Recognizing the ongoing value of benzoyl peroxide, educating patients about the role of antibiotics, and embracing spironolactone are among the acne treatment pearls provided by Hilary Baldwin, MD, during a virtual presentation at MedscapeLive’s annual Las Vegas Dermatology Seminar.

Courtesy Wikimedia Commons/Kinan Ayu/Creative Commons license

Benzoyl peroxide celebrates its 60th birthday and is still going strong as an acne treatment, said Dr. Baldwin, of the department of dermatology, Rutgers Robert Wood Johnston Medical Center, New Brunswick, N.J. Benzoyl peroxide can be used as a stand-alone and has the added benefit of not being associated with antimicrobial resistance. In addition, “benzoyl peroxide is the heavy lifter in combinations,” she said. In fact, benzoyl peroxide can prevent the development of resistance to topical and oral antibiotics such as clindamycin, and can reverse resistance that has occurred, she noted.

However, patient compliance can be an issue. Benzoyl peroxide often is underused because of its tendency to bleach fabric, noted Dr. Baldwin, who is also medical director of The Acne Treatment and Research Center in New York. To help combat this problem and improve compliance, she advises patients to establish a dosing schedule for benzoyl peroxide, such as using it first thing in the morning, or applying in the afternoon and using a paper towel first, or a white towel, to wash their faces at bedtime, she said. When dealing with teenagers, “it sounds like a lot of work, but it makes the mothers much happier not to have their towels bleached.”

Although clinicians want to reduce unnecessary antibiotic use in acne, there is a place for antibiotics, but not as monotherapy, Dr. Baldwin said. Instead, initiate topical therapy, such as a retinoid or benzoyl peroxide, simultaneously with antibiotics and evaluate the response in 6-8 weeks, she advised. At that point, the antibiotics can be stopped, even if 100% clearing has not been achieved, and “the topicals can carry you on for months and months,” she noted.

Also, in female patients, consider oral contraceptive pills or spironolactone at the same time as oral antibiotics, then discontinue the antibiotics and continue with the hormonal therapy, she added. “Plan your exit strategy early,” she said. Explain to patients that you will stop the oral antibiotics after 2 months, so they must continue with the topicals.

“Embrace spironolactone if you haven’t already,” said Dr. Baldwin, who noted that spironolactone has been underused in recent years. Spironolactone use for acne has not been well studied, “but consensus groups and expert opinions certainly favor its use,” she added.

Recognizing the ongoing value of benzoyl peroxide, educating patients about the role of antibiotics, and embracing spironolactone are among the acne treatment pearls provided by Hilary Baldwin, MD, during a virtual presentation at MedscapeLive’s annual Las Vegas Dermatology Seminar.

Courtesy Wikimedia Commons/Kinan Ayu/Creative Commons license

Benzoyl peroxide celebrates its 60th birthday and is still going strong as an acne treatment, said Dr. Baldwin, of the department of dermatology, Rutgers Robert Wood Johnston Medical Center, New Brunswick, N.J. Benzoyl peroxide can be used as a stand-alone and has the added benefit of not being associated with antimicrobial resistance. In addition, “benzoyl peroxide is the heavy lifter in combinations,” she said. In fact, benzoyl peroxide can prevent the development of resistance to topical and oral antibiotics such as clindamycin, and can reverse resistance that has occurred, she noted.

However, patient compliance can be an issue. Benzoyl peroxide often is underused because of its tendency to bleach fabric, noted Dr. Baldwin, who is also medical director of The Acne Treatment and Research Center in New York. To help combat this problem and improve compliance, she advises patients to establish a dosing schedule for benzoyl peroxide, such as using it first thing in the morning, or applying in the afternoon and using a paper towel first, or a white towel, to wash their faces at bedtime, she said. When dealing with teenagers, “it sounds like a lot of work, but it makes the mothers much happier not to have their towels bleached.”

Although clinicians want to reduce unnecessary antibiotic use in acne, there is a place for antibiotics, but not as monotherapy, Dr. Baldwin said. Instead, initiate topical therapy, such as a retinoid or benzoyl peroxide, simultaneously with antibiotics and evaluate the response in 6-8 weeks, she advised. At that point, the antibiotics can be stopped, even if 100% clearing has not been achieved, and “the topicals can carry you on for months and months,” she noted.

Also, in female patients, consider oral contraceptive pills or spironolactone at the same time as oral antibiotics, then discontinue the antibiotics and continue with the hormonal therapy, she added. “Plan your exit strategy early,” she said. Explain to patients that you will stop the oral antibiotics after 2 months, so they must continue with the topicals.

“Embrace spironolactone if you haven’t already,” said Dr. Baldwin, who noted that spironolactone has been underused in recent years. Spironolactone use for acne has not been well studied, “but consensus groups and expert opinions certainly favor its use,” she added.

Recognizing the ongoing value of benzoyl peroxide, educating patients about the role of antibiotics, and embracing spironolactone are among the acne treatment pearls provided by Hilary Baldwin, MD, during a virtual presentation at MedscapeLive’s annual Las Vegas Dermatology Seminar.

Courtesy Wikimedia Commons/Kinan Ayu/Creative Commons license

Benzoyl peroxide celebrates its 60th birthday and is still going strong as an acne treatment, said Dr. Baldwin, of the department of dermatology, Rutgers Robert Wood Johnston Medical Center, New Brunswick, N.J. Benzoyl peroxide can be used as a stand-alone and has the added benefit of not being associated with antimicrobial resistance. In addition, “benzoyl peroxide is the heavy lifter in combinations,” she said. In fact, benzoyl peroxide can prevent the development of resistance to topical and oral antibiotics such as clindamycin, and can reverse resistance that has occurred, she noted.

However, patient compliance can be an issue. Benzoyl peroxide often is underused because of its tendency to bleach fabric, noted Dr. Baldwin, who is also medical director of The Acne Treatment and Research Center in New York. To help combat this problem and improve compliance, she advises patients to establish a dosing schedule for benzoyl peroxide, such as using it first thing in the morning, or applying in the afternoon and using a paper towel first, or a white towel, to wash their faces at bedtime, she said. When dealing with teenagers, “it sounds like a lot of work, but it makes the mothers much happier not to have their towels bleached.”

Although clinicians want to reduce unnecessary antibiotic use in acne, there is a place for antibiotics, but not as monotherapy, Dr. Baldwin said. Instead, initiate topical therapy, such as a retinoid or benzoyl peroxide, simultaneously with antibiotics and evaluate the response in 6-8 weeks, she advised. At that point, the antibiotics can be stopped, even if 100% clearing has not been achieved, and “the topicals can carry you on for months and months,” she noted.

Also, in female patients, consider oral contraceptive pills or spironolactone at the same time as oral antibiotics, then discontinue the antibiotics and continue with the hormonal therapy, she added. “Plan your exit strategy early,” she said. Explain to patients that you will stop the oral antibiotics after 2 months, so they must continue with the topicals.

“Embrace spironolactone if you haven’t already,” said Dr. Baldwin, who noted that spironolactone has been underused in recent years. Spironolactone use for acne has not been well studied, “but consensus groups and expert opinions certainly favor its use,” she added.

Patients with hepatitis C virus (HCV) genotype 3 infection have shown resistance to direct-acting antiviral (DAA) treatments. However, a meta-analysis of 34 research reports found that DAA combo treatment can be effective in achieving sustained virologic response (SVR) in patients with HCV genotype 3, according to a study published online in Annals of Hepatology.

This study aimed to analyze the effectiveness of four regimens: sofosbuvir (SOF)/daclatasvir (DCV) with or without ribavirin (RBV); SOF/velpatasvir (VEL) with or without RBV; SOF/VEL/voxilaprevir (VOX);and glecaprevir (GLE)/pibrentasvir (PIB) in the treatment of HCV genotype 3–infected patients in real-world situations, according to Liwei Zhuang, of Beijing Ditan Hospital, Capital Medical University, and colleagues.

A total of 34 studies, comprising 7,328 patients from 22 countries, met the inclusion criteria and formed the basis of the analysis.
 

Promising results

The pooled SVR rate after 12 or 24 weeks of treatment for the four regimens was 92.1%.

For each regimen, the SVR rate was 91.2% in patients treated with SOF/DCV with or without RBV; 95.1% in patients treated with SOF/VEL with or without RBV; 85.0% in patients treated with SOF/VEL/VOX; and 98.5% in patients treated with GLE/PIB.

In addition, the pooled SVR rate of the four regimens was 95.2% in patients without cirrhosis and 89.4% in patients with cirrhosis, and the pooled SVR rate was 94.4% in treatment-naive patients and 88.0% in treatment-experienced patients. All results were within 95% confidence intervals.

The researchers pointed out that their meta-analysis had limitations. “We think that no strong conclusions can be drawn due to high heterogeneity in four DAA regimens administration in real-world setting from 22 countries, as well as small numbers of patients treated with SOF + VEL + VOX and GLE + PIB. More studies are needed in the future in order to better analyze the antiviral effectiveness of DAAs in GT3 HCV patients in real-world studies,” they authors stated.

However, they also concluded that “the antiviral effectiveness of treatment regimens for HCV-GT3 [genotype 3] infection, including SOF + DCV ± RBV, SOF + VEL ± RBV, GLE + PIB, and SOF + VEL + VOX, was good. The SVR rate of GLE + PIB was higher, and the treatment duration was shorter than other regimens.”

The study was funded by the Chinese government and public institutions. The authors reported that they had no conflicts of interest.

