Half a million people. That’s pretty close to the population of Sacramento. It’s also the estimated number of adults living with chronic urticaria in the United States, according to analysis of a database including over 55 million individuals.

That cross-sectional analysis put the overall standardized prevalence of chronic urticaria in the United States at 0.23%, or 229.8 per 100,000 adults, with women’s prevalence well above at 309.3 per 100,000 (0.31%) and men well below at 145.5 per 100,000 (0.15%), Sara Wertenteil, BA, and her associates at Hofstra University, Hempstead, N.Y., wrote in the Journal of the American Academy of Dermatology.

Overall prevalence of chronic urticaria was similar for all age groups, ranging from 0.21% for those aged 18-29 years and those aged 30-39 years to 0.26% for those aged 40-49, and prevalence was higher for females than males in all age groups, the investigators reported.

“Epidemiologic studies estimating disease burden for chronic urticaria are sparse, [but this study] is based on one of the largest and most ethnically diversified population samples in the United States. It is also drawn from patients with all insurance types and self-pay patients across various types of health care settings and from all census regions,” Ms. Wertenteil and her associates wrote.


The study involved an IBM Watson Health database encompassing 27 participating integrated health care organizations and representing approximately 17% of the population. The analysis identified 69,570 adult patients with chronic urticaria, and the ratio of women to men was 2.7:1.

The senior author, Amit Garg, MD, has served as an advisor for AbbVie, Pfizer, Janssen, and Asana Biosciences.

[email protected]

SOURCE: Wertenteil S et al. J Am Acad Dermatol. 2019. doi: 10.1016/j.jaad.2019.02.064.

Half a million people. That’s pretty close to the population of Sacramento. It’s also the estimated number of adults living with chronic urticaria in the United States, according to analysis of a database including over 55 million individuals.

That cross-sectional analysis put the overall standardized prevalence of chronic urticaria in the United States at 0.23%, or 229.8 per 100,000 adults, with women’s prevalence well above at 309.3 per 100,000 (0.31%) and men well below at 145.5 per 100,000 (0.15%), Sara Wertenteil, BA, and her associates at Hofstra University, Hempstead, N.Y., wrote in the Journal of the American Academy of Dermatology.

Overall prevalence of chronic urticaria was similar for all age groups, ranging from 0.21% for those aged 18-29 years and those aged 30-39 years to 0.26% for those aged 40-49, and prevalence was higher for females than males in all age groups, the investigators reported.

“Epidemiologic studies estimating disease burden for chronic urticaria are sparse, [but this study] is based on one of the largest and most ethnically diversified population samples in the United States. It is also drawn from patients with all insurance types and self-pay patients across various types of health care settings and from all census regions,” Ms. Wertenteil and her associates wrote.


The study involved an IBM Watson Health database encompassing 27 participating integrated health care organizations and representing approximately 17% of the population. The analysis identified 69,570 adult patients with chronic urticaria, and the ratio of women to men was 2.7:1.

The senior author, Amit Garg, MD, has served as an advisor for AbbVie, Pfizer, Janssen, and Asana Biosciences.

[email protected]

SOURCE: Wertenteil S et al. J Am Acad Dermatol. 2019. doi: 10.1016/j.jaad.2019.02.064.

Half a million people. That’s pretty close to the population of Sacramento. It’s also the estimated number of adults living with chronic urticaria in the United States, according to analysis of a database including over 55 million individuals.

That cross-sectional analysis put the overall standardized prevalence of chronic urticaria in the United States at 0.23%, or 229.8 per 100,000 adults, with women’s prevalence well above at 309.3 per 100,000 (0.31%) and men well below at 145.5 per 100,000 (0.15%), Sara Wertenteil, BA, and her associates at Hofstra University, Hempstead, N.Y., wrote in the Journal of the American Academy of Dermatology.

Overall prevalence of chronic urticaria was similar for all age groups, ranging from 0.21% for those aged 18-29 years and those aged 30-39 years to 0.26% for those aged 40-49, and prevalence was higher for females than males in all age groups, the investigators reported.

