Jennie Smith

Redundant combinations of intravenous antibiotics are used in nearly 8 of 10 hospitals, even though they are very infrequently indicated, said a group of researchers working to promote antimicrobial stewardship in hospitals.

In an article published in the October issue of Infection Control and Hospital Epidemiology, Leslie Schultz, R.N., Ph.D., of Premier Safety Institute in Charlotte, N.C., and colleagues reported that a review of cases from more than 500 U.S. hospitals revealed that about 150,000 days of inappropriate antibiotic therapy were prescribed, at an estimated excess cost of more than $12 million over the 4-year study period. Some 78% of hospitals in the study used the unnecessary drug combinations, they said.

©Bhakpong/thinkstockphotos.com

The combination of metronidazole and piperacillin-tazobactam accounted for more than half of the redundant treatments detected in the study, with some 32,500 cases receiving this combination for 2 days or more. Other commonly seen redundant treatments included metronidazole and ampicillin-sulbactam, along with metronidazole and ertapenem, which, together with the metronidazole and piperacillin-tazobactam combination, were seen as responsible for 70% of redundant treatments administered to patients (Infect. Control Hosp. Epidemiol. 2014; 35:1229-35).

In a telephone press conference on Sept. 10, one of Dr. Schultz’s coauthors on the paper, Dr. Arjun Srinivasan of the Centers for Disease Control and Prevention, Atlanta, said that, while concerns about antimicrobial stewardship are not new, the findings came as a surprise. "We would expect the use of these combinations to be vanishingly rare given how often they’re indicated," Dr. Srinivasan said, citing a lack of training in antibiotics as a contributing factor.

"We’ve heard from a lot of clinicians that providers don’t know that piperacillin-tazobactam very effectively kills anaerobic bacteria – but they do know that metronidazole is effective," Dr. Srinivasan said. "People are not as aware as they need to be about what antibiotics kill what bacteria, and we need to make sure people know which antibiotics need to be combined and when – and that with some, you don’t gain anything by adding the second drug. You only increase the risk of side effects."

Another physician taking part in the press conference, Dr. Sara Cosgrove of Johns Hopkins Hospital, Baltimore, agreed. "We have suboptimal training among medical students and house staff about what antibiotics cover what bugs," she said. "We have seen publications suggesting that medical students and residents want more info on antibiotics."

Dr. Cosgrove also noted that changes in hospital work practices may have contributed to the problem. "More people are working in hospitals on shorter shifts, and there are communication issues from one physician to the next. One physician may start an antibiotic and a second physician starts a second. There are many ways we can address the problem of unintended duplicate therapy," she said, including the use of alerts generated when pharmacy receives a request for a redundant drug.

Dr. Srinivasan said that hospitals that have implemented alerts have found them effective. Still, both physicians stressed that whatever the methods used, dedicated antimicrobial stewardship teams in hospitals were essential to ensuring the avoidance of redundant treatments.

"Many hospitals report that they are thinking about having an antimicrobial stewardship program. We’d like to nudge them to actually have one," said Dr. Cosgrove, who is chair of the antimicrobial stewardship committee for the Society for Healthcare Epidemiology of America, which publishes Infection Control and Hospital Epidemiology.

Though Johns Hopkins has had an antimicrobial stewardship team since 2002, most hospitals do not have formal groups in place, she said. The Society for Healthcare Epidemiology of America will publish checklists and guidelines in 2015 to help hospitals set up teams, Dr. Cosgrove said, noting that California has recently passed legislation mandating their creation in all hospitals in that state.

All the coauthors of Dr. Schultz’s study except Dr. Srinivasan are employees of Premier Inc., which is a for-profit research corporation. Dr. Srinivasan reported having no conflicts of interest.

Redundant combinations of intravenous antibiotics are used in nearly 8 of 10 hospitals, even though they are very infrequently indicated, said a group of researchers working to promote antimicrobial stewardship in hospitals.

In an article published in the October issue of Infection Control and Hospital Epidemiology, Leslie Schultz, R.N., Ph.D., of Premier Safety Institute in Charlotte, N.C., and colleagues reported that a review of cases from more than 500 U.S. hospitals revealed that about 150,000 days of inappropriate antibiotic therapy were prescribed, at an estimated excess cost of more than $12 million over the 4-year study period. Some 78% of hospitals in the study used the unnecessary drug combinations, they said.

©Bhakpong/thinkstockphotos.com

The combination of metronidazole and piperacillin-tazobactam accounted for more than half of the redundant treatments detected in the study, with some 32,500 cases receiving this combination for 2 days or more. Other commonly seen redundant treatments included metronidazole and ampicillin-sulbactam, along with metronidazole and ertapenem, which, together with the metronidazole and piperacillin-tazobactam combination, were seen as responsible for 70% of redundant treatments administered to patients (Infect. Control Hosp. Epidemiol. 2014; 35:1229-35).

In a telephone press conference on Sept. 10, one of Dr. Schultz’s coauthors on the paper, Dr. Arjun Srinivasan of the Centers for Disease Control and Prevention, Atlanta, said that, while concerns about antimicrobial stewardship are not new, the findings came as a surprise. "We would expect the use of these combinations to be vanishingly rare given how often they’re indicated," Dr. Srinivasan said, citing a lack of training in antibiotics as a contributing factor.

"We’ve heard from a lot of clinicians that providers don’t know that piperacillin-tazobactam very effectively kills anaerobic bacteria – but they do know that metronidazole is effective," Dr. Srinivasan said. "People are not as aware as they need to be about what antibiotics kill what bacteria, and we need to make sure people know which antibiotics need to be combined and when – and that with some, you don’t gain anything by adding the second drug. You only increase the risk of side effects."

Another physician taking part in the press conference, Dr. Sara Cosgrove of Johns Hopkins Hospital, Baltimore, agreed. "We have suboptimal training among medical students and house staff about what antibiotics cover what bugs," she said. "We have seen publications suggesting that medical students and residents want more info on antibiotics."

Dr. Cosgrove also noted that changes in hospital work practices may have contributed to the problem. "More people are working in hospitals on shorter shifts, and there are communication issues from one physician to the next. One physician may start an antibiotic and a second physician starts a second. There are many ways we can address the problem of unintended duplicate therapy," she said, including the use of alerts generated when pharmacy receives a request for a redundant drug.

Dr. Srinivasan said that hospitals that have implemented alerts have found them effective. Still, both physicians stressed that whatever the methods used, dedicated antimicrobial stewardship teams in hospitals were essential to ensuring the avoidance of redundant treatments.

"Many hospitals report that they are thinking about having an antimicrobial stewardship program. We’d like to nudge them to actually have one," said Dr. Cosgrove, who is chair of the antimicrobial stewardship committee for the Society for Healthcare Epidemiology of America, which publishes Infection Control and Hospital Epidemiology.

Though Johns Hopkins has had an antimicrobial stewardship team since 2002, most hospitals do not have formal groups in place, she said. The Society for Healthcare Epidemiology of America will publish checklists and guidelines in 2015 to help hospitals set up teams, Dr. Cosgrove said, noting that California has recently passed legislation mandating their creation in all hospitals in that state.

All the coauthors of Dr. Schultz’s study except Dr. Srinivasan are employees of Premier Inc., which is a for-profit research corporation. Dr. Srinivasan reported having no conflicts of interest.

Redundant combinations of intravenous antibiotics are used in nearly 8 of 10 hospitals, even though they are very infrequently indicated, said a group of researchers working to promote antimicrobial stewardship in hospitals.

In an article published in the October issue of Infection Control and Hospital Epidemiology, Leslie Schultz, R.N., Ph.D., of Premier Safety Institute in Charlotte, N.C., and colleagues reported that a review of cases from more than 500 U.S. hospitals revealed that about 150,000 days of inappropriate antibiotic therapy were prescribed, at an estimated excess cost of more than $12 million over the 4-year study period. Some 78% of hospitals in the study used the unnecessary drug combinations, they said.

©Bhakpong/thinkstockphotos.com

The combination of metronidazole and piperacillin-tazobactam accounted for more than half of the redundant treatments detected in the study, with some 32,500 cases receiving this combination for 2 days or more. Other commonly seen redundant treatments included metronidazole and ampicillin-sulbactam, along with metronidazole and ertapenem, which, together with the metronidazole and piperacillin-tazobactam combination, were seen as responsible for 70% of redundant treatments administered to patients (Infect. Control Hosp. Epidemiol. 2014; 35:1229-35).

In a telephone press conference on Sept. 10, one of Dr. Schultz’s coauthors on the paper, Dr. Arjun Srinivasan of the Centers for Disease Control and Prevention, Atlanta, said that, while concerns about antimicrobial stewardship are not new, the findings came as a surprise. "We would expect the use of these combinations to be vanishingly rare given how often they’re indicated," Dr. Srinivasan said, citing a lack of training in antibiotics as a contributing factor.

"We’ve heard from a lot of clinicians that providers don’t know that piperacillin-tazobactam very effectively kills anaerobic bacteria – but they do know that metronidazole is effective," Dr. Srinivasan said. "People are not as aware as they need to be about what antibiotics kill what bacteria, and we need to make sure people know which antibiotics need to be combined and when – and that with some, you don’t gain anything by adding the second drug. You only increase the risk of side effects."

Another physician taking part in the press conference, Dr. Sara Cosgrove of Johns Hopkins Hospital, Baltimore, agreed. "We have suboptimal training among medical students and house staff about what antibiotics cover what bugs," she said. "We have seen publications suggesting that medical students and residents want more info on antibiotics."

Dr. Cosgrove also noted that changes in hospital work practices may have contributed to the problem. "More people are working in hospitals on shorter shifts, and there are communication issues from one physician to the next. One physician may start an antibiotic and a second physician starts a second. There are many ways we can address the problem of unintended duplicate therapy," she said, including the use of alerts generated when pharmacy receives a request for a redundant drug.

Dr. Srinivasan said that hospitals that have implemented alerts have found them effective. Still, both physicians stressed that whatever the methods used, dedicated antimicrobial stewardship teams in hospitals were essential to ensuring the avoidance of redundant treatments.

"Many hospitals report that they are thinking about having an antimicrobial stewardship program. We’d like to nudge them to actually have one," said Dr. Cosgrove, who is chair of the antimicrobial stewardship committee for the Society for Healthcare Epidemiology of America, which publishes Infection Control and Hospital Epidemiology.

Though Johns Hopkins has had an antimicrobial stewardship team since 2002, most hospitals do not have formal groups in place, she said. The Society for Healthcare Epidemiology of America will publish checklists and guidelines in 2015 to help hospitals set up teams, Dr. Cosgrove said, noting that California has recently passed legislation mandating their creation in all hospitals in that state.

