Mobile applications and other tech solutions that target the specific needs of patients with Alzheimer and their caregivers won the day in the first Eureka prize competition, sponsored by the National Institute on Aging.

The Improving Care for People with Alzheimer’s Disease and Related Dementias Using Technology (iCare-AD/ADRD) Challenge received 33 applications for mobile device applications or web-based methods to help users coordinate and navigate life with dementia. The judging was based on creativity and innovation, rationale and potential impact, value to relevant stakeholders, usability, and functionality and feasibility.

First place, with $250,000, went to MapHabit for mobile software that provides behavior prompts with customizable picture-and-keyword visual maps to help people with activities of daily living. The platform has different interfaces for users: people with impaired memory, caregiver, or long-term care community manager. Simple commands, such as “take a shower,” are scheduled, with feedback provided to caregivers. The system takes advantage of the brain’s habit (procedural) memory system, the researchers say, rather than the hippocampal (declarative) memory system that is damaged early in AD.

A team from University of California, Los Angeles, won second prize of $100,000 for their web-based Dementia Care Software system, which helps coordinate complex medical and social services. The software, which can be integrated into any of the leading electronic health record systems, has already been used in support of the UCLA Alzheimer’s and Dementia Care Program, a nurse-practitioner co-management approach that includes structured needs assessment, individualized dementia care plans, and round-the-clock access for assistance and advice. The researchers say more than 2,600 patients with dementia have participated in the program so far.  

Caregiver411, developed by researchers from North Carolina Agricultural and Technical State University, won the third-place prize of $50,000. The mobile app helps people make informed decisions by, for instance, capturing the care recipient’s stage of AD in order to provide targeted recommendations. Dementia caregivers can obtain tailored resources related to mental, emotional, physical, social, legal, and financial concerns. The app also gives them a forum for social connections and family chat groups through a messaging center.

The Eureka Challenge is part of the 21st Century Cures Act, signed into law in 2016, designed to help accelerate medical product development with innovations incorporating the perspectives of patients. More detailed project descriptions are available at www.nia.nih.gov/challenge-prize.

Mobile applications and other tech solutions that target the specific needs of patients with Alzheimer and their caregivers won the day in the first Eureka prize competition, sponsored by the National Institute on Aging.

The Improving Care for People with Alzheimer’s Disease and Related Dementias Using Technology (iCare-AD/ADRD) Challenge received 33 applications for mobile device applications or web-based methods to help users coordinate and navigate life with dementia. The judging was based on creativity and innovation, rationale and potential impact, value to relevant stakeholders, usability, and functionality and feasibility.

First place, with $250,000, went to MapHabit for mobile software that provides behavior prompts with customizable picture-and-keyword visual maps to help people with activities of daily living. The platform has different interfaces for users: people with impaired memory, caregiver, or long-term care community manager. Simple commands, such as “take a shower,” are scheduled, with feedback provided to caregivers. The system takes advantage of the brain’s habit (procedural) memory system, the researchers say, rather than the hippocampal (declarative) memory system that is damaged early in AD.

A team from University of California, Los Angeles, won second prize of $100,000 for their web-based Dementia Care Software system, which helps coordinate complex medical and social services. The software, which can be integrated into any of the leading electronic health record systems, has already been used in support of the UCLA Alzheimer’s and Dementia Care Program, a nurse-practitioner co-management approach that includes structured needs assessment, individualized dementia care plans, and round-the-clock access for assistance and advice. The researchers say more than 2,600 patients with dementia have participated in the program so far.  

Caregiver411, developed by researchers from North Carolina Agricultural and Technical State University, won the third-place prize of $50,000. The mobile app helps people make informed decisions by, for instance, capturing the care recipient’s stage of AD in order to provide targeted recommendations. Dementia caregivers can obtain tailored resources related to mental, emotional, physical, social, legal, and financial concerns. The app also gives them a forum for social connections and family chat groups through a messaging center.

The Eureka Challenge is part of the 21st Century Cures Act, signed into law in 2016, designed to help accelerate medical product development with innovations incorporating the perspectives of patients. More detailed project descriptions are available at www.nia.nih.gov/challenge-prize.

Mobile applications and other tech solutions that target the specific needs of patients with Alzheimer and their caregivers won the day in the first Eureka prize competition, sponsored by the National Institute on Aging.

The Improving Care for People with Alzheimer’s Disease and Related Dementias Using Technology (iCare-AD/ADRD) Challenge received 33 applications for mobile device applications or web-based methods to help users coordinate and navigate life with dementia. The judging was based on creativity and innovation, rationale and potential impact, value to relevant stakeholders, usability, and functionality and feasibility.

First place, with $250,000, went to MapHabit for mobile software that provides behavior prompts with customizable picture-and-keyword visual maps to help people with activities of daily living. The platform has different interfaces for users: people with impaired memory, caregiver, or long-term care community manager. Simple commands, such as “take a shower,” are scheduled, with feedback provided to caregivers. The system takes advantage of the brain’s habit (procedural) memory system, the researchers say, rather than the hippocampal (declarative) memory system that is damaged early in AD.

A team from University of California, Los Angeles, won second prize of $100,000 for their web-based Dementia Care Software system, which helps coordinate complex medical and social services. The software, which can be integrated into any of the leading electronic health record systems, has already been used in support of the UCLA Alzheimer’s and Dementia Care Program, a nurse-practitioner co-management approach that includes structured needs assessment, individualized dementia care plans, and round-the-clock access for assistance and advice. The researchers say more than 2,600 patients with dementia have participated in the program so far.  

Caregiver411, developed by researchers from North Carolina Agricultural and Technical State University, won the third-place prize of $50,000. The mobile app helps people make informed decisions by, for instance, capturing the care recipient’s stage of AD in order to provide targeted recommendations. Dementia caregivers can obtain tailored resources related to mental, emotional, physical, social, legal, and financial concerns. The app also gives them a forum for social connections and family chat groups through a messaging center.

The Eureka Challenge is part of the 21st Century Cures Act, signed into law in 2016, designed to help accelerate medical product development with innovations incorporating the perspectives of patients. More detailed project descriptions are available at www.nia.nih.gov/challenge-prize.

The FP suspected that the patient had CREST (calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias) syndrome also known as limited cutaneous systemic sclerosis (LcSSc). He examined her arms and found that she had firm nodules around the elbows consistent with calcinosis. Further history revealed Raynaud's phenomenon. This clinched the diagnosis of CREST syndrome. The FP ordered blood tests, a chest x-ray (CXR), and pulmonary function tests to determine if there was pulmonary involvement and to learn more about possible systemic effects of her disease.

Systemic sclerosis (scleroderma) is characterized by skin induration and thickening accompanied by variable tissue fibrosis and inflammatory infiltration in numerous visceral organs. Systemic sclerosis can be diffuse or limited to the skin and adjacent tissues (LcSSc). Patients with LcSSc usually have skin sclerosis that is restricted to the hands and, to a lesser extent, the face and neck.

The patient’s antinuclear antibody test was positive with a speckled nucleolar staining pattern, which is a common finding in systemic sclerosis. Her CXR showed evidence of interstitial lung disease with a ground glass pattern. Her pulmonary function test showed a diminished diffusion capacity. Pulmonary disease is seen in all types of systemic sclerosis and not diagnostic for one type. The patient was referred to Rheumatology for further diagnosis and management.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. Scleroderma and morphea. In: Usatine R, Smith M, Mayeaux EJ, et al. eds. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1204-1212.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the 3rd edition of the Color Atlas and Synopsis of Family Medicine as an app by clicking on this link: https://usatinemedia.com/app/color-atlas-of-family-medicine/

The FP suspected that the patient had CREST (calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias) syndrome also known as limited cutaneous systemic sclerosis (LcSSc). He examined her arms and found that she had firm nodules around the elbows consistent with calcinosis. Further history revealed Raynaud's phenomenon. This clinched the diagnosis of CREST syndrome. The FP ordered blood tests, a chest x-ray (CXR), and pulmonary function tests to determine if there was pulmonary involvement and to learn more about possible systemic effects of her disease.

Systemic sclerosis (scleroderma) is characterized by skin induration and thickening accompanied by variable tissue fibrosis and inflammatory infiltration in numerous visceral organs. Systemic sclerosis can be diffuse or limited to the skin and adjacent tissues (LcSSc). Patients with LcSSc usually have skin sclerosis that is restricted to the hands and, to a lesser extent, the face and neck.

The patient’s antinuclear antibody test was positive with a speckled nucleolar staining pattern, which is a common finding in systemic sclerosis. Her CXR showed evidence of interstitial lung disease with a ground glass pattern. Her pulmonary function test showed a diminished diffusion capacity. Pulmonary disease is seen in all types of systemic sclerosis and not diagnostic for one type. The patient was referred to Rheumatology for further diagnosis and management.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. Scleroderma and morphea. In: Usatine R, Smith M, Mayeaux EJ, et al. eds. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1204-1212.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the 3rd edition of the Color Atlas and Synopsis of Family Medicine as an app by clicking on this link: https://usatinemedia.com/app/color-atlas-of-family-medicine/

The FP suspected that the patient had CREST (calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias) syndrome also known as limited cutaneous systemic sclerosis (LcSSc). He examined her arms and found that she had firm nodules around the elbows consistent with calcinosis. Further history revealed Raynaud's phenomenon. This clinched the diagnosis of CREST syndrome. The FP ordered blood tests, a chest x-ray (CXR), and pulmonary function tests to determine if there was pulmonary involvement and to learn more about possible systemic effects of her disease.

Systemic sclerosis (scleroderma) is characterized by skin induration and thickening accompanied by variable tissue fibrosis and inflammatory infiltration in numerous visceral organs. Systemic sclerosis can be diffuse or limited to the skin and adjacent tissues (LcSSc). Patients with LcSSc usually have skin sclerosis that is restricted to the hands and, to a lesser extent, the face and neck.

The patient’s antinuclear antibody test was positive with a speckled nucleolar staining pattern, which is a common finding in systemic sclerosis. Her CXR showed evidence of interstitial lung disease with a ground glass pattern. Her pulmonary function test showed a diminished diffusion capacity. Pulmonary disease is seen in all types of systemic sclerosis and not diagnostic for one type. The patient was referred to Rheumatology for further diagnosis and management.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux EJ, Usatine R. Scleroderma and morphea. In: Usatine R, Smith M, Mayeaux EJ, et al. eds. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1204-1212.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the 3rd edition of the Color Atlas and Synopsis of Family Medicine as an app by clicking on this link: https://usatinemedia.com/app/color-atlas-of-family-medicine/

AUSTIN – Most patients with refractory generalized myasthenia gravis achieve clinical response by the 12th week of treatment with eculizumab (Soliris), but up to 16% of patients appear to have a late response to treatment, according to a secondary analysis presented at the annual meeting of the American Association of Neuromuscular and Electrodiagnostic Medicine.

