The Myth of the Demanding Patient

Healthcare spending projectio(Image from the Commonwealth Fund)

You’ve heard it before – the cost of healthcare is too high, and it keeps on rising! Some physicians tend to place responsibility for high medical costs more on “demanding patients” than themselves. However, new research in JAMA Oncology suggests otherwise, noting that patient “demands” directly account for a negligible change in physician behavior and thus expenditure. Take a look at the original article, or, for a more colorful read, the editorial “The Myth of the Demanding Patient.”

Triple Negative Breast Cancer – Novel Targets

Dr. Theodora Ross, from the UTSW division of hematology and oncology, speaks about a new gene, beclin-1, that may be a target in treating triple-negative breast cancer. Her team expanded on work done by Dr. Beth Levine. Click the link to hear an NPR interview with Dr. Ross:

NPR interview

For more information, check out the original research.

 

The Anti-Nuclear Antibody (ANA!)

Patterns of ANA and Disease Associations

Homogenous pattern

  • Anti dsDNA
    • Specificity for SLE 95% – false positive in some hepatitis
    • Sensitivity 40-60% in SLE
    • One of 11 criteria for SLE
    • Predicts flares: may predate nephritis
  • Anti-Histone
    • Drug-induced lupus (procainamide, hydralazine, aldomet, dilantin, INH, tegretol)
    • Best for negative predictive value

Speckled pattern (ENA or acid extractable nuclear antigens)

  • Anti-Smith
    • 99% specific, 20% sensitive for SLE
  • Anti U1-RNP
    • 30-40% sensitive for SLE (associated with Raynaud’s and less severe clinical course)
    • Mixed connective tissue disease:
      • Nearly 100% sensitive
      • SLE, Raynaud’s, myositis, non-erosive arthritis, puffy hands, esophageal dysmotility, sicca, scleroderma-like
      • Other CTD: 2-5% scleroderma, 24% PM/scleroderma overlap, 4-17% PM/DM
    • Anti Ro (SSA) and La (SSB)
      • In primary Sjogren’s: Anti-SSA 88-96% and Anti SSB 71-87%
        • Associated with increased severity (vasculitis, hypergammaglobulinemia, lympho/leukopenia)
      • SLE: SSA 25%, SSB 10%
      • Neonatal lupus: 90%

Nucleolar (RNA-associated antigens)

  • Anti SCL-70 (Topoisomerase I)
    • 95% of patients with scleroderma – predicts more subacute, progressive, systemic disease
    • Diffuse scleroderma: 25-75% sensitivity, 93% specificity
    • CREST 13%
  • Anti PM-SCL: polymyositis/scleroderma overlap syndromes

Centromere

  • Limited scleroderma: 60-80%
  • Isolated Raynaud’s: 25% – may predict risk of CREST
  • Primary biliary cirrhosis
  • Normal: nearly 1% of female blood donors

Peripheral

  • Antibodies to nuclear envelope, seen with staining for dsDNA in older systems

Cytoplasmic

  • Mitochondrial pattern: primary biliary cirrosis, autoimmune hepatitis, IBD, scleroderma
  • Anti Jo-1 (speckled cytoplasmic)
    • 20-40% of patients with dermatomyositis, polymyositis, mixed PM/DM
    • Higher prevalence of ILD (20-25%)