Denise Napoli

The term “medical home” has become a health reform buzzword. But a new model of care for patients with severe mental illness has lately emerged: the mental health home.

“The [mental health home] model of care incorporates medical home characteristics,” wrote Dr. Thomas E. Smith and Dr. Lloyd I. Sederer in a recent paper (Psychiatric Services 2009:60;528-33).

“The key characteristics of the medical home model involve commitment to the management of chronic illness, involvement of the individual and family/support system at all times, multidisciplinary collaboration, and coordination of services. These are exactly the principles we want to emphasize with our 'mental health home' approach,” said Dr. Smith, of the department of psychiatry at Columbia University, New York, in an interview.

But there are key differences. For one, in the mental health home–a term Dr. Smith and Dr. Sederer coined–the care is coordinated by a psychiatrist or other mental health physician, not a primary care doctor.

That does not mean psychiatrists will treat medical conditions. “They will, however, be much more active in monitoring basic health and wellness indicators in their patients with serious mental illness.” And considering that psychiatric treatments are often associated with weight gain, metabolic syndrome, diabetes, and obesity, “I think the onus is on the mental health provider to pay attention to some of these primary care issues,” he added.

The second difference between the proposed mental health home and the conventional medical home model is that the former would target a very exclusive group of patients: the seriously mentally ill.

“This is not for the entire mental health population,” Dr. Smith said. It would service “a population that in most states are treated within the public mental health system, either state-run clinics or clinics that bill for state services.”

The people who are cared for in these settings primarily have diagnoses like schizophrenia, bipolar disorder, or severe depression, with significant disability.

“These are [patients] who don't engage well; they don't follow up and aren't advocates for their own care… These people don't have family doctors. They have a hard enough time following up with their mental health care, never mind their primary health care,” he added.

The goal of the paper, said Dr. Smith, was to introduce the concept of a mental health home as being a complement–not replacement–to the medical home model, and to “get people thinking about how these principles could be applied to the care and of the seriously mentally ill.”

Neither Dr. Smith nor Dr. Sederer, who is with the medical director of the New York State Office of Mental Health, disclosed any conflicts of interest.

Payment Urged for Pediatricians Who Administer Mental Health Care

A new joint paper urges reimbursement for pediatricians who screen and treat patients for mental illness in the “medical home” setting.

That's because pediatricians, can and should act as effective “portals of entry” into specialty mental health treatment, according to the authors. They therefore deserve “payment for assessment and treatment of mental health problems [that is] adequate and comparable with payment for services addressing other medical illnesses,” according to the American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics.

“Furthermore, payment must be proportionate to the complexity of the situation and the additional time and work required in managing mental health conditions,” the statement said (doi: 10.1542/peds.2009-0048).

The statement is at least partly a reaction to the ongoing shortage of child and adolescent psychiatrists, which “makes coordination of treatment between primary care physicians, and child and adolescent psychiatrists paramount,” said AACAP President Robert Hendren, D.O., in a statement.

The report adds that although “almost one in five children in the United States suffers from a diagnosable mental disorder, only 20%-25% of affected children receive treatment.”

The paper was supported by an “Improving Mental Heath in Primary Care Through Access, Collaboration, and Training (IMPACT)” grant from the U.S. Department of Health and Human Services.

The term “medical home” has become a health reform buzzword. But a new model of care for patients with severe mental illness has lately emerged: the mental health home.

“The [mental health home] model of care incorporates medical home characteristics,” wrote Dr. Thomas E. Smith and Dr. Lloyd I. Sederer in a recent paper (Psychiatric Services 2009:60;528-33).

“The key characteristics of the medical home model involve commitment to the management of chronic illness, involvement of the individual and family/support system at all times, multidisciplinary collaboration, and coordination of services. These are exactly the principles we want to emphasize with our 'mental health home' approach,” said Dr. Smith, of the department of psychiatry at Columbia University, New York, in an interview.

But there are key differences. For one, in the mental health home–a term Dr. Smith and Dr. Sederer coined–the care is coordinated by a psychiatrist or other mental health physician, not a primary care doctor.

That does not mean psychiatrists will treat medical conditions. “They will, however, be much more active in monitoring basic health and wellness indicators in their patients with serious mental illness.” And considering that psychiatric treatments are often associated with weight gain, metabolic syndrome, diabetes, and obesity, “I think the onus is on the mental health provider to pay attention to some of these primary care issues,” he added.

The second difference between the proposed mental health home and the conventional medical home model is that the former would target a very exclusive group of patients: the seriously mentally ill.

“This is not for the entire mental health population,” Dr. Smith said. It would service “a population that in most states are treated within the public mental health system, either state-run clinics or clinics that bill for state services.”

The people who are cared for in these settings primarily have diagnoses like schizophrenia, bipolar disorder, or severe depression, with significant disability.

“These are [patients] who don't engage well; they don't follow up and aren't advocates for their own care… These people don't have family doctors. They have a hard enough time following up with their mental health care, never mind their primary health care,” he added.

The goal of the paper, said Dr. Smith, was to introduce the concept of a mental health home as being a complement–not replacement–to the medical home model, and to “get people thinking about how these principles could be applied to the care and of the seriously mentally ill.”

Neither Dr. Smith nor Dr. Sederer, who is with the medical director of the New York State Office of Mental Health, disclosed any conflicts of interest.

Payment Urged for Pediatricians Who Administer Mental Health Care

A new joint paper urges reimbursement for pediatricians who screen and treat patients for mental illness in the “medical home” setting.

That's because pediatricians, can and should act as effective “portals of entry” into specialty mental health treatment, according to the authors. They therefore deserve “payment for assessment and treatment of mental health problems [that is] adequate and comparable with payment for services addressing other medical illnesses,” according to the American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics.

“Furthermore, payment must be proportionate to the complexity of the situation and the additional time and work required in managing mental health conditions,” the statement said (doi: 10.1542/peds.2009-0048).

The statement is at least partly a reaction to the ongoing shortage of child and adolescent psychiatrists, which “makes coordination of treatment between primary care physicians, and child and adolescent psychiatrists paramount,” said AACAP President Robert Hendren, D.O., in a statement.

The report adds that although “almost one in five children in the United States suffers from a diagnosable mental disorder, only 20%-25% of affected children receive treatment.”

The paper was supported by an “Improving Mental Heath in Primary Care Through Access, Collaboration, and Training (IMPACT)” grant from the U.S. Department of Health and Human Services.

The term “medical home” has become a health reform buzzword. But a new model of care for patients with severe mental illness has lately emerged: the mental health home.

“The [mental health home] model of care incorporates medical home characteristics,” wrote Dr. Thomas E. Smith and Dr. Lloyd I. Sederer in a recent paper (Psychiatric Services 2009:60;528-33).

“The key characteristics of the medical home model involve commitment to the management of chronic illness, involvement of the individual and family/support system at all times, multidisciplinary collaboration, and coordination of services. These are exactly the principles we want to emphasize with our 'mental health home' approach,” said Dr. Smith, of the department of psychiatry at Columbia University, New York, in an interview.

But there are key differences. For one, in the mental health home–a term Dr. Smith and Dr. Sederer coined–the care is coordinated by a psychiatrist or other mental health physician, not a primary care doctor.

That does not mean psychiatrists will treat medical conditions. “They will, however, be much more active in monitoring basic health and wellness indicators in their patients with serious mental illness.” And considering that psychiatric treatments are often associated with weight gain, metabolic syndrome, diabetes, and obesity, “I think the onus is on the mental health provider to pay attention to some of these primary care issues,” he added.

The second difference between the proposed mental health home and the conventional medical home model is that the former would target a very exclusive group of patients: the seriously mentally ill.

“This is not for the entire mental health population,” Dr. Smith said. It would service “a population that in most states are treated within the public mental health system, either state-run clinics or clinics that bill for state services.”

The people who are cared for in these settings primarily have diagnoses like schizophrenia, bipolar disorder, or severe depression, with significant disability.

“These are [patients] who don't engage well; they don't follow up and aren't advocates for their own care… These people don't have family doctors. They have a hard enough time following up with their mental health care, never mind their primary health care,” he added.

The goal of the paper, said Dr. Smith, was to introduce the concept of a mental health home as being a complement–not replacement–to the medical home model, and to “get people thinking about how these principles could be applied to the care and of the seriously mentally ill.”

Neither Dr. Smith nor Dr. Sederer, who is with the medical director of the New York State Office of Mental Health, disclosed any conflicts of interest.

Payment Urged for Pediatricians Who Administer Mental Health Care

A new joint paper urges reimbursement for pediatricians who screen and treat patients for mental illness in the “medical home” setting.

That's because pediatricians, can and should act as effective “portals of entry” into specialty mental health treatment, according to the authors. They therefore deserve “payment for assessment and treatment of mental health problems [that is] adequate and comparable with payment for services addressing other medical illnesses,” according to the American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics.

“Furthermore, payment must be proportionate to the complexity of the situation and the additional time and work required in managing mental health conditions,” the statement said (doi: 10.1542/peds.2009-0048).

The statement is at least partly a reaction to the ongoing shortage of child and adolescent psychiatrists, which “makes coordination of treatment between primary care physicians, and child and adolescent psychiatrists paramount,” said AACAP President Robert Hendren, D.O., in a statement.

The report adds that although “almost one in five children in the United States suffers from a diagnosable mental disorder, only 20%-25% of affected children receive treatment.”

The paper was supported by an “Improving Mental Heath in Primary Care Through Access, Collaboration, and Training (IMPACT)” grant from the U.S. Department of Health and Human Services.

WASHINGTON — The most significant justification for proactive topical steroid therapy administered between atopic dermatitis flares is that "normal-looking" skin is not really normal, said Dr. Andreas Wollenberg.

"It doesn't follow our dermatological tradition to treat skin that doesn't look diseased," Dr. Wollenberg said during a debate session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. But even when symptoms temporarily subside, "there is a barrier defect in the normal-looking skin. There is an infiltration of inflammatory cells in the normal looking skin. And there is an alteration of the dendritic cells in the normal looking skin."

Administering therapy proactively, as opposed to only upon flaring, increases a patient's sense of control over the disease. "From the patient's point of view, it's the patient who rules the disease, and not the disease who rules the patient," he said. "Our patients love proactive therapy."

Proactive treatment also can decrease the number of flares, as well as flare duration and severity, compared with as-needed therapy, said Dr. Wollenberg, of the Department of Dermatology and Allergy, Ludwig-Maximilians-Universität, Munich. He recently completed a study showing that tacrolimus 0.1% ointment given twice weekly "significantly reduced the number of [disease exacerbations or DE] requiring substantial therapeutic intervention … the percentage of DE treatment days … and increased the time to first DE," (Allergy 2008;63:742-50).

In a rebuttal, Dr. Mark Boguniewicz of the National Jewish Medical and Research Center in Denver, cautioned that "before we accept a new paradigm like this we need to consider a few things. A critical appraisal of the current data would be useful."