Evidence for the sustained effectiveness of eculizumab, a terminal complement inhibitor, in adult patients with antiacetylcholine receptor antibody-positive refractory generalized myasthenia gravis was provided by the 6-month, double-blind, placebo-controlled REGAIN study and its open-label extension. James F. Howard Jr., MD, distinguished professor of neuromuscular disease at the University of North Carolina in Chapel Hill and colleagues sought to analyze response profiles in REGAIN and its open-label extension.

The findings raise the possibility that complement inhibition with eculizumab should not be abandoned rapidly. “We accept that [eculizumab] works quickly,” Dr. Howard said. “There is an impression that if you don’t respond within the first 3 months, you’re not going to respond. I think these data would suggest otherwise.”

The investigators analyzed participants’ Myasthenia Gravis–Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores, which had been recorded throughout REGAIN and the extension. They defined early and late responses as improvement in MG-ADL score (i.e., a decrease of three or more points) or QMG score (i.e., a decrease of five or more points) occurring at 12 weeks or earlier or after 12 weeks, respectively, after initiation of eculizumab therapy. Patients randomized to eculizumab in REGAIN initially were treated with an IV induction dose of 900 mg/week before receiving 1,200 mg every 2 weeks thereafter.

Dr. Howard and colleagues included 98 patients in their analysis. Approximately 32% of patients achieved their first response within the first week of treatment, and 15% responded at week 2. About 16% of patients had a late response.

Responses to treatment on the MG-ADL scale had occurred in 67.3% by week 12 and in 84.7% by the end of the extension. Treatment with eculizumab resulted in QMG responses in 56.1% by week 12 and 71.4% by the end of the extension. The investigators observed response over multiple consecutive assessments for the vast majority of patients.

At week 130, the least-squares mean percentage changes from baseline in MG-ADL score were −61.9% and −47.5% in early and late MG-ADL responders, respectively. The least-squares mean percentage changes from baseline in QMG score were −40.8% and −55.5% in early and late QMG responders, respectively.

The investigators observed significant baseline differences between early versus late QMG responders in mean duration of myasthenia gravis (10.46 years vs. 5.46 years) and mean QMG score (18.6 vs. 15.1).

“I can’t explain [this finding]. It may simply be due to the low numbers of patients,” Dr. Howard said. “Whether this is going to hold up in postmarketing analysis remains to be seen. I’m not convinced that that is meaningful.”

Study funding was provided by Alexion Pharmaceuticals (the developer of eculizumab), the Centers for Disease Control and Prevention, and the National Institutes of Health. Dr. Howard reported receiving research support and consulting fees or honoraria from Alexion and several other pharmaceutical companies. Several other authors reported financial relationships with Alexion and other pharmaceutical companies; two authors are employees of Alexion.

[email protected]

Howard J et al. AANEM 2019. Unnumbered Abstract.

AUSTIN – Most patients with refractory generalized myasthenia gravis achieve clinical response by the 12th week of treatment with eculizumab (Soliris), but up to 16% of patients appear to have a late response to treatment, according to a secondary analysis presented at the annual meeting of the American Association of Neuromuscular and Electrodiagnostic Medicine.

Evidence for the sustained effectiveness of eculizumab, a terminal complement inhibitor, in adult patients with antiacetylcholine receptor antibody-positive refractory generalized myasthenia gravis was provided by the 6-month, double-blind, placebo-controlled REGAIN study and its open-label extension. James F. Howard Jr., MD, distinguished professor of neuromuscular disease at the University of North Carolina in Chapel Hill and colleagues sought to analyze response profiles in REGAIN and its open-label extension.

The findings raise the possibility that complement inhibition with eculizumab should not be abandoned rapidly. “We accept that [eculizumab] works quickly,” Dr. Howard said. “There is an impression that if you don’t respond within the first 3 months, you’re not going to respond. I think these data would suggest otherwise.”

The investigators analyzed participants’ Myasthenia Gravis–Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores, which had been recorded throughout REGAIN and the extension. They defined early and late responses as improvement in MG-ADL score (i.e., a decrease of three or more points) or QMG score (i.e., a decrease of five or more points) occurring at 12 weeks or earlier or after 12 weeks, respectively, after initiation of eculizumab therapy. Patients randomized to eculizumab in REGAIN initially were treated with an IV induction dose of 900 mg/week before receiving 1,200 mg every 2 weeks thereafter.

Dr. Howard and colleagues included 98 patients in their analysis. Approximately 32% of patients achieved their first response within the first week of treatment, and 15% responded at week 2. About 16% of patients had a late response.

Responses to treatment on the MG-ADL scale had occurred in 67.3% by week 12 and in 84.7% by the end of the extension. Treatment with eculizumab resulted in QMG responses in 56.1% by week 12 and 71.4% by the end of the extension. The investigators observed response over multiple consecutive assessments for the vast majority of patients.

At week 130, the least-squares mean percentage changes from baseline in MG-ADL score were −61.9% and −47.5% in early and late MG-ADL responders, respectively. The least-squares mean percentage changes from baseline in QMG score were −40.8% and −55.5% in early and late QMG responders, respectively.

The investigators observed significant baseline differences between early versus late QMG responders in mean duration of myasthenia gravis (10.46 years vs. 5.46 years) and mean QMG score (18.6 vs. 15.1).

“I can’t explain [this finding]. It may simply be due to the low numbers of patients,” Dr. Howard said. “Whether this is going to hold up in postmarketing analysis remains to be seen. I’m not convinced that that is meaningful.”

Study funding was provided by Alexion Pharmaceuticals (the developer of eculizumab), the Centers for Disease Control and Prevention, and the National Institutes of Health. Dr. Howard reported receiving research support and consulting fees or honoraria from Alexion and several other pharmaceutical companies. Several other authors reported financial relationships with Alexion and other pharmaceutical companies; two authors are employees of Alexion.

[email protected]

Howard J et al. AANEM 2019. Unnumbered Abstract.

AUSTIN – Most patients with refractory generalized myasthenia gravis achieve clinical response by the 12th week of treatment with eculizumab (Soliris), but up to 16% of patients appear to have a late response to treatment, according to a secondary analysis presented at the annual meeting of the American Association of Neuromuscular and Electrodiagnostic Medicine.

Evidence for the sustained effectiveness of eculizumab, a terminal complement inhibitor, in adult patients with antiacetylcholine receptor antibody-positive refractory generalized myasthenia gravis was provided by the 6-month, double-blind, placebo-controlled REGAIN study and its open-label extension. James F. Howard Jr., MD, distinguished professor of neuromuscular disease at the University of North Carolina in Chapel Hill and colleagues sought to analyze response profiles in REGAIN and its open-label extension.

The findings raise the possibility that complement inhibition with eculizumab should not be abandoned rapidly. “We accept that [eculizumab] works quickly,” Dr. Howard said. “There is an impression that if you don’t respond within the first 3 months, you’re not going to respond. I think these data would suggest otherwise.”

The investigators analyzed participants’ Myasthenia Gravis–Activities of Daily Living (MG-ADL) and Quantitative Myasthenia Gravis (QMG) scores, which had been recorded throughout REGAIN and the extension. They defined early and late responses as improvement in MG-ADL score (i.e., a decrease of three or more points) or QMG score (i.e., a decrease of five or more points) occurring at 12 weeks or earlier or after 12 weeks, respectively, after initiation of eculizumab therapy. Patients randomized to eculizumab in REGAIN initially were treated with an IV induction dose of 900 mg/week before receiving 1,200 mg every 2 weeks thereafter.

Dr. Howard and colleagues included 98 patients in their analysis. Approximately 32% of patients achieved their first response within the first week of treatment, and 15% responded at week 2. About 16% of patients had a late response.

Responses to treatment on the MG-ADL scale had occurred in 67.3% by week 12 and in 84.7% by the end of the extension. Treatment with eculizumab resulted in QMG responses in 56.1% by week 12 and 71.4% by the end of the extension. The investigators observed response over multiple consecutive assessments for the vast majority of patients.

At week 130, the least-squares mean percentage changes from baseline in MG-ADL score were −61.9% and −47.5% in early and late MG-ADL responders, respectively. The least-squares mean percentage changes from baseline in QMG score were −40.8% and −55.5% in early and late QMG responders, respectively.

The investigators observed significant baseline differences between early versus late QMG responders in mean duration of myasthenia gravis (10.46 years vs. 5.46 years) and mean QMG score (18.6 vs. 15.1).

“I can’t explain [this finding]. It may simply be due to the low numbers of patients,” Dr. Howard said. “Whether this is going to hold up in postmarketing analysis remains to be seen. I’m not convinced that that is meaningful.”

Study funding was provided by Alexion Pharmaceuticals (the developer of eculizumab), the Centers for Disease Control and Prevention, and the National Institutes of Health. Dr. Howard reported receiving research support and consulting fees or honoraria from Alexion and several other pharmaceutical companies. Several other authors reported financial relationships with Alexion and other pharmaceutical companies; two authors are employees of Alexion.

[email protected]

Howard J et al. AANEM 2019. Unnumbered Abstract.

Surgery may be more effective than medical therapy, according to results from a randomized trial in 78 patients with reflux-related heartburn refractory to proton pump inhibitors (PPIs).

Stuart J. Spechler, MD, from Baylor University Medical Center, Dallas, and coauthors wrote in the New England Journal of Medicine that, for these patients, there were no medical treatment options that had been shown to have long-term benefit, so PPIs were often continued despite not offering adequate symptom relief. Other medical options such as baclofen and neuromodulators often have unacceptable side effects, and studies of their efficacy were few and of short duration.

In this study, patients were randomized either to laparoscopic Nissen fundoplication, treatment with omeprazole plus baclofen with desipramine depending on symptoms, or a control treatment of omeprazole plus placebo.

At 1 year, researchers saw a significantly higher rate of treatment success – defined as 50% or greater improvement in gastroesophageal reflux disease health-related quality of life score – in the surgery group (67%), compared with the medical-treatment group (28%) and control-medical group (12%).

This translated to an unadjusted 138% greater chance of treatment success with surgery, compared with active medical treatment, and a greater than 400% increase for surgery, compared with the control medical treatment.

Researchers also did a prespecified subgroup analysis among people with reflex hypersensitivity or abnormal acid reflux, and found the incidence of success with surgery was 71% and 62%, respectively.

They described this finding as “noteworthy,” given that reflux hypersensitivity was considered a functional disorder that would not be expected to improve with a procedure that didn’t alter abnormal esophageal pain perception.