All the coauthors of Dr. Schultz’s study except Dr. Srinivasan are employees of Premier Inc., which is a for-profit research corporation. Dr. Srinivasan reported having no conflicts of interest.

Redundant combinations of intravenous antibiotics are used in nearly 8 of 10 hospitals, even though they are very infrequently indicated, said a group of researchers working to promote antimicrobial stewardship in hospitals.

In an article published in the October issue of Infection Control and Hospital Epidemiology, Leslie Schultz, R.N., Ph.D., of Premier Safety Institute in Charlotte, N.C., and colleagues reported that a review of cases from more than 500 U.S. hospitals revealed that about 150,000 days of inappropriate antibiotic therapy were prescribed, at an estimated excess cost of more than $12 million over the 4-year study period. Some 78% of hospitals in the study used the unnecessary drug combinations, they said.

©Bhakpong/thinkstockphotos.com

The combination of metronidazole and piperacillin-tazobactam accounted for more than half of the redundant treatments detected in the study, with some 32,500 cases receiving this combination for 2 days or more. Other commonly seen redundant treatments included metronidazole and ampicillin-sulbactam, along with metronidazole and ertapenem, which, together with the metronidazole and piperacillin-tazobactam combination, were seen as responsible for 70% of redundant treatments administered to patients (Infect. Control Hosp. Epidemiol. 2014; 35:1229-35).

In a telephone press conference on Sept. 10, one of Dr. Schultz’s coauthors on the paper, Dr. Arjun Srinivasan of the Centers for Disease Control and Prevention, Atlanta, said that, while concerns about antimicrobial stewardship are not new, the findings came as a surprise. "We would expect the use of these combinations to be vanishingly rare given how often they’re indicated," Dr. Srinivasan said, citing a lack of training in antibiotics as a contributing factor.

"We’ve heard from a lot of clinicians that providers don’t know that piperacillin-tazobactam very effectively kills anaerobic bacteria – but they do know that metronidazole is effective," Dr. Srinivasan said. "People are not as aware as they need to be about what antibiotics kill what bacteria, and we need to make sure people know which antibiotics need to be combined and when – and that with some, you don’t gain anything by adding the second drug. You only increase the risk of side effects."

Another physician taking part in the press conference, Dr. Sara Cosgrove of Johns Hopkins Hospital, Baltimore, agreed. "We have suboptimal training among medical students and house staff about what antibiotics cover what bugs," she said. "We have seen publications suggesting that medical students and residents want more info on antibiotics."

Dr. Cosgrove also noted that changes in hospital work practices may have contributed to the problem. "More people are working in hospitals on shorter shifts, and there are communication issues from one physician to the next. One physician may start an antibiotic and a second physician starts a second. There are many ways we can address the problem of unintended duplicate therapy," she said, including the use of alerts generated when pharmacy receives a request for a redundant drug.

Dr. Srinivasan said that hospitals that have implemented alerts have found them effective. Still, both physicians stressed that whatever the methods used, dedicated antimicrobial stewardship teams in hospitals were essential to ensuring the avoidance of redundant treatments.

"Many hospitals report that they are thinking about having an antimicrobial stewardship program. We’d like to nudge them to actually have one," said Dr. Cosgrove, who is chair of the antimicrobial stewardship committee for the Society for Healthcare Epidemiology of America, which publishes Infection Control and Hospital Epidemiology.

Though Johns Hopkins has had an antimicrobial stewardship team since 2002, most hospitals do not have formal groups in place, she said. The Society for Healthcare Epidemiology of America will publish checklists and guidelines in 2015 to help hospitals set up teams, Dr. Cosgrove said, noting that California has recently passed legislation mandating their creation in all hospitals in that state.

All the coauthors of Dr. Schultz’s study except Dr. Srinivasan are employees of Premier Inc., which is a for-profit research corporation. Dr. Srinivasan reported having no conflicts of interest.

Redundant combinations of intravenous antibiotics are used in nearly 8 of 10 hospitals, even though they are very infrequently indicated, said a group of researchers working to promote antimicrobial stewardship in hospitals.

In an article published in the October issue of Infection Control and Hospital Epidemiology, Leslie Schultz, R.N., Ph.D., of Premier Safety Institute in Charlotte, N.C., and colleagues reported that a review of cases from more than 500 U.S. hospitals revealed that about 150,000 days of inappropriate antibiotic therapy were prescribed, at an estimated excess cost of more than $12 million over the 4-year study period. Some 78% of hospitals in the study used the unnecessary drug combinations, they said.

©Bhakpong/thinkstockphotos.com

The combination of metronidazole and piperacillin-tazobactam accounted for more than half of the redundant treatments detected in the study, with some 32,500 cases receiving this combination for 2 days or more. Other commonly seen redundant treatments included metronidazole and ampicillin-sulbactam, along with metronidazole and ertapenem, which, together with the metronidazole and piperacillin-tazobactam combination, were seen as responsible for 70% of redundant treatments administered to patients (Infect. Control Hosp. Epidemiol. 2014; 35:1229-35).

In a telephone press conference on Sept. 10, one of Dr. Schultz’s coauthors on the paper, Dr. Arjun Srinivasan of the Centers for Disease Control and Prevention, Atlanta, said that, while concerns about antimicrobial stewardship are not new, the findings came as a surprise. "We would expect the use of these combinations to be vanishingly rare given how often they’re indicated," Dr. Srinivasan said, citing a lack of training in antibiotics as a contributing factor.

"We’ve heard from a lot of clinicians that providers don’t know that piperacillin-tazobactam very effectively kills anaerobic bacteria – but they do know that metronidazole is effective," Dr. Srinivasan said. "People are not as aware as they need to be about what antibiotics kill what bacteria, and we need to make sure people know which antibiotics need to be combined and when – and that with some, you don’t gain anything by adding the second drug. You only increase the risk of side effects."

Another physician taking part in the press conference, Dr. Sara Cosgrove of Johns Hopkins Hospital, Baltimore, agreed. "We have suboptimal training among medical students and house staff about what antibiotics cover what bugs," she said. "We have seen publications suggesting that medical students and residents want more info on antibiotics."

Dr. Cosgrove also noted that changes in hospital work practices may have contributed to the problem. "More people are working in hospitals on shorter shifts, and there are communication issues from one physician to the next. One physician may start an antibiotic and a second physician starts a second. There are many ways we can address the problem of unintended duplicate therapy," she said, including the use of alerts generated when pharmacy receives a request for a redundant drug.

Dr. Srinivasan said that hospitals that have implemented alerts have found them effective. Still, both physicians stressed that whatever the methods used, dedicated antimicrobial stewardship teams in hospitals were essential to ensuring the avoidance of redundant treatments.

"Many hospitals report that they are thinking about having an antimicrobial stewardship program. We’d like to nudge them to actually have one," said Dr. Cosgrove, who is chair of the antimicrobial stewardship committee for the Society for Healthcare Epidemiology of America, which publishes Infection Control and Hospital Epidemiology.

Though Johns Hopkins has had an antimicrobial stewardship team since 2002, most hospitals do not have formal groups in place, she said. The Society for Healthcare Epidemiology of America will publish checklists and guidelines in 2015 to help hospitals set up teams, Dr. Cosgrove said, noting that California has recently passed legislation mandating their creation in all hospitals in that state.

All the coauthors of Dr. Schultz’s study except Dr. Srinivasan are employees of Premier Inc., which is a for-profit research corporation. Dr. Srinivasan reported having no conflicts of interest.

Redundant combinations of intravenous antibiotics are used in nearly 8 of 10 hospitals, even though they are very infrequently indicated, said a group of researchers working to promote antimicrobial stewardship in hospitals.

In an article published in the October issue of Infection Control and Hospital Epidemiology, Leslie Schultz, R.N., Ph.D., of Premier Safety Institute in Charlotte, N.C., and colleagues reported that a review of cases from more than 500 U.S. hospitals revealed that about 150,000 days of inappropriate antibiotic therapy were prescribed, at an estimated excess cost of more than $12 million over the 4-year study period. Some 78% of hospitals in the study used the unnecessary drug combinations, they said.

©Bhakpong/thinkstockphotos.com

The combination of metronidazole and piperacillin-tazobactam accounted for more than half of the redundant treatments detected in the study, with some 32,500 cases receiving this combination for 2 days or more. Other commonly seen redundant treatments included metronidazole and ampicillin-sulbactam, along with metronidazole and ertapenem, which, together with the metronidazole and piperacillin-tazobactam combination, were seen as responsible for 70% of redundant treatments administered to patients (Infect. Control Hosp. Epidemiol. 2014; 35:1229-35).

In a telephone press conference on Sept. 10, one of Dr. Schultz’s coauthors on the paper, Dr. Arjun Srinivasan of the Centers for Disease Control and Prevention, Atlanta, said that, while concerns about antimicrobial stewardship are not new, the findings came as a surprise. "We would expect the use of these combinations to be vanishingly rare given how often they’re indicated," Dr. Srinivasan said, citing a lack of training in antibiotics as a contributing factor.

"We’ve heard from a lot of clinicians that providers don’t know that piperacillin-tazobactam very effectively kills anaerobic bacteria – but they do know that metronidazole is effective," Dr. Srinivasan said. "People are not as aware as they need to be about what antibiotics kill what bacteria, and we need to make sure people know which antibiotics need to be combined and when – and that with some, you don’t gain anything by adding the second drug. You only increase the risk of side effects."

Another physician taking part in the press conference, Dr. Sara Cosgrove of Johns Hopkins Hospital, Baltimore, agreed. "We have suboptimal training among medical students and house staff about what antibiotics cover what bugs," she said. "We have seen publications suggesting that medical students and residents want more info on antibiotics."

Dr. Cosgrove also noted that changes in hospital work practices may have contributed to the problem. "More people are working in hospitals on shorter shifts, and there are communication issues from one physician to the next. One physician may start an antibiotic and a second physician starts a second. There are many ways we can address the problem of unintended duplicate therapy," she said, including the use of alerts generated when pharmacy receives a request for a redundant drug.

Dr. Srinivasan said that hospitals that have implemented alerts have found them effective. Still, both physicians stressed that whatever the methods used, dedicated antimicrobial stewardship teams in hospitals were essential to ensuring the avoidance of redundant treatments.

"Many hospitals report that they are thinking about having an antimicrobial stewardship program. We’d like to nudge them to actually have one," said Dr. Cosgrove, who is chair of the antimicrobial stewardship committee for the Society for Healthcare Epidemiology of America, which publishes Infection Control and Hospital Epidemiology.

