Smartphone Use During Attending Rounds

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Smartphone use during inpatient attending rounds: Prevalence, patterns and potential for distraction
Author(s)
Rachel J. Katz‐Sidlow, MD
Allison Ludwig, MD
Scott Miller, MD
Robert Sidlow, MD, MBA

Healthcare market research has predicted that over 80% of physicians will use smartphones by 2012.1 These handheld devices allow users immediate access to various forms of electronic media such as Internet, instant messaging, and e‐mail. Smartphones provide numerous benefits to physicians, including rapid access to medical references, research applications, and patient information.2 These devices have been used for teleconsultation3 and patient education,4 and applications have been developed for numerous clinical specialties.48

Housestaff perceive that communication improves when they use smartphones rather than traditional pagers on the inpatient service,9 and patients may have a positive view of physicians' use of handheld computers.10 Medical schools and residency programs are increasingly requiring smartphone ownership for their trainees, with the expectation that smartphone use will enhance the educational experience, ensure the highest level of patient care, improve user efficiency, and help control the costs associated with purchasing updated textbooks.7, 1113 In the future, hospitals may rely on smartphone technologies to help reduce the enormous economic burden created by inefficient communication.14

Despite their numerous benefits for physicians and patients, little is known about the potential for smartphones to distract users in clinical care settings. Studies from the psychology and traffic safety fields have documented untoward consequences when individuals use electronic devices to multitask.1519 Given these concerns, we investigated the prevalence and patterns of smartphone use during inpatient attending rounds, and whether these devices can distract team members in this period of important information transfer.

METHODS

At our institution, attending rounds are faculty‐led inpatient teaching rounds that focus on clinical care and patient management; these sessions may be conducted either in the classroom or at the bedside, depending on patient and learner needs, and faculty preference. Inpatient teams are comprised of 1 attending, housestaff, and third and fourth year medical students. Each team conducts attending rounds independently; these rounds range in length from 1 hour (Pediatrics) to 2 hours (Medicine).

A survey instrument was designed to evaluate smartphone usage patterns during hospital inpatient attending rounds, and perceived distraction from smartphones in this setting. A preliminary version of the survey was pilot tested by a group of housestaff for face validity, redundancy, and ease of use, and it was subsequently revised. For the purposes of this study, a smartphone was defined broadly as any mobile, personal communication device (cellphone, iPhone, Android, Blackberry, iPad, etc). Residents were asked about their own smartphone use, as well as their observations of supervising attendings and other learners' devices use during rounds (see Supporting Appendix 1 in the online version of this article).

In February 2011, the anonymous online survey was administered using Survey Monkey (www.surveymonkey.com) and was distributed via e‐mail to medical and pediatric housestaff at Jacobi Medical Center, a public teaching hospital located in Bronx, NY, affiliated with the Albert Einstein College of Medicine of Yeshiva University. A similar survey was distributed to faculty who were known to conduct inpatient attending rounds (see Supporting Appendix 2 in the online version of this article). The e‐mail solicitation process was repeated for both groups of respondents at 2 and 4 weeks after the initial request. The study was approved by the Institutional Review Board of the Albert Einstein College of Medicine.

Respondents were not required to answer each question in order to complete the survey. With the exception of free‐text comments, all responses were either yes/no or were graded on a 5‐point frequency scale (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always). This scale was chosen because it allowed for adequate dispersion of responses, and for the identification of meaningful smartphone usage among respondents (score 3) and data dichotomization. The z test was used to compare the proportions between independent groups.

All free‐text comments were imported into a Microsoft Word table. Comments were separated into 2 groups: housestaff and attending. Each comment was hand‐coded by 2 authors (R.J.K.‐S. and R.S.) to reach consensus for 1 of the following 4 categories: the comment was a positive statement; a negative statement; a positive/negative statement; or a neutral one, ie, neither positive nor negative. The terms positive and negative here refer to whether the statement explicitly highlighted benefits of smartphone use or a negative aspect of smartphone use, respectively. A comment was coded as positive/negative if it highlighted both benefits and drawbacks in the same comment. In addition, each comment that mentioned texting or call functions was secondarily coded as personal, patient, both, or unknown depending on the purpose of the texting or calls described in each comment. Comments were also reviewed for possible subthemes.

RESULTS

The overall response rate was 73% (156/214), with 81% (116/143) of housestaff and 56% (40/71) of faculty participating. The mean tenure of faculty respondents was 13 years. Eighty‐nine percent (103/116) of residents and 98% (39/40) of faculty owned devices, with 57% of housestaff and 28% of attendings reporting regular personal use of smartphones during attending rounds (Table 1).

How Often Are Smartphones Used During Inpatient Attending Rounds?
Smartphone UserSelf‐Report % (n/N)Resident Observations of Other Team Members % (n/N)Faculty Observations of Trainees % (n/N)

  • NOTE: Respondents reporting regular use, defined as score 3. Abbreviations: n/a, not applicable.

  • N reflects that 3 residents skipped the question.

Resident57% (59/103)91% (103/113)*73% (29/40)
Faculty28% (11/39)43% (49/113)*n/a

Respondents reported that they used their smartphones during attending rounds for the following reasons: 1) patient care (85% residents, 48% faculty); 2) reading/responding to personal texts/e‐mails (37% residents, 12% faculty); and 3) other non‐patient care uses, such as Web surfing (15% residents, 0% faculty) (Tables 2 and 3). Nineteen percent of residents reported that they missed important clinical information due to distraction from smartphone use, as did 12% of attendings (Table 4). Respondents reported observing other team members using smartphones and missing important clinical data at higher rates than they reported for themselves (see Tables 1, 4, and 5). A majority of both residents (56%) and faculty (73%) agreed (score >3) that smartphones can be a serious distraction during attending rounds, and 77% of attendings affirmed that teaching hospitals should establish smartphone use codes of conduct in order to minimize unnecessary distraction during attending rounds.

Reasons That Housestaff Use Smartphones During Attending Rounds
ReasonBased on Housestaff Self‐Report (n = 85)*Based on Trainee Observations of One Another (n = 112)P Value

  • NOTE: Score 3. Abbreviations: NS, not significant.

  • n excludes 31 smartphone non‐owners and those who never use the device during rounds.

  • n reflects that 4 residents skipped this question.

Patient care‐related use (ePocrates, MedCalc, Medline, Google Scholar)85%86%NS
Reading or responding to personal texts or e‐mail37%55%<0.01
Other non‐patient care‐related use, Web surfing15%37%<0.01
Reasons That Faculty Use Smartphones During Attending Rounds
ReasonBased on Faculty Self‐Report (n = 25)*Based on Housestaff Observations of Faculty (n = 91)P Value

  • NOTE: Score 3. Abbreviations: NS, not significant.

  • n excludes 15 smartphone non‐owners and those who never use the device during rounds.

  • n reflects a reduced number of resident responses to this question.

Patient care‐related use (ePocrates, MedCalc, Medline, Google Scholar)48%48%NS
Reading or responding to personal texts or e‐mail12%47%<0.01
Other non‐patient care‐related use, Web surfing0%20%<0.05
Do You Think You Ever Missed an Important Piece of Clinical Information Because You Were Distracted by Smartphone Use During Rounds?
Smartphone UserSelf‐Report % (n/N)

  • NOTE: Respondents who answered yes.

  • All eligible faculty and residents answered this question; N excludes smartphone non‐owners and those who never use smartphones during rounds.

Housestaff19% (18/85)*
Faculty12% (3/25)*
Have You Ever Witnessed Another Team Member Miss an Important Piece of Clinical Information Because He/She Was Distracted by Smartphone Use During Rounds?
Smartphone UserBased on Housestaff Observation % (n/N)Based on Faculty Observation % (n/N)

  • NOTE: Respondents who answered yes. Abbreviations: n/a, not applicable.

  • N reflects a reduced number of responses for these questions.

  • At our institution, rounds take place with only 1 faculty member per team.

Trainee34% (38/112)*43% (17/40)
Faculty20% (18/91)*n/a

Despite not requiring responses in order to complete the questionnaires, we found that, in general, few eligible faculty or residents skipped questions on the survey. Nevertheless, there was a substantial drop in responses (91/116) for the last 2 questions on the housestaff survey. These questions asked for resident observations of attending smartphone usage patterns during rounds, and whether they had seen attendings miss clinical information because of distractions from smartphone use.

There were 25 free‐text comments from residents and 11 from attendings. The resultant comments highlight differences in residents' and attendings' perspectives toward smartphone use during attending rounds. Housestaff comments included 7 positive comments, 7 positive/negative comments, 1 negative comment, and 10 neutral comments. A subtheme that emerged in 2 of the housestaff comments was the importance of personal autonomy in being able to use one's smartphone. Attending comments included 2 positive comments, 0 positive/negative comments, 4 negative comments, and 5 neutral comments. Faculty comments revealed that attendings use their smartphones' e‐mail/texting and call capabilities during rounds both for patient care issues (3 comments) and/or urgent family concerns (2 comments). In 2 other attending comments, the reason for calls/texts during rounds was not specified.

Housestaff comments included: I do not know why it is that attendings never use it these phones are so easy to use and [enhance] patient care in a number of ways, Depending on how they are used, if strictly for pt care then they can be a great mobile tool, Of course they can be a distraction, but they are also a very good tool. You take the good with the bad, If you are bored you will find other things to occupy your mind. If you can look up some info at the time of rounding you are actively participating. Please, do not make it worse than it is already, and It is a personal choice. Faculty negative comments highlighted the potential for distraction from the e‐mail beeps, the fact that some of the housestaff will be tuned into their SmartPhones, that residents frequently check their phones during roundsa distraction and frankly rude when the attending or fellow are giving a brief lecture, and that sometimes more focus is on the SmartPhone than rounds.

DISCUSSION

Physicians and their patients benefit from the wide‐ranging capabilities of personal, mobile communication devices in the healthcare environment. Smartphones house the latest medical references, provide access to patients' medical records and imaging studies, can photograph or video physical findings, and educate and monitor patients.28 Smartphones can facilitate information transfer in the medical setting and may improve housestaff efficiency and communication.9

Despite their significant benefits, smartphones introduce another source of interruption, multitasking, and distraction into the hospital environment. There is increasing awareness that breaks‐in‐task in the clinical setting may have negative consequences.2024 While some types of interruptions are beneficial and can facilitate patient care (eg, an alarm ringing to indicate abnormal vitals signs on a patient),2024 other forms of interruptions, even those that are self‐initiated,22 can be distracting and detrimental. Along these lines, recommendations for safe handoffs and information transfer have specifically included advice to minimize potential distractions.25

In addition, studies from the psychology and education literature have previously documented negative consequences on learning when individuals use electronic devices to multitask.1517 Students who used a laptop in class were likely to multitask, become distracted, and distract others; the more a student used the laptop in class, the lower the student's class performance.15 Multitasking with a cellphone during driving can be especially hazardous.18, 19 According to National Highway Traffic Safety Administration data, 20% of injury crashes in 2009 involved reports of distracted driving, and cellphones were implicated in 18% of distracted driving deaths that year.18

Little is known about any negative effects of using personal electronic devices in the context of patient care. A 2011 study of Internal Medicine residents who used smartphones for team communication documented both positive and negative consequences of smartphone use in the hospital setting. Negative consequences included frequent interruptions, a weakening of interprofessional behaviors as housestaff relied on texting over direct communication with nurses, and unprofessional housestaff behaviors.26 The Agency for Healthcare Quality and Research published a case report in which a resident's smartphone use during clinical care resulted in patient harm.27 To our knowledge, this is the first study to detail housestaff and faculty smartphone usage patterns and potential for user distractibility during inpatient attending rounds.

Our data show that device use during attending rounds is prevalent among residents and faculty alike, with the majority of use related to patient care. However, attendings were half as likely as residents to report using devices regularly during rounds. This finding may reflect attendings' inability to multitask while leading the rounds, or a deliberate role‐modeling of desired conduct during rounds. Generational differences may also play a role, with residents more likely than their older attendings to multitask and self‐interrupt. Along these lines, traffic safety research has found that younger drivers are more likely to text during driving; approximately 30% of drivers under 30 years old reported texting while driving in the previous 30 days, compared to 9% of respondents over 30 years old.19 Increased smartphone use by housestaff during rounds may also reflect attitudinal differences between the 2 groups. As seen in the free‐text comments, housestaff tended to emphasize the benefits of smartphone use, and with 1 exception, all negative housestaff comments were balanced by a positive statement. Faculty more commonly underscored the negative aspects of smartphone use during rounds, including the devices' adverse effects on housestaff professional behavior in this setting.

Faculty and housestaff consistently reported observing others using smartphones at higher rates than they reported for themselves. This discrepancy may reflect underrecognition of self‐use, or a discomfort in reporting self‐use during attending rounds. In addition, residents' observations of other trainees' usage of smartphones (91%) was higher than faculty observation of the same group (73%). Trainees' smartphone use may be less obvious to attendings who are involved in facilitating rounds. Alternatively, trainees may use their smartphones in subtle ways to prevent attending awareness.

There are several limitations to our study. Our research focused specifically on attending rounds. Smartphone usage patterns by faculty and housestaff at other times in the work day, such as during resident handoffs, at a patient's bedside, or during academic conferences, may differ. Nevertheless, we specifically chose to study smartphone use during attending rounds, as these sessions are discrete time frames during which important teaching occurs and clinical management decisions are made. With recent Accreditation Council for Graduate Medical Education (ACGME) work hour restrictions, these faculty‐led rounds may become increasingly important in ensuring the safe transition of patient care. Secondly, despite asking respondents how often they use their smartphones for personal texts or e‐mails, it was clear from the free‐text comments that respondents use their smartphone e‐mail/texting capabilities and take urgent calls during rounds for both patient care and/or family issues. It is not possible from the data to sort out the subset of respondents who use texting or e‐mailing exclusively for patient care during rounds. Third, we did not survey medical students on the teams, so it is possible that their device use on rounds differs from that of housestaff and faculty. Fourth, since the survey could be completed without answering every question, response rates for some items varied slightly; there was a substantial reduction in the number of eligible residents who answered the final 2 questions on the survey about their observations of attendings' smartphone usage patterns and distraction during rounds. While the flexibility in survey completion was intended to enhance overall study participation, it is unknown how nonresponders might have affected the study results; as such, those specific results should be interpreted with some caution. Finally, our findings were based on respondents' retrospective recall, and therefore may not accurately reflect true usage patterns. Timemotion studies with real‐time observation of smartphone use would provide more accurate data.