[email protected]

SOURCE: Zhuang L et al. Ann Hepatol. 2020 Oct 12. doi: 10.1016/j.aohep.2020.09.012.

Patients with hepatitis C virus (HCV) genotype 3 infection have shown resistance to direct-acting antiviral (DAA) treatments. However, a meta-analysis of 34 research reports found that DAA combo treatment can be effective in achieving sustained virologic response (SVR) in patients with HCV genotype 3, according to a study published online in Annals of Hepatology.

This study aimed to analyze the effectiveness of four regimens: sofosbuvir (SOF)/daclatasvir (DCV) with or without ribavirin (RBV); SOF/velpatasvir (VEL) with or without RBV; SOF/VEL/voxilaprevir (VOX);and glecaprevir (GLE)/pibrentasvir (PIB) in the treatment of HCV genotype 3–infected patients in real-world situations, according to Liwei Zhuang, of Beijing Ditan Hospital, Capital Medical University, and colleagues.

A total of 34 studies, comprising 7,328 patients from 22 countries, met the inclusion criteria and formed the basis of the analysis.
 

Promising results

The pooled SVR rate after 12 or 24 weeks of treatment for the four regimens was 92.1%.

For each regimen, the SVR rate was 91.2% in patients treated with SOF/DCV with or without RBV; 95.1% in patients treated with SOF/VEL with or without RBV; 85.0% in patients treated with SOF/VEL/VOX; and 98.5% in patients treated with GLE/PIB.

In addition, the pooled SVR rate of the four regimens was 95.2% in patients without cirrhosis and 89.4% in patients with cirrhosis, and the pooled SVR rate was 94.4% in treatment-naive patients and 88.0% in treatment-experienced patients. All results were within 95% confidence intervals.

The researchers pointed out that their meta-analysis had limitations. “We think that no strong conclusions can be drawn due to high heterogeneity in four DAA regimens administration in real-world setting from 22 countries, as well as small numbers of patients treated with SOF + VEL + VOX and GLE + PIB. More studies are needed in the future in order to better analyze the antiviral effectiveness of DAAs in GT3 HCV patients in real-world studies,” they authors stated.

However, they also concluded that “the antiviral effectiveness of treatment regimens for HCV-GT3 [genotype 3] infection, including SOF + DCV ± RBV, SOF + VEL ± RBV, GLE + PIB, and SOF + VEL + VOX, was good. The SVR rate of GLE + PIB was higher, and the treatment duration was shorter than other regimens.”

The study was funded by the Chinese government and public institutions. The authors reported that they had no conflicts of interest.

[email protected]

SOURCE: Zhuang L et al. Ann Hepatol. 2020 Oct 12. doi: 10.1016/j.aohep.2020.09.012.

Patients with hepatitis C virus (HCV) genotype 3 infection have shown resistance to direct-acting antiviral (DAA) treatments. However, a meta-analysis of 34 research reports found that DAA combo treatment can be effective in achieving sustained virologic response (SVR) in patients with HCV genotype 3, according to a study published online in Annals of Hepatology.

This study aimed to analyze the effectiveness of four regimens: sofosbuvir (SOF)/daclatasvir (DCV) with or without ribavirin (RBV); SOF/velpatasvir (VEL) with or without RBV; SOF/VEL/voxilaprevir (VOX);and glecaprevir (GLE)/pibrentasvir (PIB) in the treatment of HCV genotype 3–infected patients in real-world situations, according to Liwei Zhuang, of Beijing Ditan Hospital, Capital Medical University, and colleagues.

A total of 34 studies, comprising 7,328 patients from 22 countries, met the inclusion criteria and formed the basis of the analysis.
 

Promising results

The pooled SVR rate after 12 or 24 weeks of treatment for the four regimens was 92.1%.

For each regimen, the SVR rate was 91.2% in patients treated with SOF/DCV with or without RBV; 95.1% in patients treated with SOF/VEL with or without RBV; 85.0% in patients treated with SOF/VEL/VOX; and 98.5% in patients treated with GLE/PIB.

In addition, the pooled SVR rate of the four regimens was 95.2% in patients without cirrhosis and 89.4% in patients with cirrhosis, and the pooled SVR rate was 94.4% in treatment-naive patients and 88.0% in treatment-experienced patients. All results were within 95% confidence intervals.

The researchers pointed out that their meta-analysis had limitations. “We think that no strong conclusions can be drawn due to high heterogeneity in four DAA regimens administration in real-world setting from 22 countries, as well as small numbers of patients treated with SOF + VEL + VOX and GLE + PIB. More studies are needed in the future in order to better analyze the antiviral effectiveness of DAAs in GT3 HCV patients in real-world studies,” they authors stated.

However, they also concluded that “the antiviral effectiveness of treatment regimens for HCV-GT3 [genotype 3] infection, including SOF + DCV ± RBV, SOF + VEL ± RBV, GLE + PIB, and SOF + VEL + VOX, was good. The SVR rate of GLE + PIB was higher, and the treatment duration was shorter than other regimens.”

The study was funded by the Chinese government and public institutions. The authors reported that they had no conflicts of interest.

[email protected]

SOURCE: Zhuang L et al. Ann Hepatol. 2020 Oct 12. doi: 10.1016/j.aohep.2020.09.012.

References 

1. US Preventive Services Task Force. Colorectal cancer: screening [draft recommendation statement]. https://uspreventiveservicestaskforce.org/uspstf/draft-recommendation/colorectal-cancer-screening3. Published October 27, 2020. Accessed November 23, 2020.

References 

1. US Preventive Services Task Force. Colorectal cancer: screening [draft recommendation statement]. https://uspreventiveservicestaskforce.org/uspstf/draft-recommendation/colorectal-cancer-screening3. Published October 27, 2020. Accessed November 23, 2020.

References 

1. US Preventive Services Task Force. Colorectal cancer: screening [draft recommendation statement]. https://uspreventiveservicestaskforce.org/uspstf/draft-recommendation/colorectal-cancer-screening3. Published October 27, 2020. Accessed November 23, 2020.

Dermoscopy showed polylobular, whitish yellow, amorphous structures at the center of the lesion surrounded by a crown of vessels (Figure 1). Histopathology revealed hyperplastic crateriform lesions containing large eosinophilic intracytoplasmic inclusion bodies within keratinocytes (Figure 2). At follow-up 2 weeks after the biopsy, the patient presented with approximately 20 more reddish papules of varying sizes on the abdomen and back that presented as dome-shaped papules and had a typical umbilicated center. The clinical manifestations, dermoscopy, and pathology findings were consistent with molluscum contagiosum (MC).

Molluscum contagiosum was first described in 1814. It is a benign cutaneous infectious disease caused by a double-stranded DNA virus of the poxvirus family. Molluscum contagiosum lesions usually manifest clinically as dome-shaped, flesh-colored or translucent, umbilicated papules measuring 1 to 5 mm in diameter that are commonly distributed over the face, trunk, and extremities and usually are self-limiting.¹

Giant MC is rare and can be seen either in patients on immunosuppressive therapy or in those with diseases that can cause immunosuppression, such as human immunodeficiency virus, leukemia, atopic dermatitis, Wiskott-Aldrich syndrome, and sarcoidosis. In these instances, MC often is greater than 1 cm in diameter. Atypical variants may have an eczematous presentation or a lesion with secondary abscess formation and also can be spread widely over the body.² Due to these atypical appearances and large dimensions in immunocompromised patients, other dermatologic diseases should be considered in the differential diagnosis, such as basal cell carcinoma, keratoacanthoma, squamous cell carcinoma, cutaneous horn, cutaneous cryptococcosis, histoplasmosis, and xanthomatosis.³

In our patient, the differential diagnosis included keratoacanthoma, which may present as a solitary, discrete, round to oval, flesh-colored, umbilicated nodule with a central keratin-filled crater and has a rapid clinical evolution, usually regressing within 4 to 6 months.

Squamous cell carcinoma may appear as scaly red patches, open sores, warts, or elevated growths with a central depression and may crust or bleed. Basal cell carcinoma typically may appear as a dome-shaped skin nodule with visible blood vessels or sometimes presents as a red patch similar to eczema. Xanthomatosis often appears as yellow to orange, mostly asymptomatic, supple patches or plaques, usually with sharp and distinctive edges.

Ancillary diagnostic modalities such as dermoscopy may be used to improve diagnostic accuracy. The best known capillaroscopic feature of MC is the peripheral crown of vessels in a radial distribution. A study of 258 MC lesions highlighted that crown and crown plus radial arrangements are the most common vascular structure patterns under dermoscopy. In addition, polylobular amorphous white structures in the center of the lesions tend to be a feature of larger MC papules.⁴ Histologically, MC shows lobulated crateriform lesions, thickening of the epidermis into the dermis, and the typical appearance of large eosinophilic intracytoplasmic inclusion bodies within keratinocytes.⁵

There are several treatment options available for MC. Common modalities include liquid nitrogen cryospray, curettage, and electrocauterization. In immunocompromised patients, MC lesions usually are resistant to ordinary therapy. The efficacy of topical agents such as imiquimod, which can induce high levels of IFN-α and other cytokines, has been demonstrated in these patients.⁶ Cidofovir, a nucleoside analog that has potent antiviral properties, also can be included as a therapeutic option.³ Our patient’s largest MC lesion was treated with surgical excision, the 2 large lesions on the left side of the chest with cryotherapy, and the other small lesions with curettage.