“Epidemiologic studies estimating disease burden for chronic urticaria are sparse, [but this study] is based on one of the largest and most ethnically diversified population samples in the United States. It is also drawn from patients with all insurance types and self-pay patients across various types of health care settings and from all census regions,” Ms. Wertenteil and her associates wrote.


The study involved an IBM Watson Health database encompassing 27 participating integrated health care organizations and representing approximately 17% of the population. The analysis identified 69,570 adult patients with chronic urticaria, and the ratio of women to men was 2.7:1.

The senior author, Amit Garg, MD, has served as an advisor for AbbVie, Pfizer, Janssen, and Asana Biosciences.

[email protected]

SOURCE: Wertenteil S et al. J Am Acad Dermatol. 2019. doi: 10.1016/j.jaad.2019.02.064.

ORLANDO – Using games to promote exercise – or “exergaming” – is proving to boost the motivation of schizophrenia patients to engage in physical activity and help with symptoms, researchers said at the annual congress of the Schizophrenia International Research Society.

Physical fitness has been shown to boost cognitive function in people with schizophrenia – a particularly attractive option because it does not create stigma in the way that engaging in in-person therapy or taking medications might – and it is essentially free of side effects, said Jimmy Choi, PsyD, a senior scientist at the Olin Neuropsychiatry Research Center and staff neuropsychologist at the Institute of Living’s Schizophrenia Rehabilitation Program in Hartford, Conn.

The problem, Dr. Choi said, is that many studies have shown that compliance – or completion of half of an exercise program by participants – is fairly low, at 65%-68%. Among those who are not compliant, the benefits of exercise programs on cognition, psychosis symptoms, and mental status are conspicuously lower.

Effect sizes in laboratory trials on the efficacy of physical fitness are much higher than effectiveness seen in studies of community programs, Dr. Choi said, likely because laboratory trials offer participants a monetary reward for participation, while community studies might offer less attractive incentives, such as tickets for weekly or monthly raffles.

At Olin, a more true-to-life community program of exergaming – which included the use of virtual reality – was created by recreational therapists, exercise physiologists, psychologists, and technology experts to optimize the experience and outcomes, each with a distinct role – either developing the overall experience to promote enjoyment, achieving exhaustion but without an injury risk, incorporating patients’ baseline cognitive profile to make the programs suitable, or tailoring virtual experiences for each participant.

With 35 participants, researchers saw encouraging effects on working memory, processing speed, as well as positive and negative schizophrenia symptoms – with effect sizes ranging from 0.54 for working memory scores to 0.19 for positive schizophrenia symptoms, such as hallucinations.

The attrition rate of 14% was the same for those assessed as having low motivation as it was for those assessed as having high motivation, suggesting that exergaming helped boost and sustain motivation among patients for whom it is usually difficult, said Dr. Choi, who added that he and his colleagues have a paper in press outlining these results in Schizophrenia Research: Cognition.

“Exergaming shows promise in improving adherence to physical exercise and reducing attrition,” he said. “Highly motivated participants benefited more in terms of cognition and symptoms, but even those with low motivation saw improvements in working memory and negative symptoms.”

Dr. Choi added that his center is continuing to evaluate exergaming.

“A nice bike exercise or treadmill, that’s still more portable and cheaper for community clinics to do,” he said. “That’s one of the reasons ... we’re currently doing a randomized, controlled trial looking to see if exergaming could stand up to doing a singular exercise aerobic program.”

The study and Exergame equipment were funded by a Hartford Hospital auxiliary special projects grant. Dr. Choi reported having no financial conflicts.

ORLANDO – Using games to promote exercise – or “exergaming” – is proving to boost the motivation of schizophrenia patients to engage in physical activity and help with symptoms, researchers said at the annual congress of the Schizophrenia International Research Society.

Physical fitness has been shown to boost cognitive function in people with schizophrenia – a particularly attractive option because it does not create stigma in the way that engaging in in-person therapy or taking medications might – and it is essentially free of side effects, said Jimmy Choi, PsyD, a senior scientist at the Olin Neuropsychiatry Research Center and staff neuropsychologist at the Institute of Living’s Schizophrenia Rehabilitation Program in Hartford, Conn.