A majority of residents and attendings in our study agreed that smartphones can pose a serious distraction during attending rounds, and attendings strongly favored the institution of formal codes of conduct for smartphone use during inpatient attending rounds. The development of such policies are important for patient safety; at the same time, they are in line with medical institutions' increasing awareness about the need for guidelines regarding other aspects of digital professionalism.28 In February 2012, our hospital instituted a policy regarding appropriate device use during inpatient attending rounds (see Supporting Appendix 3 in the online version of this article). Because our research found differences in housestaff and faculty attitudes toward smartphone use during rounds, we developed our policy after discussion with, and feedback from, all members of the inpatient team, including faculty, residents, and medical students. Incorporating the various perspectives of all stakeholders can be helpful to institutions in developing guidelines that maximize the benefits of smartphone use in the learning environment, while reducing the potential for distraction and adverse outcomes.

Acknowledgements

Disclosure: Nothing to report.

Files
Supporting Information Appendix 1 (1)
Supporting Information Appendix 2 (2)
Supporting Information Appendix 3 (3)
Supporting Information (4)
References
  1. Dolan B. 72 percent of US physicians use smartphones. MobiHealthNews. Available at: http://mobihealthnews.com/7505/72‐percent‐of‐us‐physicians‐use‐smartphones/. Accessed April 16, 2012.
  2. Baumgart DC. Smartphones in clinical practice, medical education, and research. Arch Intern Med. 2011;171(14):1294–1296.
  3. Aziz SR,Ziccardi VB. Telemedicine using smartphones for oral and maxillofacial surgery consultation, communication, and treatment planning.J Oral Maxillofac Surg.2009;67:2505–2509.
  4. Busis N. Mobile phones to improve the practice of neurology. Neurol Clin. 2010;28(2):395–410.
  5. Oehler RL, Smith K, Toney JF. Infectious diseases resources for the iPhone. Clin Infect Dis. 2010;50(9):1268–1274.
  6. Lord RK, Shah VA, San Filippo AN, Krishna R. Novel uses of smartphones in ophthalmology. Ophthalmology. 2010;117:1274–1274.e3.
  7. Dala‐Ali BM, Lloyd MA, Al‐Abed Y. The uses of the iPhone for surgeons. Surgeon. 2011;9(1):44–48.
  8. Franko OI. Smartphone apps for orthopaedic surgeons. Clin Orthop Relat Res. 2011;469(7):2042–2048.
  9. Wu RC, Morra D, Quan S, et al. The use of smartphones for clinical communication on internal medicine wards. J Hosp Med. 2010;5(9):553–559.
  10. Strayer SM, Semler MW, Kington ML, Tanabe KO. Patient attitudes toward physician use of tablet computers in the exam room. Fam Med. 2010;42(9):643–647.
  11. White T. iPads to be distributed to incoming class by Stanford Medical School. Available at: http://med.stanford.edu/ism/2010/august/ipad.html. Accessed April 16, 2012.
  12. University of Virginia School of Medicine. Third year medical student mobile device requirement. Available at: http://www.medicine.virginia.edu/education/medical‐students/ome/edtech/pda_recom‐page/. Accessed April 16, 2012.
  13. Huff C. Tablet computers in the hospital. ACP Hospitalist 2011. Available at: http://www.acphospitalist.org/archives/2011/08/tablet. htm. Accessed April 16, 2012.
  14. Agarwal R, Sands DZ, Diaz‐Schneider J. Quantifying the economic impact of communication inefficiencies in US hospitals. Available at: http://www.rhsmith.umd.edu/chids/pdfs_docs/ResearchBriefings/CHIDS‐ResearchBriefing‐Vol3Issue1b.pdf. Accessed April 16, 2012.
  15. Fried CB. In‐class laptop use and its effects on student learning. Computers 50(3):906–914.
  16. Fox AB, Rosen J, Crawford M. Distractions, distractions: does instant messaging affect college students' performance on a concurrent reading comprehension task? CyberPsychology 12(1):51–53.
  17. Bowman LL, Levine LE, Waite BM, Gendron M. Can students really multitask? An experimental study of instant messaging while reading. Computers 54(4):927–931.
  18. US Department of Transportation. Statistics and facts about distracted driving. Available at: http://www.distraction.gov/stats‐and‐facts/index.html. Accessed November 17, 2011.
  19. Driving distracted. Consumer Reports. April 2011:22–25. See also: http://www.distraction.gov/files/for‐media/2011/2011–03‐04‐cr‐dot‐distracted‐driving‐initiative.pdf. Accessed November 25, 2011.
  20. Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians “interrupt‐driven” and “multitasking”? Acad Emerg Med. 2000;7(11):1239–1243.
  21. Kalisch BJ, Aebersold M. Interruptions and multitasking in nursing care. Jt Comm J Qual Paient Saf. 2010;36(3):126–132.
  22. Rivera‐Rodriguez AJ, Karsh BT. Interruptions and distractions in healthcare: review and reappraisal. Qual Saf Health Care. 2010;19(4):304–312.
  23. O'Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88–93.
  24. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683–690.
  25. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician‐to‐physician communication during patient handoffs. Acad Med. 2005;80(12):1094–1099.
  26. Wu R, Rossos P, Quan S, et al. An evaluation of the use of smartphones to communicate between clinicians: a mixed‐methods study. J Med Internet Res. 2011;13(3):e59.
  27. Agency for Healthcare Research and Quality. Spotlight case. Order interrupted by text: multitasking mishap. Commentary by Halamka J. December 2011. Available at: http://www.webmm.ahrq.gov/case.aspx?caseID=257. Accessed April 16, 2012.
  28. Kind T, Genrich G, Sodhi A, Chretien KC. Social media policies at US medical schools. Med Educ Online. 2010;15:5324. DOI: 10.3402/meo.v15i0.5324.
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Author(s)
Rachel J. Katz‐Sidlow, MD
Allison Ludwig, MD
Scott Miller, MD
Robert Sidlow, MD, MBA
Author(s)
Rachel J. Katz‐Sidlow, MD
Allison Ludwig, MD
Scott Miller, MD
Robert Sidlow, MD, MBA
Files
Supporting Information Appendix 1 (1)
Supporting Information Appendix 2 (2)
Supporting Information Appendix 3 (3)
Supporting Information (4)
Files
Supporting Information Appendix 1 (1)
Supporting Information Appendix 2 (2)
Supporting Information Appendix 3 (3)
Supporting Information (4)
Article PDF
1950_ftp.pdf
Article PDF
1950_ftp.pdf

Healthcare market research has predicted that over 80% of physicians will use smartphones by 2012.1 These handheld devices allow users immediate access to various forms of electronic media such as Internet, instant messaging, and e‐mail. Smartphones provide numerous benefits to physicians, including rapid access to medical references, research applications, and patient information.2 These devices have been used for teleconsultation3 and patient education,4 and applications have been developed for numerous clinical specialties.48

Housestaff perceive that communication improves when they use smartphones rather than traditional pagers on the inpatient service,9 and patients may have a positive view of physicians' use of handheld computers.10 Medical schools and residency programs are increasingly requiring smartphone ownership for their trainees, with the expectation that smartphone use will enhance the educational experience, ensure the highest level of patient care, improve user efficiency, and help control the costs associated with purchasing updated textbooks.7, 1113 In the future, hospitals may rely on smartphone technologies to help reduce the enormous economic burden created by inefficient communication.14

Despite their numerous benefits for physicians and patients, little is known about the potential for smartphones to distract users in clinical care settings. Studies from the psychology and traffic safety fields have documented untoward consequences when individuals use electronic devices to multitask.1519 Given these concerns, we investigated the prevalence and patterns of smartphone use during inpatient attending rounds, and whether these devices can distract team members in this period of important information transfer.

METHODS

At our institution, attending rounds are faculty‐led inpatient teaching rounds that focus on clinical care and patient management; these sessions may be conducted either in the classroom or at the bedside, depending on patient and learner needs, and faculty preference. Inpatient teams are comprised of 1 attending, housestaff, and third and fourth year medical students. Each team conducts attending rounds independently; these rounds range in length from 1 hour (Pediatrics) to 2 hours (Medicine).

A survey instrument was designed to evaluate smartphone usage patterns during hospital inpatient attending rounds, and perceived distraction from smartphones in this setting. A preliminary version of the survey was pilot tested by a group of housestaff for face validity, redundancy, and ease of use, and it was subsequently revised. For the purposes of this study, a smartphone was defined broadly as any mobile, personal communication device (cellphone, iPhone, Android, Blackberry, iPad, etc). Residents were asked about their own smartphone use, as well as their observations of supervising attendings and other learners' devices use during rounds (see Supporting Appendix 1 in the online version of this article).

In February 2011, the anonymous online survey was administered using Survey Monkey (www.surveymonkey.com) and was distributed via e‐mail to medical and pediatric housestaff at Jacobi Medical Center, a public teaching hospital located in Bronx, NY, affiliated with the Albert Einstein College of Medicine of Yeshiva University. A similar survey was distributed to faculty who were known to conduct inpatient attending rounds (see Supporting Appendix 2 in the online version of this article). The e‐mail solicitation process was repeated for both groups of respondents at 2 and 4 weeks after the initial request. The study was approved by the Institutional Review Board of the Albert Einstein College of Medicine.

Respondents were not required to answer each question in order to complete the survey. With the exception of free‐text comments, all responses were either yes/no or were graded on a 5‐point frequency scale (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always). This scale was chosen because it allowed for adequate dispersion of responses, and for the identification of meaningful smartphone usage among respondents (score 3) and data dichotomization. The z test was used to compare the proportions between independent groups.

All free‐text comments were imported into a Microsoft Word table. Comments were separated into 2 groups: housestaff and attending. Each comment was hand‐coded by 2 authors (R.J.K.‐S. and R.S.) to reach consensus for 1 of the following 4 categories: the comment was a positive statement; a negative statement; a positive/negative statement; or a neutral one, ie, neither positive nor negative. The terms positive and negative here refer to whether the statement explicitly highlighted benefits of smartphone use or a negative aspect of smartphone use, respectively. A comment was coded as positive/negative if it highlighted both benefits and drawbacks in the same comment. In addition, each comment that mentioned texting or call functions was secondarily coded as personal, patient, both, or unknown depending on the purpose of the texting or calls described in each comment. Comments were also reviewed for possible subthemes.

RESULTS

The overall response rate was 73% (156/214), with 81% (116/143) of housestaff and 56% (40/71) of faculty participating. The mean tenure of faculty respondents was 13 years. Eighty‐nine percent (103/116) of residents and 98% (39/40) of faculty owned devices, with 57% of housestaff and 28% of attendings reporting regular personal use of smartphones during attending rounds (Table 1).

How Often Are Smartphones Used During Inpatient Attending Rounds?
Smartphone UserSelf‐Report % (n/N)Resident Observations of Other Team Members % (n/N)Faculty Observations of Trainees % (n/N)

  • NOTE: Respondents reporting regular use, defined as score 3. Abbreviations: n/a, not applicable.

  • N reflects that 3 residents skipped the question.

Resident57% (59/103)91% (103/113)*73% (29/40)
Faculty28% (11/39)43% (49/113)*n/a

Respondents reported that they used their smartphones during attending rounds for the following reasons: 1) patient care (85% residents, 48% faculty); 2) reading/responding to personal texts/e‐mails (37% residents, 12% faculty); and 3) other non‐patient care uses, such as Web surfing (15% residents, 0% faculty) (Tables 2 and 3). Nineteen percent of residents reported that they missed important clinical information due to distraction from smartphone use, as did 12% of attendings (Table 4). Respondents reported observing other team members using smartphones and missing important clinical data at higher rates than they reported for themselves (see Tables 1, 4, and 5). A majority of both residents (56%) and faculty (73%) agreed (score >3) that smartphones can be a serious distraction during attending rounds, and 77% of attendings affirmed that teaching hospitals should establish smartphone use codes of conduct in order to minimize unnecessary distraction during attending rounds.

Reasons That Housestaff Use Smartphones During Attending Rounds
ReasonBased on Housestaff Self‐Report (n = 85)*Based on Trainee Observations of One Another (n = 112)P Value

  • NOTE: Score 3. Abbreviations: NS, not significant.

  • n excludes 31 smartphone non‐owners and those who never use the device during rounds.

  • n reflects that 4 residents skipped this question.

Patient care‐related use (ePocrates, MedCalc, Medline, Google Scholar)85%86%NS
Reading or responding to personal texts or e‐mail37%55%<0.01
Other non‐patient care‐related use, Web surfing15%37%<0.01
Reasons That Faculty Use Smartphones During Attending Rounds
ReasonBased on Faculty Self‐Report (n = 25)*Based on Housestaff Observations of Faculty (n = 91)P Value

  • NOTE: Score 3. Abbreviations: NS, not significant.

  • n excludes 15 smartphone non‐owners and those who never use the device during rounds.

  • n reflects a reduced number of resident responses to this question.

Patient care‐related use (ePocrates, MedCalc, Medline, Google Scholar)48%48%NS
Reading or responding to personal texts or e‐mail12%47%<0.01
Other non‐patient care‐related use, Web surfing0%20%<0.05
Do You Think You Ever Missed an Important Piece of Clinical Information Because You Were Distracted by Smartphone Use During Rounds?
Smartphone UserSelf‐Report % (n/N)

  • NOTE: Respondents who answered yes.

  • All eligible faculty and residents answered this question; N excludes smartphone non‐owners and those who never use smartphones during rounds.

Housestaff19% (18/85)*
Faculty12% (3/25)*
Have You Ever Witnessed Another Team Member Miss an Important Piece of Clinical Information Because He/She Was Distracted by Smartphone Use During Rounds?
Smartphone UserBased on Housestaff Observation % (n/N)Based on Faculty Observation % (n/N)

  • NOTE: Respondents who answered yes. Abbreviations: n/a, not applicable.

  • N reflects a reduced number of responses for these questions.

  • At our institution, rounds take place with only 1 faculty member per team.

Trainee34% (38/112)*43% (17/40)
Faculty20% (18/91)*n/a

Despite not requiring responses in order to complete the questionnaires, we found that, in general, few eligible faculty or residents skipped questions on the survey. Nevertheless, there was a substantial drop in responses (91/116) for the last 2 questions on the housestaff survey. These questions asked for resident observations of attending smartphone usage patterns during rounds, and whether they had seen attendings miss clinical information because of distractions from smartphone use.