Though Johns Hopkins has had an antimicrobial stewardship team since 2002, most hospitals do not have formal groups in place, she said. The Society for Healthcare Epidemiology of America will publish checklists and guidelines in 2015 to help hospitals set up teams, Dr. Cosgrove said, noting that California has recently passed legislation mandating their creation in all hospitals in that state.

All the coauthors of Dr. Schultz’s study except Dr. Srinivasan are employees of Premier Inc., which is a for-profit research corporation. Dr. Srinivasan reported having no conflicts of interest.

Benzodiazepine use for 3 months or more is associated with a significantly increased likelihood of developing Alzheimer’s disease, and longer exposure is associated with greater odds, according to results from a case-control study published in BMJ.

The authors, led by Sophie Billioti de Gage of Université de Bordeaux (France), conducted a nested case-control study of 1,796 members of a public drug plan in Quebec aged 66 years and older who had been diagnosed with Alzheimer’s disease at least 6 years prior, and more than 7,000 non-Alzheimer’s controls matched for age and sex.

Ms. Billioti de Gage and her colleagues found a cumulative dose-effect association between exposure to benzodiazepines at least 5 years before diagnosis and the odds of developing Alzheimer’s disease, with a significantly greater likelihood observed with benzodiazepine use of 90 or more consecutive days (adjusted odds ratio, 1.51; 95% confidence interval, 1.36-1.69) and daily exposure to benzodiazepines for 180 or more days (adjusted OR, 1.84; 95% CI, 1.62-2.08).

The researchers also found that the type of benzodiazepine prescribed affected risk. Drugs with longer half-life, such as diazepam and clonazepam, were associated with greater likelihood of Alzheimer’s disease (OR, 1.70; 95% CI, 1.46-1.98), compared with shorter-acting drugs, such as lorazepam and alprazolam (OR, 1.43; 95% CI, 1.27-1.61). The association between benzodiazepine use and Alzheimer’s persisted even after researchers adjusted for symptoms that could be indicative of a future dementia diagnosis, including depression, anxiety, and insomnia (BMJ 2014 Sept. 9 [doi:10.1136/bmj.g5205]).

While the study authors acknowledged that they could not rule out that anxiety and sleep disorders, two of the main indications for benzodiazepines, “could be associated with early beta amyloid lesions in brain, and persistent mid-life anxiety could be associated with a greater risk of dementia in older people,” they also noted that their study was designed to reduce the possibility of reverse causation bias “and to provide additional arguments linking benzodiazepine use with Alzheimer’s disease, such as a dose-effect relation.”

The findings, Ms. Billioti de Gage and her colleagues added, argue for “carefully evaluating the indications for use of this drug class … especially considering the prevalence and chronicity of benzodiazepine use in older people and the high and increasing incidence of dementia in developed countries.”

The study was funded by INSERM (Institut National de la Santé et de la Recherche Médicale) and the University of Bordeaux, as well as by unconditional grants from IRESP (Institut de Recherche en Santé Publique), the French Ministry of Health, and the Funding Agency for Health Research of Quebec. One of the study’s coauthors, Dr. Tobias Kurth, declared payment from BMJ and Cephalalgia; another co-author, Marie Tournier, declared receiving honoraria from AstraZeneca, Bristol-Myers Squibb, and Janssen.

Benzodiazepine use for 3 months or more is associated with a significantly increased likelihood of developing Alzheimer’s disease, and longer exposure is associated with greater odds, according to results from a case-control study published in BMJ.

The authors, led by Sophie Billioti de Gage of Université de Bordeaux (France), conducted a nested case-control study of 1,796 members of a public drug plan in Quebec aged 66 years and older who had been diagnosed with Alzheimer’s disease at least 6 years prior, and more than 7,000 non-Alzheimer’s controls matched for age and sex.

Ms. Billioti de Gage and her colleagues found a cumulative dose-effect association between exposure to benzodiazepines at least 5 years before diagnosis and the odds of developing Alzheimer’s disease, with a significantly greater likelihood observed with benzodiazepine use of 90 or more consecutive days (adjusted odds ratio, 1.51; 95% confidence interval, 1.36-1.69) and daily exposure to benzodiazepines for 180 or more days (adjusted OR, 1.84; 95% CI, 1.62-2.08).

The researchers also found that the type of benzodiazepine prescribed affected risk. Drugs with longer half-life, such as diazepam and clonazepam, were associated with greater likelihood of Alzheimer’s disease (OR, 1.70; 95% CI, 1.46-1.98), compared with shorter-acting drugs, such as lorazepam and alprazolam (OR, 1.43; 95% CI, 1.27-1.61). The association between benzodiazepine use and Alzheimer’s persisted even after researchers adjusted for symptoms that could be indicative of a future dementia diagnosis, including depression, anxiety, and insomnia (BMJ 2014 Sept. 9 [doi:10.1136/bmj.g5205]).

While the study authors acknowledged that they could not rule out that anxiety and sleep disorders, two of the main indications for benzodiazepines, “could be associated with early beta amyloid lesions in brain, and persistent mid-life anxiety could be associated with a greater risk of dementia in older people,” they also noted that their study was designed to reduce the possibility of reverse causation bias “and to provide additional arguments linking benzodiazepine use with Alzheimer’s disease, such as a dose-effect relation.”

The findings, Ms. Billioti de Gage and her colleagues added, argue for “carefully evaluating the indications for use of this drug class … especially considering the prevalence and chronicity of benzodiazepine use in older people and the high and increasing incidence of dementia in developed countries.”

The study was funded by INSERM (Institut National de la Santé et de la Recherche Médicale) and the University of Bordeaux, as well as by unconditional grants from IRESP (Institut de Recherche en Santé Publique), the French Ministry of Health, and the Funding Agency for Health Research of Quebec. One of the study’s coauthors, Dr. Tobias Kurth, declared payment from BMJ and Cephalalgia; another co-author, Marie Tournier, declared receiving honoraria from AstraZeneca, Bristol-Myers Squibb, and Janssen.

Benzodiazepine use for 3 months or more is associated with a significantly increased likelihood of developing Alzheimer’s disease, and longer exposure is associated with greater odds, according to results from a case-control study published in BMJ.

The authors, led by Sophie Billioti de Gage of Université de Bordeaux (France), conducted a nested case-control study of 1,796 members of a public drug plan in Quebec aged 66 years and older who had been diagnosed with Alzheimer’s disease at least 6 years prior, and more than 7,000 non-Alzheimer’s controls matched for age and sex.

Ms. Billioti de Gage and her colleagues found a cumulative dose-effect association between exposure to benzodiazepines at least 5 years before diagnosis and the odds of developing Alzheimer’s disease, with a significantly greater likelihood observed with benzodiazepine use of 90 or more consecutive days (adjusted odds ratio, 1.51; 95% confidence interval, 1.36-1.69) and daily exposure to benzodiazepines for 180 or more days (adjusted OR, 1.84; 95% CI, 1.62-2.08).

The researchers also found that the type of benzodiazepine prescribed affected risk. Drugs with longer half-life, such as diazepam and clonazepam, were associated with greater likelihood of Alzheimer’s disease (OR, 1.70; 95% CI, 1.46-1.98), compared with shorter-acting drugs, such as lorazepam and alprazolam (OR, 1.43; 95% CI, 1.27-1.61). The association between benzodiazepine use and Alzheimer’s persisted even after researchers adjusted for symptoms that could be indicative of a future dementia diagnosis, including depression, anxiety, and insomnia (BMJ 2014 Sept. 9 [doi:10.1136/bmj.g5205]).

While the study authors acknowledged that they could not rule out that anxiety and sleep disorders, two of the main indications for benzodiazepines, “could be associated with early beta amyloid lesions in brain, and persistent mid-life anxiety could be associated with a greater risk of dementia in older people,” they also noted that their study was designed to reduce the possibility of reverse causation bias “and to provide additional arguments linking benzodiazepine use with Alzheimer’s disease, such as a dose-effect relation.”

The findings, Ms. Billioti de Gage and her colleagues added, argue for “carefully evaluating the indications for use of this drug class … especially considering the prevalence and chronicity of benzodiazepine use in older people and the high and increasing incidence of dementia in developed countries.”

The study was funded by INSERM (Institut National de la Santé et de la Recherche Médicale) and the University of Bordeaux, as well as by unconditional grants from IRESP (Institut de Recherche en Santé Publique), the French Ministry of Health, and the Funding Agency for Health Research of Quebec. One of the study’s coauthors, Dr. Tobias Kurth, declared payment from BMJ and Cephalalgia; another co-author, Marie Tournier, declared receiving honoraria from AstraZeneca, Bristol-Myers Squibb, and Janssen.

Benzodiazepine use for 3 months or more is associated with a significantly increased likelihood of developing Alzheimer’s disease, and longer exposure is associated with greater odds, according to results from a case-control study published Sept. 9 in BMJ.

The authors, led by Sophie Billioti de Gage of Université de Bordeaux (France), conducted a nested case-control study of 1,796 members of a public drug plan in Quebec, Canada, aged 66 years and older who had been diagnosed with Alzheimer’s disease at least 6 years prior, and more than 7,000 non-Alzheimer’s controls matched for age and sex.

Ms. Billioti de Gage and her colleagues found a cumulative dose-effect association between exposure to benzodiazepines at least 5 years before diagnosis and the odds of developing Alzheimer’s disease, with a significantly greater likelihood observed with benzodiazepine use of 90 or more consecutive days (adjusted odds ratio, 1.51; 95% confidence interval, 1.36-1.69) and daily exposure to benzodiazepines for 180 or more days (adjusted OR, 1.84; 95% CI, 1.62-2.08).

The researchers also found that the type of benzodiazepine prescribed affected risk. Drugs with longer half-life, such as diazepam and clonazepam, were associated with greater likelihood of Alzheimer’s disease (OR, 1.70; 95% CI, 1.46-1.98), compared with shorter-acting drugs, such as lorazepam and alprazolam (OR, 1.43; 95% CI, 1.27-1.61). The association between benzodiazepine use and Alzheimer’s persisted even after researchers adjusted for symptoms that could be indicative of a future dementia diagnosis, including depression, anxiety, and insomnia (BMJ 2014 Sept. 9 [doi:10.1136/bmj.g5205]).

While the study authors acknowledged that they could not rule out that anxiety and sleep disorders, two of the main indications for benzodiazepines, "could be associated with early beta amyloid lesions in brain, and persistent mid-life anxiety could be associated with a greater risk of dementia in older people," they also noted that their study was designed to reduce the possibility of reverse causation bias "and to provide additional arguments linking benzodiazepine use with Alzheimer’s disease, such as a dose-effect relation."

