User login
VIDEO: Tips, tricks, and pearls for keloid scar steroid injections
ORLANDO – What are the best ways to avoid atrophy when treating keloid scars with steroid injections? When should a keloid be treated with smaller amounts, but with a stronger steroid concentration? What is the most effective way to avoid precipitation in the syringe?
The answers to these questions – along with other tips, tricks, and pearls for treating keloids, both in patients with skin of color and those with white skin – are provided by Temitayo Ogunleye, MD, of the department of dermatology, University of Pennsylvania, Philadelphia, in a video interview at the annual meeting of the American Academy of Dermatology.
Dr. Ogunleye had no relevant disclosures.
[email protected]
On Twitter @whitneymcknight
ORLANDO – What are the best ways to avoid atrophy when treating keloid scars with steroid injections? When should a keloid be treated with smaller amounts, but with a stronger steroid concentration? What is the most effective way to avoid precipitation in the syringe?
The answers to these questions – along with other tips, tricks, and pearls for treating keloids, both in patients with skin of color and those with white skin – are provided by Temitayo Ogunleye, MD, of the department of dermatology, University of Pennsylvania, Philadelphia, in a video interview at the annual meeting of the American Academy of Dermatology.
Dr. Ogunleye had no relevant disclosures.
[email protected]
On Twitter @whitneymcknight
ORLANDO – What are the best ways to avoid atrophy when treating keloid scars with steroid injections? When should a keloid be treated with smaller amounts, but with a stronger steroid concentration? What is the most effective way to avoid precipitation in the syringe?
The answers to these questions – along with other tips, tricks, and pearls for treating keloids, both in patients with skin of color and those with white skin – are provided by Temitayo Ogunleye, MD, of the department of dermatology, University of Pennsylvania, Philadelphia, in a video interview at the annual meeting of the American Academy of Dermatology.
Dr. Ogunleye had no relevant disclosures.
[email protected]
On Twitter @whitneymcknight
AT AAD 17
VIDEO: Working with alopecia patients’ insurers when using novel therapies
ORLANDO – Janus kinase inhibitors are “currently the most promising treatments” for alopecia areata, but they are expensive, are not approved for this indication, and so getting insurance coverage for these treatments can be difficult, Carolyn Goh, MD, said at the annual meeting of the American Academy of Dermatology.
In a video interview at the meeting, Dr. Goh of the department of dermatology, University of California, Los Angeles, shares the latest treatment algorithms that include these novel therapies, and thoughts on how to work with patients to increase their likelihood of getting insurance coverage for these treatments. Referring to the Janus kinase inhibitors, also known as JAK inhibitors, she said, “I think they would be very helpful for all patients with alopecia areata, but really given their side effect profile and risks involved, they should be reserved for more extensive disease.”
In the interview, Dr. Goh also discusses screening for thyroid disease in this patient population.
She had no disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @whitneymcknight
ORLANDO – Janus kinase inhibitors are “currently the most promising treatments” for alopecia areata, but they are expensive, are not approved for this indication, and so getting insurance coverage for these treatments can be difficult, Carolyn Goh, MD, said at the annual meeting of the American Academy of Dermatology.
In a video interview at the meeting, Dr. Goh of the department of dermatology, University of California, Los Angeles, shares the latest treatment algorithms that include these novel therapies, and thoughts on how to work with patients to increase their likelihood of getting insurance coverage for these treatments. Referring to the Janus kinase inhibitors, also known as JAK inhibitors, she said, “I think they would be very helpful for all patients with alopecia areata, but really given their side effect profile and risks involved, they should be reserved for more extensive disease.”
In the interview, Dr. Goh also discusses screening for thyroid disease in this patient population.
She had no disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @whitneymcknight
ORLANDO – Janus kinase inhibitors are “currently the most promising treatments” for alopecia areata, but they are expensive, are not approved for this indication, and so getting insurance coverage for these treatments can be difficult, Carolyn Goh, MD, said at the annual meeting of the American Academy of Dermatology.
In a video interview at the meeting, Dr. Goh of the department of dermatology, University of California, Los Angeles, shares the latest treatment algorithms that include these novel therapies, and thoughts on how to work with patients to increase their likelihood of getting insurance coverage for these treatments. Referring to the Janus kinase inhibitors, also known as JAK inhibitors, she said, “I think they would be very helpful for all patients with alopecia areata, but really given their side effect profile and risks involved, they should be reserved for more extensive disease.”
In the interview, Dr. Goh also discusses screening for thyroid disease in this patient population.
She had no disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @whitneymcknight
AT AAD 17
VIDEO: Grading tools help set alopecia treatment expectations and monitor progress
ORLANDO – Two hair loss clinical grading tools can help physicians and their female androgenetic alopecia patients set medical treatment expectations, and make tracking progress both easier and more accurate, according to the dermatologist who developed the scales.
The five-point clinical grading scale helps physicians with diagnosing female pattern hair loss and grading the severity, Rodney Sinclair, MD, said in a video interview at the annual meeting of the American Academy of Dermatology. “And you can use that clinical grading scale to monitor the response to treatment” and show patients what to expect with treatment, added Dr. Sinclair, professor and chairman, department of dermatology, Epworth Hospital, Melbourne.
He also discussed a validated hair shedding scale, “a really simple and easy test to use,” with six photographs to help patients determine how much hair they are shedding on a daily basis. “Most women don’t know what’s a normal amount of hair to shed,” he said. In the interview, Dr. Sinclair explains more about the two scales, and how they can be used to obtain clinically relevant information to help guide treatment – and shares his tips for how to work with women who are anxious about their hair loss improvement.
Dr. Sinclair owns the copyrights for the Sinclair Severity Scale. He has no other relevant disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @whitneymcknight
ORLANDO – Two hair loss clinical grading tools can help physicians and their female androgenetic alopecia patients set medical treatment expectations, and make tracking progress both easier and more accurate, according to the dermatologist who developed the scales.
The five-point clinical grading scale helps physicians with diagnosing female pattern hair loss and grading the severity, Rodney Sinclair, MD, said in a video interview at the annual meeting of the American Academy of Dermatology. “And you can use that clinical grading scale to monitor the response to treatment” and show patients what to expect with treatment, added Dr. Sinclair, professor and chairman, department of dermatology, Epworth Hospital, Melbourne.
He also discussed a validated hair shedding scale, “a really simple and easy test to use,” with six photographs to help patients determine how much hair they are shedding on a daily basis. “Most women don’t know what’s a normal amount of hair to shed,” he said. In the interview, Dr. Sinclair explains more about the two scales, and how they can be used to obtain clinically relevant information to help guide treatment – and shares his tips for how to work with women who are anxious about their hair loss improvement.
Dr. Sinclair owns the copyrights for the Sinclair Severity Scale. He has no other relevant disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @whitneymcknight
ORLANDO – Two hair loss clinical grading tools can help physicians and their female androgenetic alopecia patients set medical treatment expectations, and make tracking progress both easier and more accurate, according to the dermatologist who developed the scales.
The five-point clinical grading scale helps physicians with diagnosing female pattern hair loss and grading the severity, Rodney Sinclair, MD, said in a video interview at the annual meeting of the American Academy of Dermatology. “And you can use that clinical grading scale to monitor the response to treatment” and show patients what to expect with treatment, added Dr. Sinclair, professor and chairman, department of dermatology, Epworth Hospital, Melbourne.
He also discussed a validated hair shedding scale, “a really simple and easy test to use,” with six photographs to help patients determine how much hair they are shedding on a daily basis. “Most women don’t know what’s a normal amount of hair to shed,” he said. In the interview, Dr. Sinclair explains more about the two scales, and how they can be used to obtain clinically relevant information to help guide treatment – and shares his tips for how to work with women who are anxious about their hair loss improvement.
Dr. Sinclair owns the copyrights for the Sinclair Severity Scale. He has no other relevant disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @whitneymcknight
AT AAD 17
Physicians need to take hyperhidrosis in teens seriously
ORLANDO – Not quite a fifth of teens experience excessive, uncontrollable sweating, according to the results of an online survey presented during this year’s annual American Academy of Dermatology.
Because nearly 70% of teens who reported the condition said it interferes with their activities of daily living, late-breaking research presenter, Adelaide A. Hebert, MD, chief of pediatric dermatology at the University of Texas, Houston, said it was time medical schools paid more attention to it.