There were 25 free‐text comments from residents and 11 from attendings. The resultant comments highlight differences in residents' and attendings' perspectives toward smartphone use during attending rounds. Housestaff comments included 7 positive comments, 7 positive/negative comments, 1 negative comment, and 10 neutral comments. A subtheme that emerged in 2 of the housestaff comments was the importance of personal autonomy in being able to use one's smartphone. Attending comments included 2 positive comments, 0 positive/negative comments, 4 negative comments, and 5 neutral comments. Faculty comments revealed that attendings use their smartphones' e‐mail/texting and call capabilities during rounds both for patient care issues (3 comments) and/or urgent family concerns (2 comments). In 2 other attending comments, the reason for calls/texts during rounds was not specified.

Housestaff comments included: I do not know why it is that attendings never use it these phones are so easy to use and [enhance] patient care in a number of ways, Depending on how they are used, if strictly for pt care then they can be a great mobile tool, Of course they can be a distraction, but they are also a very good tool. You take the good with the bad, If you are bored you will find other things to occupy your mind. If you can look up some info at the time of rounding you are actively participating. Please, do not make it worse than it is already, and It is a personal choice. Faculty negative comments highlighted the potential for distraction from the e‐mail beeps, the fact that some of the housestaff will be tuned into their SmartPhones, that residents frequently check their phones during roundsa distraction and frankly rude when the attending or fellow are giving a brief lecture, and that sometimes more focus is on the SmartPhone than rounds.

DISCUSSION

Physicians and their patients benefit from the wide‐ranging capabilities of personal, mobile communication devices in the healthcare environment. Smartphones house the latest medical references, provide access to patients' medical records and imaging studies, can photograph or video physical findings, and educate and monitor patients.28 Smartphones can facilitate information transfer in the medical setting and may improve housestaff efficiency and communication.9

Despite their significant benefits, smartphones introduce another source of interruption, multitasking, and distraction into the hospital environment. There is increasing awareness that breaks‐in‐task in the clinical setting may have negative consequences.2024 While some types of interruptions are beneficial and can facilitate patient care (eg, an alarm ringing to indicate abnormal vitals signs on a patient),2024 other forms of interruptions, even those that are self‐initiated,22 can be distracting and detrimental. Along these lines, recommendations for safe handoffs and information transfer have specifically included advice to minimize potential distractions.25

In addition, studies from the psychology and education literature have previously documented negative consequences on learning when individuals use electronic devices to multitask.1517 Students who used a laptop in class were likely to multitask, become distracted, and distract others; the more a student used the laptop in class, the lower the student's class performance.15 Multitasking with a cellphone during driving can be especially hazardous.18, 19 According to National Highway Traffic Safety Administration data, 20% of injury crashes in 2009 involved reports of distracted driving, and cellphones were implicated in 18% of distracted driving deaths that year.18

Little is known about any negative effects of using personal electronic devices in the context of patient care. A 2011 study of Internal Medicine residents who used smartphones for team communication documented both positive and negative consequences of smartphone use in the hospital setting. Negative consequences included frequent interruptions, a weakening of interprofessional behaviors as housestaff relied on texting over direct communication with nurses, and unprofessional housestaff behaviors.26 The Agency for Healthcare Quality and Research published a case report in which a resident's smartphone use during clinical care resulted in patient harm.27 To our knowledge, this is the first study to detail housestaff and faculty smartphone usage patterns and potential for user distractibility during inpatient attending rounds.

Our data show that device use during attending rounds is prevalent among residents and faculty alike, with the majority of use related to patient care. However, attendings were half as likely as residents to report using devices regularly during rounds. This finding may reflect attendings' inability to multitask while leading the rounds, or a deliberate role‐modeling of desired conduct during rounds. Generational differences may also play a role, with residents more likely than their older attendings to multitask and self‐interrupt. Along these lines, traffic safety research has found that younger drivers are more likely to text during driving; approximately 30% of drivers under 30 years old reported texting while driving in the previous 30 days, compared to 9% of respondents over 30 years old.19 Increased smartphone use by housestaff during rounds may also reflect attitudinal differences between the 2 groups. As seen in the free‐text comments, housestaff tended to emphasize the benefits of smartphone use, and with 1 exception, all negative housestaff comments were balanced by a positive statement. Faculty more commonly underscored the negative aspects of smartphone use during rounds, including the devices' adverse effects on housestaff professional behavior in this setting.

Faculty and housestaff consistently reported observing others using smartphones at higher rates than they reported for themselves. This discrepancy may reflect underrecognition of self‐use, or a discomfort in reporting self‐use during attending rounds. In addition, residents' observations of other trainees' usage of smartphones (91%) was higher than faculty observation of the same group (73%). Trainees' smartphone use may be less obvious to attendings who are involved in facilitating rounds. Alternatively, trainees may use their smartphones in subtle ways to prevent attending awareness.

There are several limitations to our study. Our research focused specifically on attending rounds. Smartphone usage patterns by faculty and housestaff at other times in the work day, such as during resident handoffs, at a patient's bedside, or during academic conferences, may differ. Nevertheless, we specifically chose to study smartphone use during attending rounds, as these sessions are discrete time frames during which important teaching occurs and clinical management decisions are made. With recent Accreditation Council for Graduate Medical Education (ACGME) work hour restrictions, these faculty‐led rounds may become increasingly important in ensuring the safe transition of patient care. Secondly, despite asking respondents how often they use their smartphones for personal texts or e‐mails, it was clear from the free‐text comments that respondents use their smartphone e‐mail/texting capabilities and take urgent calls during rounds for both patient care and/or family issues. It is not possible from the data to sort out the subset of respondents who use texting or e‐mailing exclusively for patient care during rounds. Third, we did not survey medical students on the teams, so it is possible that their device use on rounds differs from that of housestaff and faculty. Fourth, since the survey could be completed without answering every question, response rates for some items varied slightly; there was a substantial reduction in the number of eligible residents who answered the final 2 questions on the survey about their observations of attendings' smartphone usage patterns and distraction during rounds. While the flexibility in survey completion was intended to enhance overall study participation, it is unknown how nonresponders might have affected the study results; as such, those specific results should be interpreted with some caution. Finally, our findings were based on respondents' retrospective recall, and therefore may not accurately reflect true usage patterns. Timemotion studies with real‐time observation of smartphone use would provide more accurate data.

A majority of residents and attendings in our study agreed that smartphones can pose a serious distraction during attending rounds, and attendings strongly favored the institution of formal codes of conduct for smartphone use during inpatient attending rounds. The development of such policies are important for patient safety; at the same time, they are in line with medical institutions' increasing awareness about the need for guidelines regarding other aspects of digital professionalism.28 In February 2012, our hospital instituted a policy regarding appropriate device use during inpatient attending rounds (see Supporting Appendix 3 in the online version of this article). Because our research found differences in housestaff and faculty attitudes toward smartphone use during rounds, we developed our policy after discussion with, and feedback from, all members of the inpatient team, including faculty, residents, and medical students. Incorporating the various perspectives of all stakeholders can be helpful to institutions in developing guidelines that maximize the benefits of smartphone use in the learning environment, while reducing the potential for distraction and adverse outcomes.

Acknowledgements

Disclosure: Nothing to report.

Healthcare market research has predicted that over 80% of physicians will use smartphones by 2012.1 These handheld devices allow users immediate access to various forms of electronic media such as Internet, instant messaging, and e‐mail. Smartphones provide numerous benefits to physicians, including rapid access to medical references, research applications, and patient information.2 These devices have been used for teleconsultation3 and patient education,4 and applications have been developed for numerous clinical specialties.48

Housestaff perceive that communication improves when they use smartphones rather than traditional pagers on the inpatient service,9 and patients may have a positive view of physicians' use of handheld computers.10 Medical schools and residency programs are increasingly requiring smartphone ownership for their trainees, with the expectation that smartphone use will enhance the educational experience, ensure the highest level of patient care, improve user efficiency, and help control the costs associated with purchasing updated textbooks.7, 1113 In the future, hospitals may rely on smartphone technologies to help reduce the enormous economic burden created by inefficient communication.14

Despite their numerous benefits for physicians and patients, little is known about the potential for smartphones to distract users in clinical care settings. Studies from the psychology and traffic safety fields have documented untoward consequences when individuals use electronic devices to multitask.1519 Given these concerns, we investigated the prevalence and patterns of smartphone use during inpatient attending rounds, and whether these devices can distract team members in this period of important information transfer.

METHODS

At our institution, attending rounds are faculty‐led inpatient teaching rounds that focus on clinical care and patient management; these sessions may be conducted either in the classroom or at the bedside, depending on patient and learner needs, and faculty preference. Inpatient teams are comprised of 1 attending, housestaff, and third and fourth year medical students. Each team conducts attending rounds independently; these rounds range in length from 1 hour (Pediatrics) to 2 hours (Medicine).

A survey instrument was designed to evaluate smartphone usage patterns during hospital inpatient attending rounds, and perceived distraction from smartphones in this setting. A preliminary version of the survey was pilot tested by a group of housestaff for face validity, redundancy, and ease of use, and it was subsequently revised. For the purposes of this study, a smartphone was defined broadly as any mobile, personal communication device (cellphone, iPhone, Android, Blackberry, iPad, etc). Residents were asked about their own smartphone use, as well as their observations of supervising attendings and other learners' devices use during rounds (see Supporting Appendix 1 in the online version of this article).

In February 2011, the anonymous online survey was administered using Survey Monkey (www.surveymonkey.com) and was distributed via e‐mail to medical and pediatric housestaff at Jacobi Medical Center, a public teaching hospital located in Bronx, NY, affiliated with the Albert Einstein College of Medicine of Yeshiva University. A similar survey was distributed to faculty who were known to conduct inpatient attending rounds (see Supporting Appendix 2 in the online version of this article). The e‐mail solicitation process was repeated for both groups of respondents at 2 and 4 weeks after the initial request. The study was approved by the Institutional Review Board of the Albert Einstein College of Medicine.

Respondents were not required to answer each question in order to complete the survey. With the exception of free‐text comments, all responses were either yes/no or were graded on a 5‐point frequency scale (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always). This scale was chosen because it allowed for adequate dispersion of responses, and for the identification of meaningful smartphone usage among respondents (score 3) and data dichotomization. The z test was used to compare the proportions between independent groups.

All free‐text comments were imported into a Microsoft Word table. Comments were separated into 2 groups: housestaff and attending. Each comment was hand‐coded by 2 authors (R.J.K.‐S. and R.S.) to reach consensus for 1 of the following 4 categories: the comment was a positive statement; a negative statement; a positive/negative statement; or a neutral one, ie, neither positive nor negative. The terms positive and negative here refer to whether the statement explicitly highlighted benefits of smartphone use or a negative aspect of smartphone use, respectively. A comment was coded as positive/negative if it highlighted both benefits and drawbacks in the same comment. In addition, each comment that mentioned texting or call functions was secondarily coded as personal, patient, both, or unknown depending on the purpose of the texting or calls described in each comment. Comments were also reviewed for possible subthemes.

RESULTS

The overall response rate was 73% (156/214), with 81% (116/143) of housestaff and 56% (40/71) of faculty participating. The mean tenure of faculty respondents was 13 years. Eighty‐nine percent (103/116) of residents and 98% (39/40) of faculty owned devices, with 57% of housestaff and 28% of attendings reporting regular personal use of smartphones during attending rounds (Table 1).

How Often Are Smartphones Used During Inpatient Attending Rounds?
Smartphone UserSelf‐Report % (n/N)Resident Observations of Other Team Members % (n/N)Faculty Observations of Trainees % (n/N)

  • NOTE: Respondents reporting regular use, defined as score 3. Abbreviations: n/a, not applicable.

  • N reflects that 3 residents skipped the question.

Resident57% (59/103)91% (103/113)*73% (29/40)
Faculty28% (11/39)43% (49/113)*n/a

Respondents reported that they used their smartphones during attending rounds for the following reasons: 1) patient care (85% residents, 48% faculty); 2) reading/responding to personal texts/e‐mails (37% residents, 12% faculty); and 3) other non‐patient care uses, such as Web surfing (15% residents, 0% faculty) (Tables 2 and 3). Nineteen percent of residents reported that they missed important clinical information due to distraction from smartphone use, as did 12% of attendings (Table 4). Respondents reported observing other team members using smartphones and missing important clinical data at higher rates than they reported for themselves (see Tables 1, 4, and 5). A majority of both residents (56%) and faculty (73%) agreed (score >3) that smartphones can be a serious distraction during attending rounds, and 77% of attendings affirmed that teaching hospitals should establish smartphone use codes of conduct in order to minimize unnecessary distraction during attending rounds.

Reasons That Housestaff Use Smartphones During Attending Rounds
ReasonBased on Housestaff Self‐Report (n = 85)*Based on Trainee Observations of One Another (n = 112)P Value

  • NOTE: Score 3. Abbreviations: NS, not significant.

  • n excludes 31 smartphone non‐owners and those who never use the device during rounds.

  • n reflects that 4 residents skipped this question.

Patient care‐related use (ePocrates, MedCalc, Medline, Google Scholar)85%86%NS
Reading or responding to personal texts or e‐mail37%55%<0.01
Other non‐patient care‐related use, Web surfing15%37%<0.01
Reasons That Faculty Use Smartphones During Attending Rounds
ReasonBased on Faculty Self‐Report (n = 25)*Based on Housestaff Observations of Faculty (n = 91)P Value

  • NOTE: Score 3. Abbreviations: NS, not significant.

  • n excludes 15 smartphone non‐owners and those who never use the device during rounds.

  • n reflects a reduced number of resident responses to this question.

Patient care‐related use (ePocrates, MedCalc, Medline, Google Scholar)48%48%NS
Reading or responding to personal texts or e‐mail12%47%<0.01
Other non‐patient care‐related use, Web surfing0%20%<0.05
Do You Think You Ever Missed an Important Piece of Clinical Information Because You Were Distracted by Smartphone Use During Rounds?
Smartphone UserSelf‐Report % (n/N)

  • NOTE: Respondents who answered yes.

  • All eligible faculty and residents answered this question; N excludes smartphone non‐owners and those who never use smartphones during rounds.

Housestaff19% (18/85)*
Faculty12% (3/25)*
Have You Ever Witnessed Another Team Member Miss an Important Piece of Clinical Information Because He/She Was Distracted by Smartphone Use During Rounds?
Smartphone UserBased on Housestaff Observation % (n/N)Based on Faculty Observation % (n/N)

  • NOTE: Respondents who answered yes. Abbreviations: n/a, not applicable.

  • N reflects a reduced number of responses for these questions.

  • At our institution, rounds take place with only 1 faculty member per team.