"Should we ignore practice guidelines, practice parameters, consensus statements, package inserts, and the [Food and Drug Administration] boxed warnings, and can we afford to?" he asked. "And what do the adherence studies tell us?

"Does it make sense to apply topic medications to normal-appearing skin in a disease where most of our patients outgrow the problem early on?"

He also pointed out that the effects of long-term corticosteroids on unaffected skin are not known.

Both presenters disclosed financial and consulting relationships to multiple pharmaceutical companies.

WASHINGTON — The most significant justification for proactive topical steroid therapy administered between atopic dermatitis flares is that "normal-looking" skin is not really normal, said Dr. Andreas Wollenberg.

"It doesn't follow our dermatological tradition to treat skin that doesn't look diseased," Dr. Wollenberg said during a debate session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. But even when symptoms temporarily subside, "there is a barrier defect in the normal-looking skin. There is an infiltration of inflammatory cells in the normal looking skin. And there is an alteration of the dendritic cells in the normal looking skin."

Administering therapy proactively, as opposed to only upon flaring, increases a patient's sense of control over the disease. "From the patient's point of view, it's the patient who rules the disease, and not the disease who rules the patient," he said. "Our patients love proactive therapy."

Proactive treatment also can decrease the number of flares, as well as flare duration and severity, compared with as-needed therapy, said Dr. Wollenberg, of the Department of Dermatology and Allergy, Ludwig-Maximilians-Universität, Munich. He recently completed a study showing that tacrolimus 0.1% ointment given twice weekly "significantly reduced the number of [disease exacerbations or DE] requiring substantial therapeutic intervention … the percentage of DE treatment days … and increased the time to first DE," (Allergy 2008;63:742-50).

In a rebuttal, Dr. Mark Boguniewicz of the National Jewish Medical and Research Center in Denver, cautioned that "before we accept a new paradigm like this we need to consider a few things. A critical appraisal of the current data would be useful."

"Should we ignore practice guidelines, practice parameters, consensus statements, package inserts, and the [Food and Drug Administration] boxed warnings, and can we afford to?" he asked. "And what do the adherence studies tell us?

"Does it make sense to apply topic medications to normal-appearing skin in a disease where most of our patients outgrow the problem early on?"

He also pointed out that the effects of long-term corticosteroids on unaffected skin are not known.

Both presenters disclosed financial and consulting relationships to multiple pharmaceutical companies.

WASHINGTON — The most significant justification for proactive topical steroid therapy administered between atopic dermatitis flares is that "normal-looking" skin is not really normal, said Dr. Andreas Wollenberg.

"It doesn't follow our dermatological tradition to treat skin that doesn't look diseased," Dr. Wollenberg said during a debate session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. But even when symptoms temporarily subside, "there is a barrier defect in the normal-looking skin. There is an infiltration of inflammatory cells in the normal looking skin. And there is an alteration of the dendritic cells in the normal looking skin."

Administering therapy proactively, as opposed to only upon flaring, increases a patient's sense of control over the disease. "From the patient's point of view, it's the patient who rules the disease, and not the disease who rules the patient," he said. "Our patients love proactive therapy."

Proactive treatment also can decrease the number of flares, as well as flare duration and severity, compared with as-needed therapy, said Dr. Wollenberg, of the Department of Dermatology and Allergy, Ludwig-Maximilians-Universität, Munich. He recently completed a study showing that tacrolimus 0.1% ointment given twice weekly "significantly reduced the number of [disease exacerbations or DE] requiring substantial therapeutic intervention … the percentage of DE treatment days … and increased the time to first DE," (Allergy 2008;63:742-50).

In a rebuttal, Dr. Mark Boguniewicz of the National Jewish Medical and Research Center in Denver, cautioned that "before we accept a new paradigm like this we need to consider a few things. A critical appraisal of the current data would be useful."

"Should we ignore practice guidelines, practice parameters, consensus statements, package inserts, and the [Food and Drug Administration] boxed warnings, and can we afford to?" he asked. "And what do the adherence studies tell us?

"Does it make sense to apply topic medications to normal-appearing skin in a disease where most of our patients outgrow the problem early on?"

He also pointed out that the effects of long-term corticosteroids on unaffected skin are not known.

Both presenters disclosed financial and consulting relationships to multiple pharmaceutical companies.

WASHINGTON — EpiPen prescriptions were more common in U.S. cities at higher latitudes and with lower UVB exposure than more southern cities, suggesting a possible link between vitamin D levels and allergic disorders.

For every increase in latitude degree, the number of prescriptions for the allergy rescue medication (per 1,000 people) increased by 0.6, according to findings presented in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

"While we think that vitamin D is the most likely explanation, we also understand that these are population data, and that much more work needs to be done before we can say with confidence that low vitamin D causes food allergy," Dr. Carlos A. Camargo said in an interview.

Dr. Camargo, an emergency physician at Massachusetts General Hospital in Boston, and colleagues, looked at the number of EpiPen prescriptions in 38 west-coast cities in 2004. Data were obtained from Wolters Kluwer Health, a Phoenix-based health care information services provider. The cities were in Washington, Oregon, and California.

The data were correlated with average UVB exposure and controlled for 17 demographic characteristics.

In total, there were 151,073 EpiPen prescriptions, accounting for 245,169 pens, or 7.45 EpiPens per 1,000 people.

People in Bellingham, Wash. (latitude 48.76) required the greatest number of EpiPen prescriptions at 15.77 per 1,000 people in the city.

The lowest number of prescriptions (2.11 prescriptions per 1,000 people) was registered in Bakersfield, Calif. (latitude 35.37) which, according to the Bakersfield Convention and Visitor's Bureau, records about 300 days of sunshine annually. Bakersfield receives approximately 50% more UVB over a calendar year than Bellingham.

Although exact annual UVB exposure data per city weren't available, Dr. Camargo said that "The key concept is that, for the west coast of the U.S.A., latitude and UVB exposure are colinear; a higher latitude equals lower UVB." And although Washington is a notoriously rainy state, "It's not the rainy days in Washington that matter, but rather the higher latitude, though rainy/cloudy days don't help."

In their earlier analysis, he and his colleagues found that New England states had the highest levels of EpiPen prescriptions, with 8-12 per 1,000 persons, whereas southern states—including California—had only 3 per 1,000 (J. Clin. Allergy Immunol. 2007;120:131-6).

Dr. Camargo, a faculty member at Harvard Medical School, Boston, and his coauthors reported financial ties to several pharmaceutical companies on diverse topics. None of the investigators has financial ties to the food industry, supplement manufacturers, or the indoor tanning industry.

'While we think that vitamin D is the most likely explanation, we also understand that these are population data.' DR. CAMARGO

WASHINGTON — EpiPen prescriptions were more common in U.S. cities at higher latitudes and with lower UVB exposure than more southern cities, suggesting a possible link between vitamin D levels and allergic disorders.

For every increase in latitude degree, the number of prescriptions for the allergy rescue medication (per 1,000 people) increased by 0.6, according to findings presented in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

"While we think that vitamin D is the most likely explanation, we also understand that these are population data, and that much more work needs to be done before we can say with confidence that low vitamin D causes food allergy," Dr. Carlos A. Camargo said in an interview.

Dr. Camargo, an emergency physician at Massachusetts General Hospital in Boston, and colleagues, looked at the number of EpiPen prescriptions in 38 west-coast cities in 2004. Data were obtained from Wolters Kluwer Health, a Phoenix-based health care information services provider. The cities were in Washington, Oregon, and California.

The data were correlated with average UVB exposure and controlled for 17 demographic characteristics.

In total, there were 151,073 EpiPen prescriptions, accounting for 245,169 pens, or 7.45 EpiPens per 1,000 people.

People in Bellingham, Wash. (latitude 48.76) required the greatest number of EpiPen prescriptions at 15.77 per 1,000 people in the city.

The lowest number of prescriptions (2.11 prescriptions per 1,000 people) was registered in Bakersfield, Calif. (latitude 35.37) which, according to the Bakersfield Convention and Visitor's Bureau, records about 300 days of sunshine annually. Bakersfield receives approximately 50% more UVB over a calendar year than Bellingham.

Although exact annual UVB exposure data per city weren't available, Dr. Camargo said that "The key concept is that, for the west coast of the U.S.A., latitude and UVB exposure are colinear; a higher latitude equals lower UVB." And although Washington is a notoriously rainy state, "It's not the rainy days in Washington that matter, but rather the higher latitude, though rainy/cloudy days don't help."

In their earlier analysis, he and his colleagues found that New England states had the highest levels of EpiPen prescriptions, with 8-12 per 1,000 persons, whereas southern states—including California—had only 3 per 1,000 (J. Clin. Allergy Immunol. 2007;120:131-6).

Dr. Camargo, a faculty member at Harvard Medical School, Boston, and his coauthors reported financial ties to several pharmaceutical companies on diverse topics. None of the investigators has financial ties to the food industry, supplement manufacturers, or the indoor tanning industry.

'While we think that vitamin D is the most likely explanation, we also understand that these are population data.' DR. CAMARGO

WASHINGTON — EpiPen prescriptions were more common in U.S. cities at higher latitudes and with lower UVB exposure than more southern cities, suggesting a possible link between vitamin D levels and allergic disorders.

For every increase in latitude degree, the number of prescriptions for the allergy rescue medication (per 1,000 people) increased by 0.6, according to findings presented in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

"While we think that vitamin D is the most likely explanation, we also understand that these are population data, and that much more work needs to be done before we can say with confidence that low vitamin D causes food allergy," Dr. Carlos A. Camargo said in an interview.

Dr. Camargo, an emergency physician at Massachusetts General Hospital in Boston, and colleagues, looked at the number of EpiPen prescriptions in 38 west-coast cities in 2004. Data were obtained from Wolters Kluwer Health, a Phoenix-based health care information services provider. The cities were in Washington, Oregon, and California.

The data were correlated with average UVB exposure and controlled for 17 demographic characteristics.

In total, there were 151,073 EpiPen prescriptions, accounting for 245,169 pens, or 7.45 EpiPens per 1,000 people.

People in Bellingham, Wash. (latitude 48.76) required the greatest number of EpiPen prescriptions at 15.77 per 1,000 people in the city.

The lowest number of prescriptions (2.11 prescriptions per 1,000 people) was registered in Bakersfield, Calif. (latitude 35.37) which, according to the Bakersfield Convention and Visitor's Bureau, records about 300 days of sunshine annually. Bakersfield receives approximately 50% more UVB over a calendar year than Bellingham.

Although exact annual UVB exposure data per city weren't available, Dr. Camargo said that "The key concept is that, for the west coast of the U.S.A., latitude and UVB exposure are colinear; a higher latitude equals lower UVB." And although Washington is a notoriously rainy state, "It's not the rainy days in Washington that matter, but rather the higher latitude, though rainy/cloudy days don't help."