However, they acknowledged that, as the study did not include a sham-surgery group, they couldn’t determine how much the placebo effect might have contributed to the treatment success of surgery.

They also stressed that the randomized group was a highly selected group of patients, and that the systematic work-up including esophageal multichannel intraluminal impedance pH monitoring could identify a subgroup that might have a better response to surgery than to medical treatment.

Four patients in the surgery group experienced a total of five serious adverse events, including one patients who had a herniated fundoplication treated with repeat surgery; four patients in the active-medical group experienced four serious adverse events; and three patients in the control-medical group experienced five serious adverse events.

The authors noted that 366 patients with PPI-refractory heartburn were originally enrolled in the study, then treated with 20 mg of omeprazole twice daily for 2 weeks with strict instructions to take 20 minutes before breakfast and dinner. Of these patients, 42 had their symptoms relieved by the omeprazole treatment and so were excluded from the randomization.

The “strict instructions” on how to take omeprazole were important, because PPIs only bind to gastric proton pumps that are actively secreting acid, the authors wrote. They also commented that the relative potencies of individual PPIs can vary, so patients not on omeprazole before the study may have responded better to this than other PPIs.

Before randomizations, patients also underwent endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance pH monitoring. This excluded another 23 patients who were found to have non–gastroesophageal reflux disease, including eosinophilic esophagitis, other endoscopic or histologic abnormalities, and manometric abnormalities.

“This trial highlights the critical importance of systematic evaluation, similar to that recommended by Gyawali and Fass for managing the care of patients with PPI-refractory heartburn,” they wrote. “Many patients would not complete this rigorous evaluation, and among those who did, the cause of heartburn in most of them was not [gastroesophageal reflux disease].”

The study was funded by the Department of Veterans Affairs Cooperative Studies Program. Four authors declared consultancies with and/or grants from the pharmaceutical sector.

SOURCE: Spechler SJ et al. N Engl J Med. 2019 Oct 16. doi: 10.1056/NEJMoa1811424.

Surgery may be more effective than medical therapy, according to results from a randomized trial in 78 patients with reflux-related heartburn refractory to proton pump inhibitors (PPIs).

Stuart J. Spechler, MD, from Baylor University Medical Center, Dallas, and coauthors wrote in the New England Journal of Medicine that, for these patients, there were no medical treatment options that had been shown to have long-term benefit, so PPIs were often continued despite not offering adequate symptom relief. Other medical options such as baclofen and neuromodulators often have unacceptable side effects, and studies of their efficacy were few and of short duration.

In this study, patients were randomized either to laparoscopic Nissen fundoplication, treatment with omeprazole plus baclofen with desipramine depending on symptoms, or a control treatment of omeprazole plus placebo.

At 1 year, researchers saw a significantly higher rate of treatment success – defined as 50% or greater improvement in gastroesophageal reflux disease health-related quality of life score – in the surgery group (67%), compared with the medical-treatment group (28%) and control-medical group (12%).

This translated to an unadjusted 138% greater chance of treatment success with surgery, compared with active medical treatment, and a greater than 400% increase for surgery, compared with the control medical treatment.

Researchers also did a prespecified subgroup analysis among people with reflex hypersensitivity or abnormal acid reflux, and found the incidence of success with surgery was 71% and 62%, respectively.

They described this finding as “noteworthy,” given that reflux hypersensitivity was considered a functional disorder that would not be expected to improve with a procedure that didn’t alter abnormal esophageal pain perception.

However, they acknowledged that, as the study did not include a sham-surgery group, they couldn’t determine how much the placebo effect might have contributed to the treatment success of surgery.

They also stressed that the randomized group was a highly selected group of patients, and that the systematic work-up including esophageal multichannel intraluminal impedance pH monitoring could identify a subgroup that might have a better response to surgery than to medical treatment.

Four patients in the surgery group experienced a total of five serious adverse events, including one patients who had a herniated fundoplication treated with repeat surgery; four patients in the active-medical group experienced four serious adverse events; and three patients in the control-medical group experienced five serious adverse events.

The authors noted that 366 patients with PPI-refractory heartburn were originally enrolled in the study, then treated with 20 mg of omeprazole twice daily for 2 weeks with strict instructions to take 20 minutes before breakfast and dinner. Of these patients, 42 had their symptoms relieved by the omeprazole treatment and so were excluded from the randomization.

The “strict instructions” on how to take omeprazole were important, because PPIs only bind to gastric proton pumps that are actively secreting acid, the authors wrote. They also commented that the relative potencies of individual PPIs can vary, so patients not on omeprazole before the study may have responded better to this than other PPIs.

Before randomizations, patients also underwent endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance pH monitoring. This excluded another 23 patients who were found to have non–gastroesophageal reflux disease, including eosinophilic esophagitis, other endoscopic or histologic abnormalities, and manometric abnormalities.

“This trial highlights the critical importance of systematic evaluation, similar to that recommended by Gyawali and Fass for managing the care of patients with PPI-refractory heartburn,” they wrote. “Many patients would not complete this rigorous evaluation, and among those who did, the cause of heartburn in most of them was not [gastroesophageal reflux disease].”

The study was funded by the Department of Veterans Affairs Cooperative Studies Program. Four authors declared consultancies with and/or grants from the pharmaceutical sector.

SOURCE: Spechler SJ et al. N Engl J Med. 2019 Oct 16. doi: 10.1056/NEJMoa1811424.

Surgery may be more effective than medical therapy, according to results from a randomized trial in 78 patients with reflux-related heartburn refractory to proton pump inhibitors (PPIs).

Stuart J. Spechler, MD, from Baylor University Medical Center, Dallas, and coauthors wrote in the New England Journal of Medicine that, for these patients, there were no medical treatment options that had been shown to have long-term benefit, so PPIs were often continued despite not offering adequate symptom relief. Other medical options such as baclofen and neuromodulators often have unacceptable side effects, and studies of their efficacy were few and of short duration.

In this study, patients were randomized either to laparoscopic Nissen fundoplication, treatment with omeprazole plus baclofen with desipramine depending on symptoms, or a control treatment of omeprazole plus placebo.

At 1 year, researchers saw a significantly higher rate of treatment success – defined as 50% or greater improvement in gastroesophageal reflux disease health-related quality of life score – in the surgery group (67%), compared with the medical-treatment group (28%) and control-medical group (12%).

This translated to an unadjusted 138% greater chance of treatment success with surgery, compared with active medical treatment, and a greater than 400% increase for surgery, compared with the control medical treatment.

Researchers also did a prespecified subgroup analysis among people with reflex hypersensitivity or abnormal acid reflux, and found the incidence of success with surgery was 71% and 62%, respectively.

They described this finding as “noteworthy,” given that reflux hypersensitivity was considered a functional disorder that would not be expected to improve with a procedure that didn’t alter abnormal esophageal pain perception.

However, they acknowledged that, as the study did not include a sham-surgery group, they couldn’t determine how much the placebo effect might have contributed to the treatment success of surgery.

They also stressed that the randomized group was a highly selected group of patients, and that the systematic work-up including esophageal multichannel intraluminal impedance pH monitoring could identify a subgroup that might have a better response to surgery than to medical treatment.

Four patients in the surgery group experienced a total of five serious adverse events, including one patients who had a herniated fundoplication treated with repeat surgery; four patients in the active-medical group experienced four serious adverse events; and three patients in the control-medical group experienced five serious adverse events.

The authors noted that 366 patients with PPI-refractory heartburn were originally enrolled in the study, then treated with 20 mg of omeprazole twice daily for 2 weeks with strict instructions to take 20 minutes before breakfast and dinner. Of these patients, 42 had their symptoms relieved by the omeprazole treatment and so were excluded from the randomization.

The “strict instructions” on how to take omeprazole were important, because PPIs only bind to gastric proton pumps that are actively secreting acid, the authors wrote. They also commented that the relative potencies of individual PPIs can vary, so patients not on omeprazole before the study may have responded better to this than other PPIs.

Before randomizations, patients also underwent endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance pH monitoring. This excluded another 23 patients who were found to have non–gastroesophageal reflux disease, including eosinophilic esophagitis, other endoscopic or histologic abnormalities, and manometric abnormalities.

“This trial highlights the critical importance of systematic evaluation, similar to that recommended by Gyawali and Fass for managing the care of patients with PPI-refractory heartburn,” they wrote. “Many patients would not complete this rigorous evaluation, and among those who did, the cause of heartburn in most of them was not [gastroesophageal reflux disease].”

The study was funded by the Department of Veterans Affairs Cooperative Studies Program. Four authors declared consultancies with and/or grants from the pharmaceutical sector.

SOURCE: Spechler SJ et al. N Engl J Med. 2019 Oct 16. doi: 10.1056/NEJMoa1811424.

SEATTLE – After years of relying on oral anticholinergics for treating hyperhidrosis, more options have recently become available, David Pariser, MD, said at the annual Coastal Dermatology Symposium.

Koldunov/Thinkstock

Hyperhidrosis is among the dermatological conditions that have the greatest impact on quality of life, and it can be particularly concerning to teens, said Dr. Pariser, professor of dermatology at Eastern Virginia Medical School, Norfolk. He referred to some new developments for an old, often misunderstood, standby: antiperspirants. “I am amazed that many people do not know the difference between an antiperspirant and a deodorant,” he said, pointing out that antiperspirants contain active ingredients – aluminum and zirconium salts – that block sweat glands, while deodorants contain a masking fragrance.

There are new-generation topical antiperspirants available over the counter, with descriptions that include “clinical strength” or “clinical protection” on the labels; they come in a box and cost about twice as much as standard products. “But they are better, and they work just as well as some of the commercial preparations,” Dr. Pariser said at the meeting, jointly presented by the University of Louisville and Global Academy for Medical Education.

One issue he highlighted was that antiperspirants are often misapplied. They shouldn’t be applied on wet skin because they react with water to create hydrochloric acid, which can irritate the skin, he said. The best time to apply an antiperspirant is right before bedtime, since it gives the salts time to clog sweat pores before sweat or water can interfere. “The plugs last for a couple of days,” so there’s no need to worry about rinsing the product off during a morning shower, he noted.

Additional therapeutic options include agents like oral glycopyrrolate, starting at a low dose (1 mg twice per day), increasing by 1 mg/day weekly until efficacy is achieved or limited by adverse events. There is also a glycopyrrolate oral solution 1mg/5ml (Cuvposa) that can be used in children.

A topical version of the anticholinergic glycopyrronium tosylate, applied using an infused cloth, was approved for treating axillary hyperhidrosis in June2018 and offers the potential for an enhanced local anticholinergic effect. Dr. Pariser, one of the authors, discussed the recently published results of two pivotal studies that found good improvement in a specially-designed quality of life endpoint (J Am Acad Derm. 2019; Jan;80[1]:128-138.e2).