For the study, Dr. Hebert and her colleagues online-surveyed 1,000 adolescents between 12 and 17 years who meet the accepted diagnostic criteria for primary focal hyperhidrosis. An analysis of the 981 surveys that were complete showed that 17.1% of respondents experienced excessive, uncontrollable sweating and that 68.6% of these reported the sweating was moderate or major, impairing their normal functioning.
The average age of onset for the condition was 11 years, although more than a quarter of respondents said their sweating began at age 10 years. Nearly all those surveyed said they sweat from at least two focal areas, with five areas being the average number of focal areas.
Adolescence is when hyperhidrosis begins for many adults with the condition, yet few if any data exist regarding the condition in this age group, according to Dr. Hebert. “We have to figure out what is going on so maybe we can make a difference later.”
[email protected]
On Twitter @whitneymcknight
ORLANDO – Not quite a fifth of teens experience excessive, uncontrollable sweating, according to the results of an online survey presented during this year’s annual American Academy of Dermatology.
Because nearly 70% of teens who reported the condition said it interferes with their activities of daily living, late-breaking research presenter, Adelaide A. Hebert, MD, chief of pediatric dermatology at the University of Texas, Houston, said it was time medical schools paid more attention to it.
For the study, Dr. Hebert and her colleagues online-surveyed 1,000 adolescents between 12 and 17 years who meet the accepted diagnostic criteria for primary focal hyperhidrosis. An analysis of the 981 surveys that were complete showed that 17.1% of respondents experienced excessive, uncontrollable sweating and that 68.6% of these reported the sweating was moderate or major, impairing their normal functioning.
The average age of onset for the condition was 11 years, although more than a quarter of respondents said their sweating began at age 10 years. Nearly all those surveyed said they sweat from at least two focal areas, with five areas being the average number of focal areas.
Adolescence is when hyperhidrosis begins for many adults with the condition, yet few if any data exist regarding the condition in this age group, according to Dr. Hebert. “We have to figure out what is going on so maybe we can make a difference later.”
[email protected]
On Twitter @whitneymcknight
ORLANDO – Not quite a fifth of teens experience excessive, uncontrollable sweating, according to the results of an online survey presented during this year’s annual American Academy of Dermatology.
Because nearly 70% of teens who reported the condition said it interferes with their activities of daily living, late-breaking research presenter, Adelaide A. Hebert, MD, chief of pediatric dermatology at the University of Texas, Houston, said it was time medical schools paid more attention to it.
For the study, Dr. Hebert and her colleagues online-surveyed 1,000 adolescents between 12 and 17 years who meet the accepted diagnostic criteria for primary focal hyperhidrosis. An analysis of the 981 surveys that were complete showed that 17.1% of respondents experienced excessive, uncontrollable sweating and that 68.6% of these reported the sweating was moderate or major, impairing their normal functioning.
The average age of onset for the condition was 11 years, although more than a quarter of respondents said their sweating began at age 10 years. Nearly all those surveyed said they sweat from at least two focal areas, with five areas being the average number of focal areas.
Adolescence is when hyperhidrosis begins for many adults with the condition, yet few if any data exist regarding the condition in this age group, according to Dr. Hebert. “We have to figure out what is going on so maybe we can make a difference later.”
[email protected]
On Twitter @whitneymcknight
AT AAD 17
Key clinical point:
Major finding: Hyperhidrosis is common in 17% of teens surveyed; 69% of these reported hyperhidrosis interferes with activities of daily living.
Data source: Online survey of 1,000 U.S. teens between 12 and 17 years who reported excessive, uncontrollable sweating.
Disclosures: Dr. Hebert received a grant from GlaxoSmithKline for this study. She is also a board member of the International Hyperhidrosis Society.
Teletriage app reduced skin specialty care wait times
ORLANDO – A teletriage app significantly reduced the time between triage and evaluation by a dermatologist, helping a volunteer-staffed clinic for the uninsured see more patients and improve rates of accurate diagnosis and treatment.
Peter Chansky, a medical student at the University of Pennsylvania, Philadelphia, presented the data on a study of the app during a late-breaking research session at this year’s annual meeting of the American Academy of Dermatology.
The teletriage app AccessDerm, which is free to all AAD members, uses a photo of the dermatological condition, along with basic clinical and demographic information. The investigators found that with the app, the mean time from referral to teledermatology response was 1.4 days vs. 13.4 days for waiting to be seen in the next dermatology clinic (P less than .0001). Additionally, because the app requires the referring physicians to enter a differential diagnosis and a suggested treatment plan, it was established that diagnoses improved with teledermatology. Compared with self-reported primary care provider plans, the app led to an altered course of treatment in 95% of cases.
In all, 70% of cases were triaged via teledermatology without the need for an in-person evaluation, resulting in an average of 1.4 out of 8 appointments being saved monthly. This allowed the clinic to treat 18% more patients who needed in-person care, according to Mr. Chansky.
“Teletriage can be easily implemented in an underserved clinical setting, and provides an opportunity for dermatologists to make a significant and meaningful impact on the health care and outcomes of underserved populations,” Mr. Chansky said.
[email protected]
On Twitter @whitneymcknight
ORLANDO – A teletriage app significantly reduced the time between triage and evaluation by a dermatologist, helping a volunteer-staffed clinic for the uninsured see more patients and improve rates of accurate diagnosis and treatment.
Peter Chansky, a medical student at the University of Pennsylvania, Philadelphia, presented the data on a study of the app during a late-breaking research session at this year’s annual meeting of the American Academy of Dermatology.
The teletriage app AccessDerm, which is free to all AAD members, uses a photo of the dermatological condition, along with basic clinical and demographic information. The investigators found that with the app, the mean time from referral to teledermatology response was 1.4 days vs. 13.4 days for waiting to be seen in the next dermatology clinic (P less than .0001). Additionally, because the app requires the referring physicians to enter a differential diagnosis and a suggested treatment plan, it was established that diagnoses improved with teledermatology. Compared with self-reported primary care provider plans, the app led to an altered course of treatment in 95% of cases.
In all, 70% of cases were triaged via teledermatology without the need for an in-person evaluation, resulting in an average of 1.4 out of 8 appointments being saved monthly. This allowed the clinic to treat 18% more patients who needed in-person care, according to Mr. Chansky.
“Teletriage can be easily implemented in an underserved clinical setting, and provides an opportunity for dermatologists to make a significant and meaningful impact on the health care and outcomes of underserved populations,” Mr. Chansky said.
[email protected]
On Twitter @whitneymcknight
ORLANDO – A teletriage app significantly reduced the time between triage and evaluation by a dermatologist, helping a volunteer-staffed clinic for the uninsured see more patients and improve rates of accurate diagnosis and treatment.
Peter Chansky, a medical student at the University of Pennsylvania, Philadelphia, presented the data on a study of the app during a late-breaking research session at this year’s annual meeting of the American Academy of Dermatology.
The teletriage app AccessDerm, which is free to all AAD members, uses a photo of the dermatological condition, along with basic clinical and demographic information. The investigators found that with the app, the mean time from referral to teledermatology response was 1.4 days vs. 13.4 days for waiting to be seen in the next dermatology clinic (P less than .0001). Additionally, because the app requires the referring physicians to enter a differential diagnosis and a suggested treatment plan, it was established that diagnoses improved with teledermatology. Compared with self-reported primary care provider plans, the app led to an altered course of treatment in 95% of cases.
In all, 70% of cases were triaged via teledermatology without the need for an in-person evaluation, resulting in an average of 1.4 out of 8 appointments being saved monthly. This allowed the clinic to treat 18% more patients who needed in-person care, according to Mr. Chansky.
“Teletriage can be easily implemented in an underserved clinical setting, and provides an opportunity for dermatologists to make a significant and meaningful impact on the health care and outcomes of underserved populations,” Mr. Chansky said.
[email protected]
On Twitter @whitneymcknight
AT AAD 17
VIDEO: Don’t overlook psychosocial concerns of vitiligo patients
ORLANDO – There are ways to assess the psychosocial needs of your patients with vitiligo, even if you don’t believe you have the necessary skills to do a complete mental health work-up, according to Seemal R. Desai, MD.