In their earlier analysis, he and his colleagues found that New England states had the highest levels of EpiPen prescriptions, with 8-12 per 1,000 persons, whereas southern states—including California—had only 3 per 1,000 (J. Clin. Allergy Immunol. 2007;120:131-6).

Dr. Camargo, a faculty member at Harvard Medical School, Boston, and his coauthors reported financial ties to several pharmaceutical companies on diverse topics. None of the investigators has financial ties to the food industry, supplement manufacturers, or the indoor tanning industry.

'While we think that vitamin D is the most likely explanation, we also understand that these are population data.' DR. CAMARGO

A U.S. federal judge ordered the Food and Drug Administration on March 23 to make the emergency contraceptive Plan B (levonorgestrel) available to 17-year-olds without a prescription within 30 days. Currently, Plan B is available without prescription to women aged 18 years and older.

U.S. District Judge Edward R. Korman also ordered the FDA to reconsider approving over-the-counter sale of the drug without age or point-of-sale restrictions.

“While the FDA is free, on remand, to exercise its expertise and discretion,” Judge Korman wrote, “no useful purpose would be served by continuing to deprive 17-year-olds access to Plan B without a prescription. Indeed, the record shows that FDA officials and staff both agreed that 17-years-olds can use Plan B safely without a prescription.”

Dr. Beth Jordan, medical director for the Association of Reproductive Health Professionals, called the ruling “a clear message to the FDA that decisions about medical devices and drugs must be based on science—not ideology.”

She added that “It is safe and easy for reproductive-age women to self-diagnose [their] own need for Plan B and then to use it—a fact the FDA's own panel of independent medical experts advised them on prior to the FDA's politically motivated decision” to restrict the drug.

The ruling is a reaction to a citizen petition filed by the nonprofit Center for Reproductive Rights, Tummino v. Torti (formerly known as Tummino v. von Eschenbach) which requested that the FDA make Plan B available without a prescription to women of all ages.

In his ruling, Judge Korman pointed out that “Plan B and other emergency contraceptives with the same active ingredient are available without a prescription or age restriction in much of the world, including virtually all major industrialized nations.”

Clearly, the ruling has sparked controversy. Chris Gacek, a senior fellow at the Family Research Council, a Christian nonprofit and lobbying group, said, “There is a real danger that Plan B may be given to women, especially sexually abused women and minors, under coercion or without their consent.” Forcing underage children to get a prescription for the drug from a health care provider can help identify sexual abuse victims and screen for sexually transmitted diseases in these patients, he said.

Survey Implies Some Difficulties in Obtaining Plan B

SAN FRANCISCO — Emergency contraception is available in 69% of Los Angeles pharmacies, and patients usually receive accurate information when inquiring about it, according to a study using sham patients.

However, in one-third of encounters in the study, the patients received the information only after multiple calls and multiple recitations of their situation, Dr. Anita L. Nelson said at a conference on contraceptive technology sponsored by Contemporary Forums.

Some pharmacies provided inaccurate information. For example, of 1,206 pharmacies contacted, 74 (6%) referred the woman to her clinician for a prescription.

At the time of the study, Plan B was available without a prescription to women aged 18 years and older.

Dr. Nelson and Dr. Cindy M. Jaime of the Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, Calif., conducted the study between October 2007 and October 2008. They attempted to contact all 1,440 unduplicated telephone numbers for pharmacies listed in the Yellow Pages for Los Angeles County (Contraception 2009;79:206-10).

Female interviewers were trained to speak hesitantly to the person who answered and to say that she and her boyfriend had had sex the day before and that he had just told her that he had not used a condom. She then said that she had heard that maybe there was something she could take to keep from getting pregnant, and asked the person on the telephone if he or she knew about this.

Of the 1,206 pharmacies the investigators were able to contact, 835 (69%) responded that they carried emergency contraception and had it available on site without a prescription. An additional 232 (19%) responded that they did not have it in stock or did not carry it themselves but referred the caller to other pharmacies. Others provided inaccurate information regarding the timeframe in which Plan B must be taken. Seventeen pharmacists hung up the phone after hearing the caller's question, and several hung up repeatedly upon being called back. Others asked overly personal questions.

Dr. Nelson said that the study received no outside funding and she said that she has served on advisory boards and speakers bureaus, and has received research funding from, Duramed/Barr Pharmaceuticals Inc., which manufactures Plan B. Contemporary Forums and this news organization are owned by Elsevier.

—Robert Finn

A U.S. federal judge ordered the Food and Drug Administration on March 23 to make the emergency contraceptive Plan B (levonorgestrel) available to 17-year-olds without a prescription within 30 days. Currently, Plan B is available without prescription to women aged 18 years and older.

U.S. District Judge Edward R. Korman also ordered the FDA to reconsider approving over-the-counter sale of the drug without age or point-of-sale restrictions.

“While the FDA is free, on remand, to exercise its expertise and discretion,” Judge Korman wrote, “no useful purpose would be served by continuing to deprive 17-year-olds access to Plan B without a prescription. Indeed, the record shows that FDA officials and staff both agreed that 17-years-olds can use Plan B safely without a prescription.”

Dr. Beth Jordan, medical director for the Association of Reproductive Health Professionals, called the ruling “a clear message to the FDA that decisions about medical devices and drugs must be based on science—not ideology.”

She added that “It is safe and easy for reproductive-age women to self-diagnose [their] own need for Plan B and then to use it—a fact the FDA's own panel of independent medical experts advised them on prior to the FDA's politically motivated decision” to restrict the drug.

The ruling is a reaction to a citizen petition filed by the nonprofit Center for Reproductive Rights, Tummino v. Torti (formerly known as Tummino v. von Eschenbach) which requested that the FDA make Plan B available without a prescription to women of all ages.

In his ruling, Judge Korman pointed out that “Plan B and other emergency contraceptives with the same active ingredient are available without a prescription or age restriction in much of the world, including virtually all major industrialized nations.”

Clearly, the ruling has sparked controversy. Chris Gacek, a senior fellow at the Family Research Council, a Christian nonprofit and lobbying group, said, “There is a real danger that Plan B may be given to women, especially sexually abused women and minors, under coercion or without their consent.” Forcing underage children to get a prescription for the drug from a health care provider can help identify sexual abuse victims and screen for sexually transmitted diseases in these patients, he said.

Survey Implies Some Difficulties in Obtaining Plan B

SAN FRANCISCO — Emergency contraception is available in 69% of Los Angeles pharmacies, and patients usually receive accurate information when inquiring about it, according to a study using sham patients.

However, in one-third of encounters in the study, the patients received the information only after multiple calls and multiple recitations of their situation, Dr. Anita L. Nelson said at a conference on contraceptive technology sponsored by Contemporary Forums.

Some pharmacies provided inaccurate information. For example, of 1,206 pharmacies contacted, 74 (6%) referred the woman to her clinician for a prescription.

At the time of the study, Plan B was available without a prescription to women aged 18 years and older.

Dr. Nelson and Dr. Cindy M. Jaime of the Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, Calif., conducted the study between October 2007 and October 2008. They attempted to contact all 1,440 unduplicated telephone numbers for pharmacies listed in the Yellow Pages for Los Angeles County (Contraception 2009;79:206-10).

Female interviewers were trained to speak hesitantly to the person who answered and to say that she and her boyfriend had had sex the day before and that he had just told her that he had not used a condom. She then said that she had heard that maybe there was something she could take to keep from getting pregnant, and asked the person on the telephone if he or she knew about this.

Of the 1,206 pharmacies the investigators were able to contact, 835 (69%) responded that they carried emergency contraception and had it available on site without a prescription. An additional 232 (19%) responded that they did not have it in stock or did not carry it themselves but referred the caller to other pharmacies. Others provided inaccurate information regarding the timeframe in which Plan B must be taken. Seventeen pharmacists hung up the phone after hearing the caller's question, and several hung up repeatedly upon being called back. Others asked overly personal questions.

Dr. Nelson said that the study received no outside funding and she said that she has served on advisory boards and speakers bureaus, and has received research funding from, Duramed/Barr Pharmaceuticals Inc., which manufactures Plan B. Contemporary Forums and this news organization are owned by Elsevier.

—Robert Finn

A U.S. federal judge ordered the Food and Drug Administration on March 23 to make the emergency contraceptive Plan B (levonorgestrel) available to 17-year-olds without a prescription within 30 days. Currently, Plan B is available without prescription to women aged 18 years and older.

U.S. District Judge Edward R. Korman also ordered the FDA to reconsider approving over-the-counter sale of the drug without age or point-of-sale restrictions.

“While the FDA is free, on remand, to exercise its expertise and discretion,” Judge Korman wrote, “no useful purpose would be served by continuing to deprive 17-year-olds access to Plan B without a prescription. Indeed, the record shows that FDA officials and staff both agreed that 17-years-olds can use Plan B safely without a prescription.”

Dr. Beth Jordan, medical director for the Association of Reproductive Health Professionals, called the ruling “a clear message to the FDA that decisions about medical devices and drugs must be based on science—not ideology.”

She added that “It is safe and easy for reproductive-age women to self-diagnose [their] own need for Plan B and then to use it—a fact the FDA's own panel of independent medical experts advised them on prior to the FDA's politically motivated decision” to restrict the drug.

The ruling is a reaction to a citizen petition filed by the nonprofit Center for Reproductive Rights, Tummino v. Torti (formerly known as Tummino v. von Eschenbach) which requested that the FDA make Plan B available without a prescription to women of all ages.

In his ruling, Judge Korman pointed out that “Plan B and other emergency contraceptives with the same active ingredient are available without a prescription or age restriction in much of the world, including virtually all major industrialized nations.”

Clearly, the ruling has sparked controversy. Chris Gacek, a senior fellow at the Family Research Council, a Christian nonprofit and lobbying group, said, “There is a real danger that Plan B may be given to women, especially sexually abused women and minors, under coercion or without their consent.” Forcing underage children to get a prescription for the drug from a health care provider can help identify sexual abuse victims and screen for sexually transmitted diseases in these patients, he said.

Survey Implies Some Difficulties in Obtaining Plan B

SAN FRANCISCO — Emergency contraception is available in 69% of Los Angeles pharmacies, and patients usually receive accurate information when inquiring about it, according to a study using sham patients.

However, in one-third of encounters in the study, the patients received the information only after multiple calls and multiple recitations of their situation, Dr. Anita L. Nelson said at a conference on contraceptive technology sponsored by Contemporary Forums.

Some pharmacies provided inaccurate information. For example, of 1,206 pharmacies contacted, 74 (6%) referred the woman to her clinician for a prescription.

At the time of the study, Plan B was available without a prescription to women aged 18 years and older.

Dr. Nelson and Dr. Cindy M. Jaime of the Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, Calif., conducted the study between October 2007 and October 2008. They attempted to contact all 1,440 unduplicated telephone numbers for pharmacies listed in the Yellow Pages for Los Angeles County (Contraception 2009;79:206-10).