Efficacy in a subanalysis of 44 pediatric subjects (ages 9-16 years) was similar as those reported in adults, and the rate of those reporting dry mouth (24% in both age groups) was similar. Of concern was a 16% rate of mydriasis in the pediatric group, compared with 6% in the older group. One patient even wound up in the emergency room for a stroke work-up as a result, said Dr. Pariser, who is confident that the problem was caused by inadvertent exposure to the eye during application. He advises patients to avoid contact with the eyes.

Other approaches to treatment of hyperhidrosis include oxybutynin, iontophoresis, an microwave thermolysis (which may also reduce odor and hair). Endoscopic thoracic sympathectomy is effective but is the most invasive option; botulinum toxin is a minimally invasive alternative to surgery.

For those who sweat when they experience anxiety, propranolol 5-10 mg taken about 1 hour before an event that could cause hyperhydrosis can be effective, said Dr. Pariser, who recommends a test dose. “I don’t normally tell patients to try something at home. But they should try this at home” before using it prior to an important event, he added.

Dr. Pariser is a consultant and/or investigator for Dermira, Brickell Biotech, TheraVida, Atacama, TDI Surgitech, Dermavant, and Revance Therapeutics. He has not done commercial speaking, has not been on speaker’s bureaus, and has no stock or options in any company.

This publication and Global Academy for Medical Education are owned by the same parent company.

SEATTLE – After years of relying on oral anticholinergics for treating hyperhidrosis, more options have recently become available, David Pariser, MD, said at the annual Coastal Dermatology Symposium.

Koldunov/Thinkstock

Hyperhidrosis is among the dermatological conditions that have the greatest impact on quality of life, and it can be particularly concerning to teens, said Dr. Pariser, professor of dermatology at Eastern Virginia Medical School, Norfolk. He referred to some new developments for an old, often misunderstood, standby: antiperspirants. “I am amazed that many people do not know the difference between an antiperspirant and a deodorant,” he said, pointing out that antiperspirants contain active ingredients – aluminum and zirconium salts – that block sweat glands, while deodorants contain a masking fragrance.

There are new-generation topical antiperspirants available over the counter, with descriptions that include “clinical strength” or “clinical protection” on the labels; they come in a box and cost about twice as much as standard products. “But they are better, and they work just as well as some of the commercial preparations,” Dr. Pariser said at the meeting, jointly presented by the University of Louisville and Global Academy for Medical Education.

One issue he highlighted was that antiperspirants are often misapplied. They shouldn’t be applied on wet skin because they react with water to create hydrochloric acid, which can irritate the skin, he said. The best time to apply an antiperspirant is right before bedtime, since it gives the salts time to clog sweat pores before sweat or water can interfere. “The plugs last for a couple of days,” so there’s no need to worry about rinsing the product off during a morning shower, he noted.

Additional therapeutic options include agents like oral glycopyrrolate, starting at a low dose (1 mg twice per day), increasing by 1 mg/day weekly until efficacy is achieved or limited by adverse events. There is also a glycopyrrolate oral solution 1mg/5ml (Cuvposa) that can be used in children.

A topical version of the anticholinergic glycopyrronium tosylate, applied using an infused cloth, was approved for treating axillary hyperhidrosis in June2018 and offers the potential for an enhanced local anticholinergic effect. Dr. Pariser, one of the authors, discussed the recently published results of two pivotal studies that found good improvement in a specially-designed quality of life endpoint (J Am Acad Derm. 2019; Jan;80[1]:128-138.e2).

Efficacy in a subanalysis of 44 pediatric subjects (ages 9-16 years) was similar as those reported in adults, and the rate of those reporting dry mouth (24% in both age groups) was similar. Of concern was a 16% rate of mydriasis in the pediatric group, compared with 6% in the older group. One patient even wound up in the emergency room for a stroke work-up as a result, said Dr. Pariser, who is confident that the problem was caused by inadvertent exposure to the eye during application. He advises patients to avoid contact with the eyes.

Other approaches to treatment of hyperhidrosis include oxybutynin, iontophoresis, an microwave thermolysis (which may also reduce odor and hair). Endoscopic thoracic sympathectomy is effective but is the most invasive option; botulinum toxin is a minimally invasive alternative to surgery.

For those who sweat when they experience anxiety, propranolol 5-10 mg taken about 1 hour before an event that could cause hyperhydrosis can be effective, said Dr. Pariser, who recommends a test dose. “I don’t normally tell patients to try something at home. But they should try this at home” before using it prior to an important event, he added.

Dr. Pariser is a consultant and/or investigator for Dermira, Brickell Biotech, TheraVida, Atacama, TDI Surgitech, Dermavant, and Revance Therapeutics. He has not done commercial speaking, has not been on speaker’s bureaus, and has no stock or options in any company.

This publication and Global Academy for Medical Education are owned by the same parent company.

SEATTLE – After years of relying on oral anticholinergics for treating hyperhidrosis, more options have recently become available, David Pariser, MD, said at the annual Coastal Dermatology Symposium.

Koldunov/Thinkstock

Hyperhidrosis is among the dermatological conditions that have the greatest impact on quality of life, and it can be particularly concerning to teens, said Dr. Pariser, professor of dermatology at Eastern Virginia Medical School, Norfolk. He referred to some new developments for an old, often misunderstood, standby: antiperspirants. “I am amazed that many people do not know the difference between an antiperspirant and a deodorant,” he said, pointing out that antiperspirants contain active ingredients – aluminum and zirconium salts – that block sweat glands, while deodorants contain a masking fragrance.

There are new-generation topical antiperspirants available over the counter, with descriptions that include “clinical strength” or “clinical protection” on the labels; they come in a box and cost about twice as much as standard products. “But they are better, and they work just as well as some of the commercial preparations,” Dr. Pariser said at the meeting, jointly presented by the University of Louisville and Global Academy for Medical Education.

One issue he highlighted was that antiperspirants are often misapplied. They shouldn’t be applied on wet skin because they react with water to create hydrochloric acid, which can irritate the skin, he said. The best time to apply an antiperspirant is right before bedtime, since it gives the salts time to clog sweat pores before sweat or water can interfere. “The plugs last for a couple of days,” so there’s no need to worry about rinsing the product off during a morning shower, he noted.

Additional therapeutic options include agents like oral glycopyrrolate, starting at a low dose (1 mg twice per day), increasing by 1 mg/day weekly until efficacy is achieved or limited by adverse events. There is also a glycopyrrolate oral solution 1mg/5ml (Cuvposa) that can be used in children.

A topical version of the anticholinergic glycopyrronium tosylate, applied using an infused cloth, was approved for treating axillary hyperhidrosis in June2018 and offers the potential for an enhanced local anticholinergic effect. Dr. Pariser, one of the authors, discussed the recently published results of two pivotal studies that found good improvement in a specially-designed quality of life endpoint (J Am Acad Derm. 2019; Jan;80[1]:128-138.e2).

Efficacy in a subanalysis of 44 pediatric subjects (ages 9-16 years) was similar as those reported in adults, and the rate of those reporting dry mouth (24% in both age groups) was similar. Of concern was a 16% rate of mydriasis in the pediatric group, compared with 6% in the older group. One patient even wound up in the emergency room for a stroke work-up as a result, said Dr. Pariser, who is confident that the problem was caused by inadvertent exposure to the eye during application. He advises patients to avoid contact with the eyes.

Other approaches to treatment of hyperhidrosis include oxybutynin, iontophoresis, an microwave thermolysis (which may also reduce odor and hair). Endoscopic thoracic sympathectomy is effective but is the most invasive option; botulinum toxin is a minimally invasive alternative to surgery.

For those who sweat when they experience anxiety, propranolol 5-10 mg taken about 1 hour before an event that could cause hyperhydrosis can be effective, said Dr. Pariser, who recommends a test dose. “I don’t normally tell patients to try something at home. But they should try this at home” before using it prior to an important event, he added.

Dr. Pariser is a consultant and/or investigator for Dermira, Brickell Biotech, TheraVida, Atacama, TDI Surgitech, Dermavant, and Revance Therapeutics. He has not done commercial speaking, has not been on speaker’s bureaus, and has no stock or options in any company.

This publication and Global Academy for Medical Education are owned by the same parent company.

Among athletes with concussion, the effects of the injury on brain physiology may persist when they return to play and 1 year later.

MRI measures from 24 athletes with concussion significantly differed from those of controls at various time points and changed over time, according to a study published in Neurology. “Different aspects of brain physiology have different patterns of long-term recovery,” the researchers wrote.

While guidelines for safe return to play mainly rely on the resolution of symptoms, “the findings in this study indicate that more research is needed ... to better understand optimal recovery time from a biological standpoint,” wrote first author Nathan W. Churchill, PhD, a researcher at St. Michael’s Hospital in Toronto, and colleagues.

The study provides “evidence of incomplete or ongoing recovery” when athletes return to play, which could entail “a potential risk for long-term sequelae, given the evidence of worse outcomes if a second concussion occurs before recovery is complete,” according to the investigators. In addition, the study reinforces that neurobiological recovery varies across individuals and might depend on the initial clinical presentation.

To examine whether concussion-related brain changes dissipate by 1 year after athletes receive medical clearance to return to play, Dr. Churchill and colleagues analyzed MRI data from 24 college athletes with concussion and 122 control athletes without concussion.

Athletes with concussion were scanned within 1 week of the injury, at return to play a median of 27 days after the concussion, and 1 year after return to play. Control athletes were scanned before the start of the season. Participants’ sports included volleyball, hockey, soccer, football, rugby, basketball, lacrosse, and water polo. The participants had a mean age of about 20 years, and about half were women.

Athletes with concussion had elevated mean diffusivity within 1 week of injury, at return to play, and 1 year later, compared with controls. In athletes with concussion, cerebral blood flow was elevated soon after concussion, normal at return to play, and decreased 1 year later, relative to controls. Global functional connectivity increased and white matter fractional anisotropy decreased near the time of injury and at return to play, but these measures did not significantly differ from those of controls at 1 year.

The study did not capture MRI changes between return to play and 1 year later. In addition, MRI changes might be influenced by a lack of training before resuming play, as well as by exertion and subconcussive impacts after returning to play, the authors noted.

The Canadian Institutes of Health Research, the Canadian Institute for Military and Veterans Health Research, and Siemens Healthineers Canada supported the study. Siemens makes the MRI equipment used in the study. Dr. Churchill and colleagues had no relevant disclosures.

[email protected]

SOURCE: Churchill NW et al. Neurology. 2019 Oct 16. doi: 10.1212/WNL.0000000000008523.
 

