Patrice Wendling

AUSTIN, TEX. — The release of the long-awaited Joint Commission-sponsored palliative care certificate program has been put on hold in order to complete a strategic planning process, Dr. Diane Meier said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

The certificate program was expected in August 2008 after the Joint Commission announced it would release a new certificate for hospital palliative care programs. The commission convened an expert panel to establish quality standards and conducted market research showing strong interest in the program.

But that research was conducted before the economy began to tank, said Charles Mowll, executive vice president for business development, government, and external relations at the Joint Commission.

“Because of the change in the economic environment, we want to proceed carefully,” he said in an interview. “Unfortunately, it's sometimes difficult to convert that enthusiasm to spending the resources and energy to pursue and obtain certification. The next steps for us are to refresh that market research and get a more contemporary view of the world and interest in the program. But it's a clear message that we have a significant collective investment in palliative care certification.”

The fate of the program should be decided sometime this summer, he said.

In the meantime, the Center to Advance Palliative Care (CAPC) at the Mount Sinai School of Medicine in New York has agreed to advertise the program and raise funds to help offset costs to the Joint Commission to develop it, said Dr. Meier, director of CAPC and professor of geriatrics and internal medicine at Mount Sinai.

“Development of a quality assessment program to ensure high standards for the nation's 1,300 hospital palliative care programs is of the highest priority,” she said in an interview.

▸ Low-hanging fruit. Cash-strapped states are eyeing the nursing home Medicaid Hospice Benefit as a way to shore up their budgets.

“There are a lot of hospices making a very large profit on stable long-term nursing home patients that are tarring the entire industry,” Dr. Meier said. “The problem is that rather than identify and censor the bad actors, they [state and federal policy makers] just want to eliminate the benefit.”

In late 2008, Florida proposed eliminating reimbursement for hospice in nursing homes, claiming that it would save the state $343 million. The effort was defeated after a statewide group, Florida Hospices and Palliative Care, hired its own research firm, arguing that the move would actually boost state health care costs by $3.7 million.

President Obama provided some breathing room by imposing a 1-year moratorium on hospice rate cuts through Sept. 30, 2009, as part of the economic stimulus plan. The National Hospice and Palliative Care Organization (NHPCO) is urging members to push for a permanent freeze.

“We're not expecting that this will completely go away,” said audience member Judy Lund Person, NHPCO vice president of regulatory and state leadership. “There have been lots of discussions about whether it's double-dipping. … We don't believe that that's true, but it's an area where we have to be extraordinarily careful.”

▸ Part of the solution. In other circles, hospice and palliative care are being viewed as part of the solution to the health care crisis. The National Priorities Partnership, convened by the National Quality Forum in 2008, named palliative and end-of-life care as one of six national priorities for transforming the nation's health care system.

Dr. Meier noted that another benchmarking group, HealthGrades, is getting increasing inquiries for help in starting palliative care programs, a sign that health care quality assessment organizations are seeing these programs as a way to get a handle on costs.

▸ Coding conundrum. Although the Centers for Medicare and Medicaid Services began recognizing hospice and palliative care as a new physician specialty as of 2009, a specific specialty code won't be assigned until this fall, said copresenter Lynn Hill Spragens, CEO and president of the consulting firm Spragens & Associates, Durham, N.C. A delay in implementation is not unusual, but in the meantime reimbursement denials continue.

Core causes of denials include a lack of professional preparation to do Part B billing, misinformed or underinformed billing specialists, and an increasing number of providers from different core specialties delivering palliative care services in the same hospital.

Many programs are staffed by specialists with primary credentialing in a specialty such as geriatrics or hospital medicine, who are also board certified in hospice and palliative medicine, Ms. Spragens said. Pending the assignment of the new CMS specialty code, when they receive referrals from physicians in their primary specialty, there is a high potential for bill denial, unless there is very careful documentation by the provider and the billing office.

Until the new specialty code is in place, she advises providers to use the 77 modifier to report a repeat procedure by another physician, include notation about palliative care on the bill, and follow up thoroughly with denials to identify acceptable documentation with payers. After the specialty code is assigned, providers will need to revise their credentialing information, she said.

Dr. Meier and Ms. Spragens reported no conflicts of interest.

AUSTIN, TEX. — The release of the long-awaited Joint Commission-sponsored palliative care certificate program has been put on hold in order to complete a strategic planning process, Dr. Diane Meier said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

The certificate program was expected in August 2008 after the Joint Commission announced it would release a new certificate for hospital palliative care programs. The commission convened an expert panel to establish quality standards and conducted market research showing strong interest in the program.

But that research was conducted before the economy began to tank, said Charles Mowll, executive vice president for business development, government, and external relations at the Joint Commission.

“Because of the change in the economic environment, we want to proceed carefully,” he said in an interview. “Unfortunately, it's sometimes difficult to convert that enthusiasm to spending the resources and energy to pursue and obtain certification. The next steps for us are to refresh that market research and get a more contemporary view of the world and interest in the program. But it's a clear message that we have a significant collective investment in palliative care certification.”

The fate of the program should be decided sometime this summer, he said.

In the meantime, the Center to Advance Palliative Care (CAPC) at the Mount Sinai School of Medicine in New York has agreed to advertise the program and raise funds to help offset costs to the Joint Commission to develop it, said Dr. Meier, director of CAPC and professor of geriatrics and internal medicine at Mount Sinai.

“Development of a quality assessment program to ensure high standards for the nation's 1,300 hospital palliative care programs is of the highest priority,” she said in an interview.

▸ Low-hanging fruit. Cash-strapped states are eyeing the nursing home Medicaid Hospice Benefit as a way to shore up their budgets.

“There are a lot of hospices making a very large profit on stable long-term nursing home patients that are tarring the entire industry,” Dr. Meier said. “The problem is that rather than identify and censor the bad actors, they [state and federal policy makers] just want to eliminate the benefit.”

In late 2008, Florida proposed eliminating reimbursement for hospice in nursing homes, claiming that it would save the state $343 million. The effort was defeated after a statewide group, Florida Hospices and Palliative Care, hired its own research firm, arguing that the move would actually boost state health care costs by $3.7 million.

President Obama provided some breathing room by imposing a 1-year moratorium on hospice rate cuts through Sept. 30, 2009, as part of the economic stimulus plan. The National Hospice and Palliative Care Organization (NHPCO) is urging members to push for a permanent freeze.

“We're not expecting that this will completely go away,” said audience member Judy Lund Person, NHPCO vice president of regulatory and state leadership. “There have been lots of discussions about whether it's double-dipping. … We don't believe that that's true, but it's an area where we have to be extraordinarily careful.”

▸ Part of the solution. In other circles, hospice and palliative care are being viewed as part of the solution to the health care crisis. The National Priorities Partnership, convened by the National Quality Forum in 2008, named palliative and end-of-life care as one of six national priorities for transforming the nation's health care system.

Dr. Meier noted that another benchmarking group, HealthGrades, is getting increasing inquiries for help in starting palliative care programs, a sign that health care quality assessment organizations are seeing these programs as a way to get a handle on costs.

▸ Coding conundrum. Although the Centers for Medicare and Medicaid Services began recognizing hospice and palliative care as a new physician specialty as of 2009, a specific specialty code won't be assigned until this fall, said copresenter Lynn Hill Spragens, CEO and president of the consulting firm Spragens & Associates, Durham, N.C. A delay in implementation is not unusual, but in the meantime reimbursement denials continue.

Core causes of denials include a lack of professional preparation to do Part B billing, misinformed or underinformed billing specialists, and an increasing number of providers from different core specialties delivering palliative care services in the same hospital.

Many programs are staffed by specialists with primary credentialing in a specialty such as geriatrics or hospital medicine, who are also board certified in hospice and palliative medicine, Ms. Spragens said. Pending the assignment of the new CMS specialty code, when they receive referrals from physicians in their primary specialty, there is a high potential for bill denial, unless there is very careful documentation by the provider and the billing office.

Until the new specialty code is in place, she advises providers to use the 77 modifier to report a repeat procedure by another physician, include notation about palliative care on the bill, and follow up thoroughly with denials to identify acceptable documentation with payers. After the specialty code is assigned, providers will need to revise their credentialing information, she said.

Dr. Meier and Ms. Spragens reported no conflicts of interest.

AUSTIN, TEX. — The release of the long-awaited Joint Commission-sponsored palliative care certificate program has been put on hold in order to complete a strategic planning process, Dr. Diane Meier said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

The certificate program was expected in August 2008 after the Joint Commission announced it would release a new certificate for hospital palliative care programs. The commission convened an expert panel to establish quality standards and conducted market research showing strong interest in the program.

But that research was conducted before the economy began to tank, said Charles Mowll, executive vice president for business development, government, and external relations at the Joint Commission.

“Because of the change in the economic environment, we want to proceed carefully,” he said in an interview. “Unfortunately, it's sometimes difficult to convert that enthusiasm to spending the resources and energy to pursue and obtain certification. The next steps for us are to refresh that market research and get a more contemporary view of the world and interest in the program. But it's a clear message that we have a significant collective investment in palliative care certification.”

The fate of the program should be decided sometime this summer, he said.

In the meantime, the Center to Advance Palliative Care (CAPC) at the Mount Sinai School of Medicine in New York has agreed to advertise the program and raise funds to help offset costs to the Joint Commission to develop it, said Dr. Meier, director of CAPC and professor of geriatrics and internal medicine at Mount Sinai.

“Development of a quality assessment program to ensure high standards for the nation's 1,300 hospital palliative care programs is of the highest priority,” she said in an interview.

▸ Low-hanging fruit. Cash-strapped states are eyeing the nursing home Medicaid Hospice Benefit as a way to shore up their budgets.

“There are a lot of hospices making a very large profit on stable long-term nursing home patients that are tarring the entire industry,” Dr. Meier said. “The problem is that rather than identify and censor the bad actors, they [state and federal policy makers] just want to eliminate the benefit.”

In late 2008, Florida proposed eliminating reimbursement for hospice in nursing homes, claiming that it would save the state $343 million. The effort was defeated after a statewide group, Florida Hospices and Palliative Care, hired its own research firm, arguing that the move would actually boost state health care costs by $3.7 million.

President Obama provided some breathing room by imposing a 1-year moratorium on hospice rate cuts through Sept. 30, 2009, as part of the economic stimulus plan. The National Hospice and Palliative Care Organization (NHPCO) is urging members to push for a permanent freeze.

“We're not expecting that this will completely go away,” said audience member Judy Lund Person, NHPCO vice president of regulatory and state leadership. “There have been lots of discussions about whether it's double-dipping. … We don't believe that that's true, but it's an area where we have to be extraordinarily careful.”

▸ Part of the solution. In other circles, hospice and palliative care are being viewed as part of the solution to the health care crisis. The National Priorities Partnership, convened by the National Quality Forum in 2008, named palliative and end-of-life care as one of six national priorities for transforming the nation's health care system.

Dr. Meier noted that another benchmarking group, HealthGrades, is getting increasing inquiries for help in starting palliative care programs, a sign that health care quality assessment organizations are seeing these programs as a way to get a handle on costs.

▸ Coding conundrum. Although the Centers for Medicare and Medicaid Services began recognizing hospice and palliative care as a new physician specialty as of 2009, a specific specialty code won't be assigned until this fall, said copresenter Lynn Hill Spragens, CEO and president of the consulting firm Spragens & Associates, Durham, N.C. A delay in implementation is not unusual, but in the meantime reimbursement denials continue.