Dermoscopy showed polylobular, whitish yellow, amorphous structures at the center of the lesion surrounded by a crown of vessels (Figure 1). Histopathology revealed hyperplastic crateriform lesions containing large eosinophilic intracytoplasmic inclusion bodies within keratinocytes (Figure 2). At follow-up 2 weeks after the biopsy, the patient presented with approximately 20 more reddish papules of varying sizes on the abdomen and back that presented as dome-shaped papules and had a typical umbilicated center. The clinical manifestations, dermoscopy, and pathology findings were consistent with molluscum contagiosum (MC).

Molluscum contagiosum was first described in 1814. It is a benign cutaneous infectious disease caused by a double-stranded DNA virus of the poxvirus family. Molluscum contagiosum lesions usually manifest clinically as dome-shaped, flesh-colored or translucent, umbilicated papules measuring 1 to 5 mm in diameter that are commonly distributed over the face, trunk, and extremities and usually are self-limiting.¹

Giant MC is rare and can be seen either in patients on immunosuppressive therapy or in those with diseases that can cause immunosuppression, such as human immunodeficiency virus, leukemia, atopic dermatitis, Wiskott-Aldrich syndrome, and sarcoidosis. In these instances, MC often is greater than 1 cm in diameter. Atypical variants may have an eczematous presentation or a lesion with secondary abscess formation and also can be spread widely over the body.² Due to these atypical appearances and large dimensions in immunocompromised patients, other dermatologic diseases should be considered in the differential diagnosis, such as basal cell carcinoma, keratoacanthoma, squamous cell carcinoma, cutaneous horn, cutaneous cryptococcosis, histoplasmosis, and xanthomatosis.³

In our patient, the differential diagnosis included keratoacanthoma, which may present as a solitary, discrete, round to oval, flesh-colored, umbilicated nodule with a central keratin-filled crater and has a rapid clinical evolution, usually regressing within 4 to 6 months.

Squamous cell carcinoma may appear as scaly red patches, open sores, warts, or elevated growths with a central depression and may crust or bleed. Basal cell carcinoma typically may appear as a dome-shaped skin nodule with visible blood vessels or sometimes presents as a red patch similar to eczema. Xanthomatosis often appears as yellow to orange, mostly asymptomatic, supple patches or plaques, usually with sharp and distinctive edges.

Ancillary diagnostic modalities such as dermoscopy may be used to improve diagnostic accuracy. The best known capillaroscopic feature of MC is the peripheral crown of vessels in a radial distribution. A study of 258 MC lesions highlighted that crown and crown plus radial arrangements are the most common vascular structure patterns under dermoscopy. In addition, polylobular amorphous white structures in the center of the lesions tend to be a feature of larger MC papules.⁴ Histologically, MC shows lobulated crateriform lesions, thickening of the epidermis into the dermis, and the typical appearance of large eosinophilic intracytoplasmic inclusion bodies within keratinocytes.⁵

There are several treatment options available for MC. Common modalities include liquid nitrogen cryospray, curettage, and electrocauterization. In immunocompromised patients, MC lesions usually are resistant to ordinary therapy. The efficacy of topical agents such as imiquimod, which can induce high levels of IFN-α and other cytokines, has been demonstrated in these patients.⁶ Cidofovir, a nucleoside analog that has potent antiviral properties, also can be included as a therapeutic option.³ Our patient’s largest MC lesion was treated with surgical excision, the 2 large lesions on the left side of the chest with cryotherapy, and the other small lesions with curettage.

Dermoscopy showed polylobular, whitish yellow, amorphous structures at the center of the lesion surrounded by a crown of vessels (Figure 1). Histopathology revealed hyperplastic crateriform lesions containing large eosinophilic intracytoplasmic inclusion bodies within keratinocytes (Figure 2). At follow-up 2 weeks after the biopsy, the patient presented with approximately 20 more reddish papules of varying sizes on the abdomen and back that presented as dome-shaped papules and had a typical umbilicated center. The clinical manifestations, dermoscopy, and pathology findings were consistent with molluscum contagiosum (MC).

Molluscum contagiosum was first described in 1814. It is a benign cutaneous infectious disease caused by a double-stranded DNA virus of the poxvirus family. Molluscum contagiosum lesions usually manifest clinically as dome-shaped, flesh-colored or translucent, umbilicated papules measuring 1 to 5 mm in diameter that are commonly distributed over the face, trunk, and extremities and usually are self-limiting.¹

Giant MC is rare and can be seen either in patients on immunosuppressive therapy or in those with diseases that can cause immunosuppression, such as human immunodeficiency virus, leukemia, atopic dermatitis, Wiskott-Aldrich syndrome, and sarcoidosis. In these instances, MC often is greater than 1 cm in diameter. Atypical variants may have an eczematous presentation or a lesion with secondary abscess formation and also can be spread widely over the body.² Due to these atypical appearances and large dimensions in immunocompromised patients, other dermatologic diseases should be considered in the differential diagnosis, such as basal cell carcinoma, keratoacanthoma, squamous cell carcinoma, cutaneous horn, cutaneous cryptococcosis, histoplasmosis, and xanthomatosis.³

In our patient, the differential diagnosis included keratoacanthoma, which may present as a solitary, discrete, round to oval, flesh-colored, umbilicated nodule with a central keratin-filled crater and has a rapid clinical evolution, usually regressing within 4 to 6 months.

Squamous cell carcinoma may appear as scaly red patches, open sores, warts, or elevated growths with a central depression and may crust or bleed. Basal cell carcinoma typically may appear as a dome-shaped skin nodule with visible blood vessels or sometimes presents as a red patch similar to eczema. Xanthomatosis often appears as yellow to orange, mostly asymptomatic, supple patches or plaques, usually with sharp and distinctive edges.

Ancillary diagnostic modalities such as dermoscopy may be used to improve diagnostic accuracy. The best known capillaroscopic feature of MC is the peripheral crown of vessels in a radial distribution. A study of 258 MC lesions highlighted that crown and crown plus radial arrangements are the most common vascular structure patterns under dermoscopy. In addition, polylobular amorphous white structures in the center of the lesions tend to be a feature of larger MC papules.⁴ Histologically, MC shows lobulated crateriform lesions, thickening of the epidermis into the dermis, and the typical appearance of large eosinophilic intracytoplasmic inclusion bodies within keratinocytes.⁵

There are several treatment options available for MC. Common modalities include liquid nitrogen cryospray, curettage, and electrocauterization. In immunocompromised patients, MC lesions usually are resistant to ordinary therapy. The efficacy of topical agents such as imiquimod, which can induce high levels of IFN-α and other cytokines, has been demonstrated in these patients.⁶ Cidofovir, a nucleoside analog that has potent antiviral properties, also can be included as a therapeutic option.³ Our patient’s largest MC lesion was treated with surgical excision, the 2 large lesions on the left side of the chest with cryotherapy, and the other small lesions with curettage.

Since 2012, when the Centers for Medicare & Medicaid Services (CMS) began linking financial penalties to hospitals with excessive readmissions for adult patients, researchers have questioned the extent to which pediatric readmissions can be used as a reliable quality measure. Compared with readmissions among adult patients, readmissions among pediatric patients are relatively uncommon. Furthermore, few (approximately 2%) qualify as potentially preventable, and pediatric readmission rates remain largely unchanged despite targeted attempts to prevent reutilization.^1,2 Nonetheless, state Medicaid agencies have continued to reduce reimbursement for hospitals based on available readmissions metrics, most commonly the Potentially Preventable Readmissions (PPR) algorithm.¹

In this issue of the Journal of Hospital Medicine, Auger et al³ performed a retrospective study to explore four existing metrics of pediatric hospital readmissions for their ability to identify preventable and unplanned readmissions. Investigators examined 30-day readmissions (n = 1,125) from 2014-2016 across multiple subspecialties, and classified readmissions by their preventability and unplanned status with use of a validated chart abstraction tool. Using the results of chart abstraction as the gold standard, investigators calculated the sensitivity and specificity, as well as estimated the positive and negative predictive values, of each readmissions metric. Auger and colleagues found that none of the four readmissions metrics could reliably assess preventability, and that only one metric reliably predicted unplanned hospital readmissions. Specifically, the commonly used PPR algorithm was estimated to have a positive predictive value of 13.0%-35.5% across a prevalence range of 10%-30%. This means that in a hospital where 10% of readmissions are truly preventable, the PPR will be wrong approximately 87% of the time. Tying payments to this metric is difficult to justify.

The authors highlighted the policy implications of the PPR falling short in its ability to identify preventable and unplanned pediatric readmissions. A good quality measure should be consistently reliable, and neither the PPR nor other measures studied meets this benchmark. Yet the findings lead to a broader conclusion: if most pediatric readmissions are not preventable, if there is no reliable way of measuring preventability, and if we have not demonstrated the ability to change patient trajectories away from reutilization, then perhaps the sun has set on using readmissions as a comprehensive quality measure for hospital-based care.

So how, then, should the hospital-to-home transition be evaluated? The paradigm of pediatric value of care is shifting to incorporate family-centered perspectives into consideration of quality measures.² There has to be a balance between healthcare costs and outcomes that affect families; measures should take into account issues such as patient and caregiver anxiety and time away from work.² Moreover, because social determinants of health and medical complexity strongly influence readmission rates,^4,5 focus should be placed on redirecting resources toward patients and families with significant medical, social, and financial needs as they transition home from the hospital. While measures of healthcare equity are currently lacking, the overall quality and equity of pediatric care transitions could be enhanced by looking beyond the narrow lens of readmission rates to incorporate actual needs assessments of families.