The findings, Ms. Billioti de Gage and her colleagues added, argue for "carefully evaluating the indications for use of this drug class ... especially considering the prevalence and chronicity of benzodiazepine use in older people and the high and increasing incidence of dementia in developed countries."

The study was funded by INSERM (Institut National de la Santé et de la Recherche Médicale) and the University of Bordeaux, as well as by unconditional grants from IRESP (Institut de Recherche en Santé Publique), the French Ministry of Health (Direction Générale de la Santé), and the Funding Agency for Health Research of Quebec (Fonds de la Recherche en Santé du Québec). One of the study’s coauthors, Dr. Tobias Kurth, declared payment from BMJ and Cephalalgia; another co-author, Marie Tournier, declared receiving honoraria from AstraZeneca, Bristol-Myers Squibb, and Janssen.

Benzodiazepine use for 3 months or more is associated with a significantly increased likelihood of developing Alzheimer’s disease, and longer exposure is associated with greater odds, according to results from a case-control study published Sept. 9 in BMJ.

The authors, led by Sophie Billioti de Gage of Université de Bordeaux (France), conducted a nested case-control study of 1,796 members of a public drug plan in Quebec, Canada, aged 66 years and older who had been diagnosed with Alzheimer’s disease at least 6 years prior, and more than 7,000 non-Alzheimer’s controls matched for age and sex.

Ms. Billioti de Gage and her colleagues found a cumulative dose-effect association between exposure to benzodiazepines at least 5 years before diagnosis and the odds of developing Alzheimer’s disease, with a significantly greater likelihood observed with benzodiazepine use of 90 or more consecutive days (adjusted odds ratio, 1.51; 95% confidence interval, 1.36-1.69) and daily exposure to benzodiazepines for 180 or more days (adjusted OR, 1.84; 95% CI, 1.62-2.08).

The researchers also found that the type of benzodiazepine prescribed affected risk. Drugs with longer half-life, such as diazepam and clonazepam, were associated with greater likelihood of Alzheimer’s disease (OR, 1.70; 95% CI, 1.46-1.98), compared with shorter-acting drugs, such as lorazepam and alprazolam (OR, 1.43; 95% CI, 1.27-1.61). The association between benzodiazepine use and Alzheimer’s persisted even after researchers adjusted for symptoms that could be indicative of a future dementia diagnosis, including depression, anxiety, and insomnia (BMJ 2014 Sept. 9 [doi:10.1136/bmj.g5205]).

While the study authors acknowledged that they could not rule out that anxiety and sleep disorders, two of the main indications for benzodiazepines, "could be associated with early beta amyloid lesions in brain, and persistent mid-life anxiety could be associated with a greater risk of dementia in older people," they also noted that their study was designed to reduce the possibility of reverse causation bias "and to provide additional arguments linking benzodiazepine use with Alzheimer’s disease, such as a dose-effect relation."

The findings, Ms. Billioti de Gage and her colleagues added, argue for "carefully evaluating the indications for use of this drug class ... especially considering the prevalence and chronicity of benzodiazepine use in older people and the high and increasing incidence of dementia in developed countries."

The study was funded by INSERM (Institut National de la Santé et de la Recherche Médicale) and the University of Bordeaux, as well as by unconditional grants from IRESP (Institut de Recherche en Santé Publique), the French Ministry of Health (Direction Générale de la Santé), and the Funding Agency for Health Research of Quebec (Fonds de la Recherche en Santé du Québec). One of the study’s coauthors, Dr. Tobias Kurth, declared payment from BMJ and Cephalalgia; another co-author, Marie Tournier, declared receiving honoraria from AstraZeneca, Bristol-Myers Squibb, and Janssen.

Benzodiazepine use for 3 months or more is associated with a significantly increased likelihood of developing Alzheimer’s disease, and longer exposure is associated with greater odds, according to results from a case-control study published Sept. 9 in BMJ.

The authors, led by Sophie Billioti de Gage of Université de Bordeaux (France), conducted a nested case-control study of 1,796 members of a public drug plan in Quebec, Canada, aged 66 years and older who had been diagnosed with Alzheimer’s disease at least 6 years prior, and more than 7,000 non-Alzheimer’s controls matched for age and sex.

Ms. Billioti de Gage and her colleagues found a cumulative dose-effect association between exposure to benzodiazepines at least 5 years before diagnosis and the odds of developing Alzheimer’s disease, with a significantly greater likelihood observed with benzodiazepine use of 90 or more consecutive days (adjusted odds ratio, 1.51; 95% confidence interval, 1.36-1.69) and daily exposure to benzodiazepines for 180 or more days (adjusted OR, 1.84; 95% CI, 1.62-2.08).

The researchers also found that the type of benzodiazepine prescribed affected risk. Drugs with longer half-life, such as diazepam and clonazepam, were associated with greater likelihood of Alzheimer’s disease (OR, 1.70; 95% CI, 1.46-1.98), compared with shorter-acting drugs, such as lorazepam and alprazolam (OR, 1.43; 95% CI, 1.27-1.61). The association between benzodiazepine use and Alzheimer’s persisted even after researchers adjusted for symptoms that could be indicative of a future dementia diagnosis, including depression, anxiety, and insomnia (BMJ 2014 Sept. 9 [doi:10.1136/bmj.g5205]).

While the study authors acknowledged that they could not rule out that anxiety and sleep disorders, two of the main indications for benzodiazepines, "could be associated with early beta amyloid lesions in brain, and persistent mid-life anxiety could be associated with a greater risk of dementia in older people," they also noted that their study was designed to reduce the possibility of reverse causation bias "and to provide additional arguments linking benzodiazepine use with Alzheimer’s disease, such as a dose-effect relation."

The findings, Ms. Billioti de Gage and her colleagues added, argue for "carefully evaluating the indications for use of this drug class ... especially considering the prevalence and chronicity of benzodiazepine use in older people and the high and increasing incidence of dementia in developed countries."

The study was funded by INSERM (Institut National de la Santé et de la Recherche Médicale) and the University of Bordeaux, as well as by unconditional grants from IRESP (Institut de Recherche en Santé Publique), the French Ministry of Health (Direction Générale de la Santé), and the Funding Agency for Health Research of Quebec (Fonds de la Recherche en Santé du Québec). One of the study’s coauthors, Dr. Tobias Kurth, declared payment from BMJ and Cephalalgia; another co-author, Marie Tournier, declared receiving honoraria from AstraZeneca, Bristol-Myers Squibb, and Janssen.

Benzodiazepine use for 3 months or more is associated with a significantly increased likelihood of developing Alzheimer’s disease, and longer exposure is associated with greater odds, according to results from a case-control study published Sept. 9 in BMJ.

The authors, led by Sophie Billioti de Gage of Université de Bordeaux (France), conducted a nested case-control study of 1,796 members of a public drug plan in Quebec, Canada, aged 66 years and older who had been diagnosed with Alzheimer’s disease at least 6 years prior, and more than 7,000 non-Alzheimer’s controls matched for age and sex.

Ms. Billioti de Gage and her colleagues found a cumulative dose-effect association between exposure to benzodiazepines at least 5 years before diagnosis and the odds of developing Alzheimer’s disease, with a significantly greater likelihood observed with benzodiazepine use of 90 or more consecutive days (adjusted odds ratio, 1.51; 95% confidence interval, 1.36-1.69) and daily exposure to benzodiazepines for 180 or more days (adjusted OR, 1.84; 95% CI, 1.62-2.08).

The researchers also found that the type of benzodiazepine prescribed affected risk. Drugs with longer half-life, such as diazepam and clonazepam, were associated with greater likelihood of Alzheimer’s disease (OR, 1.70; 95% CI, 1.46-1.98), compared with shorter-acting drugs, such as lorazepam and alprazolam (OR, 1.43; 95% CI, 1.27-1.61). The association between benzodiazepine use and Alzheimer’s persisted even after researchers adjusted for symptoms that could be indicative of a future dementia diagnosis, including depression, anxiety, and insomnia (BMJ 2014 Sept. 9 [doi:10.1136/bmj.g5205]).

While the study authors acknowledged that they could not rule out that anxiety and sleep disorders, two of the main indications for benzodiazepines, "could be associated with early beta amyloid lesions in brain, and persistent mid-life anxiety could be associated with a greater risk of dementia in older people," they also noted that their study was designed to reduce the possibility of reverse causation bias "and to provide additional arguments linking benzodiazepine use with Alzheimer’s disease, such as a dose-effect relation."

The findings, Ms. Billioti de Gage and her colleagues added, argue for "carefully evaluating the indications for use of this drug class ... especially considering the prevalence and chronicity of benzodiazepine use in older people and the high and increasing incidence of dementia in developed countries."

The study was funded by INSERM (Institut National de la Santé et de la Recherche Médicale) and the University of Bordeaux, as well as by unconditional grants from IRESP (Institut de Recherche en Santé Publique), the French Ministry of Health (Direction Générale de la Santé), and the Funding Agency for Health Research of Quebec (Fonds de la Recherche en Santé du Québec). One of the study’s coauthors, Dr. Tobias Kurth, declared payment from BMJ and Cephalalgia; another co-author, Marie Tournier, declared receiving honoraria from AstraZeneca, Bristol-Myers Squibb, and Janssen.

Benzodiazepine use for 3 months or more is associated with a significantly increased likelihood of developing Alzheimer’s disease, and longer exposure is associated with greater odds, according to results from a case-control study published Sept. 9 in BMJ.

The authors, led by Sophie Billioti de Gage of Université de Bordeaux (France), conducted a nested case-control study of 1,796 members of a public drug plan in Quebec, Canada, aged 66 years and older who had been diagnosed with Alzheimer’s disease at least 6 years prior, and more than 7,000 non-Alzheimer’s controls matched for age and sex.

Ms. Billioti de Gage and her colleagues found a cumulative dose-effect association between exposure to benzodiazepines at least 5 years before diagnosis and the odds of developing Alzheimer’s disease, with a significantly greater likelihood observed with benzodiazepine use of 90 or more consecutive days (adjusted odds ratio, 1.51; 95% confidence interval, 1.36-1.69) and daily exposure to benzodiazepines for 180 or more days (adjusted OR, 1.84; 95% CI, 1.62-2.08).