Core causes of denials include a lack of professional preparation to do Part B billing, misinformed or underinformed billing specialists, and an increasing number of providers from different core specialties delivering palliative care services in the same hospital.

Many programs are staffed by specialists with primary credentialing in a specialty such as geriatrics or hospital medicine, who are also board certified in hospice and palliative medicine, Ms. Spragens said. Pending the assignment of the new CMS specialty code, when they receive referrals from physicians in their primary specialty, there is a high potential for bill denial, unless there is very careful documentation by the provider and the billing office.

Until the new specialty code is in place, she advises providers to use the 77 modifier to report a repeat procedure by another physician, include notation about palliative care on the bill, and follow up thoroughly with denials to identify acceptable documentation with payers. After the specialty code is assigned, providers will need to revise their credentialing information, she said.

Dr. Meier and Ms. Spragens reported no conflicts of interest.

Slightly more than 2 million cancer survivors in the United States forego necessary medical care because of cost concerns, and Hispanics and African Americans are twice as likely to do so, new research suggests.

Using the annual National Health Interview Survey database for 2003–2006, investigators identified 6,602 adult cancer survivors and 104,364 individuals with no history of cancer. During the survey, individuals were specifically asked if, during the past 12 months, there was a time when they needed medical care but did not get it because they could not afford it.

The overall prevalence of forgoing care because of cost among cancer survivors was 8% for general medical care, 10% for prescription medication, 11% for dental care, and 3% for mental health care, lead author Kathryn E. Weaver, Ph.D., and associates reported at a conference sponsored by the American Association for Cancer Research.

Based on this analysis, “slightly more than 2 million cancer survivors did not get the medical care that they needed because of cost,” Dr. Weaver, a cancer prevention fellow at the National Cancer Institute, said in an interview. There are 12 million cancer survivors in the United States, according to the most recent NCI Surveillance, Epidemiology, and End Results (SEER) data through 2007.

“Access to medical care is vitally important to this population, and we need to find ways of increasing their access to needed medical services,” she said. “Short of that, physicians should be aware that a significant number of cancer survivors are not getting care, and should make efforts to hook them up with free or low-cost services.”

When compared with white survivors, Hispanic survivors were more likely to forgo medical care (odds ratio, 1.55), prescription medications (OR, 2.14), and dental care (OR, 2.31). African American survivors were more likely than white survivors to forgo prescription medications (OR, 1.87) and dental care (OR, 1.57).

“The reason for this [underutilization] is largely due to insurance coverage rates, because when you adjust for coverage status and education, the disparity disappears,” she said.

In all, 12.5% of the 3,141 cancer survivors who were younger than 65 years had no insurance coverage, compared with 20% of those of a similar age without a history of cancer.

After adjustment of the data for health insurance status, education, and non-cancer related comorbidities, none of the interactions between cancer history and ethnicity was significant in the 3,461 survivors aged 65 years and older—a population almost entirely covered by the national Medicare program.

After adjustment, Hispanics aged younger than 65 years without a history of cancer were significantly less likely than their white counterparts to forgo medications (OR, 0.76) and dental care (OR, 0.74), but this pattern reversed for cancer survivors, Dr. Weaver said. Younger Hispanic cancer survivors were significantly more likely to forgo prescriptions (OR, 1.19) and dental care (OR, 1.31), compared with young white survivors.

Younger Hispanic cancer survivors may perceive such services, which are typically paid out of pocket, as being less important than seeing a physician, Dr. Weaver said. Some suggest that Hispanics in the general population are less likely to forgo health care services because of the “healthy immigrant effect.” This hypothesis has been suggested as an explanation for lower rates of many chronic diseases—including breast, cervical, and ovarian cancers—in recent immigrants, although this health advantage seems to disappear as time residing in the United States increases, she said.

Dr. Weaver acknowledged that the number of ethnic minority survivors in the sample was small, but said it is possible to extrapolate the findings to American cancer survivors because the population-based National Health Interview Survey is representative of the general population at large, and it oversamples the number of blacks and Hispanics.

The study was limited by a lack of information on the survivors' treatment status, she said. What was known is that 59% of survivors were more than 5 years post diagnosis at the time of the survey, 36% were 1–5 years post diagnosis, and 5% were less than 1 year since diagnosis.

The time since diagnosis was not significantly related to the forgoing of medical care, but should be studied further because of the potential for cancer recurrence and chemotherapy side effects (such as heart failure) to emerge over time.

“We need more research to look at cancer survivors who are at different points in the survival trajectory to understand what the financial barriers to care are at each of these points, because they might differ,” Dr. Weaver said. “Something we're extremely concerned about in the [NCI's] Office of Cancer Survivorship is the occurrence of late effects of cancer and its treatment.”

The study was supported by the NCI. The investigators disclosed no conflicts of interest.

ELSEVIER GLOBAL MEDICAL NEWS

Slightly more than 2 million cancer survivors in the United States forego necessary medical care because of cost concerns, and Hispanics and African Americans are twice as likely to do so, new research suggests.

Using the annual National Health Interview Survey database for 2003–2006, investigators identified 6,602 adult cancer survivors and 104,364 individuals with no history of cancer. During the survey, individuals were specifically asked if, during the past 12 months, there was a time when they needed medical care but did not get it because they could not afford it.

The overall prevalence of forgoing care because of cost among cancer survivors was 8% for general medical care, 10% for prescription medication, 11% for dental care, and 3% for mental health care, lead author Kathryn E. Weaver, Ph.D., and associates reported at a conference sponsored by the American Association for Cancer Research.

Based on this analysis, “slightly more than 2 million cancer survivors did not get the medical care that they needed because of cost,” Dr. Weaver, a cancer prevention fellow at the National Cancer Institute, said in an interview. There are 12 million cancer survivors in the United States, according to the most recent NCI Surveillance, Epidemiology, and End Results (SEER) data through 2007.

“Access to medical care is vitally important to this population, and we need to find ways of increasing their access to needed medical services,” she said. “Short of that, physicians should be aware that a significant number of cancer survivors are not getting care, and should make efforts to hook them up with free or low-cost services.”

When compared with white survivors, Hispanic survivors were more likely to forgo medical care (odds ratio, 1.55), prescription medications (OR, 2.14), and dental care (OR, 2.31). African American survivors were more likely than white survivors to forgo prescription medications (OR, 1.87) and dental care (OR, 1.57).

“The reason for this [underutilization] is largely due to insurance coverage rates, because when you adjust for coverage status and education, the disparity disappears,” she said.

In all, 12.5% of the 3,141 cancer survivors who were younger than 65 years had no insurance coverage, compared with 20% of those of a similar age without a history of cancer.

After adjustment of the data for health insurance status, education, and non-cancer related comorbidities, none of the interactions between cancer history and ethnicity was significant in the 3,461 survivors aged 65 years and older—a population almost entirely covered by the national Medicare program.

After adjustment, Hispanics aged younger than 65 years without a history of cancer were significantly less likely than their white counterparts to forgo medications (OR, 0.76) and dental care (OR, 0.74), but this pattern reversed for cancer survivors, Dr. Weaver said. Younger Hispanic cancer survivors were significantly more likely to forgo prescriptions (OR, 1.19) and dental care (OR, 1.31), compared with young white survivors.

Younger Hispanic cancer survivors may perceive such services, which are typically paid out of pocket, as being less important than seeing a physician, Dr. Weaver said. Some suggest that Hispanics in the general population are less likely to forgo health care services because of the “healthy immigrant effect.” This hypothesis has been suggested as an explanation for lower rates of many chronic diseases—including breast, cervical, and ovarian cancers—in recent immigrants, although this health advantage seems to disappear as time residing in the United States increases, she said.

Dr. Weaver acknowledged that the number of ethnic minority survivors in the sample was small, but said it is possible to extrapolate the findings to American cancer survivors because the population-based National Health Interview Survey is representative of the general population at large, and it oversamples the number of blacks and Hispanics.

The study was limited by a lack of information on the survivors' treatment status, she said. What was known is that 59% of survivors were more than 5 years post diagnosis at the time of the survey, 36% were 1–5 years post diagnosis, and 5% were less than 1 year since diagnosis.

The time since diagnosis was not significantly related to the forgoing of medical care, but should be studied further because of the potential for cancer recurrence and chemotherapy side effects (such as heart failure) to emerge over time.

“We need more research to look at cancer survivors who are at different points in the survival trajectory to understand what the financial barriers to care are at each of these points, because they might differ,” Dr. Weaver said. “Something we're extremely concerned about in the [NCI's] Office of Cancer Survivorship is the occurrence of late effects of cancer and its treatment.”

The study was supported by the NCI. The investigators disclosed no conflicts of interest.

ELSEVIER GLOBAL MEDICAL NEWS

Slightly more than 2 million cancer survivors in the United States forego necessary medical care because of cost concerns, and Hispanics and African Americans are twice as likely to do so, new research suggests.

Using the annual National Health Interview Survey database for 2003–2006, investigators identified 6,602 adult cancer survivors and 104,364 individuals with no history of cancer. During the survey, individuals were specifically asked if, during the past 12 months, there was a time when they needed medical care but did not get it because they could not afford it.

The overall prevalence of forgoing care because of cost among cancer survivors was 8% for general medical care, 10% for prescription medication, 11% for dental care, and 3% for mental health care, lead author Kathryn E. Weaver, Ph.D., and associates reported at a conference sponsored by the American Association for Cancer Research.

Based on this analysis, “slightly more than 2 million cancer survivors did not get the medical care that they needed because of cost,” Dr. Weaver, a cancer prevention fellow at the National Cancer Institute, said in an interview. There are 12 million cancer survivors in the United States, according to the most recent NCI Surveillance, Epidemiology, and End Results (SEER) data through 2007.

“Access to medical care is vitally important to this population, and we need to find ways of increasing their access to needed medical services,” she said. “Short of that, physicians should be aware that a significant number of cancer survivors are not getting care, and should make efforts to hook them up with free or low-cost services.”

When compared with white survivors, Hispanic survivors were more likely to forgo medical care (odds ratio, 1.55), prescription medications (OR, 2.14), and dental care (OR, 2.31). African American survivors were more likely than white survivors to forgo prescription medications (OR, 1.87) and dental care (OR, 1.57).

“The reason for this [underutilization] is largely due to insurance coverage rates, because when you adjust for coverage status and education, the disparity disappears,” she said.

In all, 12.5% of the 3,141 cancer survivors who were younger than 65 years had no insurance coverage, compared with 20% of those of a similar age without a history of cancer.

After adjustment of the data for health insurance status, education, and non-cancer related comorbidities, none of the interactions between cancer history and ethnicity was significant in the 3,461 survivors aged 65 years and older—a population almost entirely covered by the national Medicare program.

After adjustment, Hispanics aged younger than 65 years without a history of cancer were significantly less likely than their white counterparts to forgo medications (OR, 0.76) and dental care (OR, 0.74), but this pattern reversed for cancer survivors, Dr. Weaver said. Younger Hispanic cancer survivors were significantly more likely to forgo prescriptions (OR, 1.19) and dental care (OR, 1.31), compared with young white survivors.

