of patients were screened for all and 15% were screened for none.

Screening rates were lowest for housing problems and food insecurity at 29% each. The top three screening rates were for nutrition and fitness at 66%, education at 56%, and substance abuse at 52%.

Without screening, adolescents might miss opportunities for referral. Currently, there are no data available on actual referral needs for social problems among adolescents, said Dr. Fleegler, a pediatric emergency physician at Children's Hospital and a pediatrics instructor at Harvard Medical School, both in Boston.

In the current analysis, referrals were lowest for interpersonal violence at 11% and for safety equipment and substance abuse at 14% each.

The highest domains for referrals were nutrition and fitness at 46%, income security at 35%, and education at 31%.

The analysis was part of a larger study evaluating the efficacy of The Online Advocate, a self-administered, Web-based screening and referral tool for health-related social problems.

Major Finding: The average rate of screening for a single health-related social problem was 40%.

Data Source: Analysis of screening for health-related social problems in 362 adolescents.

Disclosures: Dr. Fleegler reported no relevant disclosures.

VANCOUVER, B.C. – Adolescents are seldom screened for health-related social problems, research suggests.

Among 362 patients, aged 15-25 years surveyed in an urban, adolescent/young adult medicine clinic, the rate of screening in the previous year by any health care provider averaged 40% per health-related social domain.

Adolescents experience a broad range of social problems that can deleteriously affect their health, Dr. Eric W. Fleegler said at the meeting. “We need to implement universal screening for health-related social problems, and we need to develop the systems that will provide our patients with the needed referrals,” he said.

Yet, office visits during adolescence are often limited by insurance protocols, even though these young people may need more frequent visits during certain times of transition and major life changes, he said.

Among the nine domains (housing problems, food insecurity, nutrition and fitness, education, substance abuse, interpersonal violence, safety equipment, income security, and health care access), 9% of patients were screened for all and 15% were screened for none.

Screening rates were lowest for housing problems and food insecurity at 29% each. The top three screening rates were for nutrition and fitness at 66%, education at 56%, and substance abuse at 52%.

Without screening, adolescents might miss opportunities for referral. Currently, there are no data available on actual referral needs for social problems among adolescents, said Dr. Fleegler, a pediatric emergency physician at Children's Hospital and a pediatrics instructor at Harvard Medical School, both in Boston.

In the current analysis, referrals were lowest for interpersonal violence at 11% and for safety equipment and substance abuse at 14% each.

The highest domains for referrals were nutrition and fitness at 46%, income security at 35%, and education at 31%.

The analysis was part of a larger study evaluating the efficacy of The Online Advocate, a self-administered, Web-based screening and referral tool for health-related social problems.

Major Finding: The average rate of screening for a single health-related social problem was 40%.

Data Source: Analysis of screening for health-related social problems in 362 adolescents.

Disclosures: Dr. Fleegler reported no relevant disclosures.

VANCOUVER, B.C. – Adolescents are seldom screened for health-related social problems, research suggests.

Among 362 patients, aged 15-25 years surveyed in an urban, adolescent/young adult medicine clinic, the rate of screening in the previous year by any health care provider averaged 40% per health-related social domain.

Adolescents experience a broad range of social problems that can deleteriously affect their health, Dr. Eric W. Fleegler said at the meeting. “We need to implement universal screening for health-related social problems, and we need to develop the systems that will provide our patients with the needed referrals,” he said.

Yet, office visits during adolescence are often limited by insurance protocols, even though these young people may need more frequent visits during certain times of transition and major life changes, he said.

Among the nine domains (housing problems, food insecurity, nutrition and fitness, education, substance abuse, interpersonal violence, safety equipment, income security, and health care access), 9% of patients were screened for all and 15% were screened for none.

Screening rates were lowest for housing problems and food insecurity at 29% each. The top three screening rates were for nutrition and fitness at 66%, education at 56%, and substance abuse at 52%.

Without screening, adolescents might miss opportunities for referral. Currently, there are no data available on actual referral needs for social problems among adolescents, said Dr. Fleegler, a pediatric emergency physician at Children's Hospital and a pediatrics instructor at Harvard Medical School, both in Boston.

In the current analysis, referrals were lowest for interpersonal violence at 11% and for safety equipment and substance abuse at 14% each.

The highest domains for referrals were nutrition and fitness at 46%, income security at 35%, and education at 31%.