In summary, Auger and colleagues identified deficits in existing readmission metrics—but creating a solution that is meaningful to all stakeholders will be more complex than simply identifying a better metric. Family-centered quality metrics show promise in creating value in pediatric care within an equitable health system, but long-term evaluation of these metrics is necessary.

The authors have nothing to disclose.

Since 2012, when the Centers for Medicare & Medicaid Services (CMS) began linking financial penalties to hospitals with excessive readmissions for adult patients, researchers have questioned the extent to which pediatric readmissions can be used as a reliable quality measure. Compared with readmissions among adult patients, readmissions among pediatric patients are relatively uncommon. Furthermore, few (approximately 2%) qualify as potentially preventable, and pediatric readmission rates remain largely unchanged despite targeted attempts to prevent reutilization.^1,2 Nonetheless, state Medicaid agencies have continued to reduce reimbursement for hospitals based on available readmissions metrics, most commonly the Potentially Preventable Readmissions (PPR) algorithm.¹

In this issue of the Journal of Hospital Medicine, Auger et al³ performed a retrospective study to explore four existing metrics of pediatric hospital readmissions for their ability to identify preventable and unplanned readmissions. Investigators examined 30-day readmissions (n = 1,125) from 2014-2016 across multiple subspecialties, and classified readmissions by their preventability and unplanned status with use of a validated chart abstraction tool. Using the results of chart abstraction as the gold standard, investigators calculated the sensitivity and specificity, as well as estimated the positive and negative predictive values, of each readmissions metric. Auger and colleagues found that none of the four readmissions metrics could reliably assess preventability, and that only one metric reliably predicted unplanned hospital readmissions. Specifically, the commonly used PPR algorithm was estimated to have a positive predictive value of 13.0%-35.5% across a prevalence range of 10%-30%. This means that in a hospital where 10% of readmissions are truly preventable, the PPR will be wrong approximately 87% of the time. Tying payments to this metric is difficult to justify.

The authors highlighted the policy implications of the PPR falling short in its ability to identify preventable and unplanned pediatric readmissions. A good quality measure should be consistently reliable, and neither the PPR nor other measures studied meets this benchmark. Yet the findings lead to a broader conclusion: if most pediatric readmissions are not preventable, if there is no reliable way of measuring preventability, and if we have not demonstrated the ability to change patient trajectories away from reutilization, then perhaps the sun has set on using readmissions as a comprehensive quality measure for hospital-based care.

So how, then, should the hospital-to-home transition be evaluated? The paradigm of pediatric value of care is shifting to incorporate family-centered perspectives into consideration of quality measures.² There has to be a balance between healthcare costs and outcomes that affect families; measures should take into account issues such as patient and caregiver anxiety and time away from work.² Moreover, because social determinants of health and medical complexity strongly influence readmission rates,^4,5 focus should be placed on redirecting resources toward patients and families with significant medical, social, and financial needs as they transition home from the hospital. While measures of healthcare equity are currently lacking, the overall quality and equity of pediatric care transitions could be enhanced by looking beyond the narrow lens of readmission rates to incorporate actual needs assessments of families.

In summary, Auger and colleagues identified deficits in existing readmission metrics—but creating a solution that is meaningful to all stakeholders will be more complex than simply identifying a better metric. Family-centered quality metrics show promise in creating value in pediatric care within an equitable health system, but long-term evaluation of these metrics is necessary.

The authors have nothing to disclose.

Since 2012, when the Centers for Medicare & Medicaid Services (CMS) began linking financial penalties to hospitals with excessive readmissions for adult patients, researchers have questioned the extent to which pediatric readmissions can be used as a reliable quality measure. Compared with readmissions among adult patients, readmissions among pediatric patients are relatively uncommon. Furthermore, few (approximately 2%) qualify as potentially preventable, and pediatric readmission rates remain largely unchanged despite targeted attempts to prevent reutilization.^1,2 Nonetheless, state Medicaid agencies have continued to reduce reimbursement for hospitals based on available readmissions metrics, most commonly the Potentially Preventable Readmissions (PPR) algorithm.¹

In this issue of the Journal of Hospital Medicine, Auger et al³ performed a retrospective study to explore four existing metrics of pediatric hospital readmissions for their ability to identify preventable and unplanned readmissions. Investigators examined 30-day readmissions (n = 1,125) from 2014-2016 across multiple subspecialties, and classified readmissions by their preventability and unplanned status with use of a validated chart abstraction tool. Using the results of chart abstraction as the gold standard, investigators calculated the sensitivity and specificity, as well as estimated the positive and negative predictive values, of each readmissions metric. Auger and colleagues found that none of the four readmissions metrics could reliably assess preventability, and that only one metric reliably predicted unplanned hospital readmissions. Specifically, the commonly used PPR algorithm was estimated to have a positive predictive value of 13.0%-35.5% across a prevalence range of 10%-30%. This means that in a hospital where 10% of readmissions are truly preventable, the PPR will be wrong approximately 87% of the time. Tying payments to this metric is difficult to justify.

The authors highlighted the policy implications of the PPR falling short in its ability to identify preventable and unplanned pediatric readmissions. A good quality measure should be consistently reliable, and neither the PPR nor other measures studied meets this benchmark. Yet the findings lead to a broader conclusion: if most pediatric readmissions are not preventable, if there is no reliable way of measuring preventability, and if we have not demonstrated the ability to change patient trajectories away from reutilization, then perhaps the sun has set on using readmissions as a comprehensive quality measure for hospital-based care.

So how, then, should the hospital-to-home transition be evaluated? The paradigm of pediatric value of care is shifting to incorporate family-centered perspectives into consideration of quality measures.² There has to be a balance between healthcare costs and outcomes that affect families; measures should take into account issues such as patient and caregiver anxiety and time away from work.² Moreover, because social determinants of health and medical complexity strongly influence readmission rates,^4,5 focus should be placed on redirecting resources toward patients and families with significant medical, social, and financial needs as they transition home from the hospital. While measures of healthcare equity are currently lacking, the overall quality and equity of pediatric care transitions could be enhanced by looking beyond the narrow lens of readmission rates to incorporate actual needs assessments of families.

In summary, Auger and colleagues identified deficits in existing readmission metrics—but creating a solution that is meaningful to all stakeholders will be more complex than simply identifying a better metric. Family-centered quality metrics show promise in creating value in pediatric care within an equitable health system, but long-term evaluation of these metrics is necessary.

The authors have nothing to disclose.

In this edition of the Journal of Hospital Medicine, Fenster and colleagues evaluate the trend of postdischarge intravenous (IV) antibiotic therapy for children with osteomyelitis, complicated pneumonia, and complicated appendicitis.¹ Children requiring prolonged antibiotic therapy were historically discharged home with a peripherally inserted central catheter (PICC) for IV antibiotics. Recent studies suggest that treatment failure occurs uncommonly, and that oral antibiotics are as effective as those administered intravenously.^2-4 Oral antibiotics also avoid the additional risk of PICC-related complications, such as line malfunction, infections, and thrombi, which all lead to increased re-visits to hospital.

New research seldom leads to rapid change in clinical practice.⁵ This is particularly the case when new evidence favors the abandonment of accepted medical practices or supports the deimplementation of low-value care. The mounting body of evidence suggests that postdischarge IV antibiotic therapy is low-value care for children with osteomyelitis, complicated pneumonia, and complicated appendicitis, and that overuse is associated with unnecessary harm. Fenster and colleagues sought to evaluate the extent to which the management of these conditions has changed over time in the United States. They conducted a retrospective cohort study of children discharged from hospitals contributing data to the Pediatric Health Information System (PHIS) database. Validated algorithms using discharge diagnosis and procedure codes were used to identify children with the three conditions who were discharged home with IV antibiotic therapy.

Between January 2000 and December 2018 and across 52 hospitals, there were 24,753 hospitalizations for osteomyelitis, 13,700 for complicated pneumonia, and 60,575 for complicated appendicitis. Rates of postdischarge IV antibiotic therapy decreased over time for all conditions, from 61% to 22% for osteomyelitis, from 29% to 19% for complicated pneumonia, and from 13% to 2% for complicated appendicitis. Rather than a gradual reduction over time, the authors used piecewise linear regression to identify an inflection point when the decrease started: the inflection points for all three occurred around 2009 or 2010. Despite the observed decrease over time, there was significant variation in practice patterns among hospitals in 2018. For example, while the median rate of postdischarge IV antibiotic therapy for osteomyelitis was 18%, the interquartile ranged from 9% to 40%.

The authors conducted several sensitivity analyses, with the exclusion of hospitals that provided data only for certain years, which supported the robustness of the findings. Yet there are important limitations, most notably the lack of data on outcomes related to overuse and efficiency: type of antibiotics used (narrow vs broad spectrum) and total duration of antibiotics or variation in length of stay. The validated algorithms were also based on older ICD-9 codes and may perform less well with ICD-10 or from 2015 onwards. Lastly, the findings are limited to children’s hospitals and may not apply to general hospitals that care for many children.

The authors suggest that the deimplementation of postdischarge IV antibiotic therapy for the three conditions occurred spontaneously. Yet it is worth considering the different levels of agents of change that may have influenced these observations, such as research evidence, national condition guidelines, national efforts at reducing overuse and improving safety, local hospital efforts, and shared decision-making.