Trainee34% (38/112)*43% (17/40)
Faculty20% (18/91)*n/a

Despite not requiring responses in order to complete the questionnaires, we found that, in general, few eligible faculty or residents skipped questions on the survey. Nevertheless, there was a substantial drop in responses (91/116) for the last 2 questions on the housestaff survey. These questions asked for resident observations of attending smartphone usage patterns during rounds, and whether they had seen attendings miss clinical information because of distractions from smartphone use.

There were 25 free‐text comments from residents and 11 from attendings. The resultant comments highlight differences in residents' and attendings' perspectives toward smartphone use during attending rounds. Housestaff comments included 7 positive comments, 7 positive/negative comments, 1 negative comment, and 10 neutral comments. A subtheme that emerged in 2 of the housestaff comments was the importance of personal autonomy in being able to use one's smartphone. Attending comments included 2 positive comments, 0 positive/negative comments, 4 negative comments, and 5 neutral comments. Faculty comments revealed that attendings use their smartphones' e‐mail/texting and call capabilities during rounds both for patient care issues (3 comments) and/or urgent family concerns (2 comments). In 2 other attending comments, the reason for calls/texts during rounds was not specified.

Housestaff comments included: I do not know why it is that attendings never use it these phones are so easy to use and [enhance] patient care in a number of ways, Depending on how they are used, if strictly for pt care then they can be a great mobile tool, Of course they can be a distraction, but they are also a very good tool. You take the good with the bad, If you are bored you will find other things to occupy your mind. If you can look up some info at the time of rounding you are actively participating. Please, do not make it worse than it is already, and It is a personal choice. Faculty negative comments highlighted the potential for distraction from the e‐mail beeps, the fact that some of the housestaff will be tuned into their SmartPhones, that residents frequently check their phones during roundsa distraction and frankly rude when the attending or fellow are giving a brief lecture, and that sometimes more focus is on the SmartPhone than rounds.

DISCUSSION

Physicians and their patients benefit from the wide‐ranging capabilities of personal, mobile communication devices in the healthcare environment. Smartphones house the latest medical references, provide access to patients' medical records and imaging studies, can photograph or video physical findings, and educate and monitor patients.28 Smartphones can facilitate information transfer in the medical setting and may improve housestaff efficiency and communication.9

Despite their significant benefits, smartphones introduce another source of interruption, multitasking, and distraction into the hospital environment. There is increasing awareness that breaks‐in‐task in the clinical setting may have negative consequences.2024 While some types of interruptions are beneficial and can facilitate patient care (eg, an alarm ringing to indicate abnormal vitals signs on a patient),2024 other forms of interruptions, even those that are self‐initiated,22 can be distracting and detrimental. Along these lines, recommendations for safe handoffs and information transfer have specifically included advice to minimize potential distractions.25

In addition, studies from the psychology and education literature have previously documented negative consequences on learning when individuals use electronic devices to multitask.1517 Students who used a laptop in class were likely to multitask, become distracted, and distract others; the more a student used the laptop in class, the lower the student's class performance.15 Multitasking with a cellphone during driving can be especially hazardous.18, 19 According to National Highway Traffic Safety Administration data, 20% of injury crashes in 2009 involved reports of distracted driving, and cellphones were implicated in 18% of distracted driving deaths that year.18

Little is known about any negative effects of using personal electronic devices in the context of patient care. A 2011 study of Internal Medicine residents who used smartphones for team communication documented both positive and negative consequences of smartphone use in the hospital setting. Negative consequences included frequent interruptions, a weakening of interprofessional behaviors as housestaff relied on texting over direct communication with nurses, and unprofessional housestaff behaviors.26 The Agency for Healthcare Quality and Research published a case report in which a resident's smartphone use during clinical care resulted in patient harm.27 To our knowledge, this is the first study to detail housestaff and faculty smartphone usage patterns and potential for user distractibility during inpatient attending rounds.

Our data show that device use during attending rounds is prevalent among residents and faculty alike, with the majority of use related to patient care. However, attendings were half as likely as residents to report using devices regularly during rounds. This finding may reflect attendings' inability to multitask while leading the rounds, or a deliberate role‐modeling of desired conduct during rounds. Generational differences may also play a role, with residents more likely than their older attendings to multitask and self‐interrupt. Along these lines, traffic safety research has found that younger drivers are more likely to text during driving; approximately 30% of drivers under 30 years old reported texting while driving in the previous 30 days, compared to 9% of respondents over 30 years old.19 Increased smartphone use by housestaff during rounds may also reflect attitudinal differences between the 2 groups. As seen in the free‐text comments, housestaff tended to emphasize the benefits of smartphone use, and with 1 exception, all negative housestaff comments were balanced by a positive statement. Faculty more commonly underscored the negative aspects of smartphone use during rounds, including the devices' adverse effects on housestaff professional behavior in this setting.

Faculty and housestaff consistently reported observing others using smartphones at higher rates than they reported for themselves. This discrepancy may reflect underrecognition of self‐use, or a discomfort in reporting self‐use during attending rounds. In addition, residents' observations of other trainees' usage of smartphones (91%) was higher than faculty observation of the same group (73%). Trainees' smartphone use may be less obvious to attendings who are involved in facilitating rounds. Alternatively, trainees may use their smartphones in subtle ways to prevent attending awareness.

There are several limitations to our study. Our research focused specifically on attending rounds. Smartphone usage patterns by faculty and housestaff at other times in the work day, such as during resident handoffs, at a patient's bedside, or during academic conferences, may differ. Nevertheless, we specifically chose to study smartphone use during attending rounds, as these sessions are discrete time frames during which important teaching occurs and clinical management decisions are made. With recent Accreditation Council for Graduate Medical Education (ACGME) work hour restrictions, these faculty‐led rounds may become increasingly important in ensuring the safe transition of patient care. Secondly, despite asking respondents how often they use their smartphones for personal texts or e‐mails, it was clear from the free‐text comments that respondents use their smartphone e‐mail/texting capabilities and take urgent calls during rounds for both patient care and/or family issues. It is not possible from the data to sort out the subset of respondents who use texting or e‐mailing exclusively for patient care during rounds. Third, we did not survey medical students on the teams, so it is possible that their device use on rounds differs from that of housestaff and faculty. Fourth, since the survey could be completed without answering every question, response rates for some items varied slightly; there was a substantial reduction in the number of eligible residents who answered the final 2 questions on the survey about their observations of attendings' smartphone usage patterns and distraction during rounds. While the flexibility in survey completion was intended to enhance overall study participation, it is unknown how nonresponders might have affected the study results; as such, those specific results should be interpreted with some caution. Finally, our findings were based on respondents' retrospective recall, and therefore may not accurately reflect true usage patterns. Timemotion studies with real‐time observation of smartphone use would provide more accurate data.

A majority of residents and attendings in our study agreed that smartphones can pose a serious distraction during attending rounds, and attendings strongly favored the institution of formal codes of conduct for smartphone use during inpatient attending rounds. The development of such policies are important for patient safety; at the same time, they are in line with medical institutions' increasing awareness about the need for guidelines regarding other aspects of digital professionalism.28 In February 2012, our hospital instituted a policy regarding appropriate device use during inpatient attending rounds (see Supporting Appendix 3 in the online version of this article). Because our research found differences in housestaff and faculty attitudes toward smartphone use during rounds, we developed our policy after discussion with, and feedback from, all members of the inpatient team, including faculty, residents, and medical students. Incorporating the various perspectives of all stakeholders can be helpful to institutions in developing guidelines that maximize the benefits of smartphone use in the learning environment, while reducing the potential for distraction and adverse outcomes.

Acknowledgements

Disclosure: Nothing to report.

References
  1. Dolan B. 72 percent of US physicians use smartphones. MobiHealthNews. Available at: http://mobihealthnews.com/7505/72‐percent‐of‐us‐physicians‐use‐smartphones/. Accessed April 16, 2012.
  2. Baumgart DC. Smartphones in clinical practice, medical education, and research. Arch Intern Med. 2011;171(14):1294–1296.
  3. Aziz SR,Ziccardi VB. Telemedicine using smartphones for oral and maxillofacial surgery consultation, communication, and treatment planning.J Oral Maxillofac Surg.2009;67:2505–2509.
  4. Busis N. Mobile phones to improve the practice of neurology. Neurol Clin. 2010;28(2):395–410.
  5. Oehler RL, Smith K, Toney JF. Infectious diseases resources for the iPhone. Clin Infect Dis. 2010;50(9):1268–1274.
  6. Lord RK, Shah VA, San Filippo AN, Krishna R. Novel uses of smartphones in ophthalmology. Ophthalmology. 2010;117:1274–1274.e3.
  7. Dala‐Ali BM, Lloyd MA, Al‐Abed Y. The uses of the iPhone for surgeons. Surgeon. 2011;9(1):44–48.
  8. Franko OI. Smartphone apps for orthopaedic surgeons. Clin Orthop Relat Res. 2011;469(7):2042–2048.
  9. Wu RC, Morra D, Quan S, et al. The use of smartphones for clinical communication on internal medicine wards. J Hosp Med. 2010;5(9):553–559.
  10. Strayer SM, Semler MW, Kington ML, Tanabe KO. Patient attitudes toward physician use of tablet computers in the exam room. Fam Med. 2010;42(9):643–647.
  11. White T. iPads to be distributed to incoming class by Stanford Medical School. Available at: http://med.stanford.edu/ism/2010/august/ipad.html. Accessed April 16, 2012.
  12. University of Virginia School of Medicine. Third year medical student mobile device requirement. Available at: http://www.medicine.virginia.edu/education/medical‐students/ome/edtech/pda_recom‐page/. Accessed April 16, 2012.
  13. Huff C. Tablet computers in the hospital. ACP Hospitalist 2011. Available at: http://www.acphospitalist.org/archives/2011/08/tablet. htm. Accessed April 16, 2012.
  14. Agarwal R, Sands DZ, Diaz‐Schneider J. Quantifying the economic impact of communication inefficiencies in US hospitals. Available at: http://www.rhsmith.umd.edu/chids/pdfs_docs/ResearchBriefings/CHIDS‐ResearchBriefing‐Vol3Issue1b.pdf. Accessed April 16, 2012.
  15. Fried CB. In‐class laptop use and its effects on student learning. Computers 50(3):906–914.
  16. Fox AB, Rosen J, Crawford M. Distractions, distractions: does instant messaging affect college students' performance on a concurrent reading comprehension task? CyberPsychology 12(1):51–53.
  17. Bowman LL, Levine LE, Waite BM, Gendron M. Can students really multitask? An experimental study of instant messaging while reading. Computers 54(4):927–931.
  18. US Department of Transportation. Statistics and facts about distracted driving. Available at: http://www.distraction.gov/stats‐and‐facts/index.html. Accessed November 17, 2011.
  19. Driving distracted. Consumer Reports. April 2011:22–25. See also: http://www.distraction.gov/files/for‐media/2011/2011–03‐04‐cr‐dot‐distracted‐driving‐initiative.pdf. Accessed November 25, 2011.
  20. Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians “interrupt‐driven” and “multitasking”? Acad Emerg Med. 2000;7(11):1239–1243.
  21. Kalisch BJ, Aebersold M. Interruptions and multitasking in nursing care. Jt Comm J Qual Paient Saf. 2010;36(3):126–132.
  22. Rivera‐Rodriguez AJ, Karsh BT. Interruptions and distractions in healthcare: review and reappraisal. Qual Saf Health Care. 2010;19(4):304–312.
  23. O'Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88–93.
  24. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683–690.
  25. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician‐to‐physician communication during patient handoffs. Acad Med. 2005;80(12):1094–1099.
  26. Wu R, Rossos P, Quan S, et al. An evaluation of the use of smartphones to communicate between clinicians: a mixed‐methods study. J Med Internet Res. 2011;13(3):e59.
  27. Agency for Healthcare Research and Quality. Spotlight case. Order interrupted by text: multitasking mishap. Commentary by Halamka J. December 2011. Available at: http://www.webmm.ahrq.gov/case.aspx?caseID=257. Accessed April 16, 2012.
  28. Kind T, Genrich G, Sodhi A, Chretien KC. Social media policies at US medical schools. Med Educ Online. 2010;15:5324. DOI: 10.3402/meo.v15i0.5324.
References
  1. Dolan B. 72 percent of US physicians use smartphones. MobiHealthNews. Available at: http://mobihealthnews.com/7505/72‐percent‐of‐us‐physicians‐use‐smartphones/. Accessed April 16, 2012.
  2. Baumgart DC. Smartphones in clinical practice, medical education, and research. Arch Intern Med. 2011;171(14):1294–1296.
  3. Aziz SR,Ziccardi VB. Telemedicine using smartphones for oral and maxillofacial surgery consultation, communication, and treatment planning.J Oral Maxillofac Surg.2009;67:2505–2509.
  4. Busis N. Mobile phones to improve the practice of neurology. Neurol Clin. 2010;28(2):395–410.
  5. Oehler RL, Smith K, Toney JF. Infectious diseases resources for the iPhone. Clin Infect Dis. 2010;50(9):1268–1274.
  6. Lord RK, Shah VA, San Filippo AN, Krishna R. Novel uses of smartphones in ophthalmology. Ophthalmology. 2010;117:1274–1274.e3.
  7. Dala‐Ali BM, Lloyd MA, Al‐Abed Y. The uses of the iPhone for surgeons. Surgeon. 2011;9(1):44–48.
  8. Franko OI. Smartphone apps for orthopaedic surgeons. Clin Orthop Relat Res. 2011;469(7):2042–2048.
  9. Wu RC, Morra D, Quan S, et al. The use of smartphones for clinical communication on internal medicine wards. J Hosp Med. 2010;5(9):553–559.
  10. Strayer SM, Semler MW, Kington ML, Tanabe KO. Patient attitudes toward physician use of tablet computers in the exam room. Fam Med. 2010;42(9):643–647.
  11. White T. iPads to be distributed to incoming class by Stanford Medical School. Available at: http://med.stanford.edu/ism/2010/august/ipad.html. Accessed April 16, 2012.
  12. University of Virginia School of Medicine. Third year medical student mobile device requirement. Available at: http://www.medicine.virginia.edu/education/medical‐students/ome/edtech/pda_recom‐page/. Accessed April 16, 2012.
  13. Huff C. Tablet computers in the hospital. ACP Hospitalist 2011. Available at: http://www.acphospitalist.org/archives/2011/08/tablet. htm. Accessed April 16, 2012.
  14. Agarwal R, Sands DZ, Diaz‐Schneider J. Quantifying the economic impact of communication inefficiencies in US hospitals. Available at: http://www.rhsmith.umd.edu/chids/pdfs_docs/ResearchBriefings/CHIDS‐ResearchBriefing‐Vol3Issue1b.pdf. Accessed April 16, 2012.
  15. Fried CB. In‐class laptop use and its effects on student learning. Computers 50(3):906–914.
  16. Fox AB, Rosen J, Crawford M. Distractions, distractions: does instant messaging affect college students' performance on a concurrent reading comprehension task? CyberPsychology 12(1):51–53.
  17. Bowman LL, Levine LE, Waite BM, Gendron M. Can students really multitask? An experimental study of instant messaging while reading. Computers 54(4):927–931.
  18. US Department of Transportation. Statistics and facts about distracted driving. Available at: http://www.distraction.gov/stats‐and‐facts/index.html. Accessed November 17, 2011.
  19. Driving distracted. Consumer Reports. April 2011:22–25. See also: http://www.distraction.gov/files/for‐media/2011/2011–03‐04‐cr‐dot‐distracted‐driving‐initiative.pdf. Accessed November 25, 2011.
  20. Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians “interrupt‐driven” and “multitasking”? Acad Emerg Med. 2000;7(11):1239–1243.
  21. Kalisch BJ, Aebersold M. Interruptions and multitasking in nursing care. Jt Comm J Qual Paient Saf. 2010;36(3):126–132.
  22. Rivera‐Rodriguez AJ, Karsh BT. Interruptions and distractions in healthcare: review and reappraisal. Qual Saf Health Care. 2010;19(4):304–312.
  23. O'Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88–93.
  24. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683–690.
  25. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician‐to‐physician communication during patient handoffs. Acad Med. 2005;80(12):1094–1099.
  26. Wu R, Rossos P, Quan S, et al. An evaluation of the use of smartphones to communicate between clinicians: a mixed‐methods study. J Med Internet Res. 2011;13(3):e59.
  27. Agency for Healthcare Research and Quality. Spotlight case. Order interrupted by text: multitasking mishap. Commentary by Halamka J. December 2011. Available at: http://www.webmm.ahrq.gov/case.aspx?caseID=257. Accessed April 16, 2012.
  28. Kind T, Genrich G, Sodhi A, Chretien KC. Social media policies at US medical schools. Med Educ Online. 2010;15:5324. DOI: 10.3402/meo.v15i0.5324.
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Journal of Hospital Medicine - 7(8)
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Rachel J. Katz‐Sidlow, MD
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New Study on Anticoagulation Therapies “Definitive Word” on Topic, Hospitalist Says