In an interview recorded at this year’s annual meeting of the American Academy of Dermatology, Dr. Desai, an assistant clinical professor of dermatology at the University of Texas, Dallas, shares his ideas for how to have casual conversations with patients that can help reveal important clues to psychosocial stress patients with this serious medical skin condition might be facing.
“There are subtle clues to look for to know that these patients are uncomfortable with others seeing their skin,” says Dr. Desai.
In the video interview, he also covers taking a multidisciplinary approach to caring for these patients, what treatments are available to those who are suffering psychosocial stress after having failed several interventions, and how patients from many Asian and African counties are especially at risk for ostracization.
“It’s important to let your patients know that you understand this is really affecting them psychosocially, and that you care,” says Dr. Desai.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @whitneymcknight
ORLANDO – There are ways to assess the psychosocial needs of your patients with vitiligo, even if you don’t believe you have the necessary skills to do a complete mental health work-up, according to Seemal R. Desai, MD.
In an interview recorded at this year’s annual meeting of the American Academy of Dermatology, Dr. Desai, an assistant clinical professor of dermatology at the University of Texas, Dallas, shares his ideas for how to have casual conversations with patients that can help reveal important clues to psychosocial stress patients with this serious medical skin condition might be facing.
“There are subtle clues to look for to know that these patients are uncomfortable with others seeing their skin,” says Dr. Desai.
In the video interview, he also covers taking a multidisciplinary approach to caring for these patients, what treatments are available to those who are suffering psychosocial stress after having failed several interventions, and how patients from many Asian and African counties are especially at risk for ostracization.
“It’s important to let your patients know that you understand this is really affecting them psychosocially, and that you care,” says Dr. Desai.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @whitneymcknight
ORLANDO – There are ways to assess the psychosocial needs of your patients with vitiligo, even if you don’t believe you have the necessary skills to do a complete mental health work-up, according to Seemal R. Desai, MD.
In an interview recorded at this year’s annual meeting of the American Academy of Dermatology, Dr. Desai, an assistant clinical professor of dermatology at the University of Texas, Dallas, shares his ideas for how to have casual conversations with patients that can help reveal important clues to psychosocial stress patients with this serious medical skin condition might be facing.
“There are subtle clues to look for to know that these patients are uncomfortable with others seeing their skin,” says Dr. Desai.
In the video interview, he also covers taking a multidisciplinary approach to caring for these patients, what treatments are available to those who are suffering psychosocial stress after having failed several interventions, and how patients from many Asian and African counties are especially at risk for ostracization.
“It’s important to let your patients know that you understand this is really affecting them psychosocially, and that you care,” says Dr. Desai.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
[email protected]
On Twitter @whitneymcknight
EXPERT ANALYSIS FROM AAD 17
CIMPASI-1 and -2 show certolizumab pegol benefits patients with severe plaque psoriasis
ORLANDO – Results from two phase III trials indicated the tumor necrosis factor alpha inhibitor certolizumab pegol led to significant improvements in moderate to severe chronic plaque psoriasis, compared with placebo, according to an oral presentation at this year’s annual Academy of Dermatology Meeting.
Across the CIMPASI-1 and CIMPASI-2 trials, at 16 weeks, both certolizumab pegol (Cimzia) 400 mg and 200 mg, administered subcutaneously every 2 weeks in groups of patients with moderate to severe chronic plaque psoriasis, demonstrated statistically significant, clinically meaningful improvements in Psoriasis Area and Severity Index (PASI) scores, and on the Physician Global Assessment (PGA) scores, when compared with placebo. The data were presented by Alice B. Gottlieb, MD, PhD, professor of dermatology at New York Medical College, Valhalla. Certolizumab pegol currently is approved in the United States for use in psoriatic arthritis, but not for psoriasis.
In CIMPASI-1, 234 mostly white male patients in their mid-40s who had moderate to severe chronic plaque psoriasis were randomly assigned to one of three groups. There were 88 participants in the arm given 400 mg every 2 weeks at weeks 0, 2, and 4; 95 given 200 mg at weeks 0, 2, and 4; and 51 given placebo. At week 16, the percentage of patients who achieved a PASI 75 was 75.8% in the first group, 66.5% in the second, and 6.5% for placebo. A PGA scale improvement of at least two points over baseline toward a final score of clear or almost clear skin at week 16 was 57.9% for group 1, 47.0% for the second group, and 4.2% for placebo.
Also at week 16, the percentage of patients who achieved a PASI 90 was 43.6% in the 400 mg dose group, 35.8% in the 200 mg dose group, and 0.4% in the placebo group.
In CIMPASI-2, 227 mostly white patients with moderate to severe chronic plaque psoriasis, most of whom were in their mid-40s, evenly distributed across the sexes, were randomly assigned to one of three groups. There were 87 participants in the 400 mg every 2 weeks at weeks 0, 2, and 4 group; 91 in the 200 mg every 2 weeks at weeks 0, 2, and 4 arm, and 49 in the placebo group. At week 16, 82.6% of patients in the first group and 81.4% in the second group had a PASI 75, compared with 11.6% of the placebo group. Also at 16 weeks, a PGA scale improvement of at least two points over baseline toward a final score of clear or almost clear skin at week 16 was 71.6% for group 1, 66.8% for the second group, and 2.0% for placebo. At week 16, 55.4% of patients receiving the 400 mg dose had a PASI 90, as did 52.6% of patients receiving the 200 mg dose every 2 weeks, compared with only 4.5% of the placebo group.
Additionally, Dr. Gottlieb said that at week 16, patients in the 400-mg and 200-mg groups showed significant improvements over baseline Dermatology Life Quality Index (DLQI) average scores, compared with placebo: a 10.2 decrease in the 400-mg group and a 9.3 decrease in the 200-mg group, compared with a 3.3 decrease in the placebo arm (P less than .001) in the CIMPASI-1 study. In the CIMPASI-2 study at week 16, there was a drop of 10.0 DLQI in average scores in the 400-mg group, 10.4 in the 200-mg group, and an average drop of only 3.8 in controls (P less than .001).
Dr. Gottlieb, who disclosed that her mother suffers from severe plaque psoriasis, told the audience that the patient improvements were on par with those seen with infliximab, which she said was “the best anti–TNF alpha in the pack to date, and that’s an intravenous drug. These are impressive drops in the DLQI.”
Adverse events were, said Dr. Gottlieb, “a whole lot of nothing. There’s nothing that stands out.” She said there were no cases of tuberculosis, one case of vulvovaginal candidiasis, and equal distribution of herpes zoster across the study.
[email protected]
On Twitter @whitneymcknight
ORLANDO – Results from two phase III trials indicated the tumor necrosis factor alpha inhibitor certolizumab pegol led to significant improvements in moderate to severe chronic plaque psoriasis, compared with placebo, according to an oral presentation at this year’s annual Academy of Dermatology Meeting.
Across the CIMPASI-1 and CIMPASI-2 trials, at 16 weeks, both certolizumab pegol (Cimzia) 400 mg and 200 mg, administered subcutaneously every 2 weeks in groups of patients with moderate to severe chronic plaque psoriasis, demonstrated statistically significant, clinically meaningful improvements in Psoriasis Area and Severity Index (PASI) scores, and on the Physician Global Assessment (PGA) scores, when compared with placebo. The data were presented by Alice B. Gottlieb, MD, PhD, professor of dermatology at New York Medical College, Valhalla. Certolizumab pegol currently is approved in the United States for use in psoriatic arthritis, but not for psoriasis.
In CIMPASI-1, 234 mostly white male patients in their mid-40s who had moderate to severe chronic plaque psoriasis were randomly assigned to one of three groups. There were 88 participants in the arm given 400 mg every 2 weeks at weeks 0, 2, and 4; 95 given 200 mg at weeks 0, 2, and 4; and 51 given placebo. At week 16, the percentage of patients who achieved a PASI 75 was 75.8% in the first group, 66.5% in the second, and 6.5% for placebo. A PGA scale improvement of at least two points over baseline toward a final score of clear or almost clear skin at week 16 was 57.9% for group 1, 47.0% for the second group, and 4.2% for placebo.
Also at week 16, the percentage of patients who achieved a PASI 90 was 43.6% in the 400 mg dose group, 35.8% in the 200 mg dose group, and 0.4% in the placebo group.