The analysis was part of a larger study evaluating the efficacy of The Online Advocate, a self-administered, Web-based screening and referral tool for health-related social problems.

MINNEAPOLIS – Smoothing hospital occupancy over the entire week could reduce weekday inpatient crowding, according to two retrospective cohort studies.

Traditionally, hospital occupancy is higher on weekdays than on weekends, typically because elective admissions are scheduled for Monday with an eye toward discharging patients by the weekend. This results in peaks and troughs in occupancy that cause midweek crowding and unused capacity on other days, particularly weekends.

Indeed, a study of 22,310 pediatric admissions, of which 22% were scheduled, found that Mondays generated 25% of all scheduled patient-hours defined as the number of patients multiplied by length of stay (LOS). Tuesday and Wednesday generated 20% each, whereas Saturdays and Sundays combined generated less than 3% of patient-hours.

Not surprisingly, Wednesday and Thursday had the highest peak daily occupancy, and were the days most likely to have occupancy above 90% and 95%, Dr. Evan Fieldston and his colleagues reported in a poster presentation at the Pediatric Hospital Medicine 2010 meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

The median LOS for scheduled patients admitted on Monday and staying less than 1 week was significantly longer at 2.49 days compared with 2.08 days for their counterparts admitted on any other weekday.

Hospitals usually respond to midweek crowding by attempting to reduce LOS, but that may not sufficiently increase functional capacity, explained Dr. Fieldston, a pediatric hospitalist at Children’s Hospital of Philadelphia. By proactively managing the inflow of scheduled admissions, hospitals can avoid unused capacity and optimize patient flow.

“Many people [believe] that nobody wants to work on weekends and no patients want to come in on weekends, but there are a number of patients who would be very happy to come on the weekends and some staff who would like to work weekends for family reasons,” he said in an interview. “It’s a matter of aligning incentives.

“The other important thing to think about with staffing is that the estimated cost of adding a bed to a children’s hospital is $2 million per bed. So if you’re going to build 20 beds to deal with your overcrowding, $40 million dollars can bring in a lot of staff.”

The researchers conducted a second study to quantify the theoretical effect of smoothing on inpatient occupancy at 39 tertiary care children’s hospitals in the Pediatric Health Information System. A retrospective smoothing algorithm was used to set each hospital’s daily occupancy to the hospital’s mean occupancy for each week. Post-smoothing reductions in weekly maximum occupancy were averaged for the entire year for each hospital.

Before smoothing, there were 550,543 discharges, with a median LOS of 3 days. The hospitals’ mean midnight occupancy ranged from 71% to 108% on weekdays and from 66% to 95% on weekends, Dr. Fieldston reported. Over all of the hospitals, the median difference between weekday and weekend occupancy was 8.2% points. For a 300-bed hospital, this would translate to a 24-patient lower census on weekends than on weekdays.

Before smoothing, the number of hospitals with mean weekday occupancy above threshold was 33 at greater than 85% occupancy, 25 at more than 90% occupancy, 14 at more than 95% occupancy, and 6 at greater than 100% occupancy. After smoothing, the number of hospitals above threshold was reduced to 32, 22, 10 and 1, respectively, which was significant at each threshold, except the 85%-threshold, he said.

By smoothing, 39,607 patients from the 39 hospitals could be removed from exposure to occupancy exceeding 95%.

Only a small percentage of all admissions (median, 2.6%; range, 0.02%-9.2% across hospitals) would have to be scheduled differently each week to achieve within-week smoothing of occupancy, Dr. Fieldston said. This represents about one-tenth of scheduled admissions per week.

The authors acknowledged that the study assumed a fixed number of beds for the whole year, that the ability to smooth occupancy rests on an adequate number of scheduled admissions to shift during a week, and that midnight census rather than peak daily census was used to determine occupancy.

Still, they concluded that “smoothing has the potential to help optimize patient flow and increase quality and safety in health care delivery.”

If this were to occur, however, then the negative associations surrounding weekend hospital stays would have to change.

“The issue of the weekends not being the best time to be in the hospital shouldn’t be a reason to not bring in patients,” Dr. Fieldston said. “We truly ought to be a 7-day institution.

“We shouldn’t make a hospital less safe for the patients who need to be there on the weekends. And potentially, you have the positive catch-22 that if you purposely schedule patients to be there on the weekend, you will bring in revenue and make it in everyone’s best interest to make the weekend safer and provide better care to all patients,” said Dr. Fieldston, who reported no conflicts of interest.