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Richard Quinn

A recent report that states the choice between warfarin and aspirin in patients with heart failure and sinus rhythm should be individualized is the most definitive word to date on the topic, says a hospitalist focused on anticoagulation therapies.

The report, “Warfarin and Aspirin in Patients with Heart Failure and Sinus Rhythm,” focused on patients in sinus rhythm who had reduced left ventricular ejection fraction (LVEF). The authors concluded that the reduced risk of ischemic stroke with warfarin was offset by an increased risk of major hemorrhage.

“The new thing about this study is it’s really the definitive, well-designed, large trial that provides guidance to us as to what is right,” says Margaret Fang, MD, MPH, an associate professor of medicine at the University of California at San Francisco (UCSF) and medical director of the UCSF Anticoagulation Clinic. “Is warfarin really the right decision?”

Dr. Fang notes that the report, known more commonly as the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial, did find that, over time, warfarin began to show improvement over aspirin. But the improvements, which favored warfarin by the fourth year of the six-year trial, were deemed only marginally significant (P=.046).

An editorial accompanying the study noted that while warfarin is often a go-to therapy, the WARCEF trial corroborates other, smaller trials that did not associate it with a reduction in mortality among heart failure patients.

“The WARCEF trial provides clear evidence that anticoagulant therapy prevents stroke, probably embolic stroke, in patients with heart failure who have severe systolic dysfunction, but the rates of stroke are too low to justify the routine clinical use of warfarin in most patients with heart failure, in light of the increase in the risk of bleeding,” the editorial reads.

 

 

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A recent report that states the choice between warfarin and aspirin in patients with heart failure and sinus rhythm should be individualized is the most definitive word to date on the topic, says a hospitalist focused on anticoagulation therapies.

The report, “Warfarin and Aspirin in Patients with Heart Failure and Sinus Rhythm,” focused on patients in sinus rhythm who had reduced left ventricular ejection fraction (LVEF). The authors concluded that the reduced risk of ischemic stroke with warfarin was offset by an increased risk of major hemorrhage.

“The new thing about this study is it’s really the definitive, well-designed, large trial that provides guidance to us as to what is right,” says Margaret Fang, MD, MPH, an associate professor of medicine at the University of California at San Francisco (UCSF) and medical director of the UCSF Anticoagulation Clinic. “Is warfarin really the right decision?”

Dr. Fang notes that the report, known more commonly as the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial, did find that, over time, warfarin began to show improvement over aspirin. But the improvements, which favored warfarin by the fourth year of the six-year trial, were deemed only marginally significant (P=.046).

An editorial accompanying the study noted that while warfarin is often a go-to therapy, the WARCEF trial corroborates other, smaller trials that did not associate it with a reduction in mortality among heart failure patients.

“The WARCEF trial provides clear evidence that anticoagulant therapy prevents stroke, probably embolic stroke, in patients with heart failure who have severe systolic dysfunction, but the rates of stroke are too low to justify the routine clinical use of warfarin in most patients with heart failure, in light of the increase in the risk of bleeding,” the editorial reads.

 

 

A recent report that states the choice between warfarin and aspirin in patients with heart failure and sinus rhythm should be individualized is the most definitive word to date on the topic, says a hospitalist focused on anticoagulation therapies.

The report, “Warfarin and Aspirin in Patients with Heart Failure and Sinus Rhythm,” focused on patients in sinus rhythm who had reduced left ventricular ejection fraction (LVEF). The authors concluded that the reduced risk of ischemic stroke with warfarin was offset by an increased risk of major hemorrhage.

“The new thing about this study is it’s really the definitive, well-designed, large trial that provides guidance to us as to what is right,” says Margaret Fang, MD, MPH, an associate professor of medicine at the University of California at San Francisco (UCSF) and medical director of the UCSF Anticoagulation Clinic. “Is warfarin really the right decision?”

Dr. Fang notes that the report, known more commonly as the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial, did find that, over time, warfarin began to show improvement over aspirin. But the improvements, which favored warfarin by the fourth year of the six-year trial, were deemed only marginally significant (P=.046).

An editorial accompanying the study noted that while warfarin is often a go-to therapy, the WARCEF trial corroborates other, smaller trials that did not associate it with a reduction in mortality among heart failure patients.

“The WARCEF trial provides clear evidence that anticoagulant therapy prevents stroke, probably embolic stroke, in patients with heart failure who have severe systolic dysfunction, but the rates of stroke are too low to justify the routine clinical use of warfarin in most patients with heart failure, in light of the increase in the risk of bleeding,” the editorial reads.

 

 

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Daniel M. Kaplan, MD
Saumil M. Chudgar, MD
Noppon Setji, MD
Thomas A. Owens, MD

Clinical question: Is the risk of recurrence of Clostridium difficile infection (CDI) increased by the use of “non-CDI” antimicrobial agents (inactive against C. diff) during or after CDI therapy?

Background: Recurrence of CDI is expected to increase with use of non-CDI antimicrobials. Previous studies have not distinguished between the timing of non-CDI agents during and after CDI treatment, nor examined the effect of frequency, duration, or type of non-CDI antibiotic therapy.

Study design: Retrospective cohort.

Setting: Academic Veterans Affairs medical center.

Synopsis: All patients with CDI over a three-year period were evaluated to determine the association between non-CDI antimicrobial during or within 30 days following CDI therapy and 90-day CDI recurrence. Of 246 patients, 57% received concurrent or subsequent non-CDI antimicrobials. CDI recurred in 40% of patients who received non-CDI antimicrobials and in 16% of those who did not (OR: 3.5, 95% CI: 1.9 to 6.5).

After multivariable adjustment (including age, duration of CDI treatment, comorbidity, hospital and ICU admission, and gastric acid suppression), those who received non-CDI antimicrobials during CDI therapy had no increased risk of recurrence. However, those who received any non-CDI antimicrobials after initial CDI treatment had an absolute recurrence rate of 48% with an adjusted OR of 3.02 (95% CI: 1.65 to 5.52). This increased risk of recurrence was unaffected by the number or duration of non-CDI antimicrobial prescriptions. Subgroup analysis by antimicrobial class revealed statistically significant associations only with beta-lactams and fluoroquinolones.

Bottom line: The risk of recurrence of CDI is tripled by exposure to non-CDI antimicrobials within 30 days after CDI treatment, irrespective of the number or duration of such exposures.

Citation: Drekonja DM, Amundson WH, DeCarolis DD, Kuskowski MA, Lederle FA, Johnson JR. Antimicrobial use and risk for recurrent Clostridium difficile infection. Am J Med. 2011;124:1081.e1-1081.e7.

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Daniel M. Kaplan, MD
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Noppon Setji, MD
Thomas A. Owens, MD
Author(s)
Daniel M. Kaplan, MD
Saumil M. Chudgar, MD
Noppon Setji, MD
Thomas A. Owens, MD

Clinical question: Is the risk of recurrence of Clostridium difficile infection (CDI) increased by the use of “non-CDI” antimicrobial agents (inactive against C. diff) during or after CDI therapy?

Background: Recurrence of CDI is expected to increase with use of non-CDI antimicrobials. Previous studies have not distinguished between the timing of non-CDI agents during and after CDI treatment, nor examined the effect of frequency, duration, or type of non-CDI antibiotic therapy.

Study design: Retrospective cohort.

Setting: Academic Veterans Affairs medical center.

Synopsis: All patients with CDI over a three-year period were evaluated to determine the association between non-CDI antimicrobial during or within 30 days following CDI therapy and 90-day CDI recurrence. Of 246 patients, 57% received concurrent or subsequent non-CDI antimicrobials. CDI recurred in 40% of patients who received non-CDI antimicrobials and in 16% of those who did not (OR: 3.5, 95% CI: 1.9 to 6.5).

After multivariable adjustment (including age, duration of CDI treatment, comorbidity, hospital and ICU admission, and gastric acid suppression), those who received non-CDI antimicrobials during CDI therapy had no increased risk of recurrence. However, those who received any non-CDI antimicrobials after initial CDI treatment had an absolute recurrence rate of 48% with an adjusted OR of 3.02 (95% CI: 1.65 to 5.52). This increased risk of recurrence was unaffected by the number or duration of non-CDI antimicrobial prescriptions. Subgroup analysis by antimicrobial class revealed statistically significant associations only with beta-lactams and fluoroquinolones.

Bottom line: The risk of recurrence of CDI is tripled by exposure to non-CDI antimicrobials within 30 days after CDI treatment, irrespective of the number or duration of such exposures.

Citation: Drekonja DM, Amundson WH, DeCarolis DD, Kuskowski MA, Lederle FA, Johnson JR. Antimicrobial use and risk for recurrent Clostridium difficile infection. Am J Med. 2011;124:1081.e1-1081.e7.

Clinical question: Is the risk of recurrence of Clostridium difficile infection (CDI) increased by the use of “non-CDI” antimicrobial agents (inactive against C. diff) during or after CDI therapy?

Background: Recurrence of CDI is expected to increase with use of non-CDI antimicrobials. Previous studies have not distinguished between the timing of non-CDI agents during and after CDI treatment, nor examined the effect of frequency, duration, or type of non-CDI antibiotic therapy.

Study design: Retrospective cohort.

Setting: Academic Veterans Affairs medical center.

Synopsis: All patients with CDI over a three-year period were evaluated to determine the association between non-CDI antimicrobial during or within 30 days following CDI therapy and 90-day CDI recurrence. Of 246 patients, 57% received concurrent or subsequent non-CDI antimicrobials. CDI recurred in 40% of patients who received non-CDI antimicrobials and in 16% of those who did not (OR: 3.5, 95% CI: 1.9 to 6.5).

After multivariable adjustment (including age, duration of CDI treatment, comorbidity, hospital and ICU admission, and gastric acid suppression), those who received non-CDI antimicrobials during CDI therapy had no increased risk of recurrence. However, those who received any non-CDI antimicrobials after initial CDI treatment had an absolute recurrence rate of 48% with an adjusted OR of 3.02 (95% CI: 1.65 to 5.52). This increased risk of recurrence was unaffected by the number or duration of non-CDI antimicrobial prescriptions. Subgroup analysis by antimicrobial class revealed statistically significant associations only with beta-lactams and fluoroquinolones.

Bottom line: The risk of recurrence of CDI is tripled by exposure to non-CDI antimicrobials within 30 days after CDI treatment, irrespective of the number or duration of such exposures.

Citation: Drekonja DM, Amundson WH, DeCarolis DD, Kuskowski MA, Lederle FA, Johnson JR. Antimicrobial use and risk for recurrent Clostridium difficile infection. Am J Med. 2011;124:1081.e1-1081.e7.

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Drug for aHUS effective but expensive

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Attendees at the 17th Annual
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AMSTERDAM—Eculizumab elicits “phenomenal” results in atypical hemolytic uremic syndrome (aHUS), according to two presentations given at the 17th Annual Congress of the European Hematology Association.

But, as one speaker pointed out, the drug may prove too expensive for a lot of patients.

“It’s the most expensive drug I’ve ever come across in my entire life,” said Adrian Newland, MD, of Barts and The London School of Medicine and Dentistry in the UK.

He noted that the drug costs about £400,000 per year in the UK. And reports have listed the US cost at around $400,000 per year.

Expense aside, the drug elicits “dramatic” improvements in aHUS patients, according to Dr Newland. And he presented data to support that statement during an EHA-JSH joint symposium on platelet disorders.

Ramon Vilalta, MD, of Hospital Vall d’Hebron in Barcelona, Spain, also presented favorable results with eculizumab at the meeting, as abstract 1155.

Dr Vilalta began his presentation by pointing out that aHUS is a life-threatening disease that results in multi-organ damage caused by thrombotic microangiopathy (TMA). And plasma exchange/plasma infusion (PE/PI) therapy does little to alter the poor prognosis in this patient population.

“Our patients—pediatric patients mainly—develop end-stage renal failure and even die, despite treatment [with PE/PI],” he said. “[E]culizumab is an anti-C5 terminal complement blocker that could give some hope in the treatment of these patients.”

In an attempt to prove this theory, Dr Vilalta and his colleagues retrospectively analyzed 19 patients with aHUS. Patients—who ranged in age from 2 months to 17 years—received eculizumab for a median of 6 months (range, less than 1 month to 16 months). 