In CIMPASI-2, 227 mostly white patients with moderate to severe chronic plaque psoriasis, most of whom were in their mid-40s, evenly distributed across the sexes, were randomly assigned to one of three groups. There were 87 participants in the 400 mg every 2 weeks at weeks 0, 2, and 4 group; 91 in the 200 mg every 2 weeks at weeks 0, 2, and 4 arm, and 49 in the placebo group. At week 16, 82.6% of patients in the first group and 81.4% in the second group had a PASI 75, compared with 11.6% of the placebo group. Also at 16 weeks, a PGA scale improvement of at least two points over baseline toward a final score of clear or almost clear skin at week 16 was 71.6% for group 1, 66.8% for the second group, and 2.0% for placebo. At week 16, 55.4% of patients receiving the 400 mg dose had a PASI 90, as did 52.6% of patients receiving the 200 mg dose every 2 weeks, compared with only 4.5% of the placebo group.
Additionally, Dr. Gottlieb said that at week 16, patients in the 400-mg and 200-mg groups showed significant improvements over baseline Dermatology Life Quality Index (DLQI) average scores, compared with placebo: a 10.2 decrease in the 400-mg group and a 9.3 decrease in the 200-mg group, compared with a 3.3 decrease in the placebo arm (P less than .001) in the CIMPASI-1 study. In the CIMPASI-2 study at week 16, there was a drop of 10.0 DLQI in average scores in the 400-mg group, 10.4 in the 200-mg group, and an average drop of only 3.8 in controls (P less than .001).
Dr. Gottlieb, who disclosed that her mother suffers from severe plaque psoriasis, told the audience that the patient improvements were on par with those seen with infliximab, which she said was “the best anti–TNF alpha in the pack to date, and that’s an intravenous drug. These are impressive drops in the DLQI.”
Adverse events were, said Dr. Gottlieb, “a whole lot of nothing. There’s nothing that stands out.” She said there were no cases of tuberculosis, one case of vulvovaginal candidiasis, and equal distribution of herpes zoster across the study.
[email protected]
On Twitter @whitneymcknight
ORLANDO – Results from two phase III trials indicated the tumor necrosis factor alpha inhibitor certolizumab pegol led to significant improvements in moderate to severe chronic plaque psoriasis, compared with placebo, according to an oral presentation at this year’s annual Academy of Dermatology Meeting.
Across the CIMPASI-1 and CIMPASI-2 trials, at 16 weeks, both certolizumab pegol (Cimzia) 400 mg and 200 mg, administered subcutaneously every 2 weeks in groups of patients with moderate to severe chronic plaque psoriasis, demonstrated statistically significant, clinically meaningful improvements in Psoriasis Area and Severity Index (PASI) scores, and on the Physician Global Assessment (PGA) scores, when compared with placebo. The data were presented by Alice B. Gottlieb, MD, PhD, professor of dermatology at New York Medical College, Valhalla. Certolizumab pegol currently is approved in the United States for use in psoriatic arthritis, but not for psoriasis.
In CIMPASI-1, 234 mostly white male patients in their mid-40s who had moderate to severe chronic plaque psoriasis were randomly assigned to one of three groups. There were 88 participants in the arm given 400 mg every 2 weeks at weeks 0, 2, and 4; 95 given 200 mg at weeks 0, 2, and 4; and 51 given placebo. At week 16, the percentage of patients who achieved a PASI 75 was 75.8% in the first group, 66.5% in the second, and 6.5% for placebo. A PGA scale improvement of at least two points over baseline toward a final score of clear or almost clear skin at week 16 was 57.9% for group 1, 47.0% for the second group, and 4.2% for placebo.
Also at week 16, the percentage of patients who achieved a PASI 90 was 43.6% in the 400 mg dose group, 35.8% in the 200 mg dose group, and 0.4% in the placebo group.
In CIMPASI-2, 227 mostly white patients with moderate to severe chronic plaque psoriasis, most of whom were in their mid-40s, evenly distributed across the sexes, were randomly assigned to one of three groups. There were 87 participants in the 400 mg every 2 weeks at weeks 0, 2, and 4 group; 91 in the 200 mg every 2 weeks at weeks 0, 2, and 4 arm, and 49 in the placebo group. At week 16, 82.6% of patients in the first group and 81.4% in the second group had a PASI 75, compared with 11.6% of the placebo group. Also at 16 weeks, a PGA scale improvement of at least two points over baseline toward a final score of clear or almost clear skin at week 16 was 71.6% for group 1, 66.8% for the second group, and 2.0% for placebo. At week 16, 55.4% of patients receiving the 400 mg dose had a PASI 90, as did 52.6% of patients receiving the 200 mg dose every 2 weeks, compared with only 4.5% of the placebo group.
Additionally, Dr. Gottlieb said that at week 16, patients in the 400-mg and 200-mg groups showed significant improvements over baseline Dermatology Life Quality Index (DLQI) average scores, compared with placebo: a 10.2 decrease in the 400-mg group and a 9.3 decrease in the 200-mg group, compared with a 3.3 decrease in the placebo arm (P less than .001) in the CIMPASI-1 study. In the CIMPASI-2 study at week 16, there was a drop of 10.0 DLQI in average scores in the 400-mg group, 10.4 in the 200-mg group, and an average drop of only 3.8 in controls (P less than .001).
Dr. Gottlieb, who disclosed that her mother suffers from severe plaque psoriasis, told the audience that the patient improvements were on par with those seen with infliximab, which she said was “the best anti–TNF alpha in the pack to date, and that’s an intravenous drug. These are impressive drops in the DLQI.”
Adverse events were, said Dr. Gottlieb, “a whole lot of nothing. There’s nothing that stands out.” She said there were no cases of tuberculosis, one case of vulvovaginal candidiasis, and equal distribution of herpes zoster across the study.
[email protected]
On Twitter @whitneymcknight
AT AAD 17
Key clinical point:
Major finding: In CIMPASI-1, at week 16, the response rate for patients who achieved a PASI 75 was 75.8% in the 400-mg group, 66.5% in the 200-mg group, and 6.5% in the placebo group.
Data source: 461 adults with moderate to severe plaque arthritis randomly assigned to either 400 mg certolizumab pegol, 200 mg of the treatment, or placebo every other week at weeks 0, 2, and 4.
Disclosures: Dr. Gottlieb had relevant disclosures, including with Dermira and UCB, the sponsors of this trial.
Data collection urged on patients treated with talk therapy
SCOTTSDALE, ARIZ. – Most psychiatrists are familiar with many of the basic tenets of psychoanalysis, but they probably aren’t relying on its therapeutic powers in practice as much as they are pharmacotherapy, according to an expert.
“There’s a great deal of discussion about whether psychoanalysis has an adequate evidence base. That’s a popular concept. It’s not so much about whether practitioners want to use it, but whether or not they can defend using it in their dialogs with insurance companies, government agencies, and other sources of support,” Robert Michels, MD, a Walsh McDermott University Professor of Medicine, and professor of psychiatry, at Cornell University, New York, said at the annual meeting of the American College of Psychiatrists. “My summary is that it has less adequate data supporting it [than pharmacologic interventions]. … There is, however, convincing evidence that all of these treatments, ranging from cognitive-behavioral therapy to [dialectical behavior therapy], to dynamic psychoanalysis, to mentalization-based treatment, do have an effect.”
“The SSRI probably did more to change psychotherapy than any other evolutionary change in the theory of psychotherapy,” Dr. Michels said. “In the beginning, [pharmacologic treatments] were not terribly useful to the patients of psychoanalysis, because they were too toxic or too psychologically disturbing to use in people without major psychiatric problems. Now, [there is] intense competition from biologic treatments.”
Whereas the goal of pharmacotherapy is cure, the point of psychoanalysis is to derive meaning from neurosis, and ultimately, from life. A sea change in thought about how psychoanalysis should be conducted was well underway before the advent of fluoxetine, however. With the death in 1939 of Sigmund Freud, MD, the founder of psychoanalysis, a wave of theories began to wash over the field. Most of those theories do not see memories as the enemy, or detachment from the patient as appropriate, according to Dr. Michels.