Younger Hispanic cancer survivors may perceive such services, which are typically paid out of pocket, as being less important than seeing a physician, Dr. Weaver said. Some suggest that Hispanics in the general population are less likely to forgo health care services because of the “healthy immigrant effect.” This hypothesis has been suggested as an explanation for lower rates of many chronic diseases—including breast, cervical, and ovarian cancers—in recent immigrants, although this health advantage seems to disappear as time residing in the United States increases, she said.

Dr. Weaver acknowledged that the number of ethnic minority survivors in the sample was small, but said it is possible to extrapolate the findings to American cancer survivors because the population-based National Health Interview Survey is representative of the general population at large, and it oversamples the number of blacks and Hispanics.

The study was limited by a lack of information on the survivors' treatment status, she said. What was known is that 59% of survivors were more than 5 years post diagnosis at the time of the survey, 36% were 1–5 years post diagnosis, and 5% were less than 1 year since diagnosis.

The time since diagnosis was not significantly related to the forgoing of medical care, but should be studied further because of the potential for cancer recurrence and chemotherapy side effects (such as heart failure) to emerge over time.

“We need more research to look at cancer survivors who are at different points in the survival trajectory to understand what the financial barriers to care are at each of these points, because they might differ,” Dr. Weaver said. “Something we're extremely concerned about in the [NCI's] Office of Cancer Survivorship is the occurrence of late effects of cancer and its treatment.”

The study was supported by the NCI. The investigators disclosed no conflicts of interest.

ELSEVIER GLOBAL MEDICAL NEWS

AUSTIN, TEX. — Palliative oxygen was no better than air delivered by nasal cannulae for relieving dyspnea or improving quality of life in a study of 239 non- or mildly hypoxemic patients with terminal illness.

During the first 24 hours, patients in the O₂ Breathe Trial had an improvement of about 10% in dyspnea symptoms with either treatment, or 1 point on a 10-point self-reported scale. The results were sustained over the 7-day study period, lead investigator Dr. Amy Abernethy and her associates reported at the annual meeting of the American Academy of Hospice and Palliative Medicine.

For the study, patients with intractable dyspnea received ordinary air or palliative oxygen, which combined air with an increased oxygen concentration of up to 28%. Both treatments were given via nasal cannulae from a blinded concentrator at 2 L per minute for at least 15 hours per day.

Regardless of treatment group, patients with worse breathlessness at baseline were more likely to respond, said Dr. Abernethy, an oncologist and co-chair of the Duke Cancer Care Research Program at Duke University Medical Center in Durham, N.C. After 7 days of treatment, the mean change from baseline in dyspnea symptoms was 1 point for patients with moderate dyspnea (baseline 4–6 points), compared with 2.5 for those with severe dyspnea (baseline 7–10 points).

The findings call into question whether it's necessary to prescribe palliative oxygen in these patients, and suggest that giving air via nasal cannulae is just as good, Dr. Abernethy said. Palliative oxygen is widely used to treat breathlessness, which affects up to 70% of patients with cancer and 90% of those with chronic obstructive pulmonary disease (COPD), and tends to worsen as death nears.

Dr. Abernethy noted that her hospice spends $250,000 per month on oxygen and oxygen concentrators in order to provide palliative oxygen.

“The most important piece in translation is focusing on which patients are likely to get the most benefit,” Dr. Abernethy said. “Clearly, it's the patient who is most dyspneic and clearly [the benefits are seen] in the first 24 hours. Whether you should use oxygen or air delivered by nasal cannulae doesn't seem to matter.”

The findings will need to be incorporated into the current evidence base and various guidelines, said Dr. Abernethy, noting that recommendations for palliative oxygen vary by guideline group and country. However, the survival benefit of oxygen therapy is well established for severely hypoxic COPD patients (PaO₂ of 55 mm Hg or less).

A trial is underway to evaluate the use of forced-air fans for treating dyspnea, she said. A review of 47 studies in 2,532 patients with breathlessness and advanced stages of malignant and nonmalignant diseases (mostly COPD) concluded that there was low strength of evidence that acupuncture/acupressure is helpful and not enough data to judge the evidence for fans, music, relaxation, counseling, and psychotherapy (Cochrane Database Syst. Rev. 2008. CD005623 [doi:10.1002/14651858]).

The O₂ Breathe Trial recruited patients with a baseline PaO₂ greater than 55 mm Hg from nine study sites in Australia, the United Kingdom, and the United States. The trial was adequately powered, Dr. Abernethy said, but she noted that it did not have a placebo arm and pulse oximetry was not used. Baseline O₂ saturation was 94%–95%. PaO₂ was measured only at baseline (mean 77 mm Hg).

The patients' mean age was 73 years, 62% were male, 64% had COPD, and 16% had cancer.

In linear regression analyses, patients receiving oxygen therapy were almost twice as likely to have a morning response as were those receiving air (odds ratio 1.86).

The O₂ Breathe Trial was funded by the U.S. National Institute on Aging, Australia's National Health and Medical Research Council, the Doris Duke Charitable Foundation, and the Duke Institute for Care at the End of Life. The authors disclosed no relevant conflicts of interest.

A related video is at www.youtube.com/InternalMedicineNews

Giving air via nasal cannulae may be just as good as palliative oxygen. ©

AUSTIN, TEX. — Palliative oxygen was no better than air delivered by nasal cannulae for relieving dyspnea or improving quality of life in a study of 239 non- or mildly hypoxemic patients with terminal illness.

During the first 24 hours, patients in the O₂ Breathe Trial had an improvement of about 10% in dyspnea symptoms with either treatment, or 1 point on a 10-point self-reported scale. The results were sustained over the 7-day study period, lead investigator Dr. Amy Abernethy and her associates reported at the annual meeting of the American Academy of Hospice and Palliative Medicine.

For the study, patients with intractable dyspnea received ordinary air or palliative oxygen, which combined air with an increased oxygen concentration of up to 28%. Both treatments were given via nasal cannulae from a blinded concentrator at 2 L per minute for at least 15 hours per day.

Regardless of treatment group, patients with worse breathlessness at baseline were more likely to respond, said Dr. Abernethy, an oncologist and co-chair of the Duke Cancer Care Research Program at Duke University Medical Center in Durham, N.C. After 7 days of treatment, the mean change from baseline in dyspnea symptoms was 1 point for patients with moderate dyspnea (baseline 4–6 points), compared with 2.5 for those with severe dyspnea (baseline 7–10 points).

The findings call into question whether it's necessary to prescribe palliative oxygen in these patients, and suggest that giving air via nasal cannulae is just as good, Dr. Abernethy said. Palliative oxygen is widely used to treat breathlessness, which affects up to 70% of patients with cancer and 90% of those with chronic obstructive pulmonary disease (COPD), and tends to worsen as death nears.

Dr. Abernethy noted that her hospice spends $250,000 per month on oxygen and oxygen concentrators in order to provide palliative oxygen.

“The most important piece in translation is focusing on which patients are likely to get the most benefit,” Dr. Abernethy said. “Clearly, it's the patient who is most dyspneic and clearly [the benefits are seen] in the first 24 hours. Whether you should use oxygen or air delivered by nasal cannulae doesn't seem to matter.”

The findings will need to be incorporated into the current evidence base and various guidelines, said Dr. Abernethy, noting that recommendations for palliative oxygen vary by guideline group and country. However, the survival benefit of oxygen therapy is well established for severely hypoxic COPD patients (PaO₂ of 55 mm Hg or less).

A trial is underway to evaluate the use of forced-air fans for treating dyspnea, she said. A review of 47 studies in 2,532 patients with breathlessness and advanced stages of malignant and nonmalignant diseases (mostly COPD) concluded that there was low strength of evidence that acupuncture/acupressure is helpful and not enough data to judge the evidence for fans, music, relaxation, counseling, and psychotherapy (Cochrane Database Syst. Rev. 2008. CD005623 [doi:10.1002/14651858]).

The O₂ Breathe Trial recruited patients with a baseline PaO₂ greater than 55 mm Hg from nine study sites in Australia, the United Kingdom, and the United States. The trial was adequately powered, Dr. Abernethy said, but she noted that it did not have a placebo arm and pulse oximetry was not used. Baseline O₂ saturation was 94%–95%. PaO₂ was measured only at baseline (mean 77 mm Hg).

The patients' mean age was 73 years, 62% were male, 64% had COPD, and 16% had cancer.

In linear regression analyses, patients receiving oxygen therapy were almost twice as likely to have a morning response as were those receiving air (odds ratio 1.86).

The O₂ Breathe Trial was funded by the U.S. National Institute on Aging, Australia's National Health and Medical Research Council, the Doris Duke Charitable Foundation, and the Duke Institute for Care at the End of Life. The authors disclosed no relevant conflicts of interest.

A related video is at www.youtube.com/InternalMedicineNews

Giving air via nasal cannulae may be just as good as palliative oxygen. ©

AUSTIN, TEX. — Palliative oxygen was no better than air delivered by nasal cannulae for relieving dyspnea or improving quality of life in a study of 239 non- or mildly hypoxemic patients with terminal illness.

During the first 24 hours, patients in the O₂ Breathe Trial had an improvement of about 10% in dyspnea symptoms with either treatment, or 1 point on a 10-point self-reported scale. The results were sustained over the 7-day study period, lead investigator Dr. Amy Abernethy and her associates reported at the annual meeting of the American Academy of Hospice and Palliative Medicine.

For the study, patients with intractable dyspnea received ordinary air or palliative oxygen, which combined air with an increased oxygen concentration of up to 28%. Both treatments were given via nasal cannulae from a blinded concentrator at 2 L per minute for at least 15 hours per day.

Regardless of treatment group, patients with worse breathlessness at baseline were more likely to respond, said Dr. Abernethy, an oncologist and co-chair of the Duke Cancer Care Research Program at Duke University Medical Center in Durham, N.C. After 7 days of treatment, the mean change from baseline in dyspnea symptoms was 1 point for patients with moderate dyspnea (baseline 4–6 points), compared with 2.5 for those with severe dyspnea (baseline 7–10 points).

The findings call into question whether it's necessary to prescribe palliative oxygen in these patients, and suggest that giving air via nasal cannulae is just as good, Dr. Abernethy said. Palliative oxygen is widely used to treat breathlessness, which affects up to 70% of patients with cancer and 90% of those with chronic obstructive pulmonary disease (COPD), and tends to worsen as death nears.

Dr. Abernethy noted that her hospice spends $250,000 per month on oxygen and oxygen concentrators in order to provide palliative oxygen.

“The most important piece in translation is focusing on which patients are likely to get the most benefit,” Dr. Abernethy said. “Clearly, it's the patient who is most dyspneic and clearly [the benefits are seen] in the first 24 hours. Whether you should use oxygen or air delivered by nasal cannulae doesn't seem to matter.”

The findings will need to be incorporated into the current evidence base and various guidelines, said Dr. Abernethy, noting that recommendations for palliative oxygen vary by guideline group and country. However, the survival benefit of oxygen therapy is well established for severely hypoxic COPD patients (PaO₂ of 55 mm Hg or less).

A trial is underway to evaluate the use of forced-air fans for treating dyspnea, she said. A review of 47 studies in 2,532 patients with breathlessness and advanced stages of malignant and nonmalignant diseases (mostly COPD) concluded that there was low strength of evidence that acupuncture/acupressure is helpful and not enough data to judge the evidence for fans, music, relaxation, counseling, and psychotherapy (Cochrane Database Syst. Rev. 2008. CD005623 [doi:10.1002/14651858]).