The problem, Dr. Choi said, is that many studies have shown that compliance – or completion of half of an exercise program by participants – is fairly low, at 65%-68%. Among those who are not compliant, the benefits of exercise programs on cognition, psychosis symptoms, and mental status are conspicuously lower.

Effect sizes in laboratory trials on the efficacy of physical fitness are much higher than effectiveness seen in studies of community programs, Dr. Choi said, likely because laboratory trials offer participants a monetary reward for participation, while community studies might offer less attractive incentives, such as tickets for weekly or monthly raffles.

At Olin, a more true-to-life community program of exergaming – which included the use of virtual reality – was created by recreational therapists, exercise physiologists, psychologists, and technology experts to optimize the experience and outcomes, each with a distinct role – either developing the overall experience to promote enjoyment, achieving exhaustion but without an injury risk, incorporating patients’ baseline cognitive profile to make the programs suitable, or tailoring virtual experiences for each participant.

With 35 participants, researchers saw encouraging effects on working memory, processing speed, as well as positive and negative schizophrenia symptoms – with effect sizes ranging from 0.54 for working memory scores to 0.19 for positive schizophrenia symptoms, such as hallucinations.

The attrition rate of 14% was the same for those assessed as having low motivation as it was for those assessed as having high motivation, suggesting that exergaming helped boost and sustain motivation among patients for whom it is usually difficult, said Dr. Choi, who added that he and his colleagues have a paper in press outlining these results in Schizophrenia Research: Cognition.

“Exergaming shows promise in improving adherence to physical exercise and reducing attrition,” he said. “Highly motivated participants benefited more in terms of cognition and symptoms, but even those with low motivation saw improvements in working memory and negative symptoms.”

Dr. Choi added that his center is continuing to evaluate exergaming.

“A nice bike exercise or treadmill, that’s still more portable and cheaper for community clinics to do,” he said. “That’s one of the reasons ... we’re currently doing a randomized, controlled trial looking to see if exergaming could stand up to doing a singular exercise aerobic program.”

The study and Exergame equipment were funded by a Hartford Hospital auxiliary special projects grant. Dr. Choi reported having no financial conflicts.

ORLANDO – Using games to promote exercise – or “exergaming” – is proving to boost the motivation of schizophrenia patients to engage in physical activity and help with symptoms, researchers said at the annual congress of the Schizophrenia International Research Society.

Physical fitness has been shown to boost cognitive function in people with schizophrenia – a particularly attractive option because it does not create stigma in the way that engaging in in-person therapy or taking medications might – and it is essentially free of side effects, said Jimmy Choi, PsyD, a senior scientist at the Olin Neuropsychiatry Research Center and staff neuropsychologist at the Institute of Living’s Schizophrenia Rehabilitation Program in Hartford, Conn.

The problem, Dr. Choi said, is that many studies have shown that compliance – or completion of half of an exercise program by participants – is fairly low, at 65%-68%. Among those who are not compliant, the benefits of exercise programs on cognition, psychosis symptoms, and mental status are conspicuously lower.

Effect sizes in laboratory trials on the efficacy of physical fitness are much higher than effectiveness seen in studies of community programs, Dr. Choi said, likely because laboratory trials offer participants a monetary reward for participation, while community studies might offer less attractive incentives, such as tickets for weekly or monthly raffles.

At Olin, a more true-to-life community program of exergaming – which included the use of virtual reality – was created by recreational therapists, exercise physiologists, psychologists, and technology experts to optimize the experience and outcomes, each with a distinct role – either developing the overall experience to promote enjoyment, achieving exhaustion but without an injury risk, incorporating patients’ baseline cognitive profile to make the programs suitable, or tailoring virtual experiences for each participant.

With 35 participants, researchers saw encouraging effects on working memory, processing speed, as well as positive and negative schizophrenia symptoms – with effect sizes ranging from 0.54 for working memory scores to 0.19 for positive schizophrenia symptoms, such as hallucinations.

The attrition rate of 14% was the same for those assessed as having low motivation as it was for those assessed as having high motivation, suggesting that exergaming helped boost and sustain motivation among patients for whom it is usually difficult, said Dr. Choi, who added that he and his colleagues have a paper in press outlining these results in Schizophrenia Research: Cognition.