Female interviewers were trained to speak hesitantly to the person who answered and to say that she and her boyfriend had had sex the day before and that he had just told her that he had not used a condom. She then said that she had heard that maybe there was something she could take to keep from getting pregnant, and asked the person on the telephone if he or she knew about this.

Of the 1,206 pharmacies the investigators were able to contact, 835 (69%) responded that they carried emergency contraception and had it available on site without a prescription. An additional 232 (19%) responded that they did not have it in stock or did not carry it themselves but referred the caller to other pharmacies. Others provided inaccurate information regarding the timeframe in which Plan B must be taken. Seventeen pharmacists hung up the phone after hearing the caller's question, and several hung up repeatedly upon being called back. Others asked overly personal questions.

Dr. Nelson said that the study received no outside funding and she said that she has served on advisory boards and speakers bureaus, and has received research funding from, Duramed/Barr Pharmaceuticals Inc., which manufactures Plan B. Contemporary Forums and this news organization are owned by Elsevier.

—Robert Finn

Average glucose levels at hospital admission for acute myocardial infarction predict 30-day mortality better than does diabetes history, even though the latter is routinely used as an assessment tool, according to an analysis of two large trials.

“Patients with no diabetes history with elevated in-hospital glucose levels have the same high risk for short-term death after AMI [acute myocardial infarction] as patients with diabetes history,” the investigators wrote.

Dr. Abhinav Goya of the Emory Schools of Public Health and Medicine in Atlanta, along with an international team of investigators, conducted a post hoc analysis of two randomized, controlled trials of AMI with ST-segment elevation: the Clinical Trial of Reviparin and Metabolic Modulation in Acute Myocardial Infarction Treatment and Evaluation-Estudios Clinicos Latino America (CREATE-ECLA) and the Organization for the Assessment of Strategies for Ischemic Syndromes-6 (OASIS-6). For the analysis, the investigators looked at glucose measurements taken at hospital admission, at 6 hours post admission, and at 24 hours post admission, and took as “average in-hospital glucose” the mean of the three. They also assessed diabetes history, and then estimated the ability of these to forecast death at 30 days. In cases where there were fewer than all three measurements available, the average glucose was taken to be the mean of two measures, or the one measure by itself.

A total of 30,536 patients were analyzed. Of them, 13,100 (43%) had an average glucose of at least 144 mg/dL, the cut-off point that was used to predict risk of 30-day mortality. Of these 13,100 patients, 8,388 (64%) did not have a history of diabetes. At 30 days, a total of 2,808 deaths were documented. Average glucose predicted mortality with a highly significant odds ratio of 1.10, and this remained undiminished after adjustment for diabetes history, according to Dr. Goya, also of the Population Health Research Institute, Hamilton, Ont. Diabetes history alone also predicted death at 30 days, with a highly significant odds ratio of 1.63; however, after adjustment for average glucose, the odds ratio fell to a nonsignificant 0.98.

Additionally, nondiabetic patients with glucose levels above 144 mg/dL had an average rate of death that nearly matched that of diabetic patients with similarly high glucose—13.2% versus 13.7%, respectively (Am. Heart J. 2009 Feb. 23 [doi:10.1016/j.ahj.2008.12.007]).

“These hyperglycemic patients with no diabetes history would have been overlooked as high risk if diabetic status alone were used for risk assessment,” the authors concluded.

The CREATE-ECLA trial had no external funding; OASIS-6 was funded by Sanofi Aventis, Organon, and GlaxoSmithKline.

Average glucose levels at hospital admission for acute myocardial infarction predict 30-day mortality better than does diabetes history, even though the latter is routinely used as an assessment tool, according to an analysis of two large trials.

“Patients with no diabetes history with elevated in-hospital glucose levels have the same high risk for short-term death after AMI [acute myocardial infarction] as patients with diabetes history,” the investigators wrote.

Dr. Abhinav Goya of the Emory Schools of Public Health and Medicine in Atlanta, along with an international team of investigators, conducted a post hoc analysis of two randomized, controlled trials of AMI with ST-segment elevation: the Clinical Trial of Reviparin and Metabolic Modulation in Acute Myocardial Infarction Treatment and Evaluation-Estudios Clinicos Latino America (CREATE-ECLA) and the Organization for the Assessment of Strategies for Ischemic Syndromes-6 (OASIS-6). For the analysis, the investigators looked at glucose measurements taken at hospital admission, at 6 hours post admission, and at 24 hours post admission, and took as “average in-hospital glucose” the mean of the three. They also assessed diabetes history, and then estimated the ability of these to forecast death at 30 days. In cases where there were fewer than all three measurements available, the average glucose was taken to be the mean of two measures, or the one measure by itself.

A total of 30,536 patients were analyzed. Of them, 13,100 (43%) had an average glucose of at least 144 mg/dL, the cut-off point that was used to predict risk of 30-day mortality. Of these 13,100 patients, 8,388 (64%) did not have a history of diabetes. At 30 days, a total of 2,808 deaths were documented. Average glucose predicted mortality with a highly significant odds ratio of 1.10, and this remained undiminished after adjustment for diabetes history, according to Dr. Goya, also of the Population Health Research Institute, Hamilton, Ont. Diabetes history alone also predicted death at 30 days, with a highly significant odds ratio of 1.63; however, after adjustment for average glucose, the odds ratio fell to a nonsignificant 0.98.

Additionally, nondiabetic patients with glucose levels above 144 mg/dL had an average rate of death that nearly matched that of diabetic patients with similarly high glucose—13.2% versus 13.7%, respectively (Am. Heart J. 2009 Feb. 23 [doi:10.1016/j.ahj.2008.12.007]).

“These hyperglycemic patients with no diabetes history would have been overlooked as high risk if diabetic status alone were used for risk assessment,” the authors concluded.

The CREATE-ECLA trial had no external funding; OASIS-6 was funded by Sanofi Aventis, Organon, and GlaxoSmithKline.

Average glucose levels at hospital admission for acute myocardial infarction predict 30-day mortality better than does diabetes history, even though the latter is routinely used as an assessment tool, according to an analysis of two large trials.

“Patients with no diabetes history with elevated in-hospital glucose levels have the same high risk for short-term death after AMI [acute myocardial infarction] as patients with diabetes history,” the investigators wrote.

Dr. Abhinav Goya of the Emory Schools of Public Health and Medicine in Atlanta, along with an international team of investigators, conducted a post hoc analysis of two randomized, controlled trials of AMI with ST-segment elevation: the Clinical Trial of Reviparin and Metabolic Modulation in Acute Myocardial Infarction Treatment and Evaluation-Estudios Clinicos Latino America (CREATE-ECLA) and the Organization for the Assessment of Strategies for Ischemic Syndromes-6 (OASIS-6). For the analysis, the investigators looked at glucose measurements taken at hospital admission, at 6 hours post admission, and at 24 hours post admission, and took as “average in-hospital glucose” the mean of the three. They also assessed diabetes history, and then estimated the ability of these to forecast death at 30 days. In cases where there were fewer than all three measurements available, the average glucose was taken to be the mean of two measures, or the one measure by itself.

A total of 30,536 patients were analyzed. Of them, 13,100 (43%) had an average glucose of at least 144 mg/dL, the cut-off point that was used to predict risk of 30-day mortality. Of these 13,100 patients, 8,388 (64%) did not have a history of diabetes. At 30 days, a total of 2,808 deaths were documented. Average glucose predicted mortality with a highly significant odds ratio of 1.10, and this remained undiminished after adjustment for diabetes history, according to Dr. Goya, also of the Population Health Research Institute, Hamilton, Ont. Diabetes history alone also predicted death at 30 days, with a highly significant odds ratio of 1.63; however, after adjustment for average glucose, the odds ratio fell to a nonsignificant 0.98.

Additionally, nondiabetic patients with glucose levels above 144 mg/dL had an average rate of death that nearly matched that of diabetic patients with similarly high glucose—13.2% versus 13.7%, respectively (Am. Heart J. 2009 Feb. 23 [doi:10.1016/j.ahj.2008.12.007]).

“These hyperglycemic patients with no diabetes history would have been overlooked as high risk if diabetic status alone were used for risk assessment,” the authors concluded.

The CREATE-ECLA trial had no external funding; OASIS-6 was funded by Sanofi Aventis, Organon, and GlaxoSmithKline.

Rheumatoid arthritis patients with comorbid depression and/or cardiovascular disease accumulated thousands more dollars in annual health care costs than did their peers with RA alone.

This finding is based on a study of over 10,000 people with rheumatoid arthritis conducted by Amie T. Joyce of Pharmetrics Inc., Watertown, Mass., and her associates.

In an interview, Edward H. Yelin, Ph.D., an expert on the economic impacts of chronic diseases who was asked by this publication to comment on this research, said “We are seeing increasingly that inflammation [is present in] many chronic diseases and, thus, it is impossible to separate out specific illness costs perfectly.”

Rheumatologists can help bring down utilization costs for these patients “by treating the whole person, rather than just the single most pressing condition,” said Dr. Yelin, who was not involved in the study. He is professor in residence of medicine and health policy in the division of rheumatology at the University of California, San Francisco.

Dr. Joyce's study looked at 10,298 RA patients culled from PharMetrics Inc.'s patient-centric database from 2001 to 2005. The database contains medical and pharmaceutical claims from 92 health plans across the United States. Of the sample, 8,916 patients (87%) had RA alone, 608 (6%) had RA with CVD, 716 (7%) had RA with depression, and 58 (0.6%) patients had all three conditions.

The annual cost for patients with RA alone was $14,257 vs. $21,410 for patients with RA plus depression, $24,444 for patients with RA plus CVD, and $35,246 for all three conditions.

Patients with RA plus depression had higher annual RA-specific costs than did patients with RA alone ($9,940 vs. $9,322; P = .014), and the RA-specific costs increased even more in patients with all three conditions, to $12,318 (P = .012). That effect was not seen in the RA plus CVD group (J. Rheumatol. 2009 Feb. 15 [doi:10.3899/jrheum.080670]).

Hospitalization contributed to the increased costs. Just 8% of patients with RA alone had a hospital stay in the 12 months prior to their index date (the date of the patient's first claim with an RA diagnosis). In the RA plus CVD cohort, this jumped to 35%. In the RA plus depression cohort, it was 19%, and among the patients who had all three diagnoses, 60% were hospitalized during that 12-month period. (For all rates, P was less than .001.)

The average number of prescriptions filled also increased with increasing comorbidities. RA-only patients filled an average of 46.8 prescriptions in the 12 months following RA diagnosis, compared with 69.2 in the RA plus CVD group, 71.3 in the RA plus depression group, and 114.3 in the RA plus depression plus CVD group.

The authors disclosed funding from Wyeth Research. Three of the authors are also Wyeth Research employees.

Rheumatoid arthritis patients with comorbid depression and/or cardiovascular disease accumulated thousands more dollars in annual health care costs than did their peers with RA alone.

This finding is based on a study of over 10,000 people with rheumatoid arthritis conducted by Amie T. Joyce of Pharmetrics Inc., Watertown, Mass., and her associates.