The researchers also found that the type of benzodiazepine prescribed affected risk. Drugs with longer half-life, such as diazepam and clonazepam, were associated with greater likelihood of Alzheimer’s disease (OR, 1.70; 95% CI, 1.46-1.98), compared with shorter-acting drugs, such as lorazepam and alprazolam (OR, 1.43; 95% CI, 1.27-1.61). The association between benzodiazepine use and Alzheimer’s persisted even after researchers adjusted for symptoms that could be indicative of a future dementia diagnosis, including depression, anxiety, and insomnia (BMJ 2014 Sept. 9 [doi:10.1136/bmj.g5205]).

While the study authors acknowledged that they could not rule out that anxiety and sleep disorders, two of the main indications for benzodiazepines, "could be associated with early beta amyloid lesions in brain, and persistent mid-life anxiety could be associated with a greater risk of dementia in older people," they also noted that their study was designed to reduce the possibility of reverse causation bias "and to provide additional arguments linking benzodiazepine use with Alzheimer’s disease, such as a dose-effect relation."

The findings, Ms. Billioti de Gage and her colleagues added, argue for "carefully evaluating the indications for use of this drug class ... especially considering the prevalence and chronicity of benzodiazepine use in older people and the high and increasing incidence of dementia in developed countries."

The study was funded by INSERM (Institut National de la Santé et de la Recherche Médicale) and the University of Bordeaux, as well as by unconditional grants from IRESP (Institut de Recherche en Santé Publique), the French Ministry of Health (Direction Générale de la Santé), and the Funding Agency for Health Research of Quebec (Fonds de la Recherche en Santé du Québec). One of the study’s coauthors, Dr. Tobias Kurth, declared payment from BMJ and Cephalalgia; another co-author, Marie Tournier, declared receiving honoraria from AstraZeneca, Bristol-Myers Squibb, and Janssen.

Benzodiazepine use for 3 months or more is associated with a significantly increased likelihood of developing Alzheimer’s disease, and longer exposure is associated with greater odds, according to results from a case-control study published Sept. 9 in BMJ.

The authors, led by Sophie Billioti de Gage of Université de Bordeaux (France), conducted a nested case-control study of 1,796 members of a public drug plan in Quebec, Canada, aged 66 years and older who had been diagnosed with Alzheimer’s disease at least 6 years prior, and more than 7,000 non-Alzheimer’s controls matched for age and sex.

Ms. Billioti de Gage and her colleagues found a cumulative dose-effect association between exposure to benzodiazepines at least 5 years before diagnosis and the odds of developing Alzheimer’s disease, with a significantly greater likelihood observed with benzodiazepine use of 90 or more consecutive days (adjusted odds ratio, 1.51; 95% confidence interval, 1.36-1.69) and daily exposure to benzodiazepines for 180 or more days (adjusted OR, 1.84; 95% CI, 1.62-2.08).

The researchers also found that the type of benzodiazepine prescribed affected risk. Drugs with longer half-life, such as diazepam and clonazepam, were associated with greater likelihood of Alzheimer’s disease (OR, 1.70; 95% CI, 1.46-1.98), compared with shorter-acting drugs, such as lorazepam and alprazolam (OR, 1.43; 95% CI, 1.27-1.61). The association between benzodiazepine use and Alzheimer’s persisted even after researchers adjusted for symptoms that could be indicative of a future dementia diagnosis, including depression, anxiety, and insomnia (BMJ 2014 Sept. 9 [doi:10.1136/bmj.g5205]).

While the study authors acknowledged that they could not rule out that anxiety and sleep disorders, two of the main indications for benzodiazepines, "could be associated with early beta amyloid lesions in brain, and persistent mid-life anxiety could be associated with a greater risk of dementia in older people," they also noted that their study was designed to reduce the possibility of reverse causation bias "and to provide additional arguments linking benzodiazepine use with Alzheimer’s disease, such as a dose-effect relation."

The findings, Ms. Billioti de Gage and her colleagues added, argue for "carefully evaluating the indications for use of this drug class ... especially considering the prevalence and chronicity of benzodiazepine use in older people and the high and increasing incidence of dementia in developed countries."

The study was funded by INSERM (Institut National de la Santé et de la Recherche Médicale) and the University of Bordeaux, as well as by unconditional grants from IRESP (Institut de Recherche en Santé Publique), the French Ministry of Health (Direction Générale de la Santé), and the Funding Agency for Health Research of Quebec (Fonds de la Recherche en Santé du Québec). One of the study’s coauthors, Dr. Tobias Kurth, declared payment from BMJ and Cephalalgia; another co-author, Marie Tournier, declared receiving honoraria from AstraZeneca, Bristol-Myers Squibb, and Janssen.

Addressing ethical challenges regarding quarantine, payment of health care workers, and the proper use of personal protective equipment could contribute significantly to the containment of the Ebola outbreak in West Africa, according to experts from Johns Hopkins University, Baltimore.

Citing reports of health care workers fleeing clinics, Nancy Kass, Sc.D., said that the international community is in good position to make sure that doctors, nurses, and other staff members at Ebola treatment centers are properly and regularly paid, noting that many are not.

CDC/Daniel J. DeNoon

Even before Ebola, "there were so many things going on in these environments that were unethical" in terms of pay and staffing practices, Dr. Kass, deputy director for bioethics and public health at the JHU Berman Institute of Bioethics, said at a forum held by the university.

The international community needs to provide personal protective equipment and training to all involved, she said, "including the person who cleans the floor."

Survivors of Ebola infection could be safely recruited to perform community outreach "and get a ton of money for doing it," Dr. Kass said.

Raising pay as well as service and staffing standards at clinics could also improve compliance with quarantine demands, she said, while also making quarantine fairer to patients and families.

"In a vacuum, we can think of the most ethical ways to manage quarantine," such as allowing family members to hold the patient’s hand through a barrier, Dr. Kass said. But when resources are tight, quarantine can mean a patient is isolated to the point of being deprived of food and water.

Tim Roberton, a fourth-year doctoral student at the university’s Bloomberg School of Public Health returned from Guinea in July. He said that he found that achieving compliance with quarantine could be a delicate matter, particularly in remote villages.

"To tell someone that you have to get to a treatment center when you get sick, that’s serious business. Do we expect people to comply knowing they’ll never see their families again?"

Even pushing for essential changes in burial practices to avoid infection "is really complicated," he said, and requires cooperation from local officials and religious leaders.

Mr. Roberton’s trip was part of a collaboration between the university and the International Foundation for the Red Cross, which has hundreds of volunteers working in Ebola-affected communities to communicate information about the outbreak, manage dead bodies, and disinfect sites.

"What will stop this is working with communities at the village level to help themselves not spread the disease," Mr. Roberton said, noting that resources should not be directed to research at the expense of controlling the outbreak.

Others at the forum, including panelist Dr. Trish Perl, a clinical epidemiologist with the Johns Hopkins Health System, disagreed with the idea that research and outbreak control goals needed to be in conflict.

"Whatever is done, it is incumbent upon all of us to make sure transparency and scientific rigor is inserted into the process," Dr. Perl said. With SARS (Severe Acute Respiratory Syndrome), "many people got steroids – this ended up hurting people, and there was not so much accountability with how that happened. We have to not do harm."

A number of attendees at the forum pressed the presenters on whether current containment strategies needed to be harder-edged or more coercive to be effective. "There is perhaps a time when coercion is necessary, Mr. Roberton acknowledged.

Dr. Perl alluded to a proposed role for the U.S. military in the Ebola crisis, though she stressed that she did not know what specific approach would be employed.

"I am far from the kind of person who would normally advocate" such a response, she said, but with the outbreak maturing and so many affected, "a command and control structure may be what is needed."

With smallpox, Dr. Perl added, "some pretty draconian things were required."

Addressing ethical challenges regarding quarantine, payment of health care workers, and the proper use of personal protective equipment could contribute significantly to the containment of the Ebola outbreak in West Africa, according to experts from Johns Hopkins University, Baltimore.

Citing reports of health care workers fleeing clinics, Nancy Kass, Sc.D., said that the international community is in good position to make sure that doctors, nurses, and other staff members at Ebola treatment centers are properly and regularly paid, noting that many are not.

CDC/Daniel J. DeNoon

Even before Ebola, "there were so many things going on in these environments that were unethical" in terms of pay and staffing practices, Dr. Kass, deputy director for bioethics and public health at the JHU Berman Institute of Bioethics, said at a forum held by the university.

The international community needs to provide personal protective equipment and training to all involved, she said, "including the person who cleans the floor."

Survivors of Ebola infection could be safely recruited to perform community outreach "and get a ton of money for doing it," Dr. Kass said.

Raising pay as well as service and staffing standards at clinics could also improve compliance with quarantine demands, she said, while also making quarantine fairer to patients and families.

"In a vacuum, we can think of the most ethical ways to manage quarantine," such as allowing family members to hold the patient’s hand through a barrier, Dr. Kass said. But when resources are tight, quarantine can mean a patient is isolated to the point of being deprived of food and water.

Tim Roberton, a fourth-year doctoral student at the university’s Bloomberg School of Public Health returned from Guinea in July. He said that he found that achieving compliance with quarantine could be a delicate matter, particularly in remote villages.

"To tell someone that you have to get to a treatment center when you get sick, that’s serious business. Do we expect people to comply knowing they’ll never see their families again?"

Even pushing for essential changes in burial practices to avoid infection "is really complicated," he said, and requires cooperation from local officials and religious leaders.

Mr. Roberton’s trip was part of a collaboration between the university and the International Foundation for the Red Cross, which has hundreds of volunteers working in Ebola-affected communities to communicate information about the outbreak, manage dead bodies, and disinfect sites.

"What will stop this is working with communities at the village level to help themselves not spread the disease," Mr. Roberton said, noting that resources should not be directed to research at the expense of controlling the outbreak.

Others at the forum, including panelist Dr. Trish Perl, a clinical epidemiologist with the Johns Hopkins Health System, disagreed with the idea that research and outbreak control goals needed to be in conflict.

"Whatever is done, it is incumbent upon all of us to make sure transparency and scientific rigor is inserted into the process," Dr. Perl said. With SARS (Severe Acute Respiratory Syndrome), "many people got steroids – this ended up hurting people, and there was not so much accountability with how that happened. We have to not do harm."

A number of attendees at the forum pressed the presenters on whether current containment strategies needed to be harder-edged or more coercive to be effective. "There is perhaps a time when coercion is necessary, Mr. Roberton acknowledged.

Dr. Perl alluded to a proposed role for the U.S. military in the Ebola crisis, though she stressed that she did not know what specific approach would be employed.

"I am far from the kind of person who would normally advocate" such a response, she said, but with the outbreak maturing and so many affected, "a command and control structure may be what is needed."