“Exergaming shows promise in improving adherence to physical exercise and reducing attrition,” he said. “Highly motivated participants benefited more in terms of cognition and symptoms, but even those with low motivation saw improvements in working memory and negative symptoms.”

Dr. Choi added that his center is continuing to evaluate exergaming.

“A nice bike exercise or treadmill, that’s still more portable and cheaper for community clinics to do,” he said. “That’s one of the reasons ... we’re currently doing a randomized, controlled trial looking to see if exergaming could stand up to doing a singular exercise aerobic program.”

The study and Exergame equipment were funded by a Hartford Hospital auxiliary special projects grant. Dr. Choi reported having no financial conflicts.

Measles cases in the United States for this year have officially passed the postelimination high set in 2014, according to the Centers for Disease Control and Prevention.

As of Wednesday, April 24, the case count for measles is 695, which eclipses the mark of 667 cases that had been the highest since the disease was declared to be eliminated from this country in 2000, the CDC reported.

“The high number of cases in 2019 is primarily the result of a few large outbreaks – one in Washington State and two large outbreaks in New York that started in late 2018. The outbreaks in New York City and New York State are among the largest and longest lasting since measles elimination in 2000. The longer these outbreaks continue, the greater the chance measles will again get a sustained foothold in the United States,” according to a written statement by the CDC.


Although these outbreaks began when the virus was brought into this country by unvaccinated travelers from other countries where there is widespread transmission, “a significant factor contributing to the outbreaks in New York is misinformation in the communities about the safety of the measles/mumps/rubella vaccine. Some organizations are deliberately targeting these communities with inaccurate and misleading information about vaccines,” according to the statement.

“Measles is not a harmless childhood illness, but a highly contagious, potentially life-threatening disease,” Health and Human Services Secretary Alex Azar said in a separate statement. “We have the ability to safely protect our children and our communities. Vaccines are a safe, highly effective public health solution that can prevent this disease. The measles vaccines are among the most extensively studied medical products we have, and their safety has been firmly established over many years in some of the largest vaccine studies ever undertaken. With a safe and effective vaccine that protects against measles, the suffering we are seeing is avoidable.”

[email protected]

Measles cases in the United States for this year have officially passed the postelimination high set in 2014, according to the Centers for Disease Control and Prevention.

As of Wednesday, April 24, the case count for measles is 695, which eclipses the mark of 667 cases that had been the highest since the disease was declared to be eliminated from this country in 2000, the CDC reported.

“The high number of cases in 2019 is primarily the result of a few large outbreaks – one in Washington State and two large outbreaks in New York that started in late 2018. The outbreaks in New York City and New York State are among the largest and longest lasting since measles elimination in 2000. The longer these outbreaks continue, the greater the chance measles will again get a sustained foothold in the United States,” according to a written statement by the CDC.


Although these outbreaks began when the virus was brought into this country by unvaccinated travelers from other countries where there is widespread transmission, “a significant factor contributing to the outbreaks in New York is misinformation in the communities about the safety of the measles/mumps/rubella vaccine. Some organizations are deliberately targeting these communities with inaccurate and misleading information about vaccines,” according to the statement.

“Measles is not a harmless childhood illness, but a highly contagious, potentially life-threatening disease,” Health and Human Services Secretary Alex Azar said in a separate statement. “We have the ability to safely protect our children and our communities. Vaccines are a safe, highly effective public health solution that can prevent this disease. The measles vaccines are among the most extensively studied medical products we have, and their safety has been firmly established over many years in some of the largest vaccine studies ever undertaken. With a safe and effective vaccine that protects against measles, the suffering we are seeing is avoidable.”

[email protected]

Measles cases in the United States for this year have officially passed the postelimination high set in 2014, according to the Centers for Disease Control and Prevention.

As of Wednesday, April 24, the case count for measles is 695, which eclipses the mark of 667 cases that had been the highest since the disease was declared to be eliminated from this country in 2000, the CDC reported.

“The high number of cases in 2019 is primarily the result of a few large outbreaks – one in Washington State and two large outbreaks in New York that started in late 2018. The outbreaks in New York City and New York State are among the largest and longest lasting since measles elimination in 2000. The longer these outbreaks continue, the greater the chance measles will again get a sustained foothold in the United States,” according to a written statement by the CDC.