The O₂ Breathe Trial recruited patients with a baseline PaO₂ greater than 55 mm Hg from nine study sites in Australia, the United Kingdom, and the United States. The trial was adequately powered, Dr. Abernethy said, but she noted that it did not have a placebo arm and pulse oximetry was not used. Baseline O₂ saturation was 94%–95%. PaO₂ was measured only at baseline (mean 77 mm Hg).

The patients' mean age was 73 years, 62% were male, 64% had COPD, and 16% had cancer.

In linear regression analyses, patients receiving oxygen therapy were almost twice as likely to have a morning response as were those receiving air (odds ratio 1.86).

The O₂ Breathe Trial was funded by the U.S. National Institute on Aging, Australia's National Health and Medical Research Council, the Doris Duke Charitable Foundation, and the Duke Institute for Care at the End of Life. The authors disclosed no relevant conflicts of interest.

A related video is at www.youtube.com/InternalMedicineNews

Giving air via nasal cannulae may be just as good as palliative oxygen. ©

Hispanic men and women living on the United States-Mexico border have little understanding about the human papillomavirus and its role in the etiology of cervical cancer, according to a small prospective study.

Not only were there very low levels of knowledge among these residents, but their misconceptions and confusion continued even after they were given some basic information about HPV and cervical cancer, Maria Fernandez, Ph.D., said in Carefree, Ariz., during a press conference sponsored by the American Association for Cancer Research. For example, participants tended to compare HPV with HIV and other sexually transmitted infections, and were confused or unaware that men could have HPV and transmit it.

She reported on 30 Hispanic women and 11 Hispanic men without a diagnosis of HPV who lived in Rio Grande Valley colonias (unincorporated border settlements) and participated in focus groups in Brownsville, Tex. The mean age was 41 years among the women (range, 20–74 years) and 39 years among the men (range, 19–76 years). The average annual income for a family of four in these semirural neighborhoods was $13,000. About 60% of participants had not completed grade school.

Analysis of the Spanish-language focus group transcripts revealed that attitudes and concerns about HPV differed by gender, said Dr. Fernandez of the division of health promotion and behavioral sciences at the University of Texas in Houston. Women in particular viewed the disease with fatalism, interpreting a diagnosis of HPV as a diagnosis of cancer. They expressed their fears of cancer and their belief that, once diagnosed, it is “essentially a death sentence.” The women said they would be reluctant to disclose their HPV status to their partners because they believed they would be accused of infidelity.

Men initially expressed anger at the possibility of an HPV diagnosis, attributing it to infidelity, Dr. Fernandez said. After a brief explanation about the ambiguity of HPV transmission, they ascribed their initial reaction to cultural ideals of machismo. Women also said that machismo would lead to reactions of anger and accusations of infidelity.

Dr. Fernandez acknowledged that the border communities and colonias face unique challenges, and that the findings of this small, qualitative study should not be generalized to other Hispanics or Mexican Americans.

“On the other hand, it raises some interesting questions about what we've heard in many other studies about cultural norms, such as things like machismo and the way we've traditionally interpreted this concept,” she said. “As we saw in these focus groups, there's sort of an initial reaction, but then people talked about standing by their partner.”

Clues about these cultural norms and beliefs are essential to the design and implementation of successful and badly needed interventions for HPV and cervical cancer prevention.

“You have to be very cautious in terms of generalizing these findings, but many of the populations that are suffering increased incidence of HPV and cervical cancer and increased mortality are in this area,” Dr. Fernandez said.

The study was funded by the National Institutes of Health. The authors reported no conflicts of interest.

Hispanic men and women living on the United States-Mexico border have little understanding about the human papillomavirus and its role in the etiology of cervical cancer, according to a small prospective study.

Not only were there very low levels of knowledge among these residents, but their misconceptions and confusion continued even after they were given some basic information about HPV and cervical cancer, Maria Fernandez, Ph.D., said in Carefree, Ariz., during a press conference sponsored by the American Association for Cancer Research. For example, participants tended to compare HPV with HIV and other sexually transmitted infections, and were confused or unaware that men could have HPV and transmit it.

She reported on 30 Hispanic women and 11 Hispanic men without a diagnosis of HPV who lived in Rio Grande Valley colonias (unincorporated border settlements) and participated in focus groups in Brownsville, Tex. The mean age was 41 years among the women (range, 20–74 years) and 39 years among the men (range, 19–76 years). The average annual income for a family of four in these semirural neighborhoods was $13,000. About 60% of participants had not completed grade school.

Analysis of the Spanish-language focus group transcripts revealed that attitudes and concerns about HPV differed by gender, said Dr. Fernandez of the division of health promotion and behavioral sciences at the University of Texas in Houston. Women in particular viewed the disease with fatalism, interpreting a diagnosis of HPV as a diagnosis of cancer. They expressed their fears of cancer and their belief that, once diagnosed, it is “essentially a death sentence.” The women said they would be reluctant to disclose their HPV status to their partners because they believed they would be accused of infidelity.

Men initially expressed anger at the possibility of an HPV diagnosis, attributing it to infidelity, Dr. Fernandez said. After a brief explanation about the ambiguity of HPV transmission, they ascribed their initial reaction to cultural ideals of machismo. Women also said that machismo would lead to reactions of anger and accusations of infidelity.

Dr. Fernandez acknowledged that the border communities and colonias face unique challenges, and that the findings of this small, qualitative study should not be generalized to other Hispanics or Mexican Americans.

“On the other hand, it raises some interesting questions about what we've heard in many other studies about cultural norms, such as things like machismo and the way we've traditionally interpreted this concept,” she said. “As we saw in these focus groups, there's sort of an initial reaction, but then people talked about standing by their partner.”

Clues about these cultural norms and beliefs are essential to the design and implementation of successful and badly needed interventions for HPV and cervical cancer prevention.

“You have to be very cautious in terms of generalizing these findings, but many of the populations that are suffering increased incidence of HPV and cervical cancer and increased mortality are in this area,” Dr. Fernandez said.

The study was funded by the National Institutes of Health. The authors reported no conflicts of interest.

Hispanic men and women living on the United States-Mexico border have little understanding about the human papillomavirus and its role in the etiology of cervical cancer, according to a small prospective study.

Not only were there very low levels of knowledge among these residents, but their misconceptions and confusion continued even after they were given some basic information about HPV and cervical cancer, Maria Fernandez, Ph.D., said in Carefree, Ariz., during a press conference sponsored by the American Association for Cancer Research. For example, participants tended to compare HPV with HIV and other sexually transmitted infections, and were confused or unaware that men could have HPV and transmit it.

She reported on 30 Hispanic women and 11 Hispanic men without a diagnosis of HPV who lived in Rio Grande Valley colonias (unincorporated border settlements) and participated in focus groups in Brownsville, Tex. The mean age was 41 years among the women (range, 20–74 years) and 39 years among the men (range, 19–76 years). The average annual income for a family of four in these semirural neighborhoods was $13,000. About 60% of participants had not completed grade school.

Analysis of the Spanish-language focus group transcripts revealed that attitudes and concerns about HPV differed by gender, said Dr. Fernandez of the division of health promotion and behavioral sciences at the University of Texas in Houston. Women in particular viewed the disease with fatalism, interpreting a diagnosis of HPV as a diagnosis of cancer. They expressed their fears of cancer and their belief that, once diagnosed, it is “essentially a death sentence.” The women said they would be reluctant to disclose their HPV status to their partners because they believed they would be accused of infidelity.

Men initially expressed anger at the possibility of an HPV diagnosis, attributing it to infidelity, Dr. Fernandez said. After a brief explanation about the ambiguity of HPV transmission, they ascribed their initial reaction to cultural ideals of machismo. Women also said that machismo would lead to reactions of anger and accusations of infidelity.

Dr. Fernandez acknowledged that the border communities and colonias face unique challenges, and that the findings of this small, qualitative study should not be generalized to other Hispanics or Mexican Americans.

“On the other hand, it raises some interesting questions about what we've heard in many other studies about cultural norms, such as things like machismo and the way we've traditionally interpreted this concept,” she said. “As we saw in these focus groups, there's sort of an initial reaction, but then people talked about standing by their partner.”

Clues about these cultural norms and beliefs are essential to the design and implementation of successful and badly needed interventions for HPV and cervical cancer prevention.

“You have to be very cautious in terms of generalizing these findings, but many of the populations that are suffering increased incidence of HPV and cervical cancer and increased mortality are in this area,” Dr. Fernandez said.

The study was funded by the National Institutes of Health. The authors reported no conflicts of interest.

Hispanic men and women living on the United States-Mexico border have little understanding about the human papillomavirus and its role in the etiology of cervical cancer, according to a small prospective study.

Not only were there very low levels of knowledge among these residents, but their misconceptions and confusion continued even after they were given some basic information about HPV and cervical cancer, Maria Fernandez, Ph.D., said in Carefree, Ariz., during a press conference sponsored by the American Association for Cancer Research. For example, participants tended to compare HPV with HIV and other sexually transmitted infections, and were confused or unaware that men could have HPV and transmit it.

She reported on 30 Hispanic women and 11 Hispanic men without a diagnosis of HPV who lived in Rio Grande Valley colonias (unincorporated border settlements) and participated in focus groups in Brownsville, Tex. The mean age was 41 years among the women (range, 20–74 years) and 39 years among the men (range, 19–76 years). The average annual income for a family of four in these semirural neighborhoods was $13,000. About 60% of participants had not completed grade school.

Analysis of the Spanish-language focus group transcripts revealed that attitudes and concerns about HPV differed by gender, said Dr. Fernandez of the division of health promotion and behavioral sciences at the University of Texas in Houston. Women in particular viewed the disease with fatalism, interpreting a diagnosis of HPV as a diagnosis of cancer. They expressed their fears of cancer and their belief that, once diagnosed, it is "essentially a death sentence." The women said they would be reluctant to disclose their HPV status to their partners because they believed they would be accused of infidelity. Men initially expressed anger at the possibility of an HPV diagnosis, attributing it to infidelity, Dr. Fernandez said. After a brief explanation about the ambiguity of HPV transmission, they ascribed their initial reaction to cultural ideals of machismo.

Dr. Fernandez acknowledged that the border communities and colonias face unique challenges, and that the findings of this small, qualitative study should not be generalized.

"On the other hand, it raises some interesting questions about what we've heard in many other studies about cultural norms, such as things like machismo and the way we've traditionally interpreted this concept," she said. "As we saw in these focus groups, there's sort of an initial reaction, but then people talked about standing by their partner."

Clues about these cultural norms and beliefs are essential to the design and implementation of successful and badly needed interventions for HPV prevention.

"You have to be very cautious in terms of generalizing these findings, but many of the populations that are suffering increased incidence of HPV and cervical cancer and increased mortality are in this area," Dr. Fernandez said.

The study was funded by the National Institutes of Health. The authors reported no conflicts of interest.

Hispanic men and women living on the United States-Mexico border have little understanding about the human papillomavirus and its role in the etiology of cervical cancer, according to a small prospective study.