MINNEAPOLIS – Smoothing hospital occupancy over the entire week could reduce weekday inpatient crowding, according to two retrospective cohort studies.

Traditionally, hospital occupancy is higher on weekdays than on weekends, typically because elective admissions are scheduled for Monday with an eye toward discharging patients by the weekend. This results in peaks and troughs in occupancy that cause midweek crowding and unused capacity on other days, particularly weekends.

Indeed, a study of 22,310 pediatric admissions, of which 22% were scheduled, found that Mondays generated 25% of all scheduled patient-hours defined as the number of patients multiplied by length of stay (LOS). Tuesday and Wednesday generated 20% each, whereas Saturdays and Sundays combined generated less than 3% of patient-hours.

Not surprisingly, Wednesday and Thursday had the highest peak daily occupancy, and were the days most likely to have occupancy above 90% and 95%, Dr. Evan Fieldston and his colleagues reported in a poster presentation at the Pediatric Hospital Medicine 2010 meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

The median LOS for scheduled patients admitted on Monday and staying less than 1 week was significantly longer at 2.49 days compared with 2.08 days for their counterparts admitted on any other weekday.

Hospitals usually respond to midweek crowding by attempting to reduce LOS, but that may not sufficiently increase functional capacity, explained Dr. Fieldston, a pediatric hospitalist at Children’s Hospital of Philadelphia. By proactively managing the inflow of scheduled admissions, hospitals can avoid unused capacity and optimize patient flow.

“Many people [believe] that nobody wants to work on weekends and no patients want to come in on weekends, but there are a number of patients who would be very happy to come on the weekends and some staff who would like to work weekends for family reasons,” he said in an interview. “It’s a matter of aligning incentives.

“The other important thing to think about with staffing is that the estimated cost of adding a bed to a children’s hospital is $2 million per bed. So if you’re going to build 20 beds to deal with your overcrowding, $40 million dollars can bring in a lot of staff.”

The researchers conducted a second study to quantify the theoretical effect of smoothing on inpatient occupancy at 39 tertiary care children’s hospitals in the Pediatric Health Information System. A retrospective smoothing algorithm was used to set each hospital’s daily occupancy to the hospital’s mean occupancy for each week. Post-smoothing reductions in weekly maximum occupancy were averaged for the entire year for each hospital.

Before smoothing, there were 550,543 discharges, with a median LOS of 3 days. The hospitals’ mean midnight occupancy ranged from 71% to 108% on weekdays and from 66% to 95% on weekends, Dr. Fieldston reported. Over all of the hospitals, the median difference between weekday and weekend occupancy was 8.2% points. For a 300-bed hospital, this would translate to a 24-patient lower census on weekends than on weekdays.

Before smoothing, the number of hospitals with mean weekday occupancy above threshold was 33 at greater than 85% occupancy, 25 at more than 90% occupancy, 14 at more than 95% occupancy, and 6 at greater than 100% occupancy. After smoothing, the number of hospitals above threshold was reduced to 32, 22, 10 and 1, respectively, which was significant at each threshold, except the 85%-threshold, he said.

By smoothing, 39,607 patients from the 39 hospitals could be removed from exposure to occupancy exceeding 95%.

Only a small percentage of all admissions (median, 2.6%; range, 0.02%-9.2% across hospitals) would have to be scheduled differently each week to achieve within-week smoothing of occupancy, Dr. Fieldston said. This represents about one-tenth of scheduled admissions per week.

The authors acknowledged that the study assumed a fixed number of beds for the whole year, that the ability to smooth occupancy rests on an adequate number of scheduled admissions to shift during a week, and that midnight census rather than peak daily census was used to determine occupancy.

Still, they concluded that “smoothing has the potential to help optimize patient flow and increase quality and safety in health care delivery.”

If this were to occur, however, then the negative associations surrounding weekend hospital stays would have to change.

“The issue of the weekends not being the best time to be in the hospital shouldn’t be a reason to not bring in patients,” Dr. Fieldston said. “We truly ought to be a 7-day institution.

“We shouldn’t make a hospital less safe for the patients who need to be there on the weekends. And potentially, you have the positive catch-22 that if you purposely schedule patients to be there on the weekend, you will bring in revenue and make it in everyone’s best interest to make the weekend safer and provide better care to all patients,” said Dr. Fieldston, who reported no conflicts of interest.