In an interview, Edward H. Yelin, Ph.D., an expert on the economic impacts of chronic diseases who was asked by this publication to comment on this research, said “We are seeing increasingly that inflammation [is present in] many chronic diseases and, thus, it is impossible to separate out specific illness costs perfectly.”

Rheumatologists can help bring down utilization costs for these patients “by treating the whole person, rather than just the single most pressing condition,” said Dr. Yelin, who was not involved in the study. He is professor in residence of medicine and health policy in the division of rheumatology at the University of California, San Francisco.

Dr. Joyce's study looked at 10,298 RA patients culled from PharMetrics Inc.'s patient-centric database from 2001 to 2005. The database contains medical and pharmaceutical claims from 92 health plans across the United States. Of the sample, 8,916 patients (87%) had RA alone, 608 (6%) had RA with CVD, 716 (7%) had RA with depression, and 58 (0.6%) patients had all three conditions.

The annual cost for patients with RA alone was $14,257 vs. $21,410 for patients with RA plus depression, $24,444 for patients with RA plus CVD, and $35,246 for all three conditions.

Patients with RA plus depression had higher annual RA-specific costs than did patients with RA alone ($9,940 vs. $9,322; P = .014), and the RA-specific costs increased even more in patients with all three conditions, to $12,318 (P = .012). That effect was not seen in the RA plus CVD group (J. Rheumatol. 2009 Feb. 15 [doi:10.3899/jrheum.080670]).

Hospitalization contributed to the increased costs. Just 8% of patients with RA alone had a hospital stay in the 12 months prior to their index date (the date of the patient's first claim with an RA diagnosis). In the RA plus CVD cohort, this jumped to 35%. In the RA plus depression cohort, it was 19%, and among the patients who had all three diagnoses, 60% were hospitalized during that 12-month period. (For all rates, P was less than .001.)

The average number of prescriptions filled also increased with increasing comorbidities. RA-only patients filled an average of 46.8 prescriptions in the 12 months following RA diagnosis, compared with 69.2 in the RA plus CVD group, 71.3 in the RA plus depression group, and 114.3 in the RA plus depression plus CVD group.

The authors disclosed funding from Wyeth Research. Three of the authors are also Wyeth Research employees.

Rheumatoid arthritis patients with comorbid depression and/or cardiovascular disease accumulated thousands more dollars in annual health care costs than did their peers with RA alone.

This finding is based on a study of over 10,000 people with rheumatoid arthritis conducted by Amie T. Joyce of Pharmetrics Inc., Watertown, Mass., and her associates.

In an interview, Edward H. Yelin, Ph.D., an expert on the economic impacts of chronic diseases who was asked by this publication to comment on this research, said “We are seeing increasingly that inflammation [is present in] many chronic diseases and, thus, it is impossible to separate out specific illness costs perfectly.”

Rheumatologists can help bring down utilization costs for these patients “by treating the whole person, rather than just the single most pressing condition,” said Dr. Yelin, who was not involved in the study. He is professor in residence of medicine and health policy in the division of rheumatology at the University of California, San Francisco.

Dr. Joyce's study looked at 10,298 RA patients culled from PharMetrics Inc.'s patient-centric database from 2001 to 2005. The database contains medical and pharmaceutical claims from 92 health plans across the United States. Of the sample, 8,916 patients (87%) had RA alone, 608 (6%) had RA with CVD, 716 (7%) had RA with depression, and 58 (0.6%) patients had all three conditions.

The annual cost for patients with RA alone was $14,257 vs. $21,410 for patients with RA plus depression, $24,444 for patients with RA plus CVD, and $35,246 for all three conditions.

Patients with RA plus depression had higher annual RA-specific costs than did patients with RA alone ($9,940 vs. $9,322; P = .014), and the RA-specific costs increased even more in patients with all three conditions, to $12,318 (P = .012). That effect was not seen in the RA plus CVD group (J. Rheumatol. 2009 Feb. 15 [doi:10.3899/jrheum.080670]).

Hospitalization contributed to the increased costs. Just 8% of patients with RA alone had a hospital stay in the 12 months prior to their index date (the date of the patient's first claim with an RA diagnosis). In the RA plus CVD cohort, this jumped to 35%. In the RA plus depression cohort, it was 19%, and among the patients who had all three diagnoses, 60% were hospitalized during that 12-month period. (For all rates, P was less than .001.)

The average number of prescriptions filled also increased with increasing comorbidities. RA-only patients filled an average of 46.8 prescriptions in the 12 months following RA diagnosis, compared with 69.2 in the RA plus CVD group, 71.3 in the RA plus depression group, and 114.3 in the RA plus depression plus CVD group.

The authors disclosed funding from Wyeth Research. Three of the authors are also Wyeth Research employees.

Obituaries

Dr. John B. Barlow, after whom Barlow syndrome is named, died in his native South Africa on Dec. 10, 2008, at the age of 84.

Dr. Barlow was a professor anddirector of cardiology at the University of the Witwatersrand, in the city of Johannesburg.

He was graduated from the university in 1951 after serving in the South African forces during World War II.

He was appointed a professor of cardiology (ad hominem) in 1970, and served as the director of the cardiovascular research unit from 1971 to 1990, when he retired. According to the University, he continued to see outpatients, do consultations, and supervise registrars up until a few months before he died.

Dr. Barlow's best-known accomplishment, his paper on the mid-systolic click and late systolic murmur syndrome that now bears his name, came about in 1963, but he earned many other accolades during his long career.

These included awards, honors and lectureships from the International Society of Heart Failure, the American Heart Association and the National Heart Hospital in London.

In a tribute, Dr. Tsung O. Cheng, of the George Washington University, Washington, D.C., wrote: “John Barlow's legacy is too expansive to describe fully. But his greatest legacy by far is the discovery of the commonest valve disease in the world. Both his patients and colleagues have benefited so much from his innovative mind, limitless energy, lifelong enthusiasm, great sense of humor and selfless dedication to principles” (Int. J. Cardiol. 2009;133:1-2).

Professor Philip Poole-Wilson died suddenly on his way to work from a suspected myocardial infarction on March 4. He was 65 years old. He was known among his colleagues as the man who put heart failure on the map in the United Kingdom.

Prof. Poole-Wilson studied at Cambridge University and received his medical degree at St. Thomas' Hospital Medical School, London.

In 1973, he was awarded a travel fellowship from the British Heart Foundation that took him to Los Angeles, where he conducted research at the University of California.

Three years later, he returned to London to accept a position as an honorary consultant cardiologist at the National Heart Hospital.

He would remain in London, holding positions through the years at the University of London, the Royal Brompton Hospital and the National Heart and Lung Institute, Imperial College, London—from which he retired as head of cardiac medicine just last October—for the rest of his life.

At the time of his death, he was still serving as the British Heart Foundation Simon Marks Professor of Cardiology at Imperial College.

Prof. Poole-Wilson gained international notoriety through his posts as president of the World Heart Federation from 2003 to 2004, where he gained an interest in global heart disease prevention strategies.

He also served as president of the European Society of Cardiology from 1994 to 1996, and was the founding chair of the British Society for Heart Failure.

Prof. Poole-Wilson was the recipient of the prestigious “Le Prix Europe et Médecine” from l'Institut des Sciences de la Santé, in Paris, in 2001.

In print, Prof. Poole-Wilson will likely be best remembered for being editor of the well known texts “Diseases of the Heart” and “Hurst's The Heart.”

The day before his death, Circ-ulation, the Journal of the American Heart Association, published “Pioneer in Cardiology: Philip Poole-Wilson” (doi:10.1161/CIRCULATIONAHA.109.192070).

Cardiologists on the Move

Dr. John “Jack” O'Connell has relocated to Atlanta to become the executive director of the Heart Failure Program at the Heart and Vascular Institute, St. Joseph's Hospital. Dr. O'Connell served previously as a professor of medicine at Northwestern University, Chicago. He was also the director of the Center for Heart Failure at the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital.

Dr. O'Connell was replaced at the Bluhm Institute by Dr. William G. Cotts, who is medical director of heart transplantation, and Dr. Edwin C. McGee, who is serving as the surgical director of heart transplantation and mechanical assistance. Both have long held leadership positions at the Institute.

DR. JOHN B. BARLOW

Obituaries

Dr. John B. Barlow, after whom Barlow syndrome is named, died in his native South Africa on Dec. 10, 2008, at the age of 84.

Dr. Barlow was a professor anddirector of cardiology at the University of the Witwatersrand, in the city of Johannesburg.

He was graduated from the university in 1951 after serving in the South African forces during World War II.

He was appointed a professor of cardiology (ad hominem) in 1970, and served as the director of the cardiovascular research unit from 1971 to 1990, when he retired. According to the University, he continued to see outpatients, do consultations, and supervise registrars up until a few months before he died.

Dr. Barlow's best-known accomplishment, his paper on the mid-systolic click and late systolic murmur syndrome that now bears his name, came about in 1963, but he earned many other accolades during his long career.

These included awards, honors and lectureships from the International Society of Heart Failure, the American Heart Association and the National Heart Hospital in London.

In a tribute, Dr. Tsung O. Cheng, of the George Washington University, Washington, D.C., wrote: “John Barlow's legacy is too expansive to describe fully. But his greatest legacy by far is the discovery of the commonest valve disease in the world. Both his patients and colleagues have benefited so much from his innovative mind, limitless energy, lifelong enthusiasm, great sense of humor and selfless dedication to principles” (Int. J. Cardiol. 2009;133:1-2).

Professor Philip Poole-Wilson died suddenly on his way to work from a suspected myocardial infarction on March 4. He was 65 years old. He was known among his colleagues as the man who put heart failure on the map in the United Kingdom.

Prof. Poole-Wilson studied at Cambridge University and received his medical degree at St. Thomas' Hospital Medical School, London.

In 1973, he was awarded a travel fellowship from the British Heart Foundation that took him to Los Angeles, where he conducted research at the University of California.

Three years later, he returned to London to accept a position as an honorary consultant cardiologist at the National Heart Hospital.

He would remain in London, holding positions through the years at the University of London, the Royal Brompton Hospital and the National Heart and Lung Institute, Imperial College, London—from which he retired as head of cardiac medicine just last October—for the rest of his life.

At the time of his death, he was still serving as the British Heart Foundation Simon Marks Professor of Cardiology at Imperial College.

Prof. Poole-Wilson gained international notoriety through his posts as president of the World Heart Federation from 2003 to 2004, where he gained an interest in global heart disease prevention strategies.

He also served as president of the European Society of Cardiology from 1994 to 1996, and was the founding chair of the British Society for Heart Failure.

Prof. Poole-Wilson was the recipient of the prestigious “Le Prix Europe et Médecine” from l'Institut des Sciences de la Santé, in Paris, in 2001.

In print, Prof. Poole-Wilson will likely be best remembered for being editor of the well known texts “Diseases of the Heart” and “Hurst's The Heart.”