Not only were there very low levels of knowledge among these residents, but their misconceptions and confusion continued even after they were given some basic information about HPV and cervical cancer, Maria Fernandez, Ph.D., said in Carefree, Ariz., during a press conference sponsored by the American Association for Cancer Research. For example, participants tended to compare HPV with HIV and other sexually transmitted infections, and were confused or unaware that men could have HPV and transmit it.

She reported on 30 Hispanic women and 11 Hispanic men without a diagnosis of HPV who lived in Rio Grande Valley colonias (unincorporated border settlements) and participated in focus groups in Brownsville, Tex. The mean age was 41 years among the women (range, 20–74 years) and 39 years among the men (range, 19–76 years). The average annual income for a family of four in these semirural neighborhoods was $13,000. About 60% of participants had not completed grade school.

Analysis of the Spanish-language focus group transcripts revealed that attitudes and concerns about HPV differed by gender, said Dr. Fernandez of the division of health promotion and behavioral sciences at the University of Texas in Houston. Women in particular viewed the disease with fatalism, interpreting a diagnosis of HPV as a diagnosis of cancer. They expressed their fears of cancer and their belief that, once diagnosed, it is "essentially a death sentence." The women said they would be reluctant to disclose their HPV status to their partners because they believed they would be accused of infidelity. Men initially expressed anger at the possibility of an HPV diagnosis, attributing it to infidelity, Dr. Fernandez said. After a brief explanation about the ambiguity of HPV transmission, they ascribed their initial reaction to cultural ideals of machismo.

Dr. Fernandez acknowledged that the border communities and colonias face unique challenges, and that the findings of this small, qualitative study should not be generalized.

"On the other hand, it raises some interesting questions about what we've heard in many other studies about cultural norms, such as things like machismo and the way we've traditionally interpreted this concept," she said. "As we saw in these focus groups, there's sort of an initial reaction, but then people talked about standing by their partner."

Clues about these cultural norms and beliefs are essential to the design and implementation of successful and badly needed interventions for HPV prevention.

"You have to be very cautious in terms of generalizing these findings, but many of the populations that are suffering increased incidence of HPV and cervical cancer and increased mortality are in this area," Dr. Fernandez said.

The study was funded by the National Institutes of Health. The authors reported no conflicts of interest.

Hispanic men and women living on the United States-Mexico border have little understanding about the human papillomavirus and its role in the etiology of cervical cancer, according to a small prospective study.

Not only were there very low levels of knowledge among these residents, but their misconceptions and confusion continued even after they were given some basic information about HPV and cervical cancer, Maria Fernandez, Ph.D., said in Carefree, Ariz., during a press conference sponsored by the American Association for Cancer Research. For example, participants tended to compare HPV with HIV and other sexually transmitted infections, and were confused or unaware that men could have HPV and transmit it.

She reported on 30 Hispanic women and 11 Hispanic men without a diagnosis of HPV who lived in Rio Grande Valley colonias (unincorporated border settlements) and participated in focus groups in Brownsville, Tex. The mean age was 41 years among the women (range, 20–74 years) and 39 years among the men (range, 19–76 years). The average annual income for a family of four in these semirural neighborhoods was $13,000. About 60% of participants had not completed grade school.

Analysis of the Spanish-language focus group transcripts revealed that attitudes and concerns about HPV differed by gender, said Dr. Fernandez of the division of health promotion and behavioral sciences at the University of Texas in Houston. Women in particular viewed the disease with fatalism, interpreting a diagnosis of HPV as a diagnosis of cancer. They expressed their fears of cancer and their belief that, once diagnosed, it is "essentially a death sentence." The women said they would be reluctant to disclose their HPV status to their partners because they believed they would be accused of infidelity. Men initially expressed anger at the possibility of an HPV diagnosis, attributing it to infidelity, Dr. Fernandez said. After a brief explanation about the ambiguity of HPV transmission, they ascribed their initial reaction to cultural ideals of machismo.

Dr. Fernandez acknowledged that the border communities and colonias face unique challenges, and that the findings of this small, qualitative study should not be generalized.

"On the other hand, it raises some interesting questions about what we've heard in many other studies about cultural norms, such as things like machismo and the way we've traditionally interpreted this concept," she said. "As we saw in these focus groups, there's sort of an initial reaction, but then people talked about standing by their partner."

Clues about these cultural norms and beliefs are essential to the design and implementation of successful and badly needed interventions for HPV prevention.

"You have to be very cautious in terms of generalizing these findings, but many of the populations that are suffering increased incidence of HPV and cervical cancer and increased mortality are in this area," Dr. Fernandez said.

The study was funded by the National Institutes of Health. The authors reported no conflicts of interest.

After participating in education and focus groups, poor, at-risk African American adolescent girls and their parents or caregivers had favorable opinions about the girls' receiving the human papillomavirus vaccine, a new study suggests.

The study also found that these teens were most focused on the HPV vaccine as a way to reduce their risk for sexually transmitted diseases, rather than as a way to reduce their risk for cervical cancer.

“For this group, talking about this as an STD vaccine is going to be what hits home for them,” said Amy Leader, Dr.P.H., who presented the results on behalf of principal investigator Dr. Ian Frank. Both researchers are with the University of Pennsylvania, Philadelphia.

The study is part of a larger project that is designed to raise awareness about HPV and cervical cancer and to increase vaccination rates in five inner-city neighborhoods in Philadelphia and in communities in northeast Pennsylvania, explained Dr. Leader, research director at the Center of Excellence in Cancer Communication Research at the university.

“This is an underserved population of girls at very high risk of HPV due to their behavior, and they have low access and awareness of the vaccine,” Dr. Leader said in an interview. “These are exactly the type of girls who will benefit most from this vaccine.”

Among 71 teens who were recruited from inner-city recreation centers and community nonprofit groups in Philadelphia, 40% reported having started the HPV vaccine series; 44% of those who had not yet started indicated they were “very likely” or “likely” to do so soon.

The 40% one-time vaccination rate in the study may be an overestimation, she said, because many of the girls were unsure if they had specifically received the HPV vaccine or if they had completed the series.

Recent data show that only 25% of American adolescents received at least one dose of the HPV vaccine (MMWR Morb. Mortal. Wkly Rep. 2008;57:1100–3).

The girls' average age was 15 years, and roughly 60% had their first sexual encounter when they were 14 years old. Overall, 94% were black, 3% were white, and 3% were identified as “other.”

Regardless of vaccination status, a majority (79%) felt that getting the HPV vaccine was either a “very good” or “good” idea. One person said that starting the vaccine would be “bad,” Dr. Leader reported at the American Association for Cancer Research conference on the science of cancer health disparities.

Most (93%) of the parents and caregivers were female; they reported an annual household income of $20,000 or less (66%) and had some form of insurance coverage for their daughters (85%).

In the study, the girls were given a brief description of the vaccine prior to participating in focus groups. In general, they had a low understanding of both HPV and the vaccine. (Gardasil was approved in June 2006 for girls and women aged 9–26 years, and is given in three shots over 6 months.)

Although many of the girls could recall Gardasil ads on television and could easily list more than a dozen STDs off the top of their head, HPV was typically not among them, she said. The girls were, however, extremely concerned about protecting themselves from STDs and the social stigma that is associated with having an STD. “Cancer wasn't a big deal for them. Parents and other caregivers, however, were very concerned about their long-term cancer risk.”

Despite its strong advertising campaign, widespread utilization of Gardasil has been slow for a variety of reasons, including Merck & Co.'s initial call for mandatory vaccination, involving a roughly $375 price tag for the series; concerns about long-term efficacy and possible side effects; and the belief by some that adolescents would be more likely to engage in sexual relations if they were inoculated against HPV, which is spread through sexual contact.

The study was funded by the Pennsylvania Department of Health. The investigators reported no conflicts of interest.

After participating in education and focus groups, poor, at-risk African American adolescent girls and their parents or caregivers had favorable opinions about the girls' receiving the human papillomavirus vaccine, a new study suggests.

The study also found that these teens were most focused on the HPV vaccine as a way to reduce their risk for sexually transmitted diseases, rather than as a way to reduce their risk for cervical cancer.

“For this group, talking about this as an STD vaccine is going to be what hits home for them,” said Amy Leader, Dr.P.H., who presented the results on behalf of principal investigator Dr. Ian Frank. Both researchers are with the University of Pennsylvania, Philadelphia.

The study is part of a larger project that is designed to raise awareness about HPV and cervical cancer and to increase vaccination rates in five inner-city neighborhoods in Philadelphia and in communities in northeast Pennsylvania, explained Dr. Leader, research director at the Center of Excellence in Cancer Communication Research at the university.

“This is an underserved population of girls at very high risk of HPV due to their behavior, and they have low access and awareness of the vaccine,” Dr. Leader said in an interview. “These are exactly the type of girls who will benefit most from this vaccine.”

Among 71 teens who were recruited from inner-city recreation centers and community nonprofit groups in Philadelphia, 40% reported having started the HPV vaccine series; 44% of those who had not yet started indicated they were “very likely” or “likely” to do so soon.

The 40% one-time vaccination rate in the study may be an overestimation, she said, because many of the girls were unsure if they had specifically received the HPV vaccine or if they had completed the series.

Recent data show that only 25% of American adolescents received at least one dose of the HPV vaccine (MMWR Morb. Mortal. Wkly Rep. 2008;57:1100–3).

The girls' average age was 15 years, and roughly 60% had their first sexual encounter when they were 14 years old. Overall, 94% were black, 3% were white, and 3% were identified as “other.”

Regardless of vaccination status, a majority (79%) felt that getting the HPV vaccine was either a “very good” or “good” idea. One person said that starting the vaccine would be “bad,” Dr. Leader reported at the American Association for Cancer Research conference on the science of cancer health disparities.

Most (93%) of the parents and caregivers were female; they reported an annual household income of $20,000 or less (66%) and had some form of insurance coverage for their daughters (85%).

In the study, the girls were given a brief description of the vaccine prior to participating in focus groups. In general, they had a low understanding of both HPV and the vaccine. (Gardasil was approved in June 2006 for girls and women aged 9–26 years, and is given in three shots over 6 months.)

Although many of the girls could recall Gardasil ads on television and could easily list more than a dozen STDs off the top of their head, HPV was typically not among them, she said. The girls were, however, extremely concerned about protecting themselves from STDs and the social stigma that is associated with having an STD. “Cancer wasn't a big deal for them. Parents and other caregivers, however, were very concerned about their long-term cancer risk.”

Despite its strong advertising campaign, widespread utilization of Gardasil has been slow for a variety of reasons, including Merck & Co.'s initial call for mandatory vaccination, involving a roughly $375 price tag for the series; concerns about long-term efficacy and possible side effects; and the belief by some that adolescents would be more likely to engage in sexual relations if they were inoculated against HPV, which is spread through sexual contact.

The study was funded by the Pennsylvania Department of Health. The investigators reported no conflicts of interest.

After participating in education and focus groups, poor, at-risk African American adolescent girls and their parents or caregivers had favorable opinions about the girls' receiving the human papillomavirus vaccine, a new study suggests.

The study also found that these teens were most focused on the HPV vaccine as a way to reduce their risk for sexually transmitted diseases, rather than as a way to reduce their risk for cervical cancer.

“For this group, talking about this as an STD vaccine is going to be what hits home for them,” said Amy Leader, Dr.P.H., who presented the results on behalf of principal investigator Dr. Ian Frank. Both researchers are with the University of Pennsylvania, Philadelphia.