All 19 patients had renal complications prior to receiving eculizumab, and 10 had renal and extra-renal complications. Eight patients had baseline platelet counts less than 150 x 109/L. Eight patients were on dialysis at the start of therapy, and 6 patients had undergone kidney transplant.

The first thing the researchers noticed was that eculizumab increased patients’ platelet counts within a week of administration. And this effect was maintained throughout the study period.

Seven of the 8 patients (88%) with abnormal platelet counts at baseline achieved normalized platelet counts. And 89% of all the patients (17/19) had platelet counts of 150 x 109/L or greater at the data cutoff point.

Eculizumab also reduced the burden of disease, Dr Vilalta said. He and his colleagues observed a significant reduction in the TMA intervention rate, which included the number of PE/PIs and new dialysis events. There were a median of 2 interventions per patient per week before treatment initiation, and a median of 0 interventions during treatment (P<0.0001).

None of the patients required new dialysis, and eculizumab eliminated the need for dialysis in 50% of patients (4/8). 

Dr Vilalta also pointed out that eculizumab demonstrated similar efficacy regardless of patients’ mutation status or age. He added that the drug appeared to be well-tolerated, although the retrospective nature of the study did not allow for the full collection of drug-specific adverse events.

Of the side effects the researchers did observe, most were mild or moderate. Nine patients experienced pyrexia, 6 had diarrhea, 6 developed an upper respiratory tract infection, 5 developed a cough, 4 experienced vomiting, 4 had nasal congestion, 4 had tachycardia, and 1 patient developed a meningococcal infection during follow-up. 

Dr Newland presented similar results from another study of eculizumab in aHUS. He discussed the results during an EHA-JSH joint symposium on platelet disorders, but the study was also presented at ASH last year as abstract 193.

The study included 17 aHUS patients who received eculizumab for a mean of 58 weeks. All of the patients achieved event-free status, which was defined as 12 weeks or more of stable platelet count, no PE/PI, and no new dialysis. Additionally, 4 of 5 patients were able to discontinue dialysis as a result of treatment with eculizumab.

As in Dr Vilalta’s study, treatment was similarly effective in patients with or without complement regulatory factor mutations. And the drug was generally well-tolerated. Twelve patients experienced adverse events, 1 of which was severe.

“[Eculizumab] showed phenomenal results here,” Dr Newland said. “Patients, particularly those treated earlier in their disease, were able to normalize their renal function.”

He said such an improvement is “dramatic” for this patient population, as 25% of aHUS patients die with the first attack, and 50% go into end-stage renal disease. Therefore, eculizumab can be considered the standard of care for aHUS patients—“if [they] can afford it.”

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Attendees at the 17th Annual
Congress of the EHA
Photo courtesy of EHA

AMSTERDAM—Eculizumab elicits “phenomenal” results in atypical hemolytic uremic syndrome (aHUS), according to two presentations given at the 17th Annual Congress of the European Hematology Association.

But, as one speaker pointed out, the drug may prove too expensive for a lot of patients.

“It’s the most expensive drug I’ve ever come across in my entire life,” said Adrian Newland, MD, of Barts and The London School of Medicine and Dentistry in the UK.

He noted that the drug costs about £400,000 per year in the UK. And reports have listed the US cost at around $400,000 per year.

Expense aside, the drug elicits “dramatic” improvements in aHUS patients, according to Dr Newland. And he presented data to support that statement during an EHA-JSH joint symposium on platelet disorders.

Ramon Vilalta, MD, of Hospital Vall d’Hebron in Barcelona, Spain, also presented favorable results with eculizumab at the meeting, as abstract 1155.

Dr Vilalta began his presentation by pointing out that aHUS is a life-threatening disease that results in multi-organ damage caused by thrombotic microangiopathy (TMA). And plasma exchange/plasma infusion (PE/PI) therapy does little to alter the poor prognosis in this patient population.

“Our patients—pediatric patients mainly—develop end-stage renal failure and even die, despite treatment [with PE/PI],” he said. “[E]culizumab is an anti-C5 terminal complement blocker that could give some hope in the treatment of these patients.”

In an attempt to prove this theory, Dr Vilalta and his colleagues retrospectively analyzed 19 patients with aHUS. Patients—who ranged in age from 2 months to 17 years—received eculizumab for a median of 6 months (range, less than 1 month to 16 months). 

All 19 patients had renal complications prior to receiving eculizumab, and 10 had renal and extra-renal complications. Eight patients had baseline platelet counts less than 150 x 109/L. Eight patients were on dialysis at the start of therapy, and 6 patients had undergone kidney transplant.

The first thing the researchers noticed was that eculizumab increased patients’ platelet counts within a week of administration. And this effect was maintained throughout the study period.

Seven of the 8 patients (88%) with abnormal platelet counts at baseline achieved normalized platelet counts. And 89% of all the patients (17/19) had platelet counts of 150 x 109/L or greater at the data cutoff point.

Eculizumab also reduced the burden of disease, Dr Vilalta said. He and his colleagues observed a significant reduction in the TMA intervention rate, which included the number of PE/PIs and new dialysis events. There were a median of 2 interventions per patient per week before treatment initiation, and a median of 0 interventions during treatment (P<0.0001).

None of the patients required new dialysis, and eculizumab eliminated the need for dialysis in 50% of patients (4/8). 

Dr Vilalta also pointed out that eculizumab demonstrated similar efficacy regardless of patients’ mutation status or age. He added that the drug appeared to be well-tolerated, although the retrospective nature of the study did not allow for the full collection of drug-specific adverse events.

Of the side effects the researchers did observe, most were mild or moderate. Nine patients experienced pyrexia, 6 had diarrhea, 6 developed an upper respiratory tract infection, 5 developed a cough, 4 experienced vomiting, 4 had nasal congestion, 4 had tachycardia, and 1 patient developed a meningococcal infection during follow-up. 

Dr Newland presented similar results from another study of eculizumab in aHUS. He discussed the results during an EHA-JSH joint symposium on platelet disorders, but the study was also presented at ASH last year as abstract 193.

The study included 17 aHUS patients who received eculizumab for a mean of 58 weeks. All of the patients achieved event-free status, which was defined as 12 weeks or more of stable platelet count, no PE/PI, and no new dialysis. Additionally, 4 of 5 patients were able to discontinue dialysis as a result of treatment with eculizumab.

As in Dr Vilalta’s study, treatment was similarly effective in patients with or without complement regulatory factor mutations. And the drug was generally well-tolerated. Twelve patients experienced adverse events, 1 of which was severe.

“[Eculizumab] showed phenomenal results here,” Dr Newland said. “Patients, particularly those treated earlier in their disease, were able to normalize their renal function.”

He said such an improvement is “dramatic” for this patient population, as 25% of aHUS patients die with the first attack, and 50% go into end-stage renal disease. Therefore, eculizumab can be considered the standard of care for aHUS patients—“if [they] can afford it.”

Attendees at the 17th Annual
Congress of the EHA
Photo courtesy of EHA

AMSTERDAM—Eculizumab elicits “phenomenal” results in atypical hemolytic uremic syndrome (aHUS), according to two presentations given at the 17th Annual Congress of the European Hematology Association.

But, as one speaker pointed out, the drug may prove too expensive for a lot of patients.

“It’s the most expensive drug I’ve ever come across in my entire life,” said Adrian Newland, MD, of Barts and The London School of Medicine and Dentistry in the UK.

He noted that the drug costs about £400,000 per year in the UK. And reports have listed the US cost at around $400,000 per year.

Expense aside, the drug elicits “dramatic” improvements in aHUS patients, according to Dr Newland. And he presented data to support that statement during an EHA-JSH joint symposium on platelet disorders.

Ramon Vilalta, MD, of Hospital Vall d’Hebron in Barcelona, Spain, also presented favorable results with eculizumab at the meeting, as abstract 1155.

Dr Vilalta began his presentation by pointing out that aHUS is a life-threatening disease that results in multi-organ damage caused by thrombotic microangiopathy (TMA). And plasma exchange/plasma infusion (PE/PI) therapy does little to alter the poor prognosis in this patient population.

“Our patients—pediatric patients mainly—develop end-stage renal failure and even die, despite treatment [with PE/PI],” he said. “[E]culizumab is an anti-C5 terminal complement blocker that could give some hope in the treatment of these patients.”

In an attempt to prove this theory, Dr Vilalta and his colleagues retrospectively analyzed 19 patients with aHUS. Patients—who ranged in age from 2 months to 17 years—received eculizumab for a median of 6 months (range, less than 1 month to 16 months). 

All 19 patients had renal complications prior to receiving eculizumab, and 10 had renal and extra-renal complications. Eight patients had baseline platelet counts less than 150 x 109/L. Eight patients were on dialysis at the start of therapy, and 6 patients had undergone kidney transplant.

The first thing the researchers noticed was that eculizumab increased patients’ platelet counts within a week of administration. And this effect was maintained throughout the study period.

Seven of the 8 patients (88%) with abnormal platelet counts at baseline achieved normalized platelet counts. And 89% of all the patients (17/19) had platelet counts of 150 x 109/L or greater at the data cutoff point.

Eculizumab also reduced the burden of disease, Dr Vilalta said. He and his colleagues observed a significant reduction in the TMA intervention rate, which included the number of PE/PIs and new dialysis events. There were a median of 2 interventions per patient per week before treatment initiation, and a median of 0 interventions during treatment (P<0.0001).

None of the patients required new dialysis, and eculizumab eliminated the need for dialysis in 50% of patients (4/8). 

Dr Vilalta also pointed out that eculizumab demonstrated similar efficacy regardless of patients’ mutation status or age. He added that the drug appeared to be well-tolerated, although the retrospective nature of the study did not allow for the full collection of drug-specific adverse events.

Of the side effects the researchers did observe, most were mild or moderate. Nine patients experienced pyrexia, 6 had diarrhea, 6 developed an upper respiratory tract infection, 5 developed a cough, 4 experienced vomiting, 4 had nasal congestion, 4 had tachycardia, and 1 patient developed a meningococcal infection during follow-up. 

Dr Newland presented similar results from another study of eculizumab in aHUS. He discussed the results during an EHA-JSH joint symposium on platelet disorders, but the study was also presented at ASH last year as abstract 193.

The study included 17 aHUS patients who received eculizumab for a mean of 58 weeks. All of the patients achieved event-free status, which was defined as 12 weeks or more of stable platelet count, no PE/PI, and no new dialysis. Additionally, 4 of 5 patients were able to discontinue dialysis as a result of treatment with eculizumab.

As in Dr Vilalta’s study, treatment was similarly effective in patients with or without complement regulatory factor mutations. And the drug was generally well-tolerated. Twelve patients experienced adverse events, 1 of which was severe.

“[Eculizumab] showed phenomenal results here,” Dr Newland said. “Patients, particularly those treated earlier in their disease, were able to normalize their renal function.”

He said such an improvement is “dramatic” for this patient population, as 25% of aHUS patients die with the first attack, and 50% go into end-stage renal disease. Therefore, eculizumab can be considered the standard of care for aHUS patients—“if [they] can afford it.”

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Perceived Levels of Pain Associated with Bone Marrow Aspirates and Biopsies

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Perceived Levels of Pain Associated with Bone Marrow Aspirates and Biopsies

  • Giampaolo Talamo, MD; Jason Liao, PhD; Jamal Joudeh, MD; Nicholas E. Lamparella, DO; Hoang Dinh, PA; Jozef Malysz, MD; W. Christopher Ehmann, MD

    Abstract

    Background

    Little is known about the degree of pain experienced by patients undergoing a bone marrow aspiration and biopsy (BMAB).

    Objective

    To evaluate the effectiveness of several strategies aimed at reducing the pain score.

    Methods

    We conducted a retrospective analysis of 258 consecutive adult patients who underwent BMAB via 6 different approaches, the first 5 of which were performed by one physician. Group A received local anesthesia with 1% lidocaine hydrochloride (5 mL) and a 5-minute wait time before the procedure; group B received local anesthesia with a double dose (10 mL) of lidocaine; group C received 5 mL of local anesthesia with a 10-minute wait; group D received 5 mL of local anesthesia plus a topical spray with ethyl chloride; group E received oral analgesia and anxiolysis 30 minutes before the procedure in addition to the group A dosage of lidocaine; and group F received the same anesthesia as did group A, but the BMAD was performed by a less experienced practitioner.

    Results

    On a 0 to 10 scale, the mean pain level among the 258 patients was 3.2 (standard deviation = 2.6). Rate of complications was low (<1%). Several strategies failed to improve the pain level, including the administration of a double dose of local anesthesia, waiting longer for the anesthesia effect, and the additional use of a topical anesthetic spray or oral analgesia and anxiolysis. Pain levels were not increased when the procedure was done by a less experienced practitioner. Younger age and female gender were associated with higher pain levels.

    Conclusions

    Given that the average level of perceived pain during BMAB is low to moderate (approximately 3 on a 0-10 scale), the routine use of conscious sedation for this procedure may not be indicated. Several strategies aimed at reducing the pain level, including doubling the dose of anesthesia and using an oral prophylactic regimen of analgesia and anxiolysis, failed to improve pain scores.

    *For a PDF of the full article click in the link to the left of this introduction.

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Original research

Perceived Levels of Pain Associated with Bone Marrow Aspirates and Biopsies

  • Giampaolo Talamo, MD; Jason Liao, PhD; Jamal Joudeh, MD; Nicholas E. Lamparella, DO; Hoang Dinh, PA; Jozef Malysz, MD; W. Christopher Ehmann, MD

    Abstract

    Background

    Little is known about the degree of pain experienced by patients undergoing a bone marrow aspiration and biopsy (BMAB).

    Objective

    To evaluate the effectiveness of several strategies aimed at reducing the pain score.

    Methods

    We conducted a retrospective analysis of 258 consecutive adult patients who underwent BMAB via 6 different approaches, the first 5 of which were performed by one physician. Group A received local anesthesia with 1% lidocaine hydrochloride (5 mL) and a 5-minute wait time before the procedure; group B received local anesthesia with a double dose (10 mL) of lidocaine; group C received 5 mL of local anesthesia with a 10-minute wait; group D received 5 mL of local anesthesia plus a topical spray with ethyl chloride; group E received oral analgesia and anxiolysis 30 minutes before the procedure in addition to the group A dosage of lidocaine; and group F received the same anesthesia as did group A, but the BMAD was performed by a less experienced practitioner.