The day before his death, Circ-ulation, the Journal of the American Heart Association, published “Pioneer in Cardiology: Philip Poole-Wilson” (doi:10.1161/CIRCULATIONAHA.109.192070).

Cardiologists on the Move

Dr. John “Jack” O'Connell has relocated to Atlanta to become the executive director of the Heart Failure Program at the Heart and Vascular Institute, St. Joseph's Hospital. Dr. O'Connell served previously as a professor of medicine at Northwestern University, Chicago. He was also the director of the Center for Heart Failure at the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital.

Dr. O'Connell was replaced at the Bluhm Institute by Dr. William G. Cotts, who is medical director of heart transplantation, and Dr. Edwin C. McGee, who is serving as the surgical director of heart transplantation and mechanical assistance. Both have long held leadership positions at the Institute.

DR. JOHN B. BARLOW

Obituaries

Dr. John B. Barlow, after whom Barlow syndrome is named, died in his native South Africa on Dec. 10, 2008, at the age of 84.

Dr. Barlow was a professor anddirector of cardiology at the University of the Witwatersrand, in the city of Johannesburg.

He was graduated from the university in 1951 after serving in the South African forces during World War II.

He was appointed a professor of cardiology (ad hominem) in 1970, and served as the director of the cardiovascular research unit from 1971 to 1990, when he retired. According to the University, he continued to see outpatients, do consultations, and supervise registrars up until a few months before he died.

Dr. Barlow's best-known accomplishment, his paper on the mid-systolic click and late systolic murmur syndrome that now bears his name, came about in 1963, but he earned many other accolades during his long career.

These included awards, honors and lectureships from the International Society of Heart Failure, the American Heart Association and the National Heart Hospital in London.

In a tribute, Dr. Tsung O. Cheng, of the George Washington University, Washington, D.C., wrote: “John Barlow's legacy is too expansive to describe fully. But his greatest legacy by far is the discovery of the commonest valve disease in the world. Both his patients and colleagues have benefited so much from his innovative mind, limitless energy, lifelong enthusiasm, great sense of humor and selfless dedication to principles” (Int. J. Cardiol. 2009;133:1-2).

Professor Philip Poole-Wilson died suddenly on his way to work from a suspected myocardial infarction on March 4. He was 65 years old. He was known among his colleagues as the man who put heart failure on the map in the United Kingdom.

Prof. Poole-Wilson studied at Cambridge University and received his medical degree at St. Thomas' Hospital Medical School, London.

In 1973, he was awarded a travel fellowship from the British Heart Foundation that took him to Los Angeles, where he conducted research at the University of California.

Three years later, he returned to London to accept a position as an honorary consultant cardiologist at the National Heart Hospital.

He would remain in London, holding positions through the years at the University of London, the Royal Brompton Hospital and the National Heart and Lung Institute, Imperial College, London—from which he retired as head of cardiac medicine just last October—for the rest of his life.

At the time of his death, he was still serving as the British Heart Foundation Simon Marks Professor of Cardiology at Imperial College.

Prof. Poole-Wilson gained international notoriety through his posts as president of the World Heart Federation from 2003 to 2004, where he gained an interest in global heart disease prevention strategies.

He also served as president of the European Society of Cardiology from 1994 to 1996, and was the founding chair of the British Society for Heart Failure.

Prof. Poole-Wilson was the recipient of the prestigious “Le Prix Europe et Médecine” from l'Institut des Sciences de la Santé, in Paris, in 2001.

In print, Prof. Poole-Wilson will likely be best remembered for being editor of the well known texts “Diseases of the Heart” and “Hurst's The Heart.”

The day before his death, Circ-ulation, the Journal of the American Heart Association, published “Pioneer in Cardiology: Philip Poole-Wilson” (doi:10.1161/CIRCULATIONAHA.109.192070).

Cardiologists on the Move

Dr. John “Jack” O'Connell has relocated to Atlanta to become the executive director of the Heart Failure Program at the Heart and Vascular Institute, St. Joseph's Hospital. Dr. O'Connell served previously as a professor of medicine at Northwestern University, Chicago. He was also the director of the Center for Heart Failure at the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital.

Dr. O'Connell was replaced at the Bluhm Institute by Dr. William G. Cotts, who is medical director of heart transplantation, and Dr. Edwin C. McGee, who is serving as the surgical director of heart transplantation and mechanical assistance. Both have long held leadership positions at the Institute.

DR. JOHN B. BARLOW

WASHINGTON — Massive budget shortfalls in 40 states coupled with greater demand for Medicaid coverage made it tough for states to expand health care coverage for their residents last year, according to the annual survey of state health care and insurance legislation conducted by the Blue Cross Blue Shield Association.

However, the American Recovery and Reinvestment Act—better known as the stimulus packages—does promise to make things easier in 2009, according to Susan Laudicina, director of state policy and research at the Blue Cross Blue Shield Association. “The money in the stimulus act is certainly going to help states avoid deep cuts to the Medicaid program. Is it adequate? Probably more money is needed.”

Nevertheless, according to Ms. Laudicina, states see better times ahead. “What's happening right now is governors are actually redoing their budgets. States are immediately factoring [the stimulus money] in. In many cases, it is closing the budget gap, and in some cases, they are avoiding cuts.”

According to the annual State of the States report, the economic crisis meant that most expansion efforts fell short in 2008, even in high-profile states with governor backing, like California, New Mexico, and Pennsylvania.

“There has not been a consensus [to mandate universal coverage] since Massachusetts, now going on 3 years ago,” said Ms. Laudicina. Still, some states are now developing universal care strategies that they will try to pass into law in 2009, she said, including Connecticut, Hawaii, Minnesota, Oregon, and Washington. “Now that Obama is pledging to reform some things this year, and put $634 billion in his budget for use in future reforms, does that mean the states are going to hold off [on these plans]?” said Ms. Laudicina in an interview. “Frankly, since we don't know when a national healthcare reform bill will be enacted, we don't know the tools that will be used.… I expect that states such as Oregon…and Minnesota and Connecticut are interested in crating commissions are going to go ahead. They're going to plan all they can. They're going to assume that they're going to be big players in whatever national bill comes down the pike.”

The State of the States report also showed that expansion of coverage for children was not spared from states' fiscal problems last year, according to the report. Nonetheless, some states did modestly expand their Children's Health Insurance Programs (CHIP), including Colorado, Florida, Kansas, and Minnesota.

In New Jersey, the Health Care Reform Act (SB 1537) mandated coverage for all children under age 18 years, though without any minimum benefit requirements. “Parents can comply with the mandate program by purchasing a licensed private product or by enrolling in Medicaid or CHIP,” according to the report.

However, the funding source for such an expansion has yet to be determined, as does the enforcement mechanism.

The survey also reported on health care transparency efforts. In the 20 states that introduced such bills in 2008, nine laws were enacted, Ms. Laudicina said. Some of these, like HB 1393 in Colorado, require hospitals to display charges for common inpatient procedures on a publicly accessible Web site. Others, like Louisiana's Right to Know Act (SB 287), require that the state's department of health and hospitals display not only cost data, but also data on quality measures among medical facilities, individual physicians, and health plans.

Regarding health information technology measures, Ms. Laudicina said that over the past 3 years, 33 states have enacted legislation promoting the adoption of electronic medical records, and bills are pending in 12 more. And the financial incentives for electronic medical records adoption in the stimulus package should mean that even more physicians and facilities implement them voluntarily.

However, concerns about compliance with yet-to-be-set federal health IT standards will likely cause some states to put IT legislation on the back burner.

Other proposals considered by states in 2008 included mandated coverage of adult dependent children until age 25, 26, or even 30 years, said Alissa Fox, senior vice president of the Office of Policy and Representation at the Blue Cross Blue Shield Association. This possibility will remain on states' agendas in 2009.

The report is based on a survey of the 39 independent Blue Cross and Blue Shield companies across the nation.

WASHINGTON — Massive budget shortfalls in 40 states coupled with greater demand for Medicaid coverage made it tough for states to expand health care coverage for their residents last year, according to the annual survey of state health care and insurance legislation conducted by the Blue Cross Blue Shield Association.

However, the American Recovery and Reinvestment Act—better known as the stimulus packages—does promise to make things easier in 2009, according to Susan Laudicina, director of state policy and research at the Blue Cross Blue Shield Association. “The money in the stimulus act is certainly going to help states avoid deep cuts to the Medicaid program. Is it adequate? Probably more money is needed.”

Nevertheless, according to Ms. Laudicina, states see better times ahead. “What's happening right now is governors are actually redoing their budgets. States are immediately factoring [the stimulus money] in. In many cases, it is closing the budget gap, and in some cases, they are avoiding cuts.”

According to the annual State of the States report, the economic crisis meant that most expansion efforts fell short in 2008, even in high-profile states with governor backing, like California, New Mexico, and Pennsylvania.

“There has not been a consensus [to mandate universal coverage] since Massachusetts, now going on 3 years ago,” said Ms. Laudicina. Still, some states are now developing universal care strategies that they will try to pass into law in 2009, she said, including Connecticut, Hawaii, Minnesota, Oregon, and Washington. “Now that Obama is pledging to reform some things this year, and put $634 billion in his budget for use in future reforms, does that mean the states are going to hold off [on these plans]?” said Ms. Laudicina in an interview. “Frankly, since we don't know when a national healthcare reform bill will be enacted, we don't know the tools that will be used.… I expect that states such as Oregon…and Minnesota and Connecticut are interested in crating commissions are going to go ahead. They're going to plan all they can. They're going to assume that they're going to be big players in whatever national bill comes down the pike.”

The State of the States report also showed that expansion of coverage for children was not spared from states' fiscal problems last year, according to the report. Nonetheless, some states did modestly expand their Children's Health Insurance Programs (CHIP), including Colorado, Florida, Kansas, and Minnesota.

In New Jersey, the Health Care Reform Act (SB 1537) mandated coverage for all children under age 18 years, though without any minimum benefit requirements. “Parents can comply with the mandate program by purchasing a licensed private product or by enrolling in Medicaid or CHIP,” according to the report.

However, the funding source for such an expansion has yet to be determined, as does the enforcement mechanism.

The survey also reported on health care transparency efforts. In the 20 states that introduced such bills in 2008, nine laws were enacted, Ms. Laudicina said. Some of these, like HB 1393 in Colorado, require hospitals to display charges for common inpatient procedures on a publicly accessible Web site. Others, like Louisiana's Right to Know Act (SB 287), require that the state's department of health and hospitals display not only cost data, but also data on quality measures among medical facilities, individual physicians, and health plans.

Regarding health information technology measures, Ms. Laudicina said that over the past 3 years, 33 states have enacted legislation promoting the adoption of electronic medical records, and bills are pending in 12 more. And the financial incentives for electronic medical records adoption in the stimulus package should mean that even more physicians and facilities implement them voluntarily.