The study is part of a larger project that is designed to raise awareness about HPV and cervical cancer and to increase vaccination rates in five inner-city neighborhoods in Philadelphia and in communities in northeast Pennsylvania, explained Dr. Leader, research director at the Center of Excellence in Cancer Communication Research at the university.

“This is an underserved population of girls at very high risk of HPV due to their behavior, and they have low access and awareness of the vaccine,” Dr. Leader said in an interview. “These are exactly the type of girls who will benefit most from this vaccine.”

Among 71 teens who were recruited from inner-city recreation centers and community nonprofit groups in Philadelphia, 40% reported having started the HPV vaccine series; 44% of those who had not yet started indicated they were “very likely” or “likely” to do so soon.

The 40% one-time vaccination rate in the study may be an overestimation, she said, because many of the girls were unsure if they had specifically received the HPV vaccine or if they had completed the series.

Recent data show that only 25% of American adolescents received at least one dose of the HPV vaccine (MMWR Morb. Mortal. Wkly Rep. 2008;57:1100–3).

The girls' average age was 15 years, and roughly 60% had their first sexual encounter when they were 14 years old. Overall, 94% were black, 3% were white, and 3% were identified as “other.”

Regardless of vaccination status, a majority (79%) felt that getting the HPV vaccine was either a “very good” or “good” idea. One person said that starting the vaccine would be “bad,” Dr. Leader reported at the American Association for Cancer Research conference on the science of cancer health disparities.

Most (93%) of the parents and caregivers were female; they reported an annual household income of $20,000 or less (66%) and had some form of insurance coverage for their daughters (85%).

In the study, the girls were given a brief description of the vaccine prior to participating in focus groups. In general, they had a low understanding of both HPV and the vaccine. (Gardasil was approved in June 2006 for girls and women aged 9–26 years, and is given in three shots over 6 months.)

Although many of the girls could recall Gardasil ads on television and could easily list more than a dozen STDs off the top of their head, HPV was typically not among them, she said. The girls were, however, extremely concerned about protecting themselves from STDs and the social stigma that is associated with having an STD. “Cancer wasn't a big deal for them. Parents and other caregivers, however, were very concerned about their long-term cancer risk.”

Despite its strong advertising campaign, widespread utilization of Gardasil has been slow for a variety of reasons, including Merck & Co.'s initial call for mandatory vaccination, involving a roughly $375 price tag for the series; concerns about long-term efficacy and possible side effects; and the belief by some that adolescents would be more likely to engage in sexual relations if they were inoculated against HPV, which is spread through sexual contact.

The study was funded by the Pennsylvania Department of Health. The investigators reported no conflicts of interest.

CHICAGO — A novel procedure that combines mammographically guided hook-wire localization followed by ultrasound-guided sampling provides a minimally invasive alternative to stereotactic biopsy of breast calcifications.

The combination procedure was used in 57 groups of microcalcifications in 48 women, aged 41–79 years, who failed or were unable to have a stereotactic biopsy. The procedures were performed between January 2001 and September 2008 at Metro Health Medical Center, an inner-city county hospital in Cleveland.

In all, 52 of the 57 groups of microcalcifications were successfully sampled, resulting in a 9% failure rate, Dr. Jill J. Schieda and her colleagues reported at the annual meeting of the Radiological Society of North America. The procedure was considered a success if the targeted calcifications were identified on specimen radiography and in the specimen by pathology. There were no postprocedural adverse events.

Two of the five failures were due to the inability to place the hook wire sufficiently close to the targeted calcifications, and one was due to excessive patient motion. In one patient, the calcification was too close to the skin, and in another patient the procedure was technically successful but no microcalcifications were seen on radiography. Three of these five patients successfully underwent the procedure within 2–6 months of the first failed attempt.

“Although the combination procedure is time consuming, the patient may be saved from unnecessary surgery, which is definitely an advantage,” said Dr. Schieda, a radiology resident at the hospital.

Approximately 3% of stereotactic biopsies are unsuccessful, typically because the calcification is not visible on mammography; excessive patient motion or the inability of the patient to get on the stereotactic table may also be problems.

In such cases, the options are limited to open surgical biopsy or imaging follow-up, she said.

During the combined procedure, mammographic guidance is used to place the hook wire just anterior to the calcifications of interest, preferably using a craniocaudal approach. One wire is usually used, but multiple wires can be deployed if additional groups of calcifications are being biopsied or if placement of the primary wire is unsatisfactory because of patient motion, Dr. Schieda said in an interview.

The depth of the wire is adjusted, and the relationship between sonographically visible markers on the wire and the calcifications is documented with a mammogram. If the wire is placed properly, the calcification should be located at the junction of the first set of markers, which look like beads on the wire, she said.

With ultrasound guidance, a large-core vacuum-assisted device is placed just deep to the wire, adjacent to the known location of the calcifications. Sampling is done with the open cutting aperture rotated toward the calcifications, with care taken not to engage the wire within the cutting aperture.

Dr. Schieda acknowledged that the procedure requires significant patient cooperation and performer experience. The same breast-imaging radiologist performed all the procedures in this investigation; although the procedure is novel, the radiologist's 30 years of professional experience may have shortened the learning curve.

Limitations of the study include the small population, lack of a gold standard for comparison, and lower-than-usual resolution of the hospital's stereotactic unit, which may have influenced the need for the alternative procedure.

The investigators reported no conflicts of interest or funding sources for the study.

In this medial-lateral view of the breast, the calcifications, indicated by dashes, are posterior to the wire and near the junction of the first set of tight and loose beads. The arrow is anterior to the wire and is directed toward the calcifications. Courtesy Dr. Jill J. Schieda/Dr. Mark Rzeszotarski

CHICAGO — A novel procedure that combines mammographically guided hook-wire localization followed by ultrasound-guided sampling provides a minimally invasive alternative to stereotactic biopsy of breast calcifications.

The combination procedure was used in 57 groups of microcalcifications in 48 women, aged 41–79 years, who failed or were unable to have a stereotactic biopsy. The procedures were performed between January 2001 and September 2008 at Metro Health Medical Center, an inner-city county hospital in Cleveland.

In all, 52 of the 57 groups of microcalcifications were successfully sampled, resulting in a 9% failure rate, Dr. Jill J. Schieda and her colleagues reported at the annual meeting of the Radiological Society of North America. The procedure was considered a success if the targeted calcifications were identified on specimen radiography and in the specimen by pathology. There were no postprocedural adverse events.

Two of the five failures were due to the inability to place the hook wire sufficiently close to the targeted calcifications, and one was due to excessive patient motion. In one patient, the calcification was too close to the skin, and in another patient the procedure was technically successful but no microcalcifications were seen on radiography. Three of these five patients successfully underwent the procedure within 2–6 months of the first failed attempt.

“Although the combination procedure is time consuming, the patient may be saved from unnecessary surgery, which is definitely an advantage,” said Dr. Schieda, a radiology resident at the hospital.

Approximately 3% of stereotactic biopsies are unsuccessful, typically because the calcification is not visible on mammography; excessive patient motion or the inability of the patient to get on the stereotactic table may also be problems.

In such cases, the options are limited to open surgical biopsy or imaging follow-up, she said.

During the combined procedure, mammographic guidance is used to place the hook wire just anterior to the calcifications of interest, preferably using a craniocaudal approach. One wire is usually used, but multiple wires can be deployed if additional groups of calcifications are being biopsied or if placement of the primary wire is unsatisfactory because of patient motion, Dr. Schieda said in an interview.

The depth of the wire is adjusted, and the relationship between sonographically visible markers on the wire and the calcifications is documented with a mammogram. If the wire is placed properly, the calcification should be located at the junction of the first set of markers, which look like beads on the wire, she said.

With ultrasound guidance, a large-core vacuum-assisted device is placed just deep to the wire, adjacent to the known location of the calcifications. Sampling is done with the open cutting aperture rotated toward the calcifications, with care taken not to engage the wire within the cutting aperture.

Dr. Schieda acknowledged that the procedure requires significant patient cooperation and performer experience. The same breast-imaging radiologist performed all the procedures in this investigation; although the procedure is novel, the radiologist's 30 years of professional experience may have shortened the learning curve.

Limitations of the study include the small population, lack of a gold standard for comparison, and lower-than-usual resolution of the hospital's stereotactic unit, which may have influenced the need for the alternative procedure.

The investigators reported no conflicts of interest or funding sources for the study.

In this medial-lateral view of the breast, the calcifications, indicated by dashes, are posterior to the wire and near the junction of the first set of tight and loose beads. The arrow is anterior to the wire and is directed toward the calcifications. Courtesy Dr. Jill J. Schieda/Dr. Mark Rzeszotarski

CHICAGO — A novel procedure that combines mammographically guided hook-wire localization followed by ultrasound-guided sampling provides a minimally invasive alternative to stereotactic biopsy of breast calcifications.

The combination procedure was used in 57 groups of microcalcifications in 48 women, aged 41–79 years, who failed or were unable to have a stereotactic biopsy. The procedures were performed between January 2001 and September 2008 at Metro Health Medical Center, an inner-city county hospital in Cleveland.

In all, 52 of the 57 groups of microcalcifications were successfully sampled, resulting in a 9% failure rate, Dr. Jill J. Schieda and her colleagues reported at the annual meeting of the Radiological Society of North America. The procedure was considered a success if the targeted calcifications were identified on specimen radiography and in the specimen by pathology. There were no postprocedural adverse events.

Two of the five failures were due to the inability to place the hook wire sufficiently close to the targeted calcifications, and one was due to excessive patient motion. In one patient, the calcification was too close to the skin, and in another patient the procedure was technically successful but no microcalcifications were seen on radiography. Three of these five patients successfully underwent the procedure within 2–6 months of the first failed attempt.

“Although the combination procedure is time consuming, the patient may be saved from unnecessary surgery, which is definitely an advantage,” said Dr. Schieda, a radiology resident at the hospital.

Approximately 3% of stereotactic biopsies are unsuccessful, typically because the calcification is not visible on mammography; excessive patient motion or the inability of the patient to get on the stereotactic table may also be problems.

In such cases, the options are limited to open surgical biopsy or imaging follow-up, she said.

During the combined procedure, mammographic guidance is used to place the hook wire just anterior to the calcifications of interest, preferably using a craniocaudal approach. One wire is usually used, but multiple wires can be deployed if additional groups of calcifications are being biopsied or if placement of the primary wire is unsatisfactory because of patient motion, Dr. Schieda said in an interview.

The depth of the wire is adjusted, and the relationship between sonographically visible markers on the wire and the calcifications is documented with a mammogram. If the wire is placed properly, the calcification should be located at the junction of the first set of markers, which look like beads on the wire, she said.

With ultrasound guidance, a large-core vacuum-assisted device is placed just deep to the wire, adjacent to the known location of the calcifications. Sampling is done with the open cutting aperture rotated toward the calcifications, with care taken not to engage the wire within the cutting aperture.

Dr. Schieda acknowledged that the procedure requires significant patient cooperation and performer experience. The same breast-imaging radiologist performed all the procedures in this investigation; although the procedure is novel, the radiologist's 30 years of professional experience may have shortened the learning curve.

Limitations of the study include the small population, lack of a gold standard for comparison, and lower-than-usual resolution of the hospital's stereotactic unit, which may have influenced the need for the alternative procedure.