MINNEAPOLIS – Smoothing hospital occupancy over the entire week could reduce weekday inpatient crowding, according to two retrospective cohort studies.

Traditionally, hospital occupancy is higher on weekdays than on weekends, typically because elective admissions are scheduled for Monday with an eye toward discharging patients by the weekend. This results in peaks and troughs in occupancy that cause midweek crowding and unused capacity on other days, particularly weekends.

Indeed, a study of 22,310 pediatric admissions, of which 22% were scheduled, found that Mondays generated 25% of all scheduled patient-hours defined as the number of patients multiplied by length of stay (LOS). Tuesday and Wednesday generated 20% each, whereas Saturdays and Sundays combined generated less than 3% of patient-hours.

Not surprisingly, Wednesday and Thursday had the highest peak daily occupancy, and were the days most likely to have occupancy above 90% and 95%, Dr. Evan Fieldston and his colleagues reported in a poster presentation at the Pediatric Hospital Medicine 2010 meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

The median LOS for scheduled patients admitted on Monday and staying less than 1 week was significantly longer at 2.49 days compared with 2.08 days for their counterparts admitted on any other weekday.

Hospitals usually respond to midweek crowding by attempting to reduce LOS, but that may not sufficiently increase functional capacity, explained Dr. Fieldston, a pediatric hospitalist at Children’s Hospital of Philadelphia. By proactively managing the inflow of scheduled admissions, hospitals can avoid unused capacity and optimize patient flow.

“Many people [believe] that nobody wants to work on weekends and no patients want to come in on weekends, but there are a number of patients who would be very happy to come on the weekends and some staff who would like to work weekends for family reasons,” he said in an interview. “It’s a matter of aligning incentives.

“The other important thing to think about with staffing is that the estimated cost of adding a bed to a children’s hospital is $2 million per bed. So if you’re going to build 20 beds to deal with your overcrowding, $40 million dollars can bring in a lot of staff.”

The researchers conducted a second study to quantify the theoretical effect of smoothing on inpatient occupancy at 39 tertiary care children’s hospitals in the Pediatric Health Information System. A retrospective smoothing algorithm was used to set each hospital’s daily occupancy to the hospital’s mean occupancy for each week. Post-smoothing reductions in weekly maximum occupancy were averaged for the entire year for each hospital.

Before smoothing, there were 550,543 discharges, with a median LOS of 3 days. The hospitals’ mean midnight occupancy ranged from 71% to 108% on weekdays and from 66% to 95% on weekends, Dr. Fieldston reported. Over all of the hospitals, the median difference between weekday and weekend occupancy was 8.2% points. For a 300-bed hospital, this would translate to a 24-patient lower census on weekends than on weekdays.

Before smoothing, the number of hospitals with mean weekday occupancy above threshold was 33 at greater than 85% occupancy, 25 at more than 90% occupancy, 14 at more than 95% occupancy, and 6 at greater than 100% occupancy. After smoothing, the number of hospitals above threshold was reduced to 32, 22, 10 and 1, respectively, which was significant at each threshold, except the 85%-threshold, he said.

By smoothing, 39,607 patients from the 39 hospitals could be removed from exposure to occupancy exceeding 95%.

Only a small percentage of all admissions (median, 2.6%; range, 0.02%-9.2% across hospitals) would have to be scheduled differently each week to achieve within-week smoothing of occupancy, Dr. Fieldston said. This represents about one-tenth of scheduled admissions per week.

The authors acknowledged that the study assumed a fixed number of beds for the whole year, that the ability to smooth occupancy rests on an adequate number of scheduled admissions to shift during a week, and that midnight census rather than peak daily census was used to determine occupancy.

Still, they concluded that “smoothing has the potential to help optimize patient flow and increase quality and safety in health care delivery.”

If this were to occur, however, then the negative associations surrounding weekend hospital stays would have to change.

“The issue of the weekends not being the best time to be in the hospital shouldn’t be a reason to not bring in patients,” Dr. Fieldston said. “We truly ought to be a 7-day institution.

“We shouldn’t make a hospital less safe for the patients who need to be there on the weekends. And potentially, you have the positive catch-22 that if you purposely schedule patients to be there on the weekend, you will bring in revenue and make it in everyone’s best interest to make the weekend safer and provide better care to all patients,” said Dr. Fieldston, who reported no conflicts of interest.