And while the form might vary across the different approaches, the function is the same. “The goal is no longer to recover the lost memory of the childhood trauma. More important is the journey in attempting to discover it,” Dr. Michels said.
Freud avoided seeing his patients as having personality disorders, while the next generations of psychotherapists largely embraced and conceptualized diagnoses, going beyond symptoms and instead focusing on the person’s predisposition to symptom formation. Psychotherapy today sees pathology not as something to be cured but as a reaction to problems tied to everyday living. It assumes that a more effective reaction to those problems can be learned.
Rather than shun what were once considered obstacles – resistance, enactment, transference, countertransference, and working through interpretations – the psychotherapist uses those to establish a relationship with the patient; emotions stirred by the therapist become important markers of patterns that have persisted in the person’s life that prevent forming smooth relationships, and vice versa. “In the new model, the therapist is an actively engaged participant whose core skill is to stay fully involved and interconnected while also being able to step back and say, ‘What is happening here?’ ” Dr. Michels said. “Transference and countertransference are essential tools to the therapeutic process. Hopefully, we change the patient’s attitude to his own mental life and toward others around him. We have a much more open, broader, wider way of dealing with patients, and we are much more humble about what we know before the treatment starts.”
In an interview, Dr. Michels said this has been especially helpful in treating people with borderline personality disorder, for whom the neutral face of a therapist can often be a trigger. “You end up being a better player through collaboration. If you carry the argument to its extreme, we’d say it doesn’t make any difference if you discover the flaw.”
Also in the interview, Dr. Michels said that, while many therapists are aware that psychotherapy has evolved and that it is effective, it is still not commonly taught in medical schools beyond a basic level because of the “finite nature of the amount of time to learn what students are required to learn in order to be a skilled psychotherapist, regardless of whether they have the raw talent for it.” Outcomes of pharmacologic therapies are easier to measure, and that is another reason psychotherapy is “troublesome,” he said. Most psychotherapists prefer not having to justify its use to third-party payers.
The tension between the therapist and insurers should not automatically be a deterrent to expanding access to talk therapy according to the meeting’s program chair, Scott T. Aaronson, MD, director of clinical research at the Sheppard Pratt Health System, Baltimore. “I don’t think that psychoanalysis has ever been a great friend of insurance. I think we need to educate insurance companies on what psychotherapy means. Instead, we just sort of allow them to make rules. It’s been a one-way street that needs to change,” Dr. Aaronson said in an interview.
He and Dr. Michels said data collection on patient outcomes would help. Collecting the hospitalization rates, morbidity and mortality, and medical care costs of people who have received psychotherapy may be worthwhile and would be fairly straightforward to do, according to Dr. Aaronson. “I would worry [about factoring in] those who have been getting psychiatric care off the grid skewing statistics, but if your patient population is of a moderate-income group, very few of those people could afford private care.”
Even if clinicians do not include newer psychoanalytic techniques in practice, Dr. Aaronson said, they “should keep up to date on the trends, and be aware that for many patients, modalities such as mentalization have been exquisitely helpful.”
Neither Dr. Michels nor Dr. Aaronson had any relevant disclosures.
[email protected]
On Twitter @whitneymcknight
SCOTTSDALE, ARIZ. – Most psychiatrists are familiar with many of the basic tenets of psychoanalysis, but they probably aren’t relying on its therapeutic powers in practice as much as they are pharmacotherapy, according to an expert.
“There’s a great deal of discussion about whether psychoanalysis has an adequate evidence base. That’s a popular concept. It’s not so much about whether practitioners want to use it, but whether or not they can defend using it in their dialogs with insurance companies, government agencies, and other sources of support,” Robert Michels, MD, a Walsh McDermott University Professor of Medicine, and professor of psychiatry, at Cornell University, New York, said at the annual meeting of the American College of Psychiatrists. “My summary is that it has less adequate data supporting it [than pharmacologic interventions]. … There is, however, convincing evidence that all of these treatments, ranging from cognitive-behavioral therapy to [dialectical behavior therapy], to dynamic psychoanalysis, to mentalization-based treatment, do have an effect.”
“The SSRI probably did more to change psychotherapy than any other evolutionary change in the theory of psychotherapy,” Dr. Michels said. “In the beginning, [pharmacologic treatments] were not terribly useful to the patients of psychoanalysis, because they were too toxic or too psychologically disturbing to use in people without major psychiatric problems. Now, [there is] intense competition from biologic treatments.”
Whereas the goal of pharmacotherapy is cure, the point of psychoanalysis is to derive meaning from neurosis, and ultimately, from life. A sea change in thought about how psychoanalysis should be conducted was well underway before the advent of fluoxetine, however. With the death in 1939 of Sigmund Freud, MD, the founder of psychoanalysis, a wave of theories began to wash over the field. Most of those theories do not see memories as the enemy, or detachment from the patient as appropriate, according to Dr. Michels.
And while the form might vary across the different approaches, the function is the same. “The goal is no longer to recover the lost memory of the childhood trauma. More important is the journey in attempting to discover it,” Dr. Michels said.
Freud avoided seeing his patients as having personality disorders, while the next generations of psychotherapists largely embraced and conceptualized diagnoses, going beyond symptoms and instead focusing on the person’s predisposition to symptom formation. Psychotherapy today sees pathology not as something to be cured but as a reaction to problems tied to everyday living. It assumes that a more effective reaction to those problems can be learned.
Rather than shun what were once considered obstacles – resistance, enactment, transference, countertransference, and working through interpretations – the psychotherapist uses those to establish a relationship with the patient; emotions stirred by the therapist become important markers of patterns that have persisted in the person’s life that prevent forming smooth relationships, and vice versa. “In the new model, the therapist is an actively engaged participant whose core skill is to stay fully involved and interconnected while also being able to step back and say, ‘What is happening here?’ ” Dr. Michels said. “Transference and countertransference are essential tools to the therapeutic process. Hopefully, we change the patient’s attitude to his own mental life and toward others around him. We have a much more open, broader, wider way of dealing with patients, and we are much more humble about what we know before the treatment starts.”
In an interview, Dr. Michels said this has been especially helpful in treating people with borderline personality disorder, for whom the neutral face of a therapist can often be a trigger. “You end up being a better player through collaboration. If you carry the argument to its extreme, we’d say it doesn’t make any difference if you discover the flaw.”
Also in the interview, Dr. Michels said that, while many therapists are aware that psychotherapy has evolved and that it is effective, it is still not commonly taught in medical schools beyond a basic level because of the “finite nature of the amount of time to learn what students are required to learn in order to be a skilled psychotherapist, regardless of whether they have the raw talent for it.” Outcomes of pharmacologic therapies are easier to measure, and that is another reason psychotherapy is “troublesome,” he said. Most psychotherapists prefer not having to justify its use to third-party payers.
The tension between the therapist and insurers should not automatically be a deterrent to expanding access to talk therapy according to the meeting’s program chair, Scott T. Aaronson, MD, director of clinical research at the Sheppard Pratt Health System, Baltimore. “I don’t think that psychoanalysis has ever been a great friend of insurance. I think we need to educate insurance companies on what psychotherapy means. Instead, we just sort of allow them to make rules. It’s been a one-way street that needs to change,” Dr. Aaronson said in an interview.
He and Dr. Michels said data collection on patient outcomes would help. Collecting the hospitalization rates, morbidity and mortality, and medical care costs of people who have received psychotherapy may be worthwhile and would be fairly straightforward to do, according to Dr. Aaronson. “I would worry [about factoring in] those who have been getting psychiatric care off the grid skewing statistics, but if your patient population is of a moderate-income group, very few of those people could afford private care.”
Even if clinicians do not include newer psychoanalytic techniques in practice, Dr. Aaronson said, they “should keep up to date on the trends, and be aware that for many patients, modalities such as mentalization have been exquisitely helpful.”
Neither Dr. Michels nor Dr. Aaronson had any relevant disclosures.
[email protected]
On Twitter @whitneymcknight
SCOTTSDALE, ARIZ. – Most psychiatrists are familiar with many of the basic tenets of psychoanalysis, but they probably aren’t relying on its therapeutic powers in practice as much as they are pharmacotherapy, according to an expert.