Postdischarge antibiotic therapy options for osteomyelitis, complicated pneumonia, and complicated appendicitis are supported by weak research evidence. Oral and parenteral therapy are equally effective but based on observational data; a randomized controlled trial is unlikely to ever be conducted because of uncommon outcomes, such as treatment failures. For these scenarios, greater emphasis should be placed on factors other than effectiveness, such as harms, availability of alternative options, and cost.⁶ For postdischarge IV antibiotic therapy, one potential explanation for the observed deimplementation is the greater awareness of harm, with up to 20% of cases with IV antibiotics requiring PICC removal.⁷ There is also a readily available alternative (oral antibiotics) with a favorable cost and effectiveness profile.

National condition guidelines advocating early transition to oral antibiotic therapy began to appear before and during the observed inflection point of 2009 and 2010. The 2002 British Thoracic Society guidelines for community-acquired pneumonia suggested considering oral agents after clear evidence of improvement,⁸ and the 2010 Infectious Diseases Society of America guidelines recommended oral antibiotic options for children discharged home with intra-abdominal infections.⁹ A systematic review published in 2002 also questioned the need for prolonged IV antibiotic therapy compared with early transition to oral agents in osteomyelitis.¹⁰ While no targeted national interventions to drive practice change existed, widespread national efforts at reducing overuse (eg, Choosing Wisely^®) and improving safety (eg, reducing central line complications) have increased in the past decade.¹¹

An important agent of change that Fenster and colleagues were not able to tease out was the impact of local hospital level efforts. In parallel to national efforts, there has likely been targeted hospital-level interventions that are disease specific (eg, order sets, pathways/guidelines, shared–decision-making tools) or focused on reducing adverse events (eg, reducing inappropriate PICC use). For example, between 2010 and 2012, one US children’s hospital increased the number of children with osteomyelitis discharged on oral antibiotics from a median of 0% to 100% with a bundle of quality improvement interventions, including standardized treatment protocols and shared decision-making.¹²

Despite the encouraging results, up to 22% of children were discharged from hospitals with postdischarge IV antibiotic therapy, and significant variation persists in 2018. Evidence of harm or even strong recommendations to change practice are themselves inadequate for behavior change.¹³ While it is clear that some element of deimplementation may have occurred organically over the past two decades, it is time for concerted deimplementation strategies that focus on practitioners or hospitals with “entrenched practices.”⁶

Dr Gill has received grant funding from the Canadian Paediatric Society, the Hospital for Sick Children, and the Canadian Institutes of Health Research (CIHR) in the past 5 years. He is on editorial board of BMJ Evidence-Based Medicine (EBM) and on the Institute Advisory Board for the CIHR Institute of Human Development and Child and Youth Health (IHDCYH), for which he has expenses reimbursed to attend meetings. He is a member of the EBMLive steering committee, and he has expenses reimbursed to attend the conference. Dr Mahant has received grant funding from CIHR in the past 5 years and is a Senior Deputy Editor of Journal of Hospital Medicine. The authors reported no conflicts of interest or financial relationships relevant to this manuscript.

In this edition of the Journal of Hospital Medicine, Fenster and colleagues evaluate the trend of postdischarge intravenous (IV) antibiotic therapy for children with osteomyelitis, complicated pneumonia, and complicated appendicitis.¹ Children requiring prolonged antibiotic therapy were historically discharged home with a peripherally inserted central catheter (PICC) for IV antibiotics. Recent studies suggest that treatment failure occurs uncommonly, and that oral antibiotics are as effective as those administered intravenously.^2-4 Oral antibiotics also avoid the additional risk of PICC-related complications, such as line malfunction, infections, and thrombi, which all lead to increased re-visits to hospital.

New research seldom leads to rapid change in clinical practice.⁵ This is particularly the case when new evidence favors the abandonment of accepted medical practices or supports the deimplementation of low-value care. The mounting body of evidence suggests that postdischarge IV antibiotic therapy is low-value care for children with osteomyelitis, complicated pneumonia, and complicated appendicitis, and that overuse is associated with unnecessary harm. Fenster and colleagues sought to evaluate the extent to which the management of these conditions has changed over time in the United States. They conducted a retrospective cohort study of children discharged from hospitals contributing data to the Pediatric Health Information System (PHIS) database. Validated algorithms using discharge diagnosis and procedure codes were used to identify children with the three conditions who were discharged home with IV antibiotic therapy.

Between January 2000 and December 2018 and across 52 hospitals, there were 24,753 hospitalizations for osteomyelitis, 13,700 for complicated pneumonia, and 60,575 for complicated appendicitis. Rates of postdischarge IV antibiotic therapy decreased over time for all conditions, from 61% to 22% for osteomyelitis, from 29% to 19% for complicated pneumonia, and from 13% to 2% for complicated appendicitis. Rather than a gradual reduction over time, the authors used piecewise linear regression to identify an inflection point when the decrease started: the inflection points for all three occurred around 2009 or 2010. Despite the observed decrease over time, there was significant variation in practice patterns among hospitals in 2018. For example, while the median rate of postdischarge IV antibiotic therapy for osteomyelitis was 18%, the interquartile ranged from 9% to 40%.

The authors conducted several sensitivity analyses, with the exclusion of hospitals that provided data only for certain years, which supported the robustness of the findings. Yet there are important limitations, most notably the lack of data on outcomes related to overuse and efficiency: type of antibiotics used (narrow vs broad spectrum) and total duration of antibiotics or variation in length of stay. The validated algorithms were also based on older ICD-9 codes and may perform less well with ICD-10 or from 2015 onwards. Lastly, the findings are limited to children’s hospitals and may not apply to general hospitals that care for many children.

The authors suggest that the deimplementation of postdischarge IV antibiotic therapy for the three conditions occurred spontaneously. Yet it is worth considering the different levels of agents of change that may have influenced these observations, such as research evidence, national condition guidelines, national efforts at reducing overuse and improving safety, local hospital efforts, and shared decision-making.

Postdischarge antibiotic therapy options for osteomyelitis, complicated pneumonia, and complicated appendicitis are supported by weak research evidence. Oral and parenteral therapy are equally effective but based on observational data; a randomized controlled trial is unlikely to ever be conducted because of uncommon outcomes, such as treatment failures. For these scenarios, greater emphasis should be placed on factors other than effectiveness, such as harms, availability of alternative options, and cost.⁶ For postdischarge IV antibiotic therapy, one potential explanation for the observed deimplementation is the greater awareness of harm, with up to 20% of cases with IV antibiotics requiring PICC removal.⁷ There is also a readily available alternative (oral antibiotics) with a favorable cost and effectiveness profile.

National condition guidelines advocating early transition to oral antibiotic therapy began to appear before and during the observed inflection point of 2009 and 2010. The 2002 British Thoracic Society guidelines for community-acquired pneumonia suggested considering oral agents after clear evidence of improvement,⁸ and the 2010 Infectious Diseases Society of America guidelines recommended oral antibiotic options for children discharged home with intra-abdominal infections.⁹ A systematic review published in 2002 also questioned the need for prolonged IV antibiotic therapy compared with early transition to oral agents in osteomyelitis.¹⁰ While no targeted national interventions to drive practice change existed, widespread national efforts at reducing overuse (eg, Choosing Wisely^®) and improving safety (eg, reducing central line complications) have increased in the past decade.¹¹

An important agent of change that Fenster and colleagues were not able to tease out was the impact of local hospital level efforts. In parallel to national efforts, there has likely been targeted hospital-level interventions that are disease specific (eg, order sets, pathways/guidelines, shared–decision-making tools) or focused on reducing adverse events (eg, reducing inappropriate PICC use). For example, between 2010 and 2012, one US children’s hospital increased the number of children with osteomyelitis discharged on oral antibiotics from a median of 0% to 100% with a bundle of quality improvement interventions, including standardized treatment protocols and shared decision-making.¹²

Despite the encouraging results, up to 22% of children were discharged from hospitals with postdischarge IV antibiotic therapy, and significant variation persists in 2018. Evidence of harm or even strong recommendations to change practice are themselves inadequate for behavior change.¹³ While it is clear that some element of deimplementation may have occurred organically over the past two decades, it is time for concerted deimplementation strategies that focus on practitioners or hospitals with “entrenched practices.”⁶

Dr Gill has received grant funding from the Canadian Paediatric Society, the Hospital for Sick Children, and the Canadian Institutes of Health Research (CIHR) in the past 5 years. He is on editorial board of BMJ Evidence-Based Medicine (EBM) and on the Institute Advisory Board for the CIHR Institute of Human Development and Child and Youth Health (IHDCYH), for which he has expenses reimbursed to attend meetings. He is a member of the EBMLive steering committee, and he has expenses reimbursed to attend the conference. Dr Mahant has received grant funding from CIHR in the past 5 years and is a Senior Deputy Editor of Journal of Hospital Medicine. The authors reported no conflicts of interest or financial relationships relevant to this manuscript.

In this edition of the Journal of Hospital Medicine, Fenster and colleagues evaluate the trend of postdischarge intravenous (IV) antibiotic therapy for children with osteomyelitis, complicated pneumonia, and complicated appendicitis.¹ Children requiring prolonged antibiotic therapy were historically discharged home with a peripherally inserted central catheter (PICC) for IV antibiotics. Recent studies suggest that treatment failure occurs uncommonly, and that oral antibiotics are as effective as those administered intravenously.^2-4 Oral antibiotics also avoid the additional risk of PICC-related complications, such as line malfunction, infections, and thrombi, which all lead to increased re-visits to hospital.