However, concerns about compliance with yet-to-be-set federal health IT standards will likely cause some states to put IT legislation on the back burner.

Other proposals considered by states in 2008 included mandated coverage of adult dependent children until age 25, 26, or even 30 years, said Alissa Fox, senior vice president of the Office of Policy and Representation at the Blue Cross Blue Shield Association. This possibility will remain on states' agendas in 2009.

The report is based on a survey of the 39 independent Blue Cross and Blue Shield companies across the nation.

WASHINGTON — Massive budget shortfalls in 40 states coupled with greater demand for Medicaid coverage made it tough for states to expand health care coverage for their residents last year, according to the annual survey of state health care and insurance legislation conducted by the Blue Cross Blue Shield Association.

However, the American Recovery and Reinvestment Act—better known as the stimulus packages—does promise to make things easier in 2009, according to Susan Laudicina, director of state policy and research at the Blue Cross Blue Shield Association. “The money in the stimulus act is certainly going to help states avoid deep cuts to the Medicaid program. Is it adequate? Probably more money is needed.”

Nevertheless, according to Ms. Laudicina, states see better times ahead. “What's happening right now is governors are actually redoing their budgets. States are immediately factoring [the stimulus money] in. In many cases, it is closing the budget gap, and in some cases, they are avoiding cuts.”

According to the annual State of the States report, the economic crisis meant that most expansion efforts fell short in 2008, even in high-profile states with governor backing, like California, New Mexico, and Pennsylvania.

“There has not been a consensus [to mandate universal coverage] since Massachusetts, now going on 3 years ago,” said Ms. Laudicina. Still, some states are now developing universal care strategies that they will try to pass into law in 2009, she said, including Connecticut, Hawaii, Minnesota, Oregon, and Washington. “Now that Obama is pledging to reform some things this year, and put $634 billion in his budget for use in future reforms, does that mean the states are going to hold off [on these plans]?” said Ms. Laudicina in an interview. “Frankly, since we don't know when a national healthcare reform bill will be enacted, we don't know the tools that will be used.… I expect that states such as Oregon…and Minnesota and Connecticut are interested in crating commissions are going to go ahead. They're going to plan all they can. They're going to assume that they're going to be big players in whatever national bill comes down the pike.”

The State of the States report also showed that expansion of coverage for children was not spared from states' fiscal problems last year, according to the report. Nonetheless, some states did modestly expand their Children's Health Insurance Programs (CHIP), including Colorado, Florida, Kansas, and Minnesota.

In New Jersey, the Health Care Reform Act (SB 1537) mandated coverage for all children under age 18 years, though without any minimum benefit requirements. “Parents can comply with the mandate program by purchasing a licensed private product or by enrolling in Medicaid or CHIP,” according to the report.

However, the funding source for such an expansion has yet to be determined, as does the enforcement mechanism.

The survey also reported on health care transparency efforts. In the 20 states that introduced such bills in 2008, nine laws were enacted, Ms. Laudicina said. Some of these, like HB 1393 in Colorado, require hospitals to display charges for common inpatient procedures on a publicly accessible Web site. Others, like Louisiana's Right to Know Act (SB 287), require that the state's department of health and hospitals display not only cost data, but also data on quality measures among medical facilities, individual physicians, and health plans.

Regarding health information technology measures, Ms. Laudicina said that over the past 3 years, 33 states have enacted legislation promoting the adoption of electronic medical records, and bills are pending in 12 more. And the financial incentives for electronic medical records adoption in the stimulus package should mean that even more physicians and facilities implement them voluntarily.

However, concerns about compliance with yet-to-be-set federal health IT standards will likely cause some states to put IT legislation on the back burner.

Other proposals considered by states in 2008 included mandated coverage of adult dependent children until age 25, 26, or even 30 years, said Alissa Fox, senior vice president of the Office of Policy and Representation at the Blue Cross Blue Shield Association. This possibility will remain on states' agendas in 2009.

The report is based on a survey of the 39 independent Blue Cross and Blue Shield companies across the nation.

Updated guidelines for candidiasis management incorporate significant changes for pediatric patients since the most recent 2004 guidelines, according to a panel of experts convened by the Infectious Diseases Society of America.

“Candidemia is the fourth most common cause of nosocomial bloodstream infections in the United States and in much of the developed world,” wrote the authors, led by Dr. Peter G. Pappas, who is with the division of infectious diseases at the University of Alabama at Birmingham.

The lengthy new guidelines address 15 clinical questions dealing with treatment in neonatal patients, neutropenic versus nonneutropenic patients, vulvovaginal candidiasis, central nervous system candidiasis, Candida-related osteoarticular infections, and yeast-related cardiovascular system infections, among other topics (Clin. Inf. Dis. 2009;48:503–35).

According to Dr. Danny Benjamin, a coauthor of the new guidelines and a member of the pediatrics department at Duke University, Durham, N.C., the treatment recommendations for neonatal candidiasis cases have changed significantly since 2004. “The dosing changes are pretty dramatic compared to what is used in adults and what is in some reference texts,” he said. For example, the guidelines recommend fluconazole in dosages of 12 mg/kg daily, given intravenously, versus a range of 5–12 mg/kg daily recommended in the 2004 guidelines.

Additionally, he said there is a firm recommendation to treat candidiasis for 3 weeks, based on a significant risk of central nervous disease in these patients. “CNS involvement in the neonate usually manifests as meningoencephalitis and should be assumed to be present in the neonate with candidemia because of the high incidence of this complication,” wrote the authors. “Neurologic impairment is common in survivors,” they add, which is why Dr. Benjamin also stressed neurodevelopmental follow-up.

Prompt replacement or removal of central catheters in this population also is strongly recommended. “Some want to leave the catheter in [for the duration of treatment]; some want to remove and use peripheral for a few days,” said Dr. Benjamin. “The guidelines advocate a middle path of remove or replace. In the replacement strategy, the bedside neonatologist/pediatrician is able to still have central access, but does so with a new catheter.”

The guidelines also include an extensive section on pediatric dosing of antifungals, which Dr. Benjamin said is often wrong in reference texts. Data are limited, according to the guidelines, although “there is growing evidence with the echinocandins in children and neonates.”

One recent study emphasized the importance of dosing based on body surface, versus weight, for example. And although 2–4 mg/kg daily of micafungin is recommended for children, “neonates may require as much as 10–12 mg/kg daily to achieve therapeutic concentrations,” they wrote.

Some additional guidelines include:

▸ Because fluconazole is rapidly cleared in children, “to achieve comparable drug exposure, the daily fluconazole dose needs to be doubled, from 6 to 12 mg/kg daily, for children of all ages and neonates.”

▸ “Children up to [approximately] 12 years of age require higher doses of voriconazole than do adults to attain similar serum concentrations,” the authors wrote. A dosage of 7 mg/kg every 12 hours is recommended to approximate the effects of 4 mg/kg in an adult.

Although the development of the guidelines was directly supported by the IDSA, several of the authors, including Dr. Benjamin, disclosed personal financial ties to pharmaceutical companies.

Updated guidelines for candidiasis management incorporate significant changes for pediatric patients since the most recent 2004 guidelines, according to a panel of experts convened by the Infectious Diseases Society of America.

“Candidemia is the fourth most common cause of nosocomial bloodstream infections in the United States and in much of the developed world,” wrote the authors, led by Dr. Peter G. Pappas, who is with the division of infectious diseases at the University of Alabama at Birmingham.

The lengthy new guidelines address 15 clinical questions dealing with treatment in neonatal patients, neutropenic versus nonneutropenic patients, vulvovaginal candidiasis, central nervous system candidiasis, Candida-related osteoarticular infections, and yeast-related cardiovascular system infections, among other topics (Clin. Inf. Dis. 2009;48:503–35).

According to Dr. Danny Benjamin, a coauthor of the new guidelines and a member of the pediatrics department at Duke University, Durham, N.C., the treatment recommendations for neonatal candidiasis cases have changed significantly since 2004. “The dosing changes are pretty dramatic compared to what is used in adults and what is in some reference texts,” he said. For example, the guidelines recommend fluconazole in dosages of 12 mg/kg daily, given intravenously, versus a range of 5–12 mg/kg daily recommended in the 2004 guidelines.

Additionally, he said there is a firm recommendation to treat candidiasis for 3 weeks, based on a significant risk of central nervous disease in these patients. “CNS involvement in the neonate usually manifests as meningoencephalitis and should be assumed to be present in the neonate with candidemia because of the high incidence of this complication,” wrote the authors. “Neurologic impairment is common in survivors,” they add, which is why Dr. Benjamin also stressed neurodevelopmental follow-up.

Prompt replacement or removal of central catheters in this population also is strongly recommended. “Some want to leave the catheter in [for the duration of treatment]; some want to remove and use peripheral for a few days,” said Dr. Benjamin. “The guidelines advocate a middle path of remove or replace. In the replacement strategy, the bedside neonatologist/pediatrician is able to still have central access, but does so with a new catheter.”

The guidelines also include an extensive section on pediatric dosing of antifungals, which Dr. Benjamin said is often wrong in reference texts. Data are limited, according to the guidelines, although “there is growing evidence with the echinocandins in children and neonates.”

One recent study emphasized the importance of dosing based on body surface, versus weight, for example. And although 2–4 mg/kg daily of micafungin is recommended for children, “neonates may require as much as 10–12 mg/kg daily to achieve therapeutic concentrations,” they wrote.

Some additional guidelines include:

▸ Because fluconazole is rapidly cleared in children, “to achieve comparable drug exposure, the daily fluconazole dose needs to be doubled, from 6 to 12 mg/kg daily, for children of all ages and neonates.”

▸ “Children up to [approximately] 12 years of age require higher doses of voriconazole than do adults to attain similar serum concentrations,” the authors wrote. A dosage of 7 mg/kg every 12 hours is recommended to approximate the effects of 4 mg/kg in an adult.

Although the development of the guidelines was directly supported by the IDSA, several of the authors, including Dr. Benjamin, disclosed personal financial ties to pharmaceutical companies.

Updated guidelines for candidiasis management incorporate significant changes for pediatric patients since the most recent 2004 guidelines, according to a panel of experts convened by the Infectious Diseases Society of America.

“Candidemia is the fourth most common cause of nosocomial bloodstream infections in the United States and in much of the developed world,” wrote the authors, led by Dr. Peter G. Pappas, who is with the division of infectious diseases at the University of Alabama at Birmingham.

The lengthy new guidelines address 15 clinical questions dealing with treatment in neonatal patients, neutropenic versus nonneutropenic patients, vulvovaginal candidiasis, central nervous system candidiasis, Candida-related osteoarticular infections, and yeast-related cardiovascular system infections, among other topics (Clin. Inf. Dis. 2009;48:503–35).

According to Dr. Danny Benjamin, a coauthor of the new guidelines and a member of the pediatrics department at Duke University, Durham, N.C., the treatment recommendations for neonatal candidiasis cases have changed significantly since 2004. “The dosing changes are pretty dramatic compared to what is used in adults and what is in some reference texts,” he said. For example, the guidelines recommend fluconazole in dosages of 12 mg/kg daily, given intravenously, versus a range of 5–12 mg/kg daily recommended in the 2004 guidelines.