With smallpox, Dr. Perl added, "some pretty draconian things were required."

Addressing ethical challenges regarding quarantine, payment of health care workers, and the proper use of personal protective equipment could contribute significantly to the containment of the Ebola outbreak in West Africa, according to experts from Johns Hopkins University, Baltimore.

Citing reports of health care workers fleeing clinics, Nancy Kass, Sc.D., said that the international community is in good position to make sure that doctors, nurses, and other staff members at Ebola treatment centers are properly and regularly paid, noting that many are not.

CDC/Daniel J. DeNoon

Even before Ebola, "there were so many things going on in these environments that were unethical" in terms of pay and staffing practices, Dr. Kass, deputy director for bioethics and public health at the JHU Berman Institute of Bioethics, said at a forum held by the university.

The international community needs to provide personal protective equipment and training to all involved, she said, "including the person who cleans the floor."

Survivors of Ebola infection could be safely recruited to perform community outreach "and get a ton of money for doing it," Dr. Kass said.

Raising pay as well as service and staffing standards at clinics could also improve compliance with quarantine demands, she said, while also making quarantine fairer to patients and families.

"In a vacuum, we can think of the most ethical ways to manage quarantine," such as allowing family members to hold the patient’s hand through a barrier, Dr. Kass said. But when resources are tight, quarantine can mean a patient is isolated to the point of being deprived of food and water.

Tim Roberton, a fourth-year doctoral student at the university’s Bloomberg School of Public Health returned from Guinea in July. He said that he found that achieving compliance with quarantine could be a delicate matter, particularly in remote villages.

"To tell someone that you have to get to a treatment center when you get sick, that’s serious business. Do we expect people to comply knowing they’ll never see their families again?"

Even pushing for essential changes in burial practices to avoid infection "is really complicated," he said, and requires cooperation from local officials and religious leaders.

Mr. Roberton’s trip was part of a collaboration between the university and the International Foundation for the Red Cross, which has hundreds of volunteers working in Ebola-affected communities to communicate information about the outbreak, manage dead bodies, and disinfect sites.

"What will stop this is working with communities at the village level to help themselves not spread the disease," Mr. Roberton said, noting that resources should not be directed to research at the expense of controlling the outbreak.

Others at the forum, including panelist Dr. Trish Perl, a clinical epidemiologist with the Johns Hopkins Health System, disagreed with the idea that research and outbreak control goals needed to be in conflict.

"Whatever is done, it is incumbent upon all of us to make sure transparency and scientific rigor is inserted into the process," Dr. Perl said. With SARS (Severe Acute Respiratory Syndrome), "many people got steroids – this ended up hurting people, and there was not so much accountability with how that happened. We have to not do harm."

A number of attendees at the forum pressed the presenters on whether current containment strategies needed to be harder-edged or more coercive to be effective. "There is perhaps a time when coercion is necessary, Mr. Roberton acknowledged.

Dr. Perl alluded to a proposed role for the U.S. military in the Ebola crisis, though she stressed that she did not know what specific approach would be employed.

"I am far from the kind of person who would normally advocate" such a response, she said, but with the outbreak maturing and so many affected, "a command and control structure may be what is needed."

With smallpox, Dr. Perl added, "some pretty draconian things were required."

The rate of secondary transmission to household members of patients with Middle East respiratory syndrome coronavirus (MERS-CoV) is 4%, a study has shown.

The researchers studied 26 symptomatic index patients in Saudi Arabia along with 280 of their household contacts, and found only 12 with laboratory evidence of infection. The report was published online Aug. 27 in the New England Journal of Medicine.

Courtesy of Maureen Metcalfe/Azaibi Tamin

Dr. Christian Drosten of the University of Bonn (Germany) Medical Center and colleagues found the 12 contacts to have laboratory evidence of MERS-CoV infection a median of 17.5 days from onset of symptoms in the index patients they lived with. Two of the infected household contacts reported having had contact with camels. All 280 contacts were screened via RT-PCR assays on RNA from throat swabs along with serologic testing that included enzyme-linked immunosorbent assays (ELISAs), and immunofluorescence assays.

Of the 12 with evidence of infection, 7 carried MERS-CoV in their upper respiratory tract, generally in low levels. Nonetheless, "positive RT-PCR findings in persons with subclinical infection who are tested soon after exposure should be complemented by serologic analysis," the investigators wrote.

The median age of the household contacts in the study was 29, and of the 12 infected, only one developed symptoms, which were mild. "Persons in the first few decades of life without coexisting illnesses may be able to carry low levels of MERS-CoV RNA without obvious symptoms," the researchers wrote (N. Engl. J. Med. 2014 Aug. 27 [doi:10.1056/NEJMoa1405858]).

The investigators cited as a weakness of their study the fact that only 44 of the 280 contacts originally tested provided follow-up samples. This was because the first round of testing was obligatory in Saudi Arabia, and the second, voluntary. The lack of follow-up testing meant that "we cannot determine whether we may have missed contacts who had delayed seroconversion," they wrote.

Dr. Drosten’s research was funded by the European Commission and German government grants. One coauthor reported receiving payment from the Institute for Experimental Immunology affiliated with EuroIMMUN, a maker of reagents for diagnostics, and another reported support from EuroIMMUN as well as a pending patent related to human betacoronavirus lineage.

The rate of secondary transmission to household members of patients with Middle East respiratory syndrome coronavirus (MERS-CoV) is 4%, a study has shown.

The researchers studied 26 symptomatic index patients in Saudi Arabia along with 280 of their household contacts, and found only 12 with laboratory evidence of infection. The report was published online Aug. 27 in the New England Journal of Medicine.

Courtesy of Maureen Metcalfe/Azaibi Tamin

Dr. Christian Drosten of the University of Bonn (Germany) Medical Center and colleagues found the 12 contacts to have laboratory evidence of MERS-CoV infection a median of 17.5 days from onset of symptoms in the index patients they lived with. Two of the infected household contacts reported having had contact with camels. All 280 contacts were screened via RT-PCR assays on RNA from throat swabs along with serologic testing that included enzyme-linked immunosorbent assays (ELISAs), and immunofluorescence assays.

Of the 12 with evidence of infection, 7 carried MERS-CoV in their upper respiratory tract, generally in low levels. Nonetheless, "positive RT-PCR findings in persons with subclinical infection who are tested soon after exposure should be complemented by serologic analysis," the investigators wrote.

The median age of the household contacts in the study was 29, and of the 12 infected, only one developed symptoms, which were mild. "Persons in the first few decades of life without coexisting illnesses may be able to carry low levels of MERS-CoV RNA without obvious symptoms," the researchers wrote (N. Engl. J. Med. 2014 Aug. 27 [doi:10.1056/NEJMoa1405858]).

The investigators cited as a weakness of their study the fact that only 44 of the 280 contacts originally tested provided follow-up samples. This was because the first round of testing was obligatory in Saudi Arabia, and the second, voluntary. The lack of follow-up testing meant that "we cannot determine whether we may have missed contacts who had delayed seroconversion," they wrote.

Dr. Drosten’s research was funded by the European Commission and German government grants. One coauthor reported receiving payment from the Institute for Experimental Immunology affiliated with EuroIMMUN, a maker of reagents for diagnostics, and another reported support from EuroIMMUN as well as a pending patent related to human betacoronavirus lineage.

The rate of secondary transmission to household members of patients with Middle East respiratory syndrome coronavirus (MERS-CoV) is 4%, a study has shown.

The researchers studied 26 symptomatic index patients in Saudi Arabia along with 280 of their household contacts, and found only 12 with laboratory evidence of infection. The report was published online Aug. 27 in the New England Journal of Medicine.

Courtesy of Maureen Metcalfe/Azaibi Tamin

Dr. Christian Drosten of the University of Bonn (Germany) Medical Center and colleagues found the 12 contacts to have laboratory evidence of MERS-CoV infection a median of 17.5 days from onset of symptoms in the index patients they lived with. Two of the infected household contacts reported having had contact with camels. All 280 contacts were screened via RT-PCR assays on RNA from throat swabs along with serologic testing that included enzyme-linked immunosorbent assays (ELISAs), and immunofluorescence assays.

Of the 12 with evidence of infection, 7 carried MERS-CoV in their upper respiratory tract, generally in low levels. Nonetheless, "positive RT-PCR findings in persons with subclinical infection who are tested soon after exposure should be complemented by serologic analysis," the investigators wrote.

The median age of the household contacts in the study was 29, and of the 12 infected, only one developed symptoms, which were mild. "Persons in the first few decades of life without coexisting illnesses may be able to carry low levels of MERS-CoV RNA without obvious symptoms," the researchers wrote (N. Engl. J. Med. 2014 Aug. 27 [doi:10.1056/NEJMoa1405858]).

The investigators cited as a weakness of their study the fact that only 44 of the 280 contacts originally tested provided follow-up samples. This was because the first round of testing was obligatory in Saudi Arabia, and the second, voluntary. The lack of follow-up testing meant that "we cannot determine whether we may have missed contacts who had delayed seroconversion," they wrote.

Dr. Drosten’s research was funded by the European Commission and German government grants. One coauthor reported receiving payment from the Institute for Experimental Immunology affiliated with EuroIMMUN, a maker of reagents for diagnostics, and another reported support from EuroIMMUN as well as a pending patent related to human betacoronavirus lineage.

Researchers in Australia have used whole exome sequencing to discover a previously unknown pathogenic allele in a 4-year-old girl with early-onset cerebral systemic lupus erythematosus.

The researchers, led by Julia Ellyard, Ph.D., of Australian National University in Canberra, characterized the allele’s deleterious activity and recommend a personalized course of therapy based on their findings. Whole exome sequencing (WES) of the patient had revealed a rare, homozygous mutation in the three prime repair exonuclease 1 (TREX1) gene. The mutant protein TREX1 R97H was associated with a 20-fold reduction in exonuclease activity and an elevated interferon-alpha signature in the patient, who was deemed a candidate for experimental neutralizing anti-interferon-alpha therapy, which is under investigation in multiple phase II clinical trials, Dr. Ellyard and her colleagues reported (Arthritis Rheumatol. 2014 Aug. 19 [doi:10.1002/art.38824]).