New research seldom leads to rapid change in clinical practice.⁵ This is particularly the case when new evidence favors the abandonment of accepted medical practices or supports the deimplementation of low-value care. The mounting body of evidence suggests that postdischarge IV antibiotic therapy is low-value care for children with osteomyelitis, complicated pneumonia, and complicated appendicitis, and that overuse is associated with unnecessary harm. Fenster and colleagues sought to evaluate the extent to which the management of these conditions has changed over time in the United States. They conducted a retrospective cohort study of children discharged from hospitals contributing data to the Pediatric Health Information System (PHIS) database. Validated algorithms using discharge diagnosis and procedure codes were used to identify children with the three conditions who were discharged home with IV antibiotic therapy.

Between January 2000 and December 2018 and across 52 hospitals, there were 24,753 hospitalizations for osteomyelitis, 13,700 for complicated pneumonia, and 60,575 for complicated appendicitis. Rates of postdischarge IV antibiotic therapy decreased over time for all conditions, from 61% to 22% for osteomyelitis, from 29% to 19% for complicated pneumonia, and from 13% to 2% for complicated appendicitis. Rather than a gradual reduction over time, the authors used piecewise linear regression to identify an inflection point when the decrease started: the inflection points for all three occurred around 2009 or 2010. Despite the observed decrease over time, there was significant variation in practice patterns among hospitals in 2018. For example, while the median rate of postdischarge IV antibiotic therapy for osteomyelitis was 18%, the interquartile ranged from 9% to 40%.

The authors conducted several sensitivity analyses, with the exclusion of hospitals that provided data only for certain years, which supported the robustness of the findings. Yet there are important limitations, most notably the lack of data on outcomes related to overuse and efficiency: type of antibiotics used (narrow vs broad spectrum) and total duration of antibiotics or variation in length of stay. The validated algorithms were also based on older ICD-9 codes and may perform less well with ICD-10 or from 2015 onwards. Lastly, the findings are limited to children’s hospitals and may not apply to general hospitals that care for many children.

The authors suggest that the deimplementation of postdischarge IV antibiotic therapy for the three conditions occurred spontaneously. Yet it is worth considering the different levels of agents of change that may have influenced these observations, such as research evidence, national condition guidelines, national efforts at reducing overuse and improving safety, local hospital efforts, and shared decision-making.

Postdischarge antibiotic therapy options for osteomyelitis, complicated pneumonia, and complicated appendicitis are supported by weak research evidence. Oral and parenteral therapy are equally effective but based on observational data; a randomized controlled trial is unlikely to ever be conducted because of uncommon outcomes, such as treatment failures. For these scenarios, greater emphasis should be placed on factors other than effectiveness, such as harms, availability of alternative options, and cost.⁶ For postdischarge IV antibiotic therapy, one potential explanation for the observed deimplementation is the greater awareness of harm, with up to 20% of cases with IV antibiotics requiring PICC removal.⁷ There is also a readily available alternative (oral antibiotics) with a favorable cost and effectiveness profile.

National condition guidelines advocating early transition to oral antibiotic therapy began to appear before and during the observed inflection point of 2009 and 2010. The 2002 British Thoracic Society guidelines for community-acquired pneumonia suggested considering oral agents after clear evidence of improvement,⁸ and the 2010 Infectious Diseases Society of America guidelines recommended oral antibiotic options for children discharged home with intra-abdominal infections.⁹ A systematic review published in 2002 also questioned the need for prolonged IV antibiotic therapy compared with early transition to oral agents in osteomyelitis.¹⁰ While no targeted national interventions to drive practice change existed, widespread national efforts at reducing overuse (eg, Choosing Wisely^®) and improving safety (eg, reducing central line complications) have increased in the past decade.¹¹

An important agent of change that Fenster and colleagues were not able to tease out was the impact of local hospital level efforts. In parallel to national efforts, there has likely been targeted hospital-level interventions that are disease specific (eg, order sets, pathways/guidelines, shared–decision-making tools) or focused on reducing adverse events (eg, reducing inappropriate PICC use). For example, between 2010 and 2012, one US children’s hospital increased the number of children with osteomyelitis discharged on oral antibiotics from a median of 0% to 100% with a bundle of quality improvement interventions, including standardized treatment protocols and shared decision-making.¹²

Despite the encouraging results, up to 22% of children were discharged from hospitals with postdischarge IV antibiotic therapy, and significant variation persists in 2018. Evidence of harm or even strong recommendations to change practice are themselves inadequate for behavior change.¹³ While it is clear that some element of deimplementation may have occurred organically over the past two decades, it is time for concerted deimplementation strategies that focus on practitioners or hospitals with “entrenched practices.”⁶

Dr Gill has received grant funding from the Canadian Paediatric Society, the Hospital for Sick Children, and the Canadian Institutes of Health Research (CIHR) in the past 5 years. He is on editorial board of BMJ Evidence-Based Medicine (EBM) and on the Institute Advisory Board for the CIHR Institute of Human Development and Child and Youth Health (IHDCYH), for which he has expenses reimbursed to attend meetings. He is a member of the EBMLive steering committee, and he has expenses reimbursed to attend the conference. Dr Mahant has received grant funding from CIHR in the past 5 years and is a Senior Deputy Editor of Journal of Hospital Medicine. The authors reported no conflicts of interest or financial relationships relevant to this manuscript.

Key clinical point: Nearly one third of patients with multiple sclerosis (MS) experience migraine.

Major finding: The pooled prevalence rate of migraine was 31% (P less than .001), which significantly varied across the continents (P less than .001).

Study details: A systematic review and meta-analysis of 11 articles and 12 conference abstracts including a total of 11,372 MS cases.

Disclosures: No funding source was identified. The authors declared no conflicts of interest.

Citation: Mirmosayyeb O et al. J Clin Neuroscience. 2020 Aug 4. doi: 10.1016/j.jocn.2020.06.021.

Key clinical point: Nearly one third of patients with multiple sclerosis (MS) experience migraine.

Major finding: The pooled prevalence rate of migraine was 31% (P less than .001), which significantly varied across the continents (P less than .001).

Study details: A systematic review and meta-analysis of 11 articles and 12 conference abstracts including a total of 11,372 MS cases.

Disclosures: No funding source was identified. The authors declared no conflicts of interest.

Citation: Mirmosayyeb O et al. J Clin Neuroscience. 2020 Aug 4. doi: 10.1016/j.jocn.2020.06.021.

Key clinical point: Nearly one third of patients with multiple sclerosis (MS) experience migraine.

Major finding: The pooled prevalence rate of migraine was 31% (P less than .001), which significantly varied across the continents (P less than .001).

Study details: A systematic review and meta-analysis of 11 articles and 12 conference abstracts including a total of 11,372 MS cases.

Disclosures: No funding source was identified. The authors declared no conflicts of interest.

Citation: Mirmosayyeb O et al. J Clin Neuroscience. 2020 Aug 4. doi: 10.1016/j.jocn.2020.06.021.

“Time is the coin of your life. It is the only coin you have, and only you can determine how it will be spent. Be careful lest you let other people spend it for you.”

—Carl Sandburg

No one went into the practice of medicine to check off boxes. Clinicians find joy and purpose by connecting with patients and interacting with colleagues. Unfortunately, our goal of practicing in an environment that allows these experiences is threatened by extreme levels of regulatory and administrative oversight.^1,2 Decreased enjoyment and meaning in work may follow and lead to burnout, poor performance, and for some, premature departure from medicine.³ The negative effects on individuals can erode the morale and productivity of the group.

Many administrative requirements add value to clinical care. For example, interdisciplinary rounds may include a mandatory review of urinary catheters that reduces catheter-associated infections. The usefulness of some requirements, however, may promote implementation of other requirements of lesser value that interfere with the positive impact of meaningful interventions. Best Practice Alerts (BPAs) that are “clicked through” sap enthusiasm. Perfunctory monthly meetings that are informational rather than productive and exhaustive e-learning modules on institutional requirements such as “Corporate Compliance” take time away from patient care. Despite being a prominent driver of burnout, the most common approach to nuisances is nihilism. It is unrealistic for anyone with a full clinical slate to tackle pervasive irritations. Similarly, leaders may not see decreasing administrative burdens as a priority; the excitement for decreasing hassles pales relative to the excitement for developing a new vision or strategic plan.

Rather than acceptance, leaders should take proactive steps to decrease wasteful tasks. Begin by explicitly assessing the burden of tasks through dialogue with administrators, such as the chief medical officer. Administrators may not realize the impact of seemingly small requests on hospitalist workflow. For example, even adding one required question for every patient at interdisciplinary rounds can meaningfully affect the flow of rounds. Hospitalist leaders are well situated to assess the yield to burden ratio (Y/B) of any requirement. High burden tasks should be justified by substantial benefit, and tasks in which the Y/B is uncertain should be limited in scope until the value proposition is established.

The electronic medical record (EMR) deserves specific attention because it is an established source of annoyance and burnout.³ Leaders should proactively collaborate with administrators to remove EMR requirements with low Y/B. The “Get Rid of Stupid Stuff” (GROSS) program demonstrated the benefits of an innovative approach to eliminating wasteful EMR tasks.⁴ Our own institution discontinued the BPA asking clinicians to add “Chronic Kidney Disease, Stage III” to the Problem List when an assessment revealed that the Problem List was rarely updated and this BPA was frequently presented; the BPA was low yield, high burden.