Additionally, he said there is a firm recommendation to treat candidiasis for 3 weeks, based on a significant risk of central nervous disease in these patients. “CNS involvement in the neonate usually manifests as meningoencephalitis and should be assumed to be present in the neonate with candidemia because of the high incidence of this complication,” wrote the authors. “Neurologic impairment is common in survivors,” they add, which is why Dr. Benjamin also stressed neurodevelopmental follow-up.

Prompt replacement or removal of central catheters in this population also is strongly recommended. “Some want to leave the catheter in [for the duration of treatment]; some want to remove and use peripheral for a few days,” said Dr. Benjamin. “The guidelines advocate a middle path of remove or replace. In the replacement strategy, the bedside neonatologist/pediatrician is able to still have central access, but does so with a new catheter.”

The guidelines also include an extensive section on pediatric dosing of antifungals, which Dr. Benjamin said is often wrong in reference texts. Data are limited, according to the guidelines, although “there is growing evidence with the echinocandins in children and neonates.”

One recent study emphasized the importance of dosing based on body surface, versus weight, for example. And although 2–4 mg/kg daily of micafungin is recommended for children, “neonates may require as much as 10–12 mg/kg daily to achieve therapeutic concentrations,” they wrote.

Some additional guidelines include:

▸ Because fluconazole is rapidly cleared in children, “to achieve comparable drug exposure, the daily fluconazole dose needs to be doubled, from 6 to 12 mg/kg daily, for children of all ages and neonates.”

▸ “Children up to [approximately] 12 years of age require higher doses of voriconazole than do adults to attain similar serum concentrations,” the authors wrote. A dosage of 7 mg/kg every 12 hours is recommended to approximate the effects of 4 mg/kg in an adult.

Although the development of the guidelines was directly supported by the IDSA, several of the authors, including Dr. Benjamin, disclosed personal financial ties to pharmaceutical companies.

Rheumatoid arthritis patients with comorbid depression and/or cardiovascular disease accumulated thousands more dollars in annual health care costs than did their peers with RA alone.

This finding is based on a study of over 10,000 people with rheumatoid arthritis conducted by Amie T. Joyce of Pharmetrics Inc., Watertown, Mass., and her associates.

“We are seeing increasingly that inflammation [is present in] many chronic diseases and, thus, it is impossible to separate out specific illness costs perfectly. The true costs are borne by people with comorbidity. When [other] studies exclude those with comorbidity, they exclude large fractions of the population,” said Edward H. Yelin, Ph.D.

Depression is also “rampant” in RA, “maybe two to three times higher than one would expect based on age and gender,” added Dr. Yelin, professor in residence of medicine and health policy in the division of rheumatology at the University of California, San Francisco. Dr. Yelin was not involved in the study.

Dr. Joyce's study looked at 10,298 RA patients culled from PharMetrics Inc.'s patient-centric database from Jan. 1, 2001 to Dec. 31, 2005. The database contains medical and pharmaceutical claims from 92 health plans across the United States. To be included in the study, patients had to be aged 18 years or older, have a diagnosis of RA, and have undergone treatment with a disease-modifying antirheumatic drug or biologic agent.

Of the sample, 8,916 patients had RA alone (86.6%), 608 had RA with CVD (5.9%), 716 had RA with depression (6.9%), and 58 patients had all three conditions (0.6%).

“Compared with patients with RA alone, patients with RA and depression, CVD, or CVD plus depression experienced significantly and progressively higher overall annual unadjusted healthcare costs,” wrote the authors. In fact, the annual cost for patients with RA alone was $14,257, vs. $21,410 for patients with RA plus depression, $24,444 for patients with RA plus CVD, and $35,246 for patients with all three conditions.

Interestingly, patients with RA plus depression had higher annual RA-specific costs than did patients with RA alone ($9,940 vs. $9,322; P = .014), and the RA-specific costs increased even more in patients with all three conditions, to $12,318 (P = .012). That effect was not seen in the RA plus CVD group (J. Rheumatol. 2009 Feb. 15 [doi:10.3899/jrheum.080670]).

The increased costs were, in part, the result of higher hospitalization rates. Just 7.9% of patients with RA alone had a hospital stay in the 12 months prior to their “index date” (the date of the patient's first claim with an RA diagnosis).

In the RA plus CVD cohort, this jumped to 34.9%. In the RA plus depression cohort, it was 18.6%, and among the patients who had all three diagnoses, 60.3% were hospitalized during that 12-month period. (For all rates, P was less than .001).

The average number of prescriptions filled also increased with increasing comorbidities. RA-only patients filled an average of 46.8 prescriptions in the 12 months following RA diagnosis, compared with 69.2 in the RA plus CVD group, 71.3 in the RA plus depression group, and 114.3 in the RA plus depression plus CVD group.

The authors disclosed that the study received funding from Wyeth Research. Three of the authors are also Wyeth Research employees.

Rheumatoid arthritis patients with comorbid depression and/or cardiovascular disease accumulated thousands more dollars in annual health care costs than did their peers with RA alone.

This finding is based on a study of over 10,000 people with rheumatoid arthritis conducted by Amie T. Joyce of Pharmetrics Inc., Watertown, Mass., and her associates.

“We are seeing increasingly that inflammation [is present in] many chronic diseases and, thus, it is impossible to separate out specific illness costs perfectly. The true costs are borne by people with comorbidity. When [other] studies exclude those with comorbidity, they exclude large fractions of the population,” said Edward H. Yelin, Ph.D.

Depression is also “rampant” in RA, “maybe two to three times higher than one would expect based on age and gender,” added Dr. Yelin, professor in residence of medicine and health policy in the division of rheumatology at the University of California, San Francisco. Dr. Yelin was not involved in the study.

Dr. Joyce's study looked at 10,298 RA patients culled from PharMetrics Inc.'s patient-centric database from Jan. 1, 2001 to Dec. 31, 2005. The database contains medical and pharmaceutical claims from 92 health plans across the United States. To be included in the study, patients had to be aged 18 years or older, have a diagnosis of RA, and have undergone treatment with a disease-modifying antirheumatic drug or biologic agent.

Of the sample, 8,916 patients had RA alone (86.6%), 608 had RA with CVD (5.9%), 716 had RA with depression (6.9%), and 58 patients had all three conditions (0.6%).

“Compared with patients with RA alone, patients with RA and depression, CVD, or CVD plus depression experienced significantly and progressively higher overall annual unadjusted healthcare costs,” wrote the authors. In fact, the annual cost for patients with RA alone was $14,257, vs. $21,410 for patients with RA plus depression, $24,444 for patients with RA plus CVD, and $35,246 for patients with all three conditions.

Interestingly, patients with RA plus depression had higher annual RA-specific costs than did patients with RA alone ($9,940 vs. $9,322; P = .014), and the RA-specific costs increased even more in patients with all three conditions, to $12,318 (P = .012). That effect was not seen in the RA plus CVD group (J. Rheumatol. 2009 Feb. 15 [doi:10.3899/jrheum.080670]).

The increased costs were, in part, the result of higher hospitalization rates. Just 7.9% of patients with RA alone had a hospital stay in the 12 months prior to their “index date” (the date of the patient's first claim with an RA diagnosis).

In the RA plus CVD cohort, this jumped to 34.9%. In the RA plus depression cohort, it was 18.6%, and among the patients who had all three diagnoses, 60.3% were hospitalized during that 12-month period. (For all rates, P was less than .001).

The average number of prescriptions filled also increased with increasing comorbidities. RA-only patients filled an average of 46.8 prescriptions in the 12 months following RA diagnosis, compared with 69.2 in the RA plus CVD group, 71.3 in the RA plus depression group, and 114.3 in the RA plus depression plus CVD group.

The authors disclosed that the study received funding from Wyeth Research. Three of the authors are also Wyeth Research employees.

Rheumatoid arthritis patients with comorbid depression and/or cardiovascular disease accumulated thousands more dollars in annual health care costs than did their peers with RA alone.

This finding is based on a study of over 10,000 people with rheumatoid arthritis conducted by Amie T. Joyce of Pharmetrics Inc., Watertown, Mass., and her associates.

“We are seeing increasingly that inflammation [is present in] many chronic diseases and, thus, it is impossible to separate out specific illness costs perfectly. The true costs are borne by people with comorbidity. When [other] studies exclude those with comorbidity, they exclude large fractions of the population,” said Edward H. Yelin, Ph.D.

Depression is also “rampant” in RA, “maybe two to three times higher than one would expect based on age and gender,” added Dr. Yelin, professor in residence of medicine and health policy in the division of rheumatology at the University of California, San Francisco. Dr. Yelin was not involved in the study.

Dr. Joyce's study looked at 10,298 RA patients culled from PharMetrics Inc.'s patient-centric database from Jan. 1, 2001 to Dec. 31, 2005. The database contains medical and pharmaceutical claims from 92 health plans across the United States. To be included in the study, patients had to be aged 18 years or older, have a diagnosis of RA, and have undergone treatment with a disease-modifying antirheumatic drug or biologic agent.

Of the sample, 8,916 patients had RA alone (86.6%), 608 had RA with CVD (5.9%), 716 had RA with depression (6.9%), and 58 patients had all three conditions (0.6%).

“Compared with patients with RA alone, patients with RA and depression, CVD, or CVD plus depression experienced significantly and progressively higher overall annual unadjusted healthcare costs,” wrote the authors. In fact, the annual cost for patients with RA alone was $14,257, vs. $21,410 for patients with RA plus depression, $24,444 for patients with RA plus CVD, and $35,246 for patients with all three conditions.

Interestingly, patients with RA plus depression had higher annual RA-specific costs than did patients with RA alone ($9,940 vs. $9,322; P = .014), and the RA-specific costs increased even more in patients with all three conditions, to $12,318 (P = .012). That effect was not seen in the RA plus CVD group (J. Rheumatol. 2009 Feb. 15 [doi:10.3899/jrheum.080670]).

The increased costs were, in part, the result of higher hospitalization rates. Just 7.9% of patients with RA alone had a hospital stay in the 12 months prior to their “index date” (the date of the patient's first claim with an RA diagnosis).

In the RA plus CVD cohort, this jumped to 34.9%. In the RA plus depression cohort, it was 18.6%, and among the patients who had all three diagnoses, 60.3% were hospitalized during that 12-month period. (For all rates, P was less than .001).

The average number of prescriptions filled also increased with increasing comorbidities. RA-only patients filled an average of 46.8 prescriptions in the 12 months following RA diagnosis, compared with 69.2 in the RA plus CVD group, 71.3 in the RA plus depression group, and 114.3 in the RA plus depression plus CVD group.

The authors disclosed that the study received funding from Wyeth Research. Three of the authors are also Wyeth Research employees.