“There’s a great deal of discussion about whether psychoanalysis has an adequate evidence base. That’s a popular concept. It’s not so much about whether practitioners want to use it, but whether or not they can defend using it in their dialogs with insurance companies, government agencies, and other sources of support,” Robert Michels, MD, a Walsh McDermott University Professor of Medicine, and professor of psychiatry, at Cornell University, New York, said at the annual meeting of the American College of Psychiatrists. “My summary is that it has less adequate data supporting it [than pharmacologic interventions]. … There is, however, convincing evidence that all of these treatments, ranging from cognitive-behavioral therapy to [dialectical behavior therapy], to dynamic psychoanalysis, to mentalization-based treatment, do have an effect.”
“The SSRI probably did more to change psychotherapy than any other evolutionary change in the theory of psychotherapy,” Dr. Michels said. “In the beginning, [pharmacologic treatments] were not terribly useful to the patients of psychoanalysis, because they were too toxic or too psychologically disturbing to use in people without major psychiatric problems. Now, [there is] intense competition from biologic treatments.”
Whereas the goal of pharmacotherapy is cure, the point of psychoanalysis is to derive meaning from neurosis, and ultimately, from life. A sea change in thought about how psychoanalysis should be conducted was well underway before the advent of fluoxetine, however. With the death in 1939 of Sigmund Freud, MD, the founder of psychoanalysis, a wave of theories began to wash over the field. Most of those theories do not see memories as the enemy, or detachment from the patient as appropriate, according to Dr. Michels.
And while the form might vary across the different approaches, the function is the same. “The goal is no longer to recover the lost memory of the childhood trauma. More important is the journey in attempting to discover it,” Dr. Michels said.
Freud avoided seeing his patients as having personality disorders, while the next generations of psychotherapists largely embraced and conceptualized diagnoses, going beyond symptoms and instead focusing on the person’s predisposition to symptom formation. Psychotherapy today sees pathology not as something to be cured but as a reaction to problems tied to everyday living. It assumes that a more effective reaction to those problems can be learned.
Rather than shun what were once considered obstacles – resistance, enactment, transference, countertransference, and working through interpretations – the psychotherapist uses those to establish a relationship with the patient; emotions stirred by the therapist become important markers of patterns that have persisted in the person’s life that prevent forming smooth relationships, and vice versa. “In the new model, the therapist is an actively engaged participant whose core skill is to stay fully involved and interconnected while also being able to step back and say, ‘What is happening here?’ ” Dr. Michels said. “Transference and countertransference are essential tools to the therapeutic process. Hopefully, we change the patient’s attitude to his own mental life and toward others around him. We have a much more open, broader, wider way of dealing with patients, and we are much more humble about what we know before the treatment starts.”
In an interview, Dr. Michels said this has been especially helpful in treating people with borderline personality disorder, for whom the neutral face of a therapist can often be a trigger. “You end up being a better player through collaboration. If you carry the argument to its extreme, we’d say it doesn’t make any difference if you discover the flaw.”
Also in the interview, Dr. Michels said that, while many therapists are aware that psychotherapy has evolved and that it is effective, it is still not commonly taught in medical schools beyond a basic level because of the “finite nature of the amount of time to learn what students are required to learn in order to be a skilled psychotherapist, regardless of whether they have the raw talent for it.” Outcomes of pharmacologic therapies are easier to measure, and that is another reason psychotherapy is “troublesome,” he said. Most psychotherapists prefer not having to justify its use to third-party payers.
The tension between the therapist and insurers should not automatically be a deterrent to expanding access to talk therapy according to the meeting’s program chair, Scott T. Aaronson, MD, director of clinical research at the Sheppard Pratt Health System, Baltimore. “I don’t think that psychoanalysis has ever been a great friend of insurance. I think we need to educate insurance companies on what psychotherapy means. Instead, we just sort of allow them to make rules. It’s been a one-way street that needs to change,” Dr. Aaronson said in an interview.
He and Dr. Michels said data collection on patient outcomes would help. Collecting the hospitalization rates, morbidity and mortality, and medical care costs of people who have received psychotherapy may be worthwhile and would be fairly straightforward to do, according to Dr. Aaronson. “I would worry [about factoring in] those who have been getting psychiatric care off the grid skewing statistics, but if your patient population is of a moderate-income group, very few of those people could afford private care.”
Even if clinicians do not include newer psychoanalytic techniques in practice, Dr. Aaronson said, they “should keep up to date on the trends, and be aware that for many patients, modalities such as mentalization have been exquisitely helpful.”
Neither Dr. Michels nor Dr. Aaronson had any relevant disclosures.
[email protected]
On Twitter @whitneymcknight
EXPERT ANALYSIS AT THE AMERICAN COLLEGE OF PSYCHIATRISTS ANNUAL MEETING
Expert to psychiatrists: Collaborative care is here to stay
SCOTTSDALE, ARIZ. – Whether or not the Affordable Care Act (ACA) is repealed, replaced, reviled, or revered should not deter psychiatrists and primary care physicians from seeking to work together, according to a leading expert on integrating mental health care in medical practice.
“Community-based psychiatrists should be focused on finding ways to help create integrated models of care, both in health systems and in other settings, to provide mental health specialty support for primary care providers, regardless of whatever else is going on [in Washington],” Paul Summergrad, MD, said in an interview at the annual meeting of the American College of Psychiatrists.
“If Medicaid expansion is replaced with block grants, that would lead to less care in general for Medicaid recipients,” Dr. Summergrad said in the interview. “It depends on how the states would view their costs of care, and how they would view the medical psychiatric issues.”
Since Medicaid is the largest payer of mental and behavioral health services in the country with reimbursable models of collaborative care, cutting funding for those services would sting. “There’s evidence that addressing mental and behavioral health issues keeps medical costs low,” said Dr. Summergrad, a past president of the American Psychiatric Association.
In his talk, Dr. Summergrad pointed to the now decade-old IMPACT study (Improving Mood: Promoting Access to Collaborative Treatment) which showed that patients screened for depression when presenting with chronic medical issues had lower overall medical costs over time.
He also referred to a more recent study in a large Utah health system that showed overall cost savings, far-fewer emergency department admissions, and better patient outcomes across a wide range of medical issues, which were achieved when mental health services were integrated into routine care: in all, a $12 million investment resulted in $52 million in savings after 4 years (JAMA. 2016;316[8]:826-34). “Utah is not exactly a blue state, but it worked for them,” Dr. Summergrad said. The key was that physicians “embraced normalizing mental health care,” he said.
As for how any changes to the Medicare Access and CHIP Reauthorization Act, which is predicated largely on team-based care for higher reimbursements, Dr. Summergrad said cash-only psychiatrists should be thinking about how to collaborate with primary care providers. “I think the important message at this point is that, however this works, we’ll have to think about integrated care.”
In an interview, Lee H. Beecher, MD, agreed. In fact, Dr. Beecher said that, in his state of Minnesota, engaging with patients on a cash-only basis is the only way a psychiatrist can have a private practice and provide valuable, essential communication with primary care physicians. “Direct-pay physicians are uniquely able to actively facilitate communication,” said Dr. Beecher, president of the nonprofit Minnesota Physician-Patient Alliance. “Most of this is done by phone, directly, with the primary care clinician – rather than inputting and sending an electronic health record.”
Dr. Summergrad had no relevant disclosures.
[email protected]
On Twitter @whitneymcknight
SCOTTSDALE, ARIZ. – Whether or not the Affordable Care Act (ACA) is repealed, replaced, reviled, or revered should not deter psychiatrists and primary care physicians from seeking to work together, according to a leading expert on integrating mental health care in medical practice.
“Community-based psychiatrists should be focused on finding ways to help create integrated models of care, both in health systems and in other settings, to provide mental health specialty support for primary care providers, regardless of whatever else is going on [in Washington],” Paul Summergrad, MD, said in an interview at the annual meeting of the American College of Psychiatrists.
“If Medicaid expansion is replaced with block grants, that would lead to less care in general for Medicaid recipients,” Dr. Summergrad said in the interview. “It depends on how the states would view their costs of care, and how they would view the medical psychiatric issues.”
Since Medicaid is the largest payer of mental and behavioral health services in the country with reimbursable models of collaborative care, cutting funding for those services would sting. “There’s evidence that addressing mental and behavioral health issues keeps medical costs low,” said Dr. Summergrad, a past president of the American Psychiatric Association.