Lastly, leaders should not become part of the problem. For example, a hospitalist-led quality improvement project may require documentation that a primary care physician has been contacted for each newly admitted patient. Assuming four patients and 5 minutes per call, this ask requires 20 minutes; the burden has been estimated but the yield is unknown, producing an unclear Y/B. Therefore, items generated within the group need to be vetted with the same scrutiny as external tasks.

Explicitly addressing wasteful burdens provides leaders with the opportunity to shift the emphasis from processes that distract from to initiatives that enhance patient care. Promoting a sense of meaning and purpose is an essential component of group success.⁵ Outstanding performance, productivity, and retention can only be realized through a work environment that prioritizes patients and minimizes tasks not aligned with this mission.

The authors have nothing to disclose.

“Time is the coin of your life. It is the only coin you have, and only you can determine how it will be spent. Be careful lest you let other people spend it for you.”

—Carl Sandburg

No one went into the practice of medicine to check off boxes. Clinicians find joy and purpose by connecting with patients and interacting with colleagues. Unfortunately, our goal of practicing in an environment that allows these experiences is threatened by extreme levels of regulatory and administrative oversight.^1,2 Decreased enjoyment and meaning in work may follow and lead to burnout, poor performance, and for some, premature departure from medicine.³ The negative effects on individuals can erode the morale and productivity of the group.

Many administrative requirements add value to clinical care. For example, interdisciplinary rounds may include a mandatory review of urinary catheters that reduces catheter-associated infections. The usefulness of some requirements, however, may promote implementation of other requirements of lesser value that interfere with the positive impact of meaningful interventions. Best Practice Alerts (BPAs) that are “clicked through” sap enthusiasm. Perfunctory monthly meetings that are informational rather than productive and exhaustive e-learning modules on institutional requirements such as “Corporate Compliance” take time away from patient care. Despite being a prominent driver of burnout, the most common approach to nuisances is nihilism. It is unrealistic for anyone with a full clinical slate to tackle pervasive irritations. Similarly, leaders may not see decreasing administrative burdens as a priority; the excitement for decreasing hassles pales relative to the excitement for developing a new vision or strategic plan.

Rather than acceptance, leaders should take proactive steps to decrease wasteful tasks. Begin by explicitly assessing the burden of tasks through dialogue with administrators, such as the chief medical officer. Administrators may not realize the impact of seemingly small requests on hospitalist workflow. For example, even adding one required question for every patient at interdisciplinary rounds can meaningfully affect the flow of rounds. Hospitalist leaders are well situated to assess the yield to burden ratio (Y/B) of any requirement. High burden tasks should be justified by substantial benefit, and tasks in which the Y/B is uncertain should be limited in scope until the value proposition is established.

The electronic medical record (EMR) deserves specific attention because it is an established source of annoyance and burnout.³ Leaders should proactively collaborate with administrators to remove EMR requirements with low Y/B. The “Get Rid of Stupid Stuff” (GROSS) program demonstrated the benefits of an innovative approach to eliminating wasteful EMR tasks.⁴ Our own institution discontinued the BPA asking clinicians to add “Chronic Kidney Disease, Stage III” to the Problem List when an assessment revealed that the Problem List was rarely updated and this BPA was frequently presented; the BPA was low yield, high burden.

Lastly, leaders should not become part of the problem. For example, a hospitalist-led quality improvement project may require documentation that a primary care physician has been contacted for each newly admitted patient. Assuming four patients and 5 minutes per call, this ask requires 20 minutes; the burden has been estimated but the yield is unknown, producing an unclear Y/B. Therefore, items generated within the group need to be vetted with the same scrutiny as external tasks.

Explicitly addressing wasteful burdens provides leaders with the opportunity to shift the emphasis from processes that distract from to initiatives that enhance patient care. Promoting a sense of meaning and purpose is an essential component of group success.⁵ Outstanding performance, productivity, and retention can only be realized through a work environment that prioritizes patients and minimizes tasks not aligned with this mission.

The authors have nothing to disclose.

“Time is the coin of your life. It is the only coin you have, and only you can determine how it will be spent. Be careful lest you let other people spend it for you.”

—Carl Sandburg

No one went into the practice of medicine to check off boxes. Clinicians find joy and purpose by connecting with patients and interacting with colleagues. Unfortunately, our goal of practicing in an environment that allows these experiences is threatened by extreme levels of regulatory and administrative oversight.^1,2 Decreased enjoyment and meaning in work may follow and lead to burnout, poor performance, and for some, premature departure from medicine.³ The negative effects on individuals can erode the morale and productivity of the group.

Many administrative requirements add value to clinical care. For example, interdisciplinary rounds may include a mandatory review of urinary catheters that reduces catheter-associated infections. The usefulness of some requirements, however, may promote implementation of other requirements of lesser value that interfere with the positive impact of meaningful interventions. Best Practice Alerts (BPAs) that are “clicked through” sap enthusiasm. Perfunctory monthly meetings that are informational rather than productive and exhaustive e-learning modules on institutional requirements such as “Corporate Compliance” take time away from patient care. Despite being a prominent driver of burnout, the most common approach to nuisances is nihilism. It is unrealistic for anyone with a full clinical slate to tackle pervasive irritations. Similarly, leaders may not see decreasing administrative burdens as a priority; the excitement for decreasing hassles pales relative to the excitement for developing a new vision or strategic plan.

Rather than acceptance, leaders should take proactive steps to decrease wasteful tasks. Begin by explicitly assessing the burden of tasks through dialogue with administrators, such as the chief medical officer. Administrators may not realize the impact of seemingly small requests on hospitalist workflow. For example, even adding one required question for every patient at interdisciplinary rounds can meaningfully affect the flow of rounds. Hospitalist leaders are well situated to assess the yield to burden ratio (Y/B) of any requirement. High burden tasks should be justified by substantial benefit, and tasks in which the Y/B is uncertain should be limited in scope until the value proposition is established.

The electronic medical record (EMR) deserves specific attention because it is an established source of annoyance and burnout.³ Leaders should proactively collaborate with administrators to remove EMR requirements with low Y/B. The “Get Rid of Stupid Stuff” (GROSS) program demonstrated the benefits of an innovative approach to eliminating wasteful EMR tasks.⁴ Our own institution discontinued the BPA asking clinicians to add “Chronic Kidney Disease, Stage III” to the Problem List when an assessment revealed that the Problem List was rarely updated and this BPA was frequently presented; the BPA was low yield, high burden.

Lastly, leaders should not become part of the problem. For example, a hospitalist-led quality improvement project may require documentation that a primary care physician has been contacted for each newly admitted patient. Assuming four patients and 5 minutes per call, this ask requires 20 minutes; the burden has been estimated but the yield is unknown, producing an unclear Y/B. Therefore, items generated within the group need to be vetted with the same scrutiny as external tasks.

Explicitly addressing wasteful burdens provides leaders with the opportunity to shift the emphasis from processes that distract from to initiatives that enhance patient care. Promoting a sense of meaning and purpose is an essential component of group success.⁵ Outstanding performance, productivity, and retention can only be realized through a work environment that prioritizes patients and minimizes tasks not aligned with this mission.

The authors have nothing to disclose.

Key clinical point: In patients with progressive multiple sclerosis (MS), impaired odor identification is associated with a greater clinical decline and higher risk for death.

Major finding: Impaired Brief-Smell Identification (B-SIT) was associated with higher risk for death (adjusted hazard ratio [aHR], 14.9; P less than .001). Among patients with progressive MS, impaired B-SIT vs normal B-SIT showed greater clinical change per month in terms of Multiple Sclerosis Severity scores (median, 0.62 vs. –0.08; P =.004) and Age-Related Multiple Sclerosis Severity scores (median, 0.54 vs. –0.07; P =.004).

Study details: Findings from a retrospective review on 149 patients with MS during a median follow-up of 121 months.

Disclosures: No funding source was identified. The authors declared no conflicts of interest.

Citation: da Silva AM et al. Mult Scler Relat Disord. 2020 Sep 3. doi: 10.1016/j.msard.2020.102486.

Key clinical point: In patients with progressive multiple sclerosis (MS), impaired odor identification is associated with a greater clinical decline and higher risk for death.

Major finding: Impaired Brief-Smell Identification (B-SIT) was associated with higher risk for death (adjusted hazard ratio [aHR], 14.9; P less than .001). Among patients with progressive MS, impaired B-SIT vs normal B-SIT showed greater clinical change per month in terms of Multiple Sclerosis Severity scores (median, 0.62 vs. –0.08; P =.004) and Age-Related Multiple Sclerosis Severity scores (median, 0.54 vs. –0.07; P =.004).

Study details: Findings from a retrospective review on 149 patients with MS during a median follow-up of 121 months.

Disclosures: No funding source was identified. The authors declared no conflicts of interest.

Citation: da Silva AM et al. Mult Scler Relat Disord. 2020 Sep 3. doi: 10.1016/j.msard.2020.102486.

Key clinical point: In patients with progressive multiple sclerosis (MS), impaired odor identification is associated with a greater clinical decline and higher risk for death.

Major finding: Impaired Brief-Smell Identification (B-SIT) was associated with higher risk for death (adjusted hazard ratio [aHR], 14.9; P less than .001). Among patients with progressive MS, impaired B-SIT vs normal B-SIT showed greater clinical change per month in terms of Multiple Sclerosis Severity scores (median, 0.62 vs. –0.08; P =.004) and Age-Related Multiple Sclerosis Severity scores (median, 0.54 vs. –0.07; P =.004).