Among athletes with concussion, the effects of the injury on brain physiology may persist when they return to play and 1 year later.

MRI measures from 24 athletes with concussion significantly differed from those of controls at various time points and changed over time, according to a study published in Neurology. “Different aspects of brain physiology have different patterns of long-term recovery,” the researchers wrote.

While guidelines for safe return to play mainly rely on the resolution of symptoms, “the findings in this study indicate that more research is needed ... to better understand optimal recovery time from a biological standpoint,” wrote first author Nathan W. Churchill, PhD, a researcher at St. Michael’s Hospital in Toronto, and colleagues.

The study provides “evidence of incomplete or ongoing recovery” when athletes return to play, which could entail “a potential risk for long-term sequelae, given the evidence of worse outcomes if a second concussion occurs before recovery is complete,” according to the investigators. In addition, the study reinforces that neurobiological recovery varies across individuals and might depend on the initial clinical presentation.

To examine whether concussion-related brain changes dissipate by 1 year after athletes receive medical clearance to return to play, Dr. Churchill and colleagues analyzed MRI data from 24 college athletes with concussion and 122 control athletes without concussion.

Athletes with concussion were scanned within 1 week of the injury, at return to play a median of 27 days after the concussion, and 1 year after return to play. Control athletes were scanned before the start of the season. Participants’ sports included volleyball, hockey, soccer, football, rugby, basketball, lacrosse, and water polo. The participants had a mean age of about 20 years, and about half were women.

Athletes with concussion had elevated mean diffusivity within 1 week of injury, at return to play, and 1 year later, compared with controls. In athletes with concussion, cerebral blood flow was elevated soon after concussion, normal at return to play, and decreased 1 year later, relative to controls. Global functional connectivity increased and white matter fractional anisotropy decreased near the time of injury and at return to play, but these measures did not significantly differ from those of controls at 1 year.

The study did not capture MRI changes between return to play and 1 year later. In addition, MRI changes might be influenced by a lack of training before resuming play, as well as by exertion and subconcussive impacts after returning to play, the authors noted.

The Canadian Institutes of Health Research, the Canadian Institute for Military and Veterans Health Research, and Siemens Healthineers Canada supported the study. Siemens makes the MRI equipment used in the study. Dr. Churchill and colleagues had no relevant disclosures.

[email protected]

SOURCE: Churchill NW et al. Neurology. 2019 Oct 16. doi: 10.1212/WNL.0000000000008523.
 

Among athletes with concussion, the effects of the injury on brain physiology may persist when they return to play and 1 year later.

MRI measures from 24 athletes with concussion significantly differed from those of controls at various time points and changed over time, according to a study published in Neurology. “Different aspects of brain physiology have different patterns of long-term recovery,” the researchers wrote.

While guidelines for safe return to play mainly rely on the resolution of symptoms, “the findings in this study indicate that more research is needed ... to better understand optimal recovery time from a biological standpoint,” wrote first author Nathan W. Churchill, PhD, a researcher at St. Michael’s Hospital in Toronto, and colleagues.

The study provides “evidence of incomplete or ongoing recovery” when athletes return to play, which could entail “a potential risk for long-term sequelae, given the evidence of worse outcomes if a second concussion occurs before recovery is complete,” according to the investigators. In addition, the study reinforces that neurobiological recovery varies across individuals and might depend on the initial clinical presentation.

To examine whether concussion-related brain changes dissipate by 1 year after athletes receive medical clearance to return to play, Dr. Churchill and colleagues analyzed MRI data from 24 college athletes with concussion and 122 control athletes without concussion.

Athletes with concussion were scanned within 1 week of the injury, at return to play a median of 27 days after the concussion, and 1 year after return to play. Control athletes were scanned before the start of the season. Participants’ sports included volleyball, hockey, soccer, football, rugby, basketball, lacrosse, and water polo. The participants had a mean age of about 20 years, and about half were women.

Athletes with concussion had elevated mean diffusivity within 1 week of injury, at return to play, and 1 year later, compared with controls. In athletes with concussion, cerebral blood flow was elevated soon after concussion, normal at return to play, and decreased 1 year later, relative to controls. Global functional connectivity increased and white matter fractional anisotropy decreased near the time of injury and at return to play, but these measures did not significantly differ from those of controls at 1 year.

The study did not capture MRI changes between return to play and 1 year later. In addition, MRI changes might be influenced by a lack of training before resuming play, as well as by exertion and subconcussive impacts after returning to play, the authors noted.

The Canadian Institutes of Health Research, the Canadian Institute for Military and Veterans Health Research, and Siemens Healthineers Canada supported the study. Siemens makes the MRI equipment used in the study. Dr. Churchill and colleagues had no relevant disclosures.

[email protected]

SOURCE: Churchill NW et al. Neurology. 2019 Oct 16. doi: 10.1212/WNL.0000000000008523.
 

A new study has found that, although the Affordable Care Act (ACA) increased health insurance coverage in states that expanded their Medicaid program, the expansion did not translate into improved access to care or decreased preventable hospitalizations of patients with systemic lupus erythematosus (SLE).

juststock/gettyimages

“Our findings emphasize the importance of addressing systemic problems with American healthcare delivery at multiple levels,” wrote Elizabeth A. Brown, PhD, of the Medical University of South Carolina, Charleston, and her coauthors. The study was published in Arthritis Care & Research.

To examine the effects of the ACA’s Medicaid expansion on lupus patients when it was implemented Jan. 1, 2014, the researchers launched a retrospective, quasi‐experimental study using administrative data from eight states to compare eight quarterly time points in the 2 years prior to implementation against seven quarterly time points in the 2 years after implementation. Four states expanded Medicaid under the ACA – Arizona, Kentucky, New Jersey, and New York – and four of them did not – Florida, Georgia, South Carolina, and Wisconsin.

During the study period, there were 204,150 lupus hospitalizations across all eight states during the 15 quarters, 53% of which occurred in the four states that did not expand Medicaid. Although the investigators’ base model found that the probability of a preventable hospitalization did not increase over time (odds ratio, 1.004; 95% confidence interval, 0.996-1.013), the four expansion states had significantly higher odds of having preventable hospitalizations in the final adjusted model (OR, 1.302; 95% CI, 1.119-1.515).

Variables that contributed to higher odds of a preventable hospitalization included age: Lupus patients who were 55-64 years old had considerably higher odds for preventable lupus hospitalizations than did patients who were 20-34 years old (OR, 1.488; 95% CI, 1.415-1.564). In addition, those with a median household income under $42,000 had higher odds of hospitalization when compared with those making over $68,000 (OR, 1.138; 95% CI, 1.415-1.564), as did those on Medicaid compared with those on private insurance (OR, 1.298; 95% CI, 1.238-1.361).

The authors acknowledged their study’s limitations, including relying on potential coding errors within administrative data. In addition, they were unable to factor in Medicaid marketing, enrollment strategies, or other related actions undertaken in each of the eight states.

The study was partially supported by the South Carolina Clinical & Translational Research Institute via a National Center for Advancing Translational Sciences grant. The authors reported no conflicts of interest.

SOURCE: Brown EA et al. Arthritis Care Res. 2019 Sept 28. doi: 10.1002/acr.24080

A new study has found that, although the Affordable Care Act (ACA) increased health insurance coverage in states that expanded their Medicaid program, the expansion did not translate into improved access to care or decreased preventable hospitalizations of patients with systemic lupus erythematosus (SLE).

juststock/gettyimages

“Our findings emphasize the importance of addressing systemic problems with American healthcare delivery at multiple levels,” wrote Elizabeth A. Brown, PhD, of the Medical University of South Carolina, Charleston, and her coauthors. The study was published in Arthritis Care & Research.

To examine the effects of the ACA’s Medicaid expansion on lupus patients when it was implemented Jan. 1, 2014, the researchers launched a retrospective, quasi‐experimental study using administrative data from eight states to compare eight quarterly time points in the 2 years prior to implementation against seven quarterly time points in the 2 years after implementation. Four states expanded Medicaid under the ACA – Arizona, Kentucky, New Jersey, and New York – and four of them did not – Florida, Georgia, South Carolina, and Wisconsin.

During the study period, there were 204,150 lupus hospitalizations across all eight states during the 15 quarters, 53% of which occurred in the four states that did not expand Medicaid. Although the investigators’ base model found that the probability of a preventable hospitalization did not increase over time (odds ratio, 1.004; 95% confidence interval, 0.996-1.013), the four expansion states had significantly higher odds of having preventable hospitalizations in the final adjusted model (OR, 1.302; 95% CI, 1.119-1.515).

Variables that contributed to higher odds of a preventable hospitalization included age: Lupus patients who were 55-64 years old had considerably higher odds for preventable lupus hospitalizations than did patients who were 20-34 years old (OR, 1.488; 95% CI, 1.415-1.564). In addition, those with a median household income under $42,000 had higher odds of hospitalization when compared with those making over $68,000 (OR, 1.138; 95% CI, 1.415-1.564), as did those on Medicaid compared with those on private insurance (OR, 1.298; 95% CI, 1.238-1.361).

The authors acknowledged their study’s limitations, including relying on potential coding errors within administrative data. In addition, they were unable to factor in Medicaid marketing, enrollment strategies, or other related actions undertaken in each of the eight states.

The study was partially supported by the South Carolina Clinical & Translational Research Institute via a National Center for Advancing Translational Sciences grant. The authors reported no conflicts of interest.

SOURCE: Brown EA et al. Arthritis Care Res. 2019 Sept 28. doi: 10.1002/acr.24080

A new study has found that, although the Affordable Care Act (ACA) increased health insurance coverage in states that expanded their Medicaid program, the expansion did not translate into improved access to care or decreased preventable hospitalizations of patients with systemic lupus erythematosus (SLE).

juststock/gettyimages

“Our findings emphasize the importance of addressing systemic problems with American healthcare delivery at multiple levels,” wrote Elizabeth A. Brown, PhD, of the Medical University of South Carolina, Charleston, and her coauthors. The study was published in Arthritis Care & Research.

To examine the effects of the ACA’s Medicaid expansion on lupus patients when it was implemented Jan. 1, 2014, the researchers launched a retrospective, quasi‐experimental study using administrative data from eight states to compare eight quarterly time points in the 2 years prior to implementation against seven quarterly time points in the 2 years after implementation. Four states expanded Medicaid under the ACA – Arizona, Kentucky, New Jersey, and New York – and four of them did not – Florida, Georgia, South Carolina, and Wisconsin.

During the study period, there were 204,150 lupus hospitalizations across all eight states during the 15 quarters, 53% of which occurred in the four states that did not expand Medicaid. Although the investigators’ base model found that the probability of a preventable hospitalization did not increase over time (odds ratio, 1.004; 95% confidence interval, 0.996-1.013), the four expansion states had significantly higher odds of having preventable hospitalizations in the final adjusted model (OR, 1.302; 95% CI, 1.119-1.515).