    Results

    On a 0 to 10 scale, the mean pain level among the 258 patients was 3.2 (standard deviation = 2.6). Rate of complications was low (<1%). Several strategies failed to improve the pain level, including the administration of a double dose of local anesthesia, waiting longer for the anesthesia effect, and the additional use of a topical anesthetic spray or oral analgesia and anxiolysis. Pain levels were not increased when the procedure was done by a less experienced practitioner. Younger age and female gender were associated with higher pain levels.

    Conclusions

    Given that the average level of perceived pain during BMAB is low to moderate (approximately 3 on a 0-10 scale), the routine use of conscious sedation for this procedure may not be indicated. Several strategies aimed at reducing the pain level, including doubling the dose of anesthesia and using an oral prophylactic regimen of analgesia and anxiolysis, failed to improve pain scores.

    *For a PDF of the full article click in the link to the left of this introduction.

Original research

Perceived Levels of Pain Associated with Bone Marrow Aspirates and Biopsies

  • Giampaolo Talamo, MD; Jason Liao, PhD; Jamal Joudeh, MD; Nicholas E. Lamparella, DO; Hoang Dinh, PA; Jozef Malysz, MD; W. Christopher Ehmann, MD

    Abstract

    Background

    Little is known about the degree of pain experienced by patients undergoing a bone marrow aspiration and biopsy (BMAB).

    Objective

    To evaluate the effectiveness of several strategies aimed at reducing the pain score.

    Methods

    We conducted a retrospective analysis of 258 consecutive adult patients who underwent BMAB via 6 different approaches, the first 5 of which were performed by one physician. Group A received local anesthesia with 1% lidocaine hydrochloride (5 mL) and a 5-minute wait time before the procedure; group B received local anesthesia with a double dose (10 mL) of lidocaine; group C received 5 mL of local anesthesia with a 10-minute wait; group D received 5 mL of local anesthesia plus a topical spray with ethyl chloride; group E received oral analgesia and anxiolysis 30 minutes before the procedure in addition to the group A dosage of lidocaine; and group F received the same anesthesia as did group A, but the BMAD was performed by a less experienced practitioner.

    Results

    On a 0 to 10 scale, the mean pain level among the 258 patients was 3.2 (standard deviation = 2.6). Rate of complications was low (<1%). Several strategies failed to improve the pain level, including the administration of a double dose of local anesthesia, waiting longer for the anesthesia effect, and the additional use of a topical anesthetic spray or oral analgesia and anxiolysis. Pain levels were not increased when the procedure was done by a less experienced practitioner. Younger age and female gender were associated with higher pain levels.

    Conclusions

    Given that the average level of perceived pain during BMAB is low to moderate (approximately 3 on a 0-10 scale), the routine use of conscious sedation for this procedure may not be indicated. Several strategies aimed at reducing the pain level, including doubling the dose of anesthesia and using an oral prophylactic regimen of analgesia and anxiolysis, failed to improve pain scores.

    *For a PDF of the full article click in the link to the left of this introduction.

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Physicians' Undecided Attitudes Toward Posthumous Reproduction: Fertility Preservation in Cancer Patients with a Poor Prognosis

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Physicians' Undecided Attitudes Toward Posthumous Reproduction: Fertility Preservation in Cancer Patients with a Poor Prognosis

  • Gwendolyn P. Quinn, PhD; Caprice A. Knapp, PhD; Teri L. Malo, PhD; Jessica McIntyre, BA; Paul B. Jacobsen, PhD; Susan T. Vadaparampil, PhD

    Abstract

    Background

    The American Society for Clinical Oncology (ASCO) established guidelines for fertility preservation for cancer patients. In a national study of US oncologists, we examined attitudes toward the use of fertility preservation among patients with a poor prognosis, focusing on attitudes toward posthumous reproduction.

    Method

    A cross-sectional survey was administered via mail and Internet to a stratified random sample of US oncologists. The survey measured demographics, knowledge, attitude, and practice behaviors regarding posthumous reproduction and fertility preservation with cancer patients of childbearing age.

    Results

    Only 16.2% supported posthumous parenting, whereas the majority (51.5%) did not have an opinion. Analysis of variance indicated that attitudes toward posthumous reproduction were significantly related to physician practice behaviors and were dependent on oncologists' knowledge of ASCO guidelines.

    Conclusions

    Physician attitudes may conflict with the recommended guidelines and may reduce the likelihood that some patients will receive information about fertility preservation. Further education may raise physicians' awareness of poor-prognostic patients' interest in pursuing this technology.

    *For a PDF of the full article click in the link to the left of this introduction.

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Physicians' Undecided Attitudes Toward Posthumous Reproduction: Fertility Preservation in Cancer Patients with a Poor Prognosis

  • Gwendolyn P. Quinn, PhD; Caprice A. Knapp, PhD; Teri L. Malo, PhD; Jessica McIntyre, BA; Paul B. Jacobsen, PhD; Susan T. Vadaparampil, PhD

    Abstract

    Background

    The American Society for Clinical Oncology (ASCO) established guidelines for fertility preservation for cancer patients. In a national study of US oncologists, we examined attitudes toward the use of fertility preservation among patients with a poor prognosis, focusing on attitudes toward posthumous reproduction.

    Method

    A cross-sectional survey was administered via mail and Internet to a stratified random sample of US oncologists. The survey measured demographics, knowledge, attitude, and practice behaviors regarding posthumous reproduction and fertility preservation with cancer patients of childbearing age.

    Results

    Only 16.2% supported posthumous parenting, whereas the majority (51.5%) did not have an opinion. Analysis of variance indicated that attitudes toward posthumous reproduction were significantly related to physician practice behaviors and were dependent on oncologists' knowledge of ASCO guidelines.

    Conclusions

    Physician attitudes may conflict with the recommended guidelines and may reduce the likelihood that some patients will receive information about fertility preservation. Further education may raise physicians' awareness of poor-prognostic patients' interest in pursuing this technology.

    *For a PDF of the full article click in the link to the left of this introduction.

Original research

Physicians' Undecided Attitudes Toward Posthumous Reproduction: Fertility Preservation in Cancer Patients with a Poor Prognosis

  • Gwendolyn P. Quinn, PhD; Caprice A. Knapp, PhD; Teri L. Malo, PhD; Jessica McIntyre, BA; Paul B. Jacobsen, PhD; Susan T. Vadaparampil, PhD

    Abstract

    Background

    The American Society for Clinical Oncology (ASCO) established guidelines for fertility preservation for cancer patients. In a national study of US oncologists, we examined attitudes toward the use of fertility preservation among patients with a poor prognosis, focusing on attitudes toward posthumous reproduction.

    Method

    A cross-sectional survey was administered via mail and Internet to a stratified random sample of US oncologists. The survey measured demographics, knowledge, attitude, and practice behaviors regarding posthumous reproduction and fertility preservation with cancer patients of childbearing age.

    Results

    Only 16.2% supported posthumous parenting, whereas the majority (51.5%) did not have an opinion. Analysis of variance indicated that attitudes toward posthumous reproduction were significantly related to physician practice behaviors and were dependent on oncologists' knowledge of ASCO guidelines.

    Conclusions

    Physician attitudes may conflict with the recommended guidelines and may reduce the likelihood that some patients will receive information about fertility preservation. Further education may raise physicians' awareness of poor-prognostic patients' interest in pursuing this technology.

    *For a PDF of the full article click in the link to the left of this introduction.

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Acyclovir Prophylaxis Against Varicella Zoster Virus Reactivation in Multiple Myeloma Patients Treated With Bortezomib-Based Therapies: A Retrospective Analysis of 100 Patients

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Acyclovir Prophylaxis Against Varicella Zoster Virus Reactivation in Multiple Myeloma Patients Treated With Bortezomib-Based Therapies: A Retrospective Analysis of 100 Patients

  • Abhisek Swaika, MD; Aneel Paulus, MD/ Kena C. Miller; MSN, FNP; Tamur Sher, MD; Nikolaos G. Almyroudis, MD; Donna Ball, NP; Margaret Wood; MSN; Aisha Masood, MD; Kelvin Lee, MD; Asher A. Chanan-Khan, MD

    Abstract

    Background

    Previous studies have indicated that, in patients with multiple myeloma (MM), bortezomib is associated with an increased incidence of herpes zoster, resulting from reactivation of latent varicella zoster virus (VZV).

    Objective

    Our objective was to determine whether increased risk of VZV reactivation could be abrogated by using prophylactic acyclovir.

    Methods

    We retrospectively evaluated 100 consecutive MM patients treated with bortezomib-based therapies at the Roswell Park Cancer Institute for development of herpes zoster. Frontline and relapsed/refractory patients were included, and patients received bortezomib alone or in combination with agents such as doxorubicin, melphalan, or dexamethasone. All patients received >4 weeks of acyclovir prophylaxis (400 mg twice daily), which was initiated prior to starting treatment with bortezomib and discontinued 4 weeks following bortezomib.

    Results

    Median patient age was 62 years, 57% were male, and most (56%) had Durie-Salmon stage IIIA MM. None of the 100 MM patients receiving acyclovir prophylaxis developed herpes zoster during treatment with bortezomib, irrespective of patients receiving a wide variety of concomitant antimyeloma therapies and regardless of response to bortezomib-based therapy. One additional patient, found to be noncompliant with acyclovir therapy, experienced VZV reactivation, having received 3 cycles of bortezomib (3 weeks each cycle) in combination with cyclophosphamide and dexamethasone.

    Limitations

    Limitations of the study include its small size and retrospective nature.

    Conclusions

    The increased risk of VZV reactivation observed in previous studies of bortezomib-based therapy was completely abrogated in this series of patients who received prophylaxis with acyclovir.

    *For a PDF of the full article click in the link to the left of this introduction.

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Acyclovir Prophylaxis Against Varicella Zoster Virus Reactivation in Multiple Myeloma Patients Treated With Bortezomib-Based Therapies: A Retrospective Analysis of 100 Patients

  • Abhisek Swaika, MD; Aneel Paulus, MD/ Kena C. Miller; MSN, FNP; Tamur Sher, MD; Nikolaos G. Almyroudis, MD; Donna Ball, NP; Margaret Wood; MSN; Aisha Masood, MD; Kelvin Lee, MD; Asher A. Chanan-Khan, MD

    Abstract

    Background

    Previous studies have indicated that, in patients with multiple myeloma (MM), bortezomib is associated with an increased incidence of herpes zoster, resulting from reactivation of latent varicella zoster virus (VZV).

    Objective

    Our objective was to determine whether increased risk of VZV reactivation could be abrogated by using prophylactic acyclovir.

    Methods

    We retrospectively evaluated 100 consecutive MM patients treated with bortezomib-based therapies at the Roswell Park Cancer Institute for development of herpes zoster. Frontline and relapsed/refractory patients were included, and patients received bortezomib alone or in combination with agents such as doxorubicin, melphalan, or dexamethasone. All patients received >4 weeks of acyclovir prophylaxis (400 mg twice daily), which was initiated prior to starting treatment with bortezomib and discontinued 4 weeks following bortezomib.

    Results

    Median patient age was 62 years, 57% were male, and most (56%) had Durie-Salmon stage IIIA MM. None of the 100 MM patients receiving acyclovir prophylaxis developed herpes zoster during treatment with bortezomib, irrespective of patients receiving a wide variety of concomitant antimyeloma therapies and regardless of response to bortezomib-based therapy. One additional patient, found to be noncompliant with acyclovir therapy, experienced VZV reactivation, having received 3 cycles of bortezomib (3 weeks each cycle) in combination with cyclophosphamide and dexamethasone.

    Limitations

    Limitations of the study include its small size and retrospective nature.

    Conclusions

    The increased risk of VZV reactivation observed in previous studies of bortezomib-based therapy was completely abrogated in this series of patients who received prophylaxis with acyclovir.

    *For a PDF of the full article click in the link to the left of this introduction.

Original research

Acyclovir Prophylaxis Against Varicella Zoster Virus Reactivation in Multiple Myeloma Patients Treated With Bortezomib-Based Therapies: A Retrospective Analysis of 100 Patients

  • Abhisek Swaika, MD; Aneel Paulus, MD/ Kena C. Miller; MSN, FNP; Tamur Sher, MD; Nikolaos G. Almyroudis, MD; Donna Ball, NP; Margaret Wood; MSN; Aisha Masood, MD; Kelvin Lee, MD; Asher A. Chanan-Khan, MD

    Abstract

    Background

    Previous studies have indicated that, in patients with multiple myeloma (MM), bortezomib is associated with an increased incidence of herpes zoster, resulting from reactivation of latent varicella zoster virus (VZV).

    Objective

    Our objective was to determine whether increased risk of VZV reactivation could be abrogated by using prophylactic acyclovir.

    Methods

    We retrospectively evaluated 100 consecutive MM patients treated with bortezomib-based therapies at the Roswell Park Cancer Institute for development of herpes zoster. Frontline and relapsed/refractory patients were included, and patients received bortezomib alone or in combination with agents such as doxorubicin, melphalan, or dexamethasone. All patients received >4 weeks of acyclovir prophylaxis (400 mg twice daily), which was initiated prior to starting treatment with bortezomib and discontinued 4 weeks following bortezomib.

    Results

    Median patient age was 62 years, 57% were male, and most (56%) had Durie-Salmon stage IIIA MM. None of the 100 MM patients receiving acyclovir prophylaxis developed herpes zoster during treatment with bortezomib, irrespective of patients receiving a wide variety of concomitant antimyeloma therapies and regardless of response to bortezomib-based therapy. One additional patient, found to be noncompliant with acyclovir therapy, experienced VZV reactivation, having received 3 cycles of bortezomib (3 weeks each cycle) in combination with cyclophosphamide and dexamethasone.

    Limitations

    Limitations of the study include its small size and retrospective nature.

    Conclusions

    The increased risk of VZV reactivation observed in previous studies of bortezomib-based therapy was completely abrogated in this series of patients who received prophylaxis with acyclovir.

    *For a PDF of the full article click in the link to the left of this introduction.

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Chemotherapy-induced nausea and vomiting in Asian women with breast cancer receiving anthracycline-based adjuvant chemotherapy

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Background Chemotherapy-induced nausea and vomiting (CINV) remain among the most frequently reported distressing side effects associated with anthracycline-based chemotherapy despite significant advances in antiemetic management. The main risk factor for severity of CINV is the emetogenic potential of the chemotherapeutic agents. However, patient-related risk factors have been identified, including genetic makeup. Although studies have noted that ethnicity influences nausea and vomiting in other contexts, there is a paucity of research regarding the impact of ethnicity on CINV. This study was undertaken to evaluate whether Asian women receiving anthracycline-based chemotherapy experience more CINV than non-Asians.