Study details: Findings from a retrospective review on 149 patients with MS during a median follow-up of 121 months.

Disclosures: No funding source was identified. The authors declared no conflicts of interest.

Citation: da Silva AM et al. Mult Scler Relat Disord. 2020 Sep 3. doi: 10.1016/j.msard.2020.102486.

Treatments in the pipeline may offer more options for rosacea sufferers, according to Linda Stein Gold, MD, director of clinical research, in the department of dermatology, Henry Ford Hospital in Detroit.

sruilk/shutterstock

In addition, topical minocycline has recently been approved by the Food and Drug Administration for the treatment of rosacea in a 1.5% foam formulation. “The reason it has taken so long to have a minocycline product is that it is challenging to deliver it topically,” she said in a presentation at MedscapeLive’s annual Las Vegas Dermatology Seminar, held virtually. Studies of higher concentrations were not significantly better for rosacea, so development of the 1.5% foam was pursued, although a 4% foam is approved for the treatment of acne.

Dr. Stein Gold shared results from a pair of 12-week randomized trials in which significantly more patients treated with topical minocycline foam showed treatment success, compared with those on vehicle, based on Investigator’s Global Assessment (IGA) scores of clear or almost clear and a decrease of at least two grades from baseline: 52.1% versus 43.0% in one study and 49.1% versus 39.0% in the second, statistically significant differences. The product also was well tolerated, with most patients reporting no side effects or mild side effects.

Research on how to maximize effectiveness of available treatments such as ivermectin is ongoing, but several new treatments in the pipeline continue to show promising results, she noted.

An up-and-coming rosacea treatment is an old product used in a new way: Benzoyl peroxide in a microencapsulated form. “Benzoyl peroxide is encased in silica molecules that allow very slow release of the benzoyl peroxide into the skin and that leads to decreased irritation,” Dr. Stein Gold explained. The deposit of active ingredient on the skin appears to stay below the level of irritation.

Dr. Stein Gold and colleagues conducted two randomized, vehicle-controlled trials in which 733 adults with moderate to severe rosacea were treated with either the encapsulated benzoyl peroxide cream formulation or a vehicle applied once daily for 12 weeks.

At 12 weeks, IGA success increased over the course of the studies, and reached 43.5% in one and 50.1% in the other, compared with 16.1% and 25.9%, respectively, for the vehicle groups in those studies (P < .001 for both). Overall, she described this as “a nice improvement for a drug that we had not considered to be part of our treatment armamentarium for our rosacea patients.”

Dr. Stein Gold also shared data from a phase 2 study of low-dose oral minocycline in adults with papulopustular rosacea. A group of 200 patients used the drug or a placebo once daily for 16 weeks. The study examined 20-mg and 40-mg extended-release formulations, and found a significant improvement with the 40-mg dose over the 20-mg dose and over placebo, in terms of those who reached an IGA of 0 or 1, with a 2 grade improvement. While this is a phase 2 study, it may lead to oral minocycline as another treatment option, she said.

“It is an exciting time for the treatment of rosacea, with a variety of options and an active pipeline, so we can aim for clear skin for our patients,” she commented.

Dr. Stein Gold disclosed serving as an investigator and consultant for Galderma, Vyne, Sun, Sol Gel, and Almirall; she is a consultant and speaker for Ortho.

MedscapeLive and this news organization are owned by the same parent company.
 

Treatments in the pipeline may offer more options for rosacea sufferers, according to Linda Stein Gold, MD, director of clinical research, in the department of dermatology, Henry Ford Hospital in Detroit.

sruilk/shutterstock

In addition, topical minocycline has recently been approved by the Food and Drug Administration for the treatment of rosacea in a 1.5% foam formulation. “The reason it has taken so long to have a minocycline product is that it is challenging to deliver it topically,” she said in a presentation at MedscapeLive’s annual Las Vegas Dermatology Seminar, held virtually. Studies of higher concentrations were not significantly better for rosacea, so development of the 1.5% foam was pursued, although a 4% foam is approved for the treatment of acne.

Dr. Stein Gold shared results from a pair of 12-week randomized trials in which significantly more patients treated with topical minocycline foam showed treatment success, compared with those on vehicle, based on Investigator’s Global Assessment (IGA) scores of clear or almost clear and a decrease of at least two grades from baseline: 52.1% versus 43.0% in one study and 49.1% versus 39.0% in the second, statistically significant differences. The product also was well tolerated, with most patients reporting no side effects or mild side effects.

Research on how to maximize effectiveness of available treatments such as ivermectin is ongoing, but several new treatments in the pipeline continue to show promising results, she noted.

An up-and-coming rosacea treatment is an old product used in a new way: Benzoyl peroxide in a microencapsulated form. “Benzoyl peroxide is encased in silica molecules that allow very slow release of the benzoyl peroxide into the skin and that leads to decreased irritation,” Dr. Stein Gold explained. The deposit of active ingredient on the skin appears to stay below the level of irritation.

Dr. Stein Gold and colleagues conducted two randomized, vehicle-controlled trials in which 733 adults with moderate to severe rosacea were treated with either the encapsulated benzoyl peroxide cream formulation or a vehicle applied once daily for 12 weeks.

At 12 weeks, IGA success increased over the course of the studies, and reached 43.5% in one and 50.1% in the other, compared with 16.1% and 25.9%, respectively, for the vehicle groups in those studies (P < .001 for both). Overall, she described this as “a nice improvement for a drug that we had not considered to be part of our treatment armamentarium for our rosacea patients.”

Dr. Stein Gold also shared data from a phase 2 study of low-dose oral minocycline in adults with papulopustular rosacea. A group of 200 patients used the drug or a placebo once daily for 16 weeks. The study examined 20-mg and 40-mg extended-release formulations, and found a significant improvement with the 40-mg dose over the 20-mg dose and over placebo, in terms of those who reached an IGA of 0 or 1, with a 2 grade improvement. While this is a phase 2 study, it may lead to oral minocycline as another treatment option, she said.

“It is an exciting time for the treatment of rosacea, with a variety of options and an active pipeline, so we can aim for clear skin for our patients,” she commented.

Dr. Stein Gold disclosed serving as an investigator and consultant for Galderma, Vyne, Sun, Sol Gel, and Almirall; she is a consultant and speaker for Ortho.

MedscapeLive and this news organization are owned by the same parent company.
 

Treatments in the pipeline may offer more options for rosacea sufferers, according to Linda Stein Gold, MD, director of clinical research, in the department of dermatology, Henry Ford Hospital in Detroit.

sruilk/shutterstock

In addition, topical minocycline has recently been approved by the Food and Drug Administration for the treatment of rosacea in a 1.5% foam formulation. “The reason it has taken so long to have a minocycline product is that it is challenging to deliver it topically,” she said in a presentation at MedscapeLive’s annual Las Vegas Dermatology Seminar, held virtually. Studies of higher concentrations were not significantly better for rosacea, so development of the 1.5% foam was pursued, although a 4% foam is approved for the treatment of acne.

Dr. Stein Gold shared results from a pair of 12-week randomized trials in which significantly more patients treated with topical minocycline foam showed treatment success, compared with those on vehicle, based on Investigator’s Global Assessment (IGA) scores of clear or almost clear and a decrease of at least two grades from baseline: 52.1% versus 43.0% in one study and 49.1% versus 39.0% in the second, statistically significant differences. The product also was well tolerated, with most patients reporting no side effects or mild side effects.

Research on how to maximize effectiveness of available treatments such as ivermectin is ongoing, but several new treatments in the pipeline continue to show promising results, she noted.

An up-and-coming rosacea treatment is an old product used in a new way: Benzoyl peroxide in a microencapsulated form. “Benzoyl peroxide is encased in silica molecules that allow very slow release of the benzoyl peroxide into the skin and that leads to decreased irritation,” Dr. Stein Gold explained. The deposit of active ingredient on the skin appears to stay below the level of irritation.

Dr. Stein Gold and colleagues conducted two randomized, vehicle-controlled trials in which 733 adults with moderate to severe rosacea were treated with either the encapsulated benzoyl peroxide cream formulation or a vehicle applied once daily for 12 weeks.

At 12 weeks, IGA success increased over the course of the studies, and reached 43.5% in one and 50.1% in the other, compared with 16.1% and 25.9%, respectively, for the vehicle groups in those studies (P < .001 for both). Overall, she described this as “a nice improvement for a drug that we had not considered to be part of our treatment armamentarium for our rosacea patients.”

Dr. Stein Gold also shared data from a phase 2 study of low-dose oral minocycline in adults with papulopustular rosacea. A group of 200 patients used the drug or a placebo once daily for 16 weeks. The study examined 20-mg and 40-mg extended-release formulations, and found a significant improvement with the 40-mg dose over the 20-mg dose and over placebo, in terms of those who reached an IGA of 0 or 1, with a 2 grade improvement. While this is a phase 2 study, it may lead to oral minocycline as another treatment option, she said.

“It is an exciting time for the treatment of rosacea, with a variety of options and an active pipeline, so we can aim for clear skin for our patients,” she commented.

Dr. Stein Gold disclosed serving as an investigator and consultant for Galderma, Vyne, Sun, Sol Gel, and Almirall; she is a consultant and speaker for Ortho.

MedscapeLive and this news organization are owned by the same parent company.