Variables that contributed to higher odds of a preventable hospitalization included age: Lupus patients who were 55-64 years old had considerably higher odds for preventable lupus hospitalizations than did patients who were 20-34 years old (OR, 1.488; 95% CI, 1.415-1.564). In addition, those with a median household income under $42,000 had higher odds of hospitalization when compared with those making over $68,000 (OR, 1.138; 95% CI, 1.415-1.564), as did those on Medicaid compared with those on private insurance (OR, 1.298; 95% CI, 1.238-1.361).

The authors acknowledged their study’s limitations, including relying on potential coding errors within administrative data. In addition, they were unable to factor in Medicaid marketing, enrollment strategies, or other related actions undertaken in each of the eight states.

The study was partially supported by the South Carolina Clinical & Translational Research Institute via a National Center for Advancing Translational Sciences grant. The authors reported no conflicts of interest.

SOURCE: Brown EA et al. Arthritis Care Res. 2019 Sept 28. doi: 10.1002/acr.24080

SAN DIEGO – Physician suicide is “a public health crisis because of the sheer volume of people who are dying,” and many medical authorities are contributing to stigma through “invasive” questionnaires, a prevention advocate said at the annual Psych Congress.

“Physicians fear sharing their mental health struggles with the state medical health board,” said Pamela Wible, MD, a family physician who practices in Eugene, Ore., at the meeting. They “pretend, deny, and lie,” she said, and sometimes they seek care and medication hours away in order to avoid detection.

One solution, she said, is to highlight state medical boards that do it right and state medical boards that do it wrong, including the “very worst,” which is that of Alaska.

Dr. Wible, who speaks of suffering from suicidal feelings herself as physician in 2004, is a leading advocate for suicide prevention in the medical profession.

She told colleagues at the Psych Congress that anesthesiologists face the highest risk of suicide, followed by surgeons, ob.gyns., and psychiatrists.

“They end their lives not because they want to die but because they want to stop the pain and they can’t find any other way,” she said. “They have a great work ethic until the end: They’re smiling, doing complex surgeries, and cracking jokes to the surgical team, then they shoot themselves in the closet.”

Colleagues are often shocked, she said: “ ‘Wait a minute. He was just joking with me yesterday. What do you mean he hung himself in his office?’ ‘She just had a newborn baby and she was so happy!’ If you see the smile, you don’t see the pain.”

In 2018, she wrote a Washington Post commentary titled “What I’ve learned from my tally of 757 doctor suicides” that was based on her registry of physician suicides. In the United States, she wrote, 1 million patients lose a physician to suicide each year. Factors contributing to suicides include patient deaths, malpractice suits, “academic distress,” and overwork. “Doctors who need help don’t seek it because they fear mental health care won’t remain confidential,” she wrote. “So they drive out of town, pay cash, and use fake names to hide from state medical boards, hospitals, and insurance plans out of fear that they will lose state licensure, hospital privileges, and health plan participation.”

Dr. Wible oversaw a 2019 research project that analyzed state medical board applications. The goal was to grade the state boards by how intrusively their application questions grill applicants about their mental health history. “Physicians fear sharing their mental health struggles with the state medical health board and with each other,” she said. Some lie, and others – “the really honest physicians” – are so dedicated to telling the truth that “they’ll withhold getting care because they want to correctly check the ‘no’ box.”

Seven states – Alabama, Alaska, Delaware, Florida, Mississippi, Rhode Island, and Washington –received “F” grades for “highly invasive mental health questions unlinked to current impairment that contain confusing, punitive, or adversarial language.”

Roke~commonswiki

Alaska, Dr. Wible said, asks multiple 25 yes-or-no questions about mental health. One question lists 14 conditions, almost all related to mental health – including depression, “any organic mental disorder,” and “any condition requiring chronic medical or behavioral treatment” – and asks, “Have you ever been diagnosed with, treated for, or do you currently have” any of them. This is “the most invasive mental health question we found on any application,” Dr. Wible wrote on her website.

States also hurt applicants by asking peers of applicants about their mental health, she said. “I’m not against getting peer references, but can we stop getting into everyone’s business with their psych history? What we really want to know is: ‘Are you are safe with patients today?’ ”

Dr. Wible also criticizes state medical boards for asking about mental health impairment over the last 5 years: They don’t get higher than a “C.”

The 13 states with “A” grades either don’t ask about mental health or simply ask about general impairment: Connecticut, Hawaii, Indiana, Kentucky, New Jersey, Maine, Maryland, Massachusetts, Michigan, Nevada, New York, Pennsylvania, and Wyoming.

Massachusetts, for example, asks, “Do you have a medical or physical condition that currently impairs your ability to practice medicine?”

“That is a question anyone can understand,” Dr. Wible said. “I think that’s good wording.”

Going forward, she said, “we’ve got to remove these mental health questions. If we could do this, our profession would be so much better, and we’d lose so many fewer people.”

And, she added, “what we really need to do is share our stories. It’s therapeutic for you and your colleagues, it creates collegial trust and bonding, and it destigmatizes physician mental health.”

Dr. Wible reported no relevant disclosures.

SAN DIEGO – Physician suicide is “a public health crisis because of the sheer volume of people who are dying,” and many medical authorities are contributing to stigma through “invasive” questionnaires, a prevention advocate said at the annual Psych Congress.

“Physicians fear sharing their mental health struggles with the state medical health board,” said Pamela Wible, MD, a family physician who practices in Eugene, Ore., at the meeting. They “pretend, deny, and lie,” she said, and sometimes they seek care and medication hours away in order to avoid detection.

One solution, she said, is to highlight state medical boards that do it right and state medical boards that do it wrong, including the “very worst,” which is that of Alaska.

Dr. Wible, who speaks of suffering from suicidal feelings herself as physician in 2004, is a leading advocate for suicide prevention in the medical profession.

She told colleagues at the Psych Congress that anesthesiologists face the highest risk of suicide, followed by surgeons, ob.gyns., and psychiatrists.

“They end their lives not because they want to die but because they want to stop the pain and they can’t find any other way,” she said. “They have a great work ethic until the end: They’re smiling, doing complex surgeries, and cracking jokes to the surgical team, then they shoot themselves in the closet.”

Colleagues are often shocked, she said: “ ‘Wait a minute. He was just joking with me yesterday. What do you mean he hung himself in his office?’ ‘She just had a newborn baby and she was so happy!’ If you see the smile, you don’t see the pain.”

In 2018, she wrote a Washington Post commentary titled “What I’ve learned from my tally of 757 doctor suicides” that was based on her registry of physician suicides. In the United States, she wrote, 1 million patients lose a physician to suicide each year. Factors contributing to suicides include patient deaths, malpractice suits, “academic distress,” and overwork. “Doctors who need help don’t seek it because they fear mental health care won’t remain confidential,” she wrote. “So they drive out of town, pay cash, and use fake names to hide from state medical boards, hospitals, and insurance plans out of fear that they will lose state licensure, hospital privileges, and health plan participation.”

Dr. Wible oversaw a 2019 research project that analyzed state medical board applications. The goal was to grade the state boards by how intrusively their application questions grill applicants about their mental health history. “Physicians fear sharing their mental health struggles with the state medical health board and with each other,” she said. Some lie, and others – “the really honest physicians” – are so dedicated to telling the truth that “they’ll withhold getting care because they want to correctly check the ‘no’ box.”

Seven states – Alabama, Alaska, Delaware, Florida, Mississippi, Rhode Island, and Washington –received “F” grades for “highly invasive mental health questions unlinked to current impairment that contain confusing, punitive, or adversarial language.”

Roke~commonswiki

Alaska, Dr. Wible said, asks multiple 25 yes-or-no questions about mental health. One question lists 14 conditions, almost all related to mental health – including depression, “any organic mental disorder,” and “any condition requiring chronic medical or behavioral treatment” – and asks, “Have you ever been diagnosed with, treated for, or do you currently have” any of them. This is “the most invasive mental health question we found on any application,” Dr. Wible wrote on her website.

States also hurt applicants by asking peers of applicants about their mental health, she said. “I’m not against getting peer references, but can we stop getting into everyone’s business with their psych history? What we really want to know is: ‘Are you are safe with patients today?’ ”

Dr. Wible also criticizes state medical boards for asking about mental health impairment over the last 5 years: They don’t get higher than a “C.”

The 13 states with “A” grades either don’t ask about mental health or simply ask about general impairment: Connecticut, Hawaii, Indiana, Kentucky, New Jersey, Maine, Maryland, Massachusetts, Michigan, Nevada, New York, Pennsylvania, and Wyoming.

Massachusetts, for example, asks, “Do you have a medical or physical condition that currently impairs your ability to practice medicine?”

“That is a question anyone can understand,” Dr. Wible said. “I think that’s good wording.”

Going forward, she said, “we’ve got to remove these mental health questions. If we could do this, our profession would be so much better, and we’d lose so many fewer people.”

And, she added, “what we really need to do is share our stories. It’s therapeutic for you and your colleagues, it creates collegial trust and bonding, and it destigmatizes physician mental health.”

Dr. Wible reported no relevant disclosures.

SAN DIEGO – Physician suicide is “a public health crisis because of the sheer volume of people who are dying,” and many medical authorities are contributing to stigma through “invasive” questionnaires, a prevention advocate said at the annual Psych Congress.

“Physicians fear sharing their mental health struggles with the state medical health board,” said Pamela Wible, MD, a family physician who practices in Eugene, Ore., at the meeting. They “pretend, deny, and lie,” she said, and sometimes they seek care and medication hours away in order to avoid detection.

One solution, she said, is to highlight state medical boards that do it right and state medical boards that do it wrong, including the “very worst,” which is that of Alaska.

Dr. Wible, who speaks of suffering from suicidal feelings herself as physician in 2004, is a leading advocate for suicide prevention in the medical profession.

She told colleagues at the Psych Congress that anesthesiologists face the highest risk of suicide, followed by surgeons, ob.gyns., and psychiatrists.

“They end their lives not because they want to die but because they want to stop the pain and they can’t find any other way,” she said. “They have a great work ethic until the end: They’re smiling, doing complex surgeries, and cracking jokes to the surgical team, then they shoot themselves in the closet.”

Colleagues are often shocked, she said: “ ‘Wait a minute. He was just joking with me yesterday. What do you mean he hung himself in his office?’ ‘She just had a newborn baby and she was so happy!’ If you see the smile, you don’t see the pain.”