In his talk, Dr. Summergrad pointed to the now decade-old IMPACT study (Improving Mood: Promoting Access to Collaborative Treatment) which showed that patients screened for depression when presenting with chronic medical issues had lower overall medical costs over time.
He also referred to a more recent study in a large Utah health system that showed overall cost savings, far-fewer emergency department admissions, and better patient outcomes across a wide range of medical issues, which were achieved when mental health services were integrated into routine care: in all, a $12 million investment resulted in $52 million in savings after 4 years (JAMA. 2016;316[8]:826-34). “Utah is not exactly a blue state, but it worked for them,” Dr. Summergrad said. The key was that physicians “embraced normalizing mental health care,” he said.
As for how any changes to the Medicare Access and CHIP Reauthorization Act, which is predicated largely on team-based care for higher reimbursements, Dr. Summergrad said cash-only psychiatrists should be thinking about how to collaborate with primary care providers. “I think the important message at this point is that, however this works, we’ll have to think about integrated care.”
In an interview, Lee H. Beecher, MD, agreed. In fact, Dr. Beecher said that, in his state of Minnesota, engaging with patients on a cash-only basis is the only way a psychiatrist can have a private practice and provide valuable, essential communication with primary care physicians. “Direct-pay physicians are uniquely able to actively facilitate communication,” said Dr. Beecher, president of the nonprofit Minnesota Physician-Patient Alliance. “Most of this is done by phone, directly, with the primary care clinician – rather than inputting and sending an electronic health record.”
Dr. Summergrad had no relevant disclosures.
[email protected]
On Twitter @whitneymcknight
SCOTTSDALE, ARIZ. – Whether or not the Affordable Care Act (ACA) is repealed, replaced, reviled, or revered should not deter psychiatrists and primary care physicians from seeking to work together, according to a leading expert on integrating mental health care in medical practice.
“Community-based psychiatrists should be focused on finding ways to help create integrated models of care, both in health systems and in other settings, to provide mental health specialty support for primary care providers, regardless of whatever else is going on [in Washington],” Paul Summergrad, MD, said in an interview at the annual meeting of the American College of Psychiatrists.
“If Medicaid expansion is replaced with block grants, that would lead to less care in general for Medicaid recipients,” Dr. Summergrad said in the interview. “It depends on how the states would view their costs of care, and how they would view the medical psychiatric issues.”
Since Medicaid is the largest payer of mental and behavioral health services in the country with reimbursable models of collaborative care, cutting funding for those services would sting. “There’s evidence that addressing mental and behavioral health issues keeps medical costs low,” said Dr. Summergrad, a past president of the American Psychiatric Association.
In his talk, Dr. Summergrad pointed to the now decade-old IMPACT study (Improving Mood: Promoting Access to Collaborative Treatment) which showed that patients screened for depression when presenting with chronic medical issues had lower overall medical costs over time.
He also referred to a more recent study in a large Utah health system that showed overall cost savings, far-fewer emergency department admissions, and better patient outcomes across a wide range of medical issues, which were achieved when mental health services were integrated into routine care: in all, a $12 million investment resulted in $52 million in savings after 4 years (JAMA. 2016;316[8]:826-34). “Utah is not exactly a blue state, but it worked for them,” Dr. Summergrad said. The key was that physicians “embraced normalizing mental health care,” he said.
As for how any changes to the Medicare Access and CHIP Reauthorization Act, which is predicated largely on team-based care for higher reimbursements, Dr. Summergrad said cash-only psychiatrists should be thinking about how to collaborate with primary care providers. “I think the important message at this point is that, however this works, we’ll have to think about integrated care.”
In an interview, Lee H. Beecher, MD, agreed. In fact, Dr. Beecher said that, in his state of Minnesota, engaging with patients on a cash-only basis is the only way a psychiatrist can have a private practice and provide valuable, essential communication with primary care physicians. “Direct-pay physicians are uniquely able to actively facilitate communication,” said Dr. Beecher, president of the nonprofit Minnesota Physician-Patient Alliance. “Most of this is done by phone, directly, with the primary care clinician – rather than inputting and sending an electronic health record.”
Dr. Summergrad had no relevant disclosures.
[email protected]
On Twitter @whitneymcknight
EXPERT ANALYSIS AT THE AMERICAN COLLEGE OF PSYCHIATRISTS ANNUAL MEETING
Sarcoidosis doubles hospitalized infection risk
Persons with sarcoidosis were found to have double the risk of hospitalization, compared with age-matched controls in a population-based cohort study that also linked glucocorticoid use with an increased risk of hospitalization in this group.
Using data from the Rochester Epidemiology Project record-linkage system, Patompong Ungprasert, MD, an assistant professor of medicine at the Mayo Clinic in Rochester, Minn., and his colleagues identified 345 incident cases of sarcoidosis recorded between 1976 and 2013, confirmed by individual medical records (Ann Am Thorac Soc. 2017 Feb 8. doi: 10.1513/AnnalsATS.201610-750OC). Using random selection, each patient was age- and sex-matched with sarcoidosis-free controls taken from the same database. Medical records across the study were examined for community-acquired infections requiring hospitalization that occurred after the index date or the date of diagnosis.
Dr. Ungprasert and his coinvestigators found that those with sarcoidosis had double the risk of all forms of specific hospitalized infection when compared with controls – a 2.00 hazard ratio (95% confidence interval, 1.41-2.84). The results were similar when adjusted for infection risk factors: 2.13 HR (95% CI, 1.35-3.34).
The risk of hospitalized infection in the sarcoidosis arm was higher than in controls regardless of disease stage: an HR of 1.70 (95% CI, 1.12-2.58, P = .013) in those with Stage I; an HR of 2.00 (95% CI, 1.22-3.29, P = .006) among those with stage II; and an HR of 2.63 (95% CI, 1.58-4.39, P less than .001) in those with Stage III and Stage IV disease.
Biopsies taken in 251 cases resulted in 229 positive results for noncaseating granuloma, and just over half of patients had stage I disease. Stage II disease was found in 29%, Stage III in 15%, and Stage IV in 2%.
Patients in the sarcoidosis group who had not been exposed to immunosuppressive treatment had significantly higher risk of hospitalization with an HR of 1.73 (95% CI, 1.16-2.60; P = .008) when compared with controls. The risk was even higher in study patients who had received immunosuppressive therapy: an HR of 2.41 (95% CI, 1.60-3.64; P less than .001), when compared with controls. Less than half of all sarcoidosis patients required immunosuppressive therapy at any point during follow-up: about 37% by year 30 after original diagnosis. Oral glucocorticoids were the most commonly prescribed medication, used in 113 cases.
A baseline diffusing capacity of the lung for carbon monoxide was associated with an overall increased risk of hospitalized infection, with an HR of 1.15 per decrease of 10% predicted in diffusing capacity of the lung for carbon monoxide (95% CI, 1.01-1.32). A baseline forced vital capacity was associated with an increased hospitalized pneumonia risk with an HR of 1.15 per decrease of 10% predicted in forced vital capacity (95% CI, 1.01-1.32).
Although the use of immunosuppressive agents was not significantly associated with the risk of hospitalized infection (HR, 1.43; 95% CI, 0.94-2.19), current use of oral glucocorticoids, whether alone or as adjunct to immunosuppressive therapy, significantly predicted risk of infection in patients with sarcoidosis, with an HR of 3.03 (95% CI, 1.33-6.90) for oral glucocorticoids up to 10 mg per day, and an HR of 4.48 (95% CI, 1.33-6.90) in patients taking oral glucocorticoids at more than 10 mg per day, when compared with controls.
In an interview, Dr. Ungprasert said the results were not surprising, but provided the following takeaways from this study for physicians caring for patients with sarcoidosis.
“These patients are at an increased risk of serious infection and should seek medical attention as soon as possible when they develop symptoms of infection, such as fever or chills,” he said in an interview. “Keeping current with vaccinations is also important for them.”
Dr. Ungprasert also said the study serves as a reminder to use oral glucocorticoids judiciously. “When considering their use, the physician should keep in mind that a large number of patients with sarcoidosis will have a spontaneous resolution of the disease.”
There were no relevant disclosures. The study was funded in part by the National Institute on Aging.