The investigators reported no conflicts of interest or funding sources for the study.

In this medial-lateral view of the breast, the calcifications, indicated by dashes, are posterior to the wire and near the junction of the first set of tight and loose beads. The arrow is anterior to the wire and is directed toward the calcifications. Courtesy Dr. Jill J. Schieda/Dr. Mark Rzeszotarski

CHICAGO — Screening by breast magnetic resonance imaging is warranted in women with a personal history of breast cancer, data from a retrospective study of 144 women suggest.

A review of 1,699 breast MRI studies performed at Memorial Sloan-Kettering Cancer Center in New York from 1999 to 2001 yielded 144 women with prior breast cancer who underwent breast MRI screening during that time and had more than 1 year of follow-up.

Biopsies were prompted by MRI screening in 44 women (31%), yielding malignancies in 17 (12%), Dr. Sandra B. Brennan reported at the annual meeting of the Radiological Society of North America. One patient had two metachronous cancers; thus 18 malignancies were found right away (17 cancers and 1 myxoid liposarcoma).

“In and of itself, a history of a prior breast cancer is a strong enough indication for screening MRI,” she said.

Of the 17 cancers, 12 (70.6%), were invasive (11 infiltrating ductal carcinoma and 1 invasive lobular carcinoma) and 5 cancers (29.4%) were ductal carcinoma in situ (DCIS). The median histologic size of invasive cancer was 0.8 cm (range, 0.2–4.3 cm).

Prior cancer histology had no significant impact on the cancer detection rate, said Dr. Brennan, a radiologist specializing in breast cancer imaging at Memorial Sloan-Kettering. Prior breast cancer histology was invasive in 126 patients (95 ductal, 26 lobular, 4 mixed lobular and ductal, and 1 unknown) and DCIS in 18 patients.

Of the 17 cancers detected by MRI, 10 were nonpalpable and detected by MRI only, and 7 had correlates on post-MRI mammography, ultrasound (2), or ultrasound, mammography, and physical examination (3).

The 10 cancers detected by MRI only were significantly more likely than the 7 cancers detected by other means to be DCIS (40% vs. 14%) or minimal breast cancer (70% vs. 43%), Dr. Brennan said. Minimal breast cancer was defined as DCIS or node-negative invasive breast cancer less than 1 cm in size.

More than two-thirds of cancers were detected during the first 2 years of screening (35% each in year 1 and in year 2), with two cancers (12%) detected in year 4 and one in each of years 5, 6, and 9.

The median MRI follow-up was 4 years (range, 1–9 years).

The investigators disclosed no conflicts of interest and received no funding for the study.

CHICAGO — Screening by breast magnetic resonance imaging is warranted in women with a personal history of breast cancer, data from a retrospective study of 144 women suggest.

A review of 1,699 breast MRI studies performed at Memorial Sloan-Kettering Cancer Center in New York from 1999 to 2001 yielded 144 women with prior breast cancer who underwent breast MRI screening during that time and had more than 1 year of follow-up.

Biopsies were prompted by MRI screening in 44 women (31%), yielding malignancies in 17 (12%), Dr. Sandra B. Brennan reported at the annual meeting of the Radiological Society of North America. One patient had two metachronous cancers; thus 18 malignancies were found right away (17 cancers and 1 myxoid liposarcoma).

“In and of itself, a history of a prior breast cancer is a strong enough indication for screening MRI,” she said.

Of the 17 cancers, 12 (70.6%), were invasive (11 infiltrating ductal carcinoma and 1 invasive lobular carcinoma) and 5 cancers (29.4%) were ductal carcinoma in situ (DCIS). The median histologic size of invasive cancer was 0.8 cm (range, 0.2–4.3 cm).

Prior cancer histology had no significant impact on the cancer detection rate, said Dr. Brennan, a radiologist specializing in breast cancer imaging at Memorial Sloan-Kettering. Prior breast cancer histology was invasive in 126 patients (95 ductal, 26 lobular, 4 mixed lobular and ductal, and 1 unknown) and DCIS in 18 patients.

Of the 17 cancers detected by MRI, 10 were nonpalpable and detected by MRI only, and 7 had correlates on post-MRI mammography, ultrasound (2), or ultrasound, mammography, and physical examination (3).

The 10 cancers detected by MRI only were significantly more likely than the 7 cancers detected by other means to be DCIS (40% vs. 14%) or minimal breast cancer (70% vs. 43%), Dr. Brennan said. Minimal breast cancer was defined as DCIS or node-negative invasive breast cancer less than 1 cm in size.

More than two-thirds of cancers were detected during the first 2 years of screening (35% each in year 1 and in year 2), with two cancers (12%) detected in year 4 and one in each of years 5, 6, and 9.

The median MRI follow-up was 4 years (range, 1–9 years).

The investigators disclosed no conflicts of interest and received no funding for the study.

CHICAGO — Screening by breast magnetic resonance imaging is warranted in women with a personal history of breast cancer, data from a retrospective study of 144 women suggest.

A review of 1,699 breast MRI studies performed at Memorial Sloan-Kettering Cancer Center in New York from 1999 to 2001 yielded 144 women with prior breast cancer who underwent breast MRI screening during that time and had more than 1 year of follow-up.

Biopsies were prompted by MRI screening in 44 women (31%), yielding malignancies in 17 (12%), Dr. Sandra B. Brennan reported at the annual meeting of the Radiological Society of North America. One patient had two metachronous cancers; thus 18 malignancies were found right away (17 cancers and 1 myxoid liposarcoma).

“In and of itself, a history of a prior breast cancer is a strong enough indication for screening MRI,” she said.

Of the 17 cancers, 12 (70.6%), were invasive (11 infiltrating ductal carcinoma and 1 invasive lobular carcinoma) and 5 cancers (29.4%) were ductal carcinoma in situ (DCIS). The median histologic size of invasive cancer was 0.8 cm (range, 0.2–4.3 cm).

Prior cancer histology had no significant impact on the cancer detection rate, said Dr. Brennan, a radiologist specializing in breast cancer imaging at Memorial Sloan-Kettering. Prior breast cancer histology was invasive in 126 patients (95 ductal, 26 lobular, 4 mixed lobular and ductal, and 1 unknown) and DCIS in 18 patients.

Of the 17 cancers detected by MRI, 10 were nonpalpable and detected by MRI only, and 7 had correlates on post-MRI mammography, ultrasound (2), or ultrasound, mammography, and physical examination (3).

The 10 cancers detected by MRI only were significantly more likely than the 7 cancers detected by other means to be DCIS (40% vs. 14%) or minimal breast cancer (70% vs. 43%), Dr. Brennan said. Minimal breast cancer was defined as DCIS or node-negative invasive breast cancer less than 1 cm in size.

More than two-thirds of cancers were detected during the first 2 years of screening (35% each in year 1 and in year 2), with two cancers (12%) detected in year 4 and one in each of years 5, 6, and 9.

The median MRI follow-up was 4 years (range, 1–9 years).

The investigators disclosed no conflicts of interest and received no funding for the study.

CHICAGO – Even when they were offered disaster mental health services free of charge, some elderly survivors of the 2004 and 2005 hurricanes in Florida refused.

Some of their reasons surprised researchers, but also serve to highlight the need to improve delivery of these services to one of the most vulnerable populations in a disaster. After reviewing two disaster crisis counseling programs, Florida researchers identified a disconnect between what clients and mental health care providers thought about disaster mental health services and the best way to conduct outreach.

“We found that most providers were really sort of flying by the seat of their pants,” Lisa M. Brown, Ph.D., said at the annual meeting of the International Society for Traumatic Stress Studies. “They were given their marching orders to get out in the field and had a strong desire to help.”

Unfortunately, they'd never been trained on how to market their services to people, particularly those contending with disrupted social networks, destroyed communities, and damaged homes.

Elderly participants who refused the free mental health services reported feeling overwhelmed by the number of people approaching them in the days after the hurricane, according to Dr. Brown.

The feeling of being besieged was compounded by the fact that the media was warning residents to be wary of anything that sounded too good to be true because there were fraudulent individuals offering to take payments up front for services they would never deliver.

“So if someone shows up at your door and says they're from this agency and are offering you free mental health services, it was like, 'Yeah, right,' “she said.”

Many of these elders also had a lack of awareness about existing disaster mental health services and an uncertainty about the benefits of using these services, said Dr. Brown, of the department of aging and mental health, Florida Mental Health Institute, University of South Florida in Tampa.

Older adults who opted to use the services reported that they did so because they had an adult child or close friend who had received services and encouraged them to accept treatment.

The findings were based on interviews with 68 staff and contract employees directly responsible for outreach efforts and clinical care, and focus groups conducted with 36 older adults who did not use disaster mental health services and 52 older adults who did. Before the hurricane, none of the survivors had received any type of mental health treatment. Their mean age was 76 years (range 65–94 years).

Dr. Brown offered a variety of suggestions aimed at improving use of disaster mental health care services among the elderly, noting that case management is a good starting point.

Other suggestions include the need to:

▸ Distribute written information about hurricane-related services before an event.

▸ Explain the differences between disaster mental health services and traditional mental health intervention to reduce stigma and barriers to care.

▸ Partner with trusted and recognized agencies that provide care or services to elders.

▸ Use informal leaders and faith-based organizations.

The study was supported by a grant from the University of South Florida Collaborative for Children, Families, and Communities, and the Florida Department of Children and Families. The investigators reported no conflicts of interest. The conference was cosponsored by Boston University.

CHICAGO – Even when they were offered disaster mental health services free of charge, some elderly survivors of the 2004 and 2005 hurricanes in Florida refused.

Some of their reasons surprised researchers, but also serve to highlight the need to improve delivery of these services to one of the most vulnerable populations in a disaster. After reviewing two disaster crisis counseling programs, Florida researchers identified a disconnect between what clients and mental health care providers thought about disaster mental health services and the best way to conduct outreach.

“We found that most providers were really sort of flying by the seat of their pants,” Lisa M. Brown, Ph.D., said at the annual meeting of the International Society for Traumatic Stress Studies. “They were given their marching orders to get out in the field and had a strong desire to help.”

Unfortunately, they'd never been trained on how to market their services to people, particularly those contending with disrupted social networks, destroyed communities, and damaged homes.

Elderly participants who refused the free mental health services reported feeling overwhelmed by the number of people approaching them in the days after the hurricane, according to Dr. Brown.

The feeling of being besieged was compounded by the fact that the media was warning residents to be wary of anything that sounded too good to be true because there were fraudulent individuals offering to take payments up front for services they would never deliver.

“So if someone shows up at your door and says they're from this agency and are offering you free mental health services, it was like, 'Yeah, right,' “she said.”

Many of these elders also had a lack of awareness about existing disaster mental health services and an uncertainty about the benefits of using these services, said Dr. Brown, of the department of aging and mental health, Florida Mental Health Institute, University of South Florida in Tampa.

Older adults who opted to use the services reported that they did so because they had an adult child or close friend who had received services and encouraged them to accept treatment.

The findings were based on interviews with 68 staff and contract employees directly responsible for outreach efforts and clinical care, and focus groups conducted with 36 older adults who did not use disaster mental health services and 52 older adults who did. Before the hurricane, none of the survivors had received any type of mental health treatment. Their mean age was 76 years (range 65–94 years).

Dr. Brown offered a variety of suggestions aimed at improving use of disaster mental health care services among the elderly, noting that case management is a good starting point.