In 2018, she wrote a Washington Post commentary titled “What I’ve learned from my tally of 757 doctor suicides” that was based on her registry of physician suicides. In the United States, she wrote, 1 million patients lose a physician to suicide each year. Factors contributing to suicides include patient deaths, malpractice suits, “academic distress,” and overwork. “Doctors who need help don’t seek it because they fear mental health care won’t remain confidential,” she wrote. “So they drive out of town, pay cash, and use fake names to hide from state medical boards, hospitals, and insurance plans out of fear that they will lose state licensure, hospital privileges, and health plan participation.”

Dr. Wible oversaw a 2019 research project that analyzed state medical board applications. The goal was to grade the state boards by how intrusively their application questions grill applicants about their mental health history. “Physicians fear sharing their mental health struggles with the state medical health board and with each other,” she said. Some lie, and others – “the really honest physicians” – are so dedicated to telling the truth that “they’ll withhold getting care because they want to correctly check the ‘no’ box.”

Seven states – Alabama, Alaska, Delaware, Florida, Mississippi, Rhode Island, and Washington –received “F” grades for “highly invasive mental health questions unlinked to current impairment that contain confusing, punitive, or adversarial language.”

Roke~commonswiki

Alaska, Dr. Wible said, asks multiple 25 yes-or-no questions about mental health. One question lists 14 conditions, almost all related to mental health – including depression, “any organic mental disorder,” and “any condition requiring chronic medical or behavioral treatment” – and asks, “Have you ever been diagnosed with, treated for, or do you currently have” any of them. This is “the most invasive mental health question we found on any application,” Dr. Wible wrote on her website.

States also hurt applicants by asking peers of applicants about their mental health, she said. “I’m not against getting peer references, but can we stop getting into everyone’s business with their psych history? What we really want to know is: ‘Are you are safe with patients today?’ ”

Dr. Wible also criticizes state medical boards for asking about mental health impairment over the last 5 years: They don’t get higher than a “C.”

The 13 states with “A” grades either don’t ask about mental health or simply ask about general impairment: Connecticut, Hawaii, Indiana, Kentucky, New Jersey, Maine, Maryland, Massachusetts, Michigan, Nevada, New York, Pennsylvania, and Wyoming.

Massachusetts, for example, asks, “Do you have a medical or physical condition that currently impairs your ability to practice medicine?”

“That is a question anyone can understand,” Dr. Wible said. “I think that’s good wording.”

Going forward, she said, “we’ve got to remove these mental health questions. If we could do this, our profession would be so much better, and we’d lose so many fewer people.”

And, she added, “what we really need to do is share our stories. It’s therapeutic for you and your colleagues, it creates collegial trust and bonding, and it destigmatizes physician mental health.”

Dr. Wible reported no relevant disclosures.

In a Pediatrics article, Hsuan-hsiu Annie Chen, MD, offers a very personal and candid narrative of her struggle with depression during medical school and residency (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-1210). Dr. Chen knows from personal experience that she was not alone in her cohort as she faced the challenges of sleep deprivation and emotional trauma that continue to be a part of a physician’s education and training. In her discussion of how future medical trainees might be spared some of the long hours she endured, Dr. Chen suggests that this country consider expanding its physician workforce by “increasing the number of medical schools and recruiting foreign medical graduates” as some European countries have done. Dr. Chen now works in the pediatric residency office at Children’s Hospital, Los Angeles.

Cameravit/iStock/Getty Images

Ironically, or maybe it was intentionally, the editors of Pediatrics chose to open the same issue in which Dr. Chen’s personal story appears with a Pediatrics Perspective commentary that looks into the murky waters of physician workforce research (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-0469). Gary L. Freed, MD, MPH, at the Child Health Evaluation and Research Center at the University of Michigan, Ann Arbor, claims that, in general, the data currently being generated by workforce research must be interpreted with caution because many of the studies are flawed by one or more biases.

You may have survived the gauntlet of medical school and residency relatively unscathed. But does your current work environment bring back memories of how stressed you felt on the worst days during your training? Is part of the problem that your clinic is seeing too many patients with too few physicians? Do your colleagues share your opinion? Is the administration actively recruiting more physicians, but failing to find interested and qualified doctors? Is this a strictly local phenomenon limited to your community, or is it a regional shortage? Do you think your situation reflects a national trend that deserves attention?

Like Dr. Chen, do you think that more medical schools and active recruitment of foreign medical students would allow you to work less hours? Obviously, even if you were a teenager when you entered your residency, opening more medical schools is not going to allow you to shorten your workday. But are more medical schools the best solution for this country’s overworked physicians even in the long term? Dr. Freed’s observations should make you hesitant to even venture a guess.

You, I, and Dr. Chen only can report on how we perceive our own work environment. Your local physician shortage may be in part because the school system in your community has a poor reputation and young physicians don’t want to move there. It may be that the hospital that owns your practice is struggling and can’t afford to offer a competitive salary. Producing more physicians may not be the answer to the physician shortage in communities like yours, even in the long run.

This is a very large country with relatively porous boundaries between the states for physicians. Physician supply and demand seldom dictates where physicians choose to practice. In fact, a medically needy community is probably the least likely place a physician just finishing her training will choose to settle.

Although adding another physician to your practice may decrease your workload, can your personal finances handle the hit that might occur as you see less patients? Particularly, if the new hire turns out to be a rock star who siphons off more of your patients than you anticipated. On the other hand, there is always the chance that, despite careful vetting, your group hires a lemon who ends up creating more trouble than he is worth.

As Dr. Freed suggests, trying to determine just how many and what kind of physicians we need is complicated. It may be just a roll of the dice at best.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

In a Pediatrics article, Hsuan-hsiu Annie Chen, MD, offers a very personal and candid narrative of her struggle with depression during medical school and residency (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-1210). Dr. Chen knows from personal experience that she was not alone in her cohort as she faced the challenges of sleep deprivation and emotional trauma that continue to be a part of a physician’s education and training. In her discussion of how future medical trainees might be spared some of the long hours she endured, Dr. Chen suggests that this country consider expanding its physician workforce by “increasing the number of medical schools and recruiting foreign medical graduates” as some European countries have done. Dr. Chen now works in the pediatric residency office at Children’s Hospital, Los Angeles.

Cameravit/iStock/Getty Images

Ironically, or maybe it was intentionally, the editors of Pediatrics chose to open the same issue in which Dr. Chen’s personal story appears with a Pediatrics Perspective commentary that looks into the murky waters of physician workforce research (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-0469). Gary L. Freed, MD, MPH, at the Child Health Evaluation and Research Center at the University of Michigan, Ann Arbor, claims that, in general, the data currently being generated by workforce research must be interpreted with caution because many of the studies are flawed by one or more biases.

You may have survived the gauntlet of medical school and residency relatively unscathed. But does your current work environment bring back memories of how stressed you felt on the worst days during your training? Is part of the problem that your clinic is seeing too many patients with too few physicians? Do your colleagues share your opinion? Is the administration actively recruiting more physicians, but failing to find interested and qualified doctors? Is this a strictly local phenomenon limited to your community, or is it a regional shortage? Do you think your situation reflects a national trend that deserves attention?

Like Dr. Chen, do you think that more medical schools and active recruitment of foreign medical students would allow you to work less hours? Obviously, even if you were a teenager when you entered your residency, opening more medical schools is not going to allow you to shorten your workday. But are more medical schools the best solution for this country’s overworked physicians even in the long term? Dr. Freed’s observations should make you hesitant to even venture a guess.

You, I, and Dr. Chen only can report on how we perceive our own work environment. Your local physician shortage may be in part because the school system in your community has a poor reputation and young physicians don’t want to move there. It may be that the hospital that owns your practice is struggling and can’t afford to offer a competitive salary. Producing more physicians may not be the answer to the physician shortage in communities like yours, even in the long run.

This is a very large country with relatively porous boundaries between the states for physicians. Physician supply and demand seldom dictates where physicians choose to practice. In fact, a medically needy community is probably the least likely place a physician just finishing her training will choose to settle.

Although adding another physician to your practice may decrease your workload, can your personal finances handle the hit that might occur as you see less patients? Particularly, if the new hire turns out to be a rock star who siphons off more of your patients than you anticipated. On the other hand, there is always the chance that, despite careful vetting, your group hires a lemon who ends up creating more trouble than he is worth.

As Dr. Freed suggests, trying to determine just how many and what kind of physicians we need is complicated. It may be just a roll of the dice at best.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

In a Pediatrics article, Hsuan-hsiu Annie Chen, MD, offers a very personal and candid narrative of her struggle with depression during medical school and residency (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-1210). Dr. Chen knows from personal experience that she was not alone in her cohort as she faced the challenges of sleep deprivation and emotional trauma that continue to be a part of a physician’s education and training. In her discussion of how future medical trainees might be spared some of the long hours she endured, Dr. Chen suggests that this country consider expanding its physician workforce by “increasing the number of medical schools and recruiting foreign medical graduates” as some European countries have done. Dr. Chen now works in the pediatric residency office at Children’s Hospital, Los Angeles.

Cameravit/iStock/Getty Images

Ironically, or maybe it was intentionally, the editors of Pediatrics chose to open the same issue in which Dr. Chen’s personal story appears with a Pediatrics Perspective commentary that looks into the murky waters of physician workforce research (Pediatrics. 2019 Sep 1. doi: 10.1542/peds.2019-0469). Gary L. Freed, MD, MPH, at the Child Health Evaluation and Research Center at the University of Michigan, Ann Arbor, claims that, in general, the data currently being generated by workforce research must be interpreted with caution because many of the studies are flawed by one or more biases.

You may have survived the gauntlet of medical school and residency relatively unscathed. But does your current work environment bring back memories of how stressed you felt on the worst days during your training? Is part of the problem that your clinic is seeing too many patients with too few physicians? Do your colleagues share your opinion? Is the administration actively recruiting more physicians, but failing to find interested and qualified doctors? Is this a strictly local phenomenon limited to your community, or is it a regional shortage? Do you think your situation reflects a national trend that deserves attention?

Like Dr. Chen, do you think that more medical schools and active recruitment of foreign medical students would allow you to work less hours? Obviously, even if you were a teenager when you entered your residency, opening more medical schools is not going to allow you to shorten your workday. But are more medical schools the best solution for this country’s overworked physicians even in the long term? Dr. Freed’s observations should make you hesitant to even venture a guess.

You, I, and Dr. Chen only can report on how we perceive our own work environment. Your local physician shortage may be in part because the school system in your community has a poor reputation and young physicians don’t want to move there. It may be that the hospital that owns your practice is struggling and can’t afford to offer a competitive salary. Producing more physicians may not be the answer to the physician shortage in communities like yours, even in the long run.