The girl first presented at 3 years of age with arthritis, malar rash, diffuse purpura rashes, episodic fever, chronic headache, and vomiting, but no history of seizures or visual disturbance. Her Lebanese parents were first cousins but had no family history of autoimmunity. Her serology was positive for high-titer antinuclear antibodies, anti-double stranded DNA antibodies, anticardiolipin antibodies, elevated immunoglobulin G and A, and lymphopenia and Coombs’ positive anemia – all of which are consistent with systemic lupus erythematosus (SLE). MRI following her development of right-sided hemiparesis at 4 years revealed occlusion of the left middle cerebral artery and left-sided MCA infarct, and subsequent MR angiography showed "widespread and marked irregularities of the medium sized vessels consistent with vasculitis in the context of cerebral SLE," the authors wrote.

The study is the first to find a homozygous TREX1 variant in a patient with systemic lupus erythematosus. It also is the first study conducted by the university’s Center for Personalized Immunology, which was established to help discover causative genetic variation with the goal of delivering individualized treatment strategies.

The findings demonstrated "the efficacy of WES in identifying the genetic basis of autoimmune disease on an individual, personalized basis. We were able to identify a pathogenic variant in TREX1, which had not been a prime candidate for sequencing, and subsequently confirmed the deleterious effect of the mutation," the researchers wrote. "WES can identify genetic causes of complex autoimmune diseases such as SLE and, through identification of rare and novel deleterious variants, improve therapeutic options."

Dr. Ellyard and her colleagues received grant and fellowship support from Australia’s National Health and Medical Research Council and the Royal Australian College of Physicians. None of the authors reported conflicts of interest.

Researchers in Australia have used whole exome sequencing to discover a previously unknown pathogenic allele in a 4-year-old girl with early-onset cerebral systemic lupus erythematosus.

The researchers, led by Julia Ellyard, Ph.D., of Australian National University in Canberra, characterized the allele’s deleterious activity and recommend a personalized course of therapy based on their findings. Whole exome sequencing (WES) of the patient had revealed a rare, homozygous mutation in the three prime repair exonuclease 1 (TREX1) gene. The mutant protein TREX1 R97H was associated with a 20-fold reduction in exonuclease activity and an elevated interferon-alpha signature in the patient, who was deemed a candidate for experimental neutralizing anti-interferon-alpha therapy, which is under investigation in multiple phase II clinical trials, Dr. Ellyard and her colleagues reported (Arthritis Rheumatol. 2014 Aug. 19 [doi:10.1002/art.38824]).

The girl first presented at 3 years of age with arthritis, malar rash, diffuse purpura rashes, episodic fever, chronic headache, and vomiting, but no history of seizures or visual disturbance. Her Lebanese parents were first cousins but had no family history of autoimmunity. Her serology was positive for high-titer antinuclear antibodies, anti-double stranded DNA antibodies, anticardiolipin antibodies, elevated immunoglobulin G and A, and lymphopenia and Coombs’ positive anemia – all of which are consistent with systemic lupus erythematosus (SLE). MRI following her development of right-sided hemiparesis at 4 years revealed occlusion of the left middle cerebral artery and left-sided MCA infarct, and subsequent MR angiography showed "widespread and marked irregularities of the medium sized vessels consistent with vasculitis in the context of cerebral SLE," the authors wrote.

The study is the first to find a homozygous TREX1 variant in a patient with systemic lupus erythematosus. It also is the first study conducted by the university’s Center for Personalized Immunology, which was established to help discover causative genetic variation with the goal of delivering individualized treatment strategies.

The findings demonstrated "the efficacy of WES in identifying the genetic basis of autoimmune disease on an individual, personalized basis. We were able to identify a pathogenic variant in TREX1, which had not been a prime candidate for sequencing, and subsequently confirmed the deleterious effect of the mutation," the researchers wrote. "WES can identify genetic causes of complex autoimmune diseases such as SLE and, through identification of rare and novel deleterious variants, improve therapeutic options."

Dr. Ellyard and her colleagues received grant and fellowship support from Australia’s National Health and Medical Research Council and the Royal Australian College of Physicians. None of the authors reported conflicts of interest.

Researchers in Australia have used whole exome sequencing to discover a previously unknown pathogenic allele in a 4-year-old girl with early-onset cerebral systemic lupus erythematosus.

The researchers, led by Julia Ellyard, Ph.D., of Australian National University in Canberra, characterized the allele’s deleterious activity and recommend a personalized course of therapy based on their findings. Whole exome sequencing (WES) of the patient had revealed a rare, homozygous mutation in the three prime repair exonuclease 1 (TREX1) gene. The mutant protein TREX1 R97H was associated with a 20-fold reduction in exonuclease activity and an elevated interferon-alpha signature in the patient, who was deemed a candidate for experimental neutralizing anti-interferon-alpha therapy, which is under investigation in multiple phase II clinical trials, Dr. Ellyard and her colleagues reported (Arthritis Rheumatol. 2014 Aug. 19 [doi:10.1002/art.38824]).

The girl first presented at 3 years of age with arthritis, malar rash, diffuse purpura rashes, episodic fever, chronic headache, and vomiting, but no history of seizures or visual disturbance. Her Lebanese parents were first cousins but had no family history of autoimmunity. Her serology was positive for high-titer antinuclear antibodies, anti-double stranded DNA antibodies, anticardiolipin antibodies, elevated immunoglobulin G and A, and lymphopenia and Coombs’ positive anemia – all of which are consistent with systemic lupus erythematosus (SLE). MRI following her development of right-sided hemiparesis at 4 years revealed occlusion of the left middle cerebral artery and left-sided MCA infarct, and subsequent MR angiography showed "widespread and marked irregularities of the medium sized vessels consistent with vasculitis in the context of cerebral SLE," the authors wrote.

The study is the first to find a homozygous TREX1 variant in a patient with systemic lupus erythematosus. It also is the first study conducted by the university’s Center for Personalized Immunology, which was established to help discover causative genetic variation with the goal of delivering individualized treatment strategies.

The findings demonstrated "the efficacy of WES in identifying the genetic basis of autoimmune disease on an individual, personalized basis. We were able to identify a pathogenic variant in TREX1, which had not been a prime candidate for sequencing, and subsequently confirmed the deleterious effect of the mutation," the researchers wrote. "WES can identify genetic causes of complex autoimmune diseases such as SLE and, through identification of rare and novel deleterious variants, improve therapeutic options."

Dr. Ellyard and her colleagues received grant and fellowship support from Australia’s National Health and Medical Research Council and the Royal Australian College of Physicians. None of the authors reported conflicts of interest.

Higher payment rates for office visits – but not higher payment rates for the tests themselves – translate into more cancer screenings for Medicaid patients, a study showed.

Increasing cancer screening among Medicaid patients is a priority, as previous studies have found these patients less likely to be screened for breast, cervical, or colon cancer than people with private insurance. Medicaid patients are also more likely to present with advanced-stage cancers.

©Jupiterimages/thinkstock.com

Dr. Michael T. Halpern of RTI International in Washington, D.C., and his colleagues, analyzed Medicaid claims data from 46 states and the District of Columbia to identify enrollees eligible for cervical screening, mammography, colonoscopy, and fecal occult blood testing in the year 2007. They looked at state-specific reimbursements for each test, which vary, along with state-specific income and eligibility requirements for Medicaid enrollment and office visit payment rates. Their findings were published Aug. 25 in Cancer (doi:10.1002/cncr.28704).

The researchers found that increases in test reimbursement rates did not consistently increase patients’ likelihood of receiving specific screening tests. Nor did the study find consistent associations concerning states’ Medicaid policies and screening. Stricter income, eligibility, and copayment requirements were associated with lower rates of screening for some tests and higher rates for others.

Higher office visit payment, though, was found to be significantly and consistently associated with an increased odds of receiving all recommended screening tests: colonoscopy (odds ratio, 1.07), a fecal occult blood test (1.09), a Pap test (1.02), and mammography (1.02).

Physician office visits were paid at rates of between $20 and $80, depending on state policy, the researchers found. A 20% increase in office visit payment was associated with increases in the odds of screening, ranging from 2.2% for mammography to 8.7% for a fecal occult blood test.

"The results of the current study are consistent with previous studies indicating that higher Medicaid reimbursements for office visits are associated with increased receipt of health care services, including preventive services," Dr. Halpern said. "As states expand Medicaid eligibility, it will be important to track state-specific changes in Medicaid enrollment, reimbursement rates, and eligibility requirements, and their impact on cancer screening, diagnosis at an early stage, and survival among individuals diagnosed with cancer."

Dr. Halpern and his colleagues said that their study was limited in that not all patients were enrolled in Medicaid for the full calendar year, the study did not capture patients in managed care plans, and investigators could not differentiate, using the data provided, between preventive cancer screenings and diagnostic procedures after symptoms or abnormal results. The study was funded by the Centers for Disease Control and Prevention, and none of its authors disclosed conflicts of interest.

Higher payment rates for office visits – but not higher payment rates for the tests themselves – translate into more cancer screenings for Medicaid patients, a study showed.

Increasing cancer screening among Medicaid patients is a priority, as previous studies have found these patients less likely to be screened for breast, cervical, or colon cancer than people with private insurance. Medicaid patients are also more likely to present with advanced-stage cancers.

©Jupiterimages/thinkstock.com

Dr. Michael T. Halpern of RTI International in Washington, D.C., and his colleagues, analyzed Medicaid claims data from 46 states and the District of Columbia to identify enrollees eligible for cervical screening, mammography, colonoscopy, and fecal occult blood testing in the year 2007. They looked at state-specific reimbursements for each test, which vary, along with state-specific income and eligibility requirements for Medicaid enrollment and office visit payment rates. Their findings were published Aug. 25 in Cancer (doi:10.1002/cncr.28704).

The researchers found that increases in test reimbursement rates did not consistently increase patients’ likelihood of receiving specific screening tests. Nor did the study find consistent associations concerning states’ Medicaid policies and screening. Stricter income, eligibility, and copayment requirements were associated with lower rates of screening for some tests and higher rates for others.

Higher office visit payment, though, was found to be significantly and consistently associated with an increased odds of receiving all recommended screening tests: colonoscopy (odds ratio, 1.07), a fecal occult blood test (1.09), a Pap test (1.02), and mammography (1.02).

Physician office visits were paid at rates of between $20 and $80, depending on state policy, the researchers found. A 20% increase in office visit payment was associated with increases in the odds of screening, ranging from 2.2% for mammography to 8.7% for a fecal occult blood test.

"The results of the current study are consistent with previous studies indicating that higher Medicaid reimbursements for office visits are associated with increased receipt of health care services, including preventive services," Dr. Halpern said. "As states expand Medicaid eligibility, it will be important to track state-specific changes in Medicaid enrollment, reimbursement rates, and eligibility requirements, and their impact on cancer screening, diagnosis at an early stage, and survival among individuals diagnosed with cancer."