Methods A retrospective, comparative, correlational chart review was performed to abstract the relevant variables.

Results Data from a convenience sample of 358 women with breast cancer who received chemotherapy with doxorubicin between 2004 and 2008 at City of Hope in Duarte, California, were evaluated. The sample consisted of Caucasians (45%), Hispanics (27.7%), Asians (19.8%), and African Americans (7.5%). The results indicate that Asian women with breast cancer undergoing anthracycline-based chemotherapy experienced statistically significantly more clinically important CINV than their non-Asian counterparts.

Limitations The data were collected retrospectively, with a certain population distribution at a specific time.

Conclusion This study provides interesting preliminary evidence that Asian ethnicity plays a role in the development of severe CINV. When managing chemotherapy toxicities in women with breast cancer, health-care providers should tailor therapy to individual risk profiles. Specifically, consideration of antiemetic therapy should accommodate patient characteristics, such as Asian descent.

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Background Chemotherapy-induced nausea and vomiting (CINV) remain among the most frequently reported distressing side effects associated with anthracycline-based chemotherapy despite significant advances in antiemetic management. The main risk factor for severity of CINV is the emetogenic potential of the chemotherapeutic agents. However, patient-related risk factors have been identified, including genetic makeup. Although studies have noted that ethnicity influences nausea and vomiting in other contexts, there is a paucity of research regarding the impact of ethnicity on CINV. This study was undertaken to evaluate whether Asian women receiving anthracycline-based chemotherapy experience more CINV than non-Asians.

Methods A retrospective, comparative, correlational chart review was performed to abstract the relevant variables.

Results Data from a convenience sample of 358 women with breast cancer who received chemotherapy with doxorubicin between 2004 and 2008 at City of Hope in Duarte, California, were evaluated. The sample consisted of Caucasians (45%), Hispanics (27.7%), Asians (19.8%), and African Americans (7.5%). The results indicate that Asian women with breast cancer undergoing anthracycline-based chemotherapy experienced statistically significantly more clinically important CINV than their non-Asian counterparts.

Limitations The data were collected retrospectively, with a certain population distribution at a specific time.

Conclusion This study provides interesting preliminary evidence that Asian ethnicity plays a role in the development of severe CINV. When managing chemotherapy toxicities in women with breast cancer, health-care providers should tailor therapy to individual risk profiles. Specifically, consideration of antiemetic therapy should accommodate patient characteristics, such as Asian descent.

Click on the PDF icon at the top of this introduction to read the full article.​

 

Background Chemotherapy-induced nausea and vomiting (CINV) remain among the most frequently reported distressing side effects associated with anthracycline-based chemotherapy despite significant advances in antiemetic management. The main risk factor for severity of CINV is the emetogenic potential of the chemotherapeutic agents. However, patient-related risk factors have been identified, including genetic makeup. Although studies have noted that ethnicity influences nausea and vomiting in other contexts, there is a paucity of research regarding the impact of ethnicity on CINV. This study was undertaken to evaluate whether Asian women receiving anthracycline-based chemotherapy experience more CINV than non-Asians.

Methods A retrospective, comparative, correlational chart review was performed to abstract the relevant variables.

Results Data from a convenience sample of 358 women with breast cancer who received chemotherapy with doxorubicin between 2004 and 2008 at City of Hope in Duarte, California, were evaluated. The sample consisted of Caucasians (45%), Hispanics (27.7%), Asians (19.8%), and African Americans (7.5%). The results indicate that Asian women with breast cancer undergoing anthracycline-based chemotherapy experienced statistically significantly more clinically important CINV than their non-Asian counterparts.

Limitations The data were collected retrospectively, with a certain population distribution at a specific time.

Conclusion This study provides interesting preliminary evidence that Asian ethnicity plays a role in the development of severe CINV. When managing chemotherapy toxicities in women with breast cancer, health-care providers should tailor therapy to individual risk profiles. Specifically, consideration of antiemetic therapy should accommodate patient characteristics, such as Asian descent.

Click on the PDF icon at the top of this introduction to read the full article.​

 

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What Can I Do? Recommendations for Responding to Issues Identified by Patient-Reported Outcomes Assessments Used in Clinical Practice

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What Can I Do? Recommendations for Responding to Issues Identified by Patient-Reported Outcomes Assessments Used in Clinical Practice

  • Elizabeth F. Hughes, RN, BSN, CHPN,
  • Albert W. Wu, MD, MPH,
  • Michael A. Carducci, MD,
  • Claire F. Snyder, PhD

  • Received 4 October 2011. Accepted 21 February 2012. Available online 18 May 2012.

    Abstract

    There is increased interest in using patient-reported outcome (PRO) measures in routine clinical practice to improve patient management. The effectiveness of this intervention may be facilitated by providing suggestions to clinicians on how to address issues identified by the PROs. We sought to develop recommendations for clinicians on how to respond to issues covered by common cancer PRO questionnaires, including functional problems (eg, physical, social, emotional), symptoms (eg, diarrhea, pain), and needs (eg, patient care and support, information). The recommendations would be incorporated into a Web-based system for PRO assessment and reporting in use at our large, academic cancer center. To develop the recommendations, we conducted a multiphase, multidisciplinary, consensus process. We reviewed the literature and conducted one-on-one interviews with experts from various disciplines.

    Experts included medical oncologists, radiation oncologists, nurses, an internist, a palliative care specialist, an outcomes researcher, a chaplain, a social worker, and patient advocates. These interviews elicited the experts' recommendations for addressing problems in common PRO domains. Finally, we held a panel meeting attended by all the experts to attain consensus on the recommendations. The final consensus suggestions recommend further assessment of the problem as a first step. Treatment suggestions range from medication adjustments to lifestyle modifications to referrals to other disciplines. Further research will test whether clinicians find these suggestions useful for patient management.

*For a PDF of the full article click in the link to the left of this introduction.

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What Can I Do? Recommendations for Responding to Issues Identified by Patient-Reported Outcomes Assessments Used in Clinical Practice

  • Elizabeth F. Hughes, RN, BSN, CHPN,
  • Albert W. Wu, MD, MPH,
  • Michael A. Carducci, MD,
  • Claire F. Snyder, PhD

  • Received 4 October 2011. Accepted 21 February 2012. Available online 18 May 2012.

    Abstract

    There is increased interest in using patient-reported outcome (PRO) measures in routine clinical practice to improve patient management. The effectiveness of this intervention may be facilitated by providing suggestions to clinicians on how to address issues identified by the PROs. We sought to develop recommendations for clinicians on how to respond to issues covered by common cancer PRO questionnaires, including functional problems (eg, physical, social, emotional), symptoms (eg, diarrhea, pain), and needs (eg, patient care and support, information). The recommendations would be incorporated into a Web-based system for PRO assessment and reporting in use at our large, academic cancer center. To develop the recommendations, we conducted a multiphase, multidisciplinary, consensus process. We reviewed the literature and conducted one-on-one interviews with experts from various disciplines.

    Experts included medical oncologists, radiation oncologists, nurses, an internist, a palliative care specialist, an outcomes researcher, a chaplain, a social worker, and patient advocates. These interviews elicited the experts' recommendations for addressing problems in common PRO domains. Finally, we held a panel meeting attended by all the experts to attain consensus on the recommendations. The final consensus suggestions recommend further assessment of the problem as a first step. Treatment suggestions range from medication adjustments to lifestyle modifications to referrals to other disciplines. Further research will test whether clinicians find these suggestions useful for patient management.

*For a PDF of the full article click in the link to the left of this introduction.

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What Can I Do? Recommendations for Responding to Issues Identified by Patient-Reported Outcomes Assessments Used in Clinical Practice

  • Elizabeth F. Hughes, RN, BSN, CHPN,
  • Albert W. Wu, MD, MPH,
  • Michael A. Carducci, MD,
  • Claire F. Snyder, PhD

  • Received 4 October 2011. Accepted 21 February 2012. Available online 18 May 2012.

    Abstract

    There is increased interest in using patient-reported outcome (PRO) measures in routine clinical practice to improve patient management. The effectiveness of this intervention may be facilitated by providing suggestions to clinicians on how to address issues identified by the PROs. We sought to develop recommendations for clinicians on how to respond to issues covered by common cancer PRO questionnaires, including functional problems (eg, physical, social, emotional), symptoms (eg, diarrhea, pain), and needs (eg, patient care and support, information). The recommendations would be incorporated into a Web-based system for PRO assessment and reporting in use at our large, academic cancer center. To develop the recommendations, we conducted a multiphase, multidisciplinary, consensus process. We reviewed the literature and conducted one-on-one interviews with experts from various disciplines.

    Experts included medical oncologists, radiation oncologists, nurses, an internist, a palliative care specialist, an outcomes researcher, a chaplain, a social worker, and patient advocates. These interviews elicited the experts' recommendations for addressing problems in common PRO domains. Finally, we held a panel meeting attended by all the experts to attain consensus on the recommendations. The final consensus suggestions recommend further assessment of the problem as a first step. Treatment suggestions range from medication adjustments to lifestyle modifications to referrals to other disciplines. Further research will test whether clinicians find these suggestions useful for patient management.

*For a PDF of the full article click in the link to the left of this introduction.

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Central Nervous System Complications of Cancer Therapy

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Central Nervous System Complications of Cancer Therapy

  • Mikael L. Rinne, MD, PhD,
  • Eudocia Q. Lee, MD, MPH,
  • Patrick Y. Wen, MD

  • Received 16 July 2011. Accepted 15 November 2011. Available online 26 April 2012.

    Abstract

    As more effective therapies prolong the survival of patients with cancer, therapy-related toxicities, particularly those affecting the central nervous system (CNS) become increasingly important. CNS complications can cause significant morbidity and can limit the dose or duration of otherwise effective treatments. Because effects on the CNS are disabling and often permanent and treatments remain limited, it is important that clinicians recognize the effects of cancer therapy on the CNS. Cytotoxic chemotherapy and radiation are well-known causes of neurotoxicity, but there is increasing recognition that novel therapies are also sources of adverse effects on the CNS. This review highlights the CNS complications that result from radiation, chemotherapy, and novel therapeutics.

    Central nervous system (CNS) toxicity is a significant source of morbidity in the treatment of patients with cancer. Radiation, traditional cytotoxic chemotherapy, and novel biologic and targeted therapies all have recognized CNS side effects; and the risks of neurotoxicity can increase with combination therapy.1 Some CNS complications appear during treatment, while others present months or even years later. When patients present with neurologic deficits, practitioners need to recognize the signs and symptoms of treatment-related toxicity in order to intervene early and minimize neurologic damage. Treatment-related CNS toxicity needs to be distinguished from other direct or indirect effects of cancer, including tumor invasion, metastasis, metabolic derangements, infections, and paraneoplastic neurologic syndromes.

    *For a PDF of the full article and accompanying viewpoint by Ivo Tremont-Lukats, click in the links to the left of this introduction.

     

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Central Nervous System Complications of Cancer Therapy

  • Mikael L. Rinne, MD, PhD,
  • Eudocia Q. Lee, MD, MPH,
  • Patrick Y. Wen, MD

  • Received 16 July 2011. Accepted 15 November 2011. Available online 26 April 2012.

    Abstract

    As more effective therapies prolong the survival of patients with cancer, therapy-related toxicities, particularly those affecting the central nervous system (CNS) become increasingly important. CNS complications can cause significant morbidity and can limit the dose or duration of otherwise effective treatments. Because effects on the CNS are disabling and often permanent and treatments remain limited, it is important that clinicians recognize the effects of cancer therapy on the CNS. Cytotoxic chemotherapy and radiation are well-known causes of neurotoxicity, but there is increasing recognition that novel therapies are also sources of adverse effects on the CNS. This review highlights the CNS complications that result from radiation, chemotherapy, and novel therapeutics.

    Central nervous system (CNS) toxicity is a significant source of morbidity in the treatment of patients with cancer. Radiation, traditional cytotoxic chemotherapy, and novel biologic and targeted therapies all have recognized CNS side effects; and the risks of neurotoxicity can increase with combination therapy.1 Some CNS complications appear during treatment, while others present months or even years later. When patients present with neurologic deficits, practitioners need to recognize the signs and symptoms of treatment-related toxicity in order to intervene early and minimize neurologic damage. Treatment-related CNS toxicity needs to be distinguished from other direct or indirect effects of cancer, including tumor invasion, metastasis, metabolic derangements, infections, and paraneoplastic neurologic syndromes.

    *For a PDF of the full article and accompanying viewpoint by Ivo Tremont-Lukats, click in the links to the left of this introduction.

     

Central Nervous System Complications of Cancer Therapy

  • Mikael L. Rinne, MD, PhD,
  • Eudocia Q. Lee, MD, MPH,
  • Patrick Y. Wen, MD

  • Received 16 July 2011. Accepted 15 November 2011. Available online 26 April 2012.

    Abstract

    As more effective therapies prolong the survival of patients with cancer, therapy-related toxicities, particularly those affecting the central nervous system (CNS) become increasingly important. CNS complications can cause significant morbidity and can limit the dose or duration of otherwise effective treatments. Because effects on the CNS are disabling and often permanent and treatments remain limited, it is important that clinicians recognize the effects of cancer therapy on the CNS. Cytotoxic chemotherapy and radiation are well-known causes of neurotoxicity, but there is increasing recognition that novel therapies are also sources of adverse effects on the CNS. This review highlights the CNS complications that result from radiation, chemotherapy, and novel therapeutics.

    Central nervous system (CNS) toxicity is a significant source of morbidity in the treatment of patients with cancer. Radiation, traditional cytotoxic chemotherapy, and novel biologic and targeted therapies all have recognized CNS side effects; and the risks of neurotoxicity can increase with combination therapy.1 Some CNS complications appear during treatment, while others present months or even years later. When patients present with neurologic deficits, practitioners need to recognize the signs and symptoms of treatment-related toxicity in order to intervene early and minimize neurologic damage. Treatment-related CNS toxicity needs to be distinguished from other direct or indirect effects of cancer, including tumor invasion, metastasis, metabolic derangements, infections, and paraneoplastic neurologic syndromes.

    *For a PDF of the full article and accompanying viewpoint by Ivo Tremont-Lukats, click in the links to the left of this introduction.

     

Publications
The Journal of Community and Supportive Oncology
MDedge Hematology and Oncology
Publications
The Journal of Community and Supportive Oncology
MDedge Hematology and Oncology
Topics
CNS/Brain Cancer
Patient & Survivor Care
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Central Nervous System Complications of Cancer Therapy
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