This is a very large country with relatively porous boundaries between the states for physicians. Physician supply and demand seldom dictates where physicians choose to practice. In fact, a medically needy community is probably the least likely place a physician just finishing her training will choose to settle.

Although adding another physician to your practice may decrease your workload, can your personal finances handle the hit that might occur as you see less patients? Particularly, if the new hire turns out to be a rock star who siphons off more of your patients than you anticipated. On the other hand, there is always the chance that, despite careful vetting, your group hires a lemon who ends up creating more trouble than he is worth.

As Dr. Freed suggests, trying to determine just how many and what kind of physicians we need is complicated. It may be just a roll of the dice at best.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

WASHINGTON – Evidence continues to mount that infants born to moms infected with Zika virus during pregnancy can have neurodevelopmental abnormalities as they age even if they showed no defects at birth, based on follow-up of 890 Colombian children tracked by epidemiologists from the U.S. Centers for Disease Control and Prevention.

Among the 890 neonates born to mothers apparently infected with Zika during pregnancy and followed for up to 2 years, 40 of the 852 (5%) without a detectable birth defect at delivery went on to show some type of neurodevelopmental sequelae during up to 24 months of age, Margaret Honein, PhD, said at an annual scientific meeting on infectious diseases.

In addition, among the children without birth defects at delivery who received follow-up examinations out to about 2 years, the incidence of “alerts” for possible neurodevelopmental issues was 15%-20% for each of the four domains studied (gross motor, fine motor, hearing and language, and personal and social functions), said Dr. Honein, an epidemiologist and chief of the birth defects branch of the CDC. In contrast, 17 of the 38 children (45%) followed who had identifiable birth defects at delivery also showed neurodevelopmental abnormalities when reexamined as long as 2 years after birth. These possible neurodevelopmental abnormalities, designated as alerts, were identified in comparison with a contemporaneous cohort of children born to uninfected mothers in the same regions of Colombia and assessed by the CDC researchers.

This cohort of children born to mothers who became infected with Zika virus during the 2016 Colombian epidemic will not undergo any planned, additional follow-up beyond the initial 2 years, Dr. Honein noted.

The findings she reported were consistent with observations from a much smaller cohort of 70 infants born to Colombian mothers infected with Zika virus while pregnant who had a normal head circumference and a normal clinical examination at delivery. When assessed once or twice 4-18 months after birth, these 70 infants showed an overall greater than one standard deviation (z-score) drop in their scores on the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA) metric by 12 months after birth and continuing out to 18 months, said Sarah B. Mulkey, MD, a fetal-neonatal neurologist at Children’s National Health System in Washington. These deficits were especially pronounced in the mobility and social cognition domains of the four-domain WIDEA metric. The social cognition domain is an important predictor of later problems with executive function and other neurologic disorders, Dr. Mulkey said while reporting her findings in a separate talk at the meeting. She acknowledged that the analysis was flawed by comparing the WIDEA outcomes of the Zika virus–exposed children to healthy children from either inner-city Chicago or Canada. Dr. Mulkey said that she and her associates plan to characterize a population of Zika virus–unexposed children in Colombia to use for future comparisons.

The study reported by Dr. Honein involved an enhanced surveillance program launched by the CDC in 2016 in three regions of Colombia and included 1,190 pregnancies accompanied by Zika symptoms in the mother and with a reported pregnancy outcome, including 1,185 live births. Nearly half of the Zika infections occurred during the first trimester, and 34% occurred during the second trimester. However, fewer than a third of the pregnant women underwent some type of laboratory testing to confirm their infection, either by serology or by a DNA-based assay, and of these 28% had a positive finding. Dr. Honein cautioned that many of the specimens that tested negative for Zika virus may have been false negatives.

The birth defects identified among the infants born from an apparently affected pregnancy included brain abnormalities, eye anomalies, and microcephaly, with 5% of the 1,185 live births showing one or more of these outcomes. The neurodevelopmental deficits identified during follow-up of 890 of the children out to 2 years included seizures; abnormalities of tone, movement, or swallowing; and impairments of vision or hearing.

[email protected]

WASHINGTON – Evidence continues to mount that infants born to moms infected with Zika virus during pregnancy can have neurodevelopmental abnormalities as they age even if they showed no defects at birth, based on follow-up of 890 Colombian children tracked by epidemiologists from the U.S. Centers for Disease Control and Prevention.

Among the 890 neonates born to mothers apparently infected with Zika during pregnancy and followed for up to 2 years, 40 of the 852 (5%) without a detectable birth defect at delivery went on to show some type of neurodevelopmental sequelae during up to 24 months of age, Margaret Honein, PhD, said at an annual scientific meeting on infectious diseases.

In addition, among the children without birth defects at delivery who received follow-up examinations out to about 2 years, the incidence of “alerts” for possible neurodevelopmental issues was 15%-20% for each of the four domains studied (gross motor, fine motor, hearing and language, and personal and social functions), said Dr. Honein, an epidemiologist and chief of the birth defects branch of the CDC. In contrast, 17 of the 38 children (45%) followed who had identifiable birth defects at delivery also showed neurodevelopmental abnormalities when reexamined as long as 2 years after birth. These possible neurodevelopmental abnormalities, designated as alerts, were identified in comparison with a contemporaneous cohort of children born to uninfected mothers in the same regions of Colombia and assessed by the CDC researchers.

This cohort of children born to mothers who became infected with Zika virus during the 2016 Colombian epidemic will not undergo any planned, additional follow-up beyond the initial 2 years, Dr. Honein noted.

The findings she reported were consistent with observations from a much smaller cohort of 70 infants born to Colombian mothers infected with Zika virus while pregnant who had a normal head circumference and a normal clinical examination at delivery. When assessed once or twice 4-18 months after birth, these 70 infants showed an overall greater than one standard deviation (z-score) drop in their scores on the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA) metric by 12 months after birth and continuing out to 18 months, said Sarah B. Mulkey, MD, a fetal-neonatal neurologist at Children’s National Health System in Washington. These deficits were especially pronounced in the mobility and social cognition domains of the four-domain WIDEA metric. The social cognition domain is an important predictor of later problems with executive function and other neurologic disorders, Dr. Mulkey said while reporting her findings in a separate talk at the meeting. She acknowledged that the analysis was flawed by comparing the WIDEA outcomes of the Zika virus–exposed children to healthy children from either inner-city Chicago or Canada. Dr. Mulkey said that she and her associates plan to characterize a population of Zika virus–unexposed children in Colombia to use for future comparisons.

The study reported by Dr. Honein involved an enhanced surveillance program launched by the CDC in 2016 in three regions of Colombia and included 1,190 pregnancies accompanied by Zika symptoms in the mother and with a reported pregnancy outcome, including 1,185 live births. Nearly half of the Zika infections occurred during the first trimester, and 34% occurred during the second trimester. However, fewer than a third of the pregnant women underwent some type of laboratory testing to confirm their infection, either by serology or by a DNA-based assay, and of these 28% had a positive finding. Dr. Honein cautioned that many of the specimens that tested negative for Zika virus may have been false negatives.

The birth defects identified among the infants born from an apparently affected pregnancy included brain abnormalities, eye anomalies, and microcephaly, with 5% of the 1,185 live births showing one or more of these outcomes. The neurodevelopmental deficits identified during follow-up of 890 of the children out to 2 years included seizures; abnormalities of tone, movement, or swallowing; and impairments of vision or hearing.

[email protected]

WASHINGTON – Evidence continues to mount that infants born to moms infected with Zika virus during pregnancy can have neurodevelopmental abnormalities as they age even if they showed no defects at birth, based on follow-up of 890 Colombian children tracked by epidemiologists from the U.S. Centers for Disease Control and Prevention.

Among the 890 neonates born to mothers apparently infected with Zika during pregnancy and followed for up to 2 years, 40 of the 852 (5%) without a detectable birth defect at delivery went on to show some type of neurodevelopmental sequelae during up to 24 months of age, Margaret Honein, PhD, said at an annual scientific meeting on infectious diseases.

In addition, among the children without birth defects at delivery who received follow-up examinations out to about 2 years, the incidence of “alerts” for possible neurodevelopmental issues was 15%-20% for each of the four domains studied (gross motor, fine motor, hearing and language, and personal and social functions), said Dr. Honein, an epidemiologist and chief of the birth defects branch of the CDC. In contrast, 17 of the 38 children (45%) followed who had identifiable birth defects at delivery also showed neurodevelopmental abnormalities when reexamined as long as 2 years after birth. These possible neurodevelopmental abnormalities, designated as alerts, were identified in comparison with a contemporaneous cohort of children born to uninfected mothers in the same regions of Colombia and assessed by the CDC researchers.

This cohort of children born to mothers who became infected with Zika virus during the 2016 Colombian epidemic will not undergo any planned, additional follow-up beyond the initial 2 years, Dr. Honein noted.

The findings she reported were consistent with observations from a much smaller cohort of 70 infants born to Colombian mothers infected with Zika virus while pregnant who had a normal head circumference and a normal clinical examination at delivery. When assessed once or twice 4-18 months after birth, these 70 infants showed an overall greater than one standard deviation (z-score) drop in their scores on the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA) metric by 12 months after birth and continuing out to 18 months, said Sarah B. Mulkey, MD, a fetal-neonatal neurologist at Children’s National Health System in Washington. These deficits were especially pronounced in the mobility and social cognition domains of the four-domain WIDEA metric. The social cognition domain is an important predictor of later problems with executive function and other neurologic disorders, Dr. Mulkey said while reporting her findings in a separate talk at the meeting. She acknowledged that the analysis was flawed by comparing the WIDEA outcomes of the Zika virus–exposed children to healthy children from either inner-city Chicago or Canada. Dr. Mulkey said that she and her associates plan to characterize a population of Zika virus–unexposed children in Colombia to use for future comparisons.

The study reported by Dr. Honein involved an enhanced surveillance program launched by the CDC in 2016 in three regions of Colombia and included 1,190 pregnancies accompanied by Zika symptoms in the mother and with a reported pregnancy outcome, including 1,185 live births. Nearly half of the Zika infections occurred during the first trimester, and 34% occurred during the second trimester. However, fewer than a third of the pregnant women underwent some type of laboratory testing to confirm their infection, either by serology or by a DNA-based assay, and of these 28% had a positive finding. Dr. Honein cautioned that many of the specimens that tested negative for Zika virus may have been false negatives.

The birth defects identified among the infants born from an apparently affected pregnancy included brain abnormalities, eye anomalies, and microcephaly, with 5% of the 1,185 live births showing one or more of these outcomes. The neurodevelopmental deficits identified during follow-up of 890 of the children out to 2 years included seizures; abnormalities of tone, movement, or swallowing; and impairments of vision or hearing.

[email protected]