Dr. Halpern and his colleagues said that their study was limited in that not all patients were enrolled in Medicaid for the full calendar year, the study did not capture patients in managed care plans, and investigators could not differentiate, using the data provided, between preventive cancer screenings and diagnostic procedures after symptoms or abnormal results. The study was funded by the Centers for Disease Control and Prevention, and none of its authors disclosed conflicts of interest.

Higher payment rates for office visits – but not higher payment rates for the tests themselves – translate into more cancer screenings for Medicaid patients, a study showed.

Increasing cancer screening among Medicaid patients is a priority, as previous studies have found these patients less likely to be screened for breast, cervical, or colon cancer than people with private insurance. Medicaid patients are also more likely to present with advanced-stage cancers.

©Jupiterimages/thinkstock.com

Dr. Michael T. Halpern of RTI International in Washington, D.C., and his colleagues, analyzed Medicaid claims data from 46 states and the District of Columbia to identify enrollees eligible for cervical screening, mammography, colonoscopy, and fecal occult blood testing in the year 2007. They looked at state-specific reimbursements for each test, which vary, along with state-specific income and eligibility requirements for Medicaid enrollment and office visit payment rates. Their findings were published Aug. 25 in Cancer (doi:10.1002/cncr.28704).

The researchers found that increases in test reimbursement rates did not consistently increase patients’ likelihood of receiving specific screening tests. Nor did the study find consistent associations concerning states’ Medicaid policies and screening. Stricter income, eligibility, and copayment requirements were associated with lower rates of screening for some tests and higher rates for others.

Higher office visit payment, though, was found to be significantly and consistently associated with an increased odds of receiving all recommended screening tests: colonoscopy (odds ratio, 1.07), a fecal occult blood test (1.09), a Pap test (1.02), and mammography (1.02).

Physician office visits were paid at rates of between $20 and $80, depending on state policy, the researchers found. A 20% increase in office visit payment was associated with increases in the odds of screening, ranging from 2.2% for mammography to 8.7% for a fecal occult blood test.

"The results of the current study are consistent with previous studies indicating that higher Medicaid reimbursements for office visits are associated with increased receipt of health care services, including preventive services," Dr. Halpern said. "As states expand Medicaid eligibility, it will be important to track state-specific changes in Medicaid enrollment, reimbursement rates, and eligibility requirements, and their impact on cancer screening, diagnosis at an early stage, and survival among individuals diagnosed with cancer."

Dr. Halpern and his colleagues said that their study was limited in that not all patients were enrolled in Medicaid for the full calendar year, the study did not capture patients in managed care plans, and investigators could not differentiate, using the data provided, between preventive cancer screenings and diagnostic procedures after symptoms or abnormal results. The study was funded by the Centers for Disease Control and Prevention, and none of its authors disclosed conflicts of interest.

Earn 0.25 hours AMA PRA Category 1 credit: Read this article, and click the link at the end to take the posttest.

Calcium and vitamin D can improve the metabolic profile of women with gestational diabetes mellitus, according to investigators in Iran who found significant reductions in fasting glucose, serum insulin levels, and low-density lipoprotein cholesterol associated with combined use of the supplements.

For their research, published June 23 in Diabetologia (doi:10.1007/s00125-014-3293-x), Zatollah Asemi, Ph.D., of Kashan (Iran) University and colleagues, randomized 56 women diagnosed with gestational diabetes mellitus (GDM) at between 24 and 28 weeks’ gestation to 1,000 mg calcium daily and to a 50,000 IU pearl of vitamin D3 at baseline and day 21 or placebo. Women and providers were blinded to treatment assignment.

At 6 weeks, compared with placebo, women assigned to the calcium-vitamin D group (n = 28) saw significantly lower fasting glucose (-0.89 ± 0.69 vs. +0.26 ± 0.92 mmol/L), serum insulin levels (-13.55 ± 35.25 vs. +9.17 ± 38.50 pmol/L) and homeostatic model assessment insulin resistance (-0.91 ± 1.18 vs + 0.63 ± 2.01).

They also saw a significant reduction in LDL cholesterol (-0.23 ± 0.79 vs. +0.26 ± 0.74 mmol/L). The treatment group saw increases in plasma glutathione, and supplementation was seen to prevent a rise in plasma malondialdehyde levels.

C-reactive protein and total antioxidant capacity were not affected by calcium and Vitamin D supplementation in this study, researchers wrote.

Dr. Asemi and colleagues, who have previously studied vitamin D supplementation in women with GDM and found it associated with improved insulin function and decreased total and LDL cholesterol (Am. J. Clin. Nutr. 2013;98:1425-32), hypothesized that calcium and vitamin D together would be more efficient in influencing metabolic profiles, possibly through their combined effects on cell cycle regulation, activation of antioxidant enzymes, and suppression of parathyroid hormone.

"GDM is associated with insulin resistance, increased inflammatory factors, and oxidative stress. Elevated circulating levels of inflammatory markers and impaired insulin metabolism in GDM can predict the progression to type 2 diabetes later in life and neonatal complications," investigators explained.

The researchers noted as weaknesses of their study that it did not capture pregnancy outcomes or certain biomarkers of inflammation and oxidative stress and that two subjects in the placebo group and three in the treatment group were lost to follow-up. The study was funded by Kashan University. None of the researchers disclosed conflicts of interest.

 To earn 0.25 hours AMA PRA Category 1 credit after reading this article, take the post-test here.

Earn 0.25 hours AMA PRA Category 1 credit: Read this article, and click the link at the end to take the posttest.

Calcium and vitamin D can improve the metabolic profile of women with gestational diabetes mellitus, according to investigators in Iran who found significant reductions in fasting glucose, serum insulin levels, and low-density lipoprotein cholesterol associated with combined use of the supplements.

For their research, published June 23 in Diabetologia (doi:10.1007/s00125-014-3293-x), Zatollah Asemi, Ph.D., of Kashan (Iran) University and colleagues, randomized 56 women diagnosed with gestational diabetes mellitus (GDM) at between 24 and 28 weeks’ gestation to 1,000 mg calcium daily and to a 50,000 IU pearl of vitamin D3 at baseline and day 21 or placebo. Women and providers were blinded to treatment assignment.

At 6 weeks, compared with placebo, women assigned to the calcium-vitamin D group (n = 28) saw significantly lower fasting glucose (-0.89 ± 0.69 vs. +0.26 ± 0.92 mmol/L), serum insulin levels (-13.55 ± 35.25 vs. +9.17 ± 38.50 pmol/L) and homeostatic model assessment insulin resistance (-0.91 ± 1.18 vs + 0.63 ± 2.01).

They also saw a significant reduction in LDL cholesterol (-0.23 ± 0.79 vs. +0.26 ± 0.74 mmol/L). The treatment group saw increases in plasma glutathione, and supplementation was seen to prevent a rise in plasma malondialdehyde levels.

C-reactive protein and total antioxidant capacity were not affected by calcium and Vitamin D supplementation in this study, researchers wrote.

Dr. Asemi and colleagues, who have previously studied vitamin D supplementation in women with GDM and found it associated with improved insulin function and decreased total and LDL cholesterol (Am. J. Clin. Nutr. 2013;98:1425-32), hypothesized that calcium and vitamin D together would be more efficient in influencing metabolic profiles, possibly through their combined effects on cell cycle regulation, activation of antioxidant enzymes, and suppression of parathyroid hormone.

"GDM is associated with insulin resistance, increased inflammatory factors, and oxidative stress. Elevated circulating levels of inflammatory markers and impaired insulin metabolism in GDM can predict the progression to type 2 diabetes later in life and neonatal complications," investigators explained.

The researchers noted as weaknesses of their study that it did not capture pregnancy outcomes or certain biomarkers of inflammation and oxidative stress and that two subjects in the placebo group and three in the treatment group were lost to follow-up. The study was funded by Kashan University. None of the researchers disclosed conflicts of interest.

 To earn 0.25 hours AMA PRA Category 1 credit after reading this article, take the post-test here.

Earn 0.25 hours AMA PRA Category 1 credit: Read this article, and click the link at the end to take the posttest.

Calcium and vitamin D can improve the metabolic profile of women with gestational diabetes mellitus, according to investigators in Iran who found significant reductions in fasting glucose, serum insulin levels, and low-density lipoprotein cholesterol associated with combined use of the supplements.

For their research, published June 23 in Diabetologia (doi:10.1007/s00125-014-3293-x), Zatollah Asemi, Ph.D., of Kashan (Iran) University and colleagues, randomized 56 women diagnosed with gestational diabetes mellitus (GDM) at between 24 and 28 weeks’ gestation to 1,000 mg calcium daily and to a 50,000 IU pearl of vitamin D3 at baseline and day 21 or placebo. Women and providers were blinded to treatment assignment.

At 6 weeks, compared with placebo, women assigned to the calcium-vitamin D group (n = 28) saw significantly lower fasting glucose (-0.89 ± 0.69 vs. +0.26 ± 0.92 mmol/L), serum insulin levels (-13.55 ± 35.25 vs. +9.17 ± 38.50 pmol/L) and homeostatic model assessment insulin resistance (-0.91 ± 1.18 vs + 0.63 ± 2.01).

They also saw a significant reduction in LDL cholesterol (-0.23 ± 0.79 vs. +0.26 ± 0.74 mmol/L). The treatment group saw increases in plasma glutathione, and supplementation was seen to prevent a rise in plasma malondialdehyde levels.

C-reactive protein and total antioxidant capacity were not affected by calcium and Vitamin D supplementation in this study, researchers wrote.

Dr. Asemi and colleagues, who have previously studied vitamin D supplementation in women with GDM and found it associated with improved insulin function and decreased total and LDL cholesterol (Am. J. Clin. Nutr. 2013;98:1425-32), hypothesized that calcium and vitamin D together would be more efficient in influencing metabolic profiles, possibly through their combined effects on cell cycle regulation, activation of antioxidant enzymes, and suppression of parathyroid hormone.

"GDM is associated with insulin resistance, increased inflammatory factors, and oxidative stress. Elevated circulating levels of inflammatory markers and impaired insulin metabolism in GDM can predict the progression to type 2 diabetes later in life and neonatal complications," investigators explained.

The researchers noted as weaknesses of their study that it did not capture pregnancy outcomes or certain biomarkers of inflammation and oxidative stress and that two subjects in the placebo group and three in the treatment group were lost to follow-up. The study was funded by Kashan University. None of the researchers disclosed conflicts of interest.

 To earn 0.25 hours AMA PRA Category 1 credit after reading this article, take the post-test here.