[email protected]
On Twitter @whitneymcknight
Persons with sarcoidosis were found to have double the risk of hospitalization, compared with age-matched controls in a population-based cohort study that also linked glucocorticoid use with an increased risk of hospitalization in this group.
Using data from the Rochester Epidemiology Project record-linkage system, Patompong Ungprasert, MD, an assistant professor of medicine at the Mayo Clinic in Rochester, Minn., and his colleagues identified 345 incident cases of sarcoidosis recorded between 1976 and 2013, confirmed by individual medical records (Ann Am Thorac Soc. 2017 Feb 8. doi: 10.1513/AnnalsATS.201610-750OC). Using random selection, each patient was age- and sex-matched with sarcoidosis-free controls taken from the same database. Medical records across the study were examined for community-acquired infections requiring hospitalization that occurred after the index date or the date of diagnosis.
Dr. Ungprasert and his coinvestigators found that those with sarcoidosis had double the risk of all forms of specific hospitalized infection when compared with controls – a 2.00 hazard ratio (95% confidence interval, 1.41-2.84). The results were similar when adjusted for infection risk factors: 2.13 HR (95% CI, 1.35-3.34).
The risk of hospitalized infection in the sarcoidosis arm was higher than in controls regardless of disease stage: an HR of 1.70 (95% CI, 1.12-2.58, P = .013) in those with Stage I; an HR of 2.00 (95% CI, 1.22-3.29, P = .006) among those with stage II; and an HR of 2.63 (95% CI, 1.58-4.39, P less than .001) in those with Stage III and Stage IV disease.
Biopsies taken in 251 cases resulted in 229 positive results for noncaseating granuloma, and just over half of patients had stage I disease. Stage II disease was found in 29%, Stage III in 15%, and Stage IV in 2%.
Patients in the sarcoidosis group who had not been exposed to immunosuppressive treatment had significantly higher risk of hospitalization with an HR of 1.73 (95% CI, 1.16-2.60; P = .008) when compared with controls. The risk was even higher in study patients who had received immunosuppressive therapy: an HR of 2.41 (95% CI, 1.60-3.64; P less than .001), when compared with controls. Less than half of all sarcoidosis patients required immunosuppressive therapy at any point during follow-up: about 37% by year 30 after original diagnosis. Oral glucocorticoids were the most commonly prescribed medication, used in 113 cases.
A baseline diffusing capacity of the lung for carbon monoxide was associated with an overall increased risk of hospitalized infection, with an HR of 1.15 per decrease of 10% predicted in diffusing capacity of the lung for carbon monoxide (95% CI, 1.01-1.32). A baseline forced vital capacity was associated with an increased hospitalized pneumonia risk with an HR of 1.15 per decrease of 10% predicted in forced vital capacity (95% CI, 1.01-1.32).
Although the use of immunosuppressive agents was not significantly associated with the risk of hospitalized infection (HR, 1.43; 95% CI, 0.94-2.19), current use of oral glucocorticoids, whether alone or as adjunct to immunosuppressive therapy, significantly predicted risk of infection in patients with sarcoidosis, with an HR of 3.03 (95% CI, 1.33-6.90) for oral glucocorticoids up to 10 mg per day, and an HR of 4.48 (95% CI, 1.33-6.90) in patients taking oral glucocorticoids at more than 10 mg per day, when compared with controls.
In an interview, Dr. Ungprasert said the results were not surprising, but provided the following takeaways from this study for physicians caring for patients with sarcoidosis.
“These patients are at an increased risk of serious infection and should seek medical attention as soon as possible when they develop symptoms of infection, such as fever or chills,” he said in an interview. “Keeping current with vaccinations is also important for them.”
Dr. Ungprasert also said the study serves as a reminder to use oral glucocorticoids judiciously. “When considering their use, the physician should keep in mind that a large number of patients with sarcoidosis will have a spontaneous resolution of the disease.”
There were no relevant disclosures. The study was funded in part by the National Institute on Aging.
[email protected]
On Twitter @whitneymcknight
Persons with sarcoidosis were found to have double the risk of hospitalization, compared with age-matched controls in a population-based cohort study that also linked glucocorticoid use with an increased risk of hospitalization in this group.
Using data from the Rochester Epidemiology Project record-linkage system, Patompong Ungprasert, MD, an assistant professor of medicine at the Mayo Clinic in Rochester, Minn., and his colleagues identified 345 incident cases of sarcoidosis recorded between 1976 and 2013, confirmed by individual medical records (Ann Am Thorac Soc. 2017 Feb 8. doi: 10.1513/AnnalsATS.201610-750OC). Using random selection, each patient was age- and sex-matched with sarcoidosis-free controls taken from the same database. Medical records across the study were examined for community-acquired infections requiring hospitalization that occurred after the index date or the date of diagnosis.
Dr. Ungprasert and his coinvestigators found that those with sarcoidosis had double the risk of all forms of specific hospitalized infection when compared with controls – a 2.00 hazard ratio (95% confidence interval, 1.41-2.84). The results were similar when adjusted for infection risk factors: 2.13 HR (95% CI, 1.35-3.34).
The risk of hospitalized infection in the sarcoidosis arm was higher than in controls regardless of disease stage: an HR of 1.70 (95% CI, 1.12-2.58, P = .013) in those with Stage I; an HR of 2.00 (95% CI, 1.22-3.29, P = .006) among those with stage II; and an HR of 2.63 (95% CI, 1.58-4.39, P less than .001) in those with Stage III and Stage IV disease.
Biopsies taken in 251 cases resulted in 229 positive results for noncaseating granuloma, and just over half of patients had stage I disease. Stage II disease was found in 29%, Stage III in 15%, and Stage IV in 2%.
Patients in the sarcoidosis group who had not been exposed to immunosuppressive treatment had significantly higher risk of hospitalization with an HR of 1.73 (95% CI, 1.16-2.60; P = .008) when compared with controls. The risk was even higher in study patients who had received immunosuppressive therapy: an HR of 2.41 (95% CI, 1.60-3.64; P less than .001), when compared with controls. Less than half of all sarcoidosis patients required immunosuppressive therapy at any point during follow-up: about 37% by year 30 after original diagnosis. Oral glucocorticoids were the most commonly prescribed medication, used in 113 cases.
A baseline diffusing capacity of the lung for carbon monoxide was associated with an overall increased risk of hospitalized infection, with an HR of 1.15 per decrease of 10% predicted in diffusing capacity of the lung for carbon monoxide (95% CI, 1.01-1.32). A baseline forced vital capacity was associated with an increased hospitalized pneumonia risk with an HR of 1.15 per decrease of 10% predicted in forced vital capacity (95% CI, 1.01-1.32).
Although the use of immunosuppressive agents was not significantly associated with the risk of hospitalized infection (HR, 1.43; 95% CI, 0.94-2.19), current use of oral glucocorticoids, whether alone or as adjunct to immunosuppressive therapy, significantly predicted risk of infection in patients with sarcoidosis, with an HR of 3.03 (95% CI, 1.33-6.90) for oral glucocorticoids up to 10 mg per day, and an HR of 4.48 (95% CI, 1.33-6.90) in patients taking oral glucocorticoids at more than 10 mg per day, when compared with controls.
In an interview, Dr. Ungprasert said the results were not surprising, but provided the following takeaways from this study for physicians caring for patients with sarcoidosis.
“These patients are at an increased risk of serious infection and should seek medical attention as soon as possible when they develop symptoms of infection, such as fever or chills,” he said in an interview. “Keeping current with vaccinations is also important for them.”
Dr. Ungprasert also said the study serves as a reminder to use oral glucocorticoids judiciously. “When considering their use, the physician should keep in mind that a large number of patients with sarcoidosis will have a spontaneous resolution of the disease.”
There were no relevant disclosures. The study was funded in part by the National Institute on Aging.
[email protected]
On Twitter @whitneymcknight
FROM ANNALS OF THE AMERICAN THORACIC SOCIETY
Key clinical point:
Major finding: 345 patients with sarcoidosis had a hazard ratio of 2.00 (95% CI, 1.41-2.84) for hospitalized infection, compared with controls.
Data source: Olmsted County, Minn. epidemiology records from 1976 to 2013.
Disclosures: There were no relevant disclosures. The study was funded in part by the National Institute on Aging.