Other suggestions include the need to:

▸ Distribute written information about hurricane-related services before an event.

▸ Explain the differences between disaster mental health services and traditional mental health intervention to reduce stigma and barriers to care.

▸ Partner with trusted and recognized agencies that provide care or services to elders.

▸ Use informal leaders and faith-based organizations.

The study was supported by a grant from the University of South Florida Collaborative for Children, Families, and Communities, and the Florida Department of Children and Families. The investigators reported no conflicts of interest. The conference was cosponsored by Boston University.

CHICAGO – Even when they were offered disaster mental health services free of charge, some elderly survivors of the 2004 and 2005 hurricanes in Florida refused.

Some of their reasons surprised researchers, but also serve to highlight the need to improve delivery of these services to one of the most vulnerable populations in a disaster. After reviewing two disaster crisis counseling programs, Florida researchers identified a disconnect between what clients and mental health care providers thought about disaster mental health services and the best way to conduct outreach.

“We found that most providers were really sort of flying by the seat of their pants,” Lisa M. Brown, Ph.D., said at the annual meeting of the International Society for Traumatic Stress Studies. “They were given their marching orders to get out in the field and had a strong desire to help.”

Unfortunately, they'd never been trained on how to market their services to people, particularly those contending with disrupted social networks, destroyed communities, and damaged homes.

Elderly participants who refused the free mental health services reported feeling overwhelmed by the number of people approaching them in the days after the hurricane, according to Dr. Brown.

The feeling of being besieged was compounded by the fact that the media was warning residents to be wary of anything that sounded too good to be true because there were fraudulent individuals offering to take payments up front for services they would never deliver.

“So if someone shows up at your door and says they're from this agency and are offering you free mental health services, it was like, 'Yeah, right,' “she said.”

Many of these elders also had a lack of awareness about existing disaster mental health services and an uncertainty about the benefits of using these services, said Dr. Brown, of the department of aging and mental health, Florida Mental Health Institute, University of South Florida in Tampa.

Older adults who opted to use the services reported that they did so because they had an adult child or close friend who had received services and encouraged them to accept treatment.

The findings were based on interviews with 68 staff and contract employees directly responsible for outreach efforts and clinical care, and focus groups conducted with 36 older adults who did not use disaster mental health services and 52 older adults who did. Before the hurricane, none of the survivors had received any type of mental health treatment. Their mean age was 76 years (range 65–94 years).

Dr. Brown offered a variety of suggestions aimed at improving use of disaster mental health care services among the elderly, noting that case management is a good starting point.

Other suggestions include the need to:

▸ Distribute written information about hurricane-related services before an event.

▸ Explain the differences between disaster mental health services and traditional mental health intervention to reduce stigma and barriers to care.

▸ Partner with trusted and recognized agencies that provide care or services to elders.

▸ Use informal leaders and faith-based organizations.

The study was supported by a grant from the University of South Florida Collaborative for Children, Families, and Communities, and the Florida Department of Children and Families. The investigators reported no conflicts of interest. The conference was cosponsored by Boston University.

CHICAGO — A computerized pretest probability device accurately predicted acute coronary syndrome in low-risk chest pain patients and significantly reduced unneeded exposure to thoracic imaging as well as return visits to the emergency department in a randomized controlled trial of 400 patients.

The Web-based software device (PRETestConsultACS) produces a point estimate of ACS based on eight predictor variables: age, sex, race, history of coronary artery disease, chest wall tenderness to palpation that reproduces chest pain, diaphoresis, ST depression greater than 0.5 mm in two leads, and T-wave inversion greater than 0.5 mm in two leads.

The variables are entered into a personal computer or personal digital assistant that searches a large database for evaluated patients who share the same profile. The percentage of matched patients who have ACS equals the pretest probability. ACS included myocardial infarction; coronary stenosis greater than 60% prompting new medical management or revascularization; ventricular arrhythmia; cardiogenic shock; or bradycardia requiring therapeutic intervention.

After obtaining a clinician's estimate of pretest probability of an ACS, 400 patients (mean age, 46 years) and their emergency clinicians were randomized to receive a written printout from the computer, or not. In all, 31 patients were excluded.

Pretest probability estimates of an ACS generated by the emergency clinician (mean, 4) correlated significantly with estimates from the software device (mean, 4), according to a poster at the annual meeting of the American College of Emergency Physicians.

A significant cardiovascular diagnosis was made in 36 (19.4%) of the 185 controls and 35 (19%) of the 184 intervention-group patients.

Researchers discovered one case of a missed or delayed diagnosis of ACS within 45 days, the study's primary safety end point, in a control-group patient, said lead investigator Dr. Jeffrey Kline and his colleagues in the department of emergency medicine, Carolinas Medical Center, Charlotte, N.C. The patient was diagnosed with unstable angina that was treated with a percutaneous intracoronary stent device 21 days after enrollment.

The rate of hospital admission of patients who had no significant cardiovascular diagnosis within 45 days was significantly higher among controls (11%) than in the intervention group (5%).

The rate of exposure to a thoracic imaging test that imparted greater than 5 mSv and had a negative result was significantly greater among controls (19.4%) than in the intervention group (8.6%). The lifetime risk of malignancy is thought to increase significantly after a dose of radiation that exceeds 5 mSv.

“If the results of this study are independently validated in a larger and different sample of patients, then clinicians will have evidence to justify the use of quantitative pretest probability, together with their own clinical instincts, to reduce excessive diagnostic testing in low-risk patients with chest pain,” Dr. Kline said in an interview.

Median length of stay in the emergency department was not significantly different between the control (11.4 hours) and intervention (9.2 hours) groups.

Based on telephone follow-up, patients in the intervention group were less likely than were those in the control group to be readmitted within 7 days of their emergency visit (4% vs. 11%), according to the investigators, who reported no relevant conflicts.

CHICAGO — A computerized pretest probability device accurately predicted acute coronary syndrome in low-risk chest pain patients and significantly reduced unneeded exposure to thoracic imaging as well as return visits to the emergency department in a randomized controlled trial of 400 patients.

The Web-based software device (PRETestConsultACS) produces a point estimate of ACS based on eight predictor variables: age, sex, race, history of coronary artery disease, chest wall tenderness to palpation that reproduces chest pain, diaphoresis, ST depression greater than 0.5 mm in two leads, and T-wave inversion greater than 0.5 mm in two leads.

The variables are entered into a personal computer or personal digital assistant that searches a large database for evaluated patients who share the same profile. The percentage of matched patients who have ACS equals the pretest probability. ACS included myocardial infarction; coronary stenosis greater than 60% prompting new medical management or revascularization; ventricular arrhythmia; cardiogenic shock; or bradycardia requiring therapeutic intervention.

After obtaining a clinician's estimate of pretest probability of an ACS, 400 patients (mean age, 46 years) and their emergency clinicians were randomized to receive a written printout from the computer, or not. In all, 31 patients were excluded.

Pretest probability estimates of an ACS generated by the emergency clinician (mean, 4) correlated significantly with estimates from the software device (mean, 4), according to a poster at the annual meeting of the American College of Emergency Physicians.

A significant cardiovascular diagnosis was made in 36 (19.4%) of the 185 controls and 35 (19%) of the 184 intervention-group patients.

Researchers discovered one case of a missed or delayed diagnosis of ACS within 45 days, the study's primary safety end point, in a control-group patient, said lead investigator Dr. Jeffrey Kline and his colleagues in the department of emergency medicine, Carolinas Medical Center, Charlotte, N.C. The patient was diagnosed with unstable angina that was treated with a percutaneous intracoronary stent device 21 days after enrollment.

The rate of hospital admission of patients who had no significant cardiovascular diagnosis within 45 days was significantly higher among controls (11%) than in the intervention group (5%).

The rate of exposure to a thoracic imaging test that imparted greater than 5 mSv and had a negative result was significantly greater among controls (19.4%) than in the intervention group (8.6%). The lifetime risk of malignancy is thought to increase significantly after a dose of radiation that exceeds 5 mSv.

“If the results of this study are independently validated in a larger and different sample of patients, then clinicians will have evidence to justify the use of quantitative pretest probability, together with their own clinical instincts, to reduce excessive diagnostic testing in low-risk patients with chest pain,” Dr. Kline said in an interview.

Median length of stay in the emergency department was not significantly different between the control (11.4 hours) and intervention (9.2 hours) groups.

Based on telephone follow-up, patients in the intervention group were less likely than were those in the control group to be readmitted within 7 days of their emergency visit (4% vs. 11%), according to the investigators, who reported no relevant conflicts.

CHICAGO — A computerized pretest probability device accurately predicted acute coronary syndrome in low-risk chest pain patients and significantly reduced unneeded exposure to thoracic imaging as well as return visits to the emergency department in a randomized controlled trial of 400 patients.

The Web-based software device (PRETestConsultACS) produces a point estimate of ACS based on eight predictor variables: age, sex, race, history of coronary artery disease, chest wall tenderness to palpation that reproduces chest pain, diaphoresis, ST depression greater than 0.5 mm in two leads, and T-wave inversion greater than 0.5 mm in two leads.

The variables are entered into a personal computer or personal digital assistant that searches a large database for evaluated patients who share the same profile. The percentage of matched patients who have ACS equals the pretest probability. ACS included myocardial infarction; coronary stenosis greater than 60% prompting new medical management or revascularization; ventricular arrhythmia; cardiogenic shock; or bradycardia requiring therapeutic intervention.

After obtaining a clinician's estimate of pretest probability of an ACS, 400 patients (mean age, 46 years) and their emergency clinicians were randomized to receive a written printout from the computer, or not. In all, 31 patients were excluded.

Pretest probability estimates of an ACS generated by the emergency clinician (mean, 4) correlated significantly with estimates from the software device (mean, 4), according to a poster at the annual meeting of the American College of Emergency Physicians.

A significant cardiovascular diagnosis was made in 36 (19.4%) of the 185 controls and 35 (19%) of the 184 intervention-group patients.

Researchers discovered one case of a missed or delayed diagnosis of ACS within 45 days, the study's primary safety end point, in a control-group patient, said lead investigator Dr. Jeffrey Kline and his colleagues in the department of emergency medicine, Carolinas Medical Center, Charlotte, N.C. The patient was diagnosed with unstable angina that was treated with a percutaneous intracoronary stent device 21 days after enrollment.

The rate of hospital admission of patients who had no significant cardiovascular diagnosis within 45 days was significantly higher among controls (11%) than in the intervention group (5%).

The rate of exposure to a thoracic imaging test that imparted greater than 5 mSv and had a negative result was significantly greater among controls (19.4%) than in the intervention group (8.6%). The lifetime risk of malignancy is thought to increase significantly after a dose of radiation that exceeds 5 mSv.

“If the results of this study are independently validated in a larger and different sample of patients, then clinicians will have evidence to justify the use of quantitative pretest probability, together with their own clinical instincts, to reduce excessive diagnostic testing in low-risk patients with chest pain,” Dr. Kline said in an interview.

Median length of stay in the emergency department was not significantly different between the control (11.4 hours) and intervention (9.2 hours) groups.

Based on telephone follow-up, patients in the intervention group were less likely than were those in the control group to be readmitted within 7 days of their emergency visit (4% vs. 11%), according to the investigators, who reported no relevant conflicts.