Although these outbreaks began when the virus was brought into this country by unvaccinated travelers from other countries where there is widespread transmission, “a significant factor contributing to the outbreaks in New York is misinformation in the communities about the safety of the measles/mumps/rubella vaccine. Some organizations are deliberately targeting these communities with inaccurate and misleading information about vaccines,” according to the statement.

“Measles is not a harmless childhood illness, but a highly contagious, potentially life-threatening disease,” Health and Human Services Secretary Alex Azar said in a separate statement. “We have the ability to safely protect our children and our communities. Vaccines are a safe, highly effective public health solution that can prevent this disease. The measles vaccines are among the most extensively studied medical products we have, and their safety has been firmly established over many years in some of the largest vaccine studies ever undertaken. With a safe and effective vaccine that protects against measles, the suffering we are seeing is avoidable.”

[email protected]

GLASGOW – Neurological abnormalities and elevated troponin predict mortality in patients with thrombotic thrombocytopenic purpura (TTP), according to retrospective analysis of 475 patients from the United Kingdom TTP registry.

Will Pass/MDedge News

In addition, low ADAMTS13 activity (less than 10%) was present in 92% of immune-mediated of TTP upon acute presentation, reported lead author Jin-Sup Shin, MD, of University College London Hospital, and colleagues.

Presenting at the annual meeting of the British Society for Haematology, Dr. Shin provided some background on TTP, a condition that most clinicians encounter infrequently.

“As recently as the 1980s and 90s, when etiology was not that well understood, TTP was associated with an untreated mortality of up to 90%,” Dr. Shin said. “However, based on improved understanding of pathophysiology, and through the creation of TTP registries worldwide, there have been major advances in diagnosis, treatment, and outcomes.”

To gain insight into diagnostic and prognostic characteristics of TTP, the investigators turned to data from 602 patients with clinically suspected TTP, based on an ADAMTS13 activity level less than 10% of normal and associated clinical signs. Out of these 602 patients, 475 consented to registry participation and data analysis.

The analysis revealed a mortality rate of 4%, although Dr. Shin said that “this is probably an underestimate of the true figure,” as it excludes those who died before treatment could be initiated.

Nearly three-quarters of patients were female. The median age at presentation was 43 years, with a range of 1-93 years. The most commonly represented racial/ethnic groups were white (60%) and Afro-Caribbean (22%). Some cases were congenital (16%), but the majority were immune mediated (84%).

The immune-mediated group was the primary focus of Dr. Shin’s report. In this cohort, 76% of cases were idiopathic, while the remainder had a defined precipitant; most common were infection, autoimmune disease, pregnancy, and HIV. The relapse rate among those with immune-mediated TTP was 19%, after a median time to relapse of 26 months.

In total, 71% of patients presented with neurological abnormalities, while slightly less than half (48%) had symptomatic thrombocytopenia (bleeding/petechiae).

Diagnostic tools showed that 64% of patients had an elevated troponin level, 92% had ADAMTS13 activity less than 10%, and 25% had a platelet count lower than 10 x 10⁹/L.

Median platelet count upon presentation was 15 x 10⁹/L, and median lactate dehydrogenase (LDH) exceeded 1,000 units/L. After 7 days of therapy, 58% of patients were still severely deficient in ADAMTS13 activity and 36% of patients still had a platelet count lower than 150 x 10⁹/L.

Where information was available, 30% of patients had positive auto-antibody screens, although not necessarily with signs or symptoms of autoimmune disease. A total of 93% of patients had elevated ADAMTS13 IgG antibody upon presentation. The median ADAMTS13 IgG antibody level at presentation was 37%, with a normal value being less than 6%.

Nearly half of patients with immune-mediated TTP (45%) required intensive care, and 10% of these patients were intubated and ventilated. Most patients were treated with steroids upon admission (81%). On average, 11 plasma exchanges (PEXs) were required before remission.

The investigators noted that “[t]he number of PEXs to remission appears to have decreased over the years.” As an example, a median of 14 PEXs were needed from 2009 to 2010, compared with 8 from 2017 to 2018.

Although rituximab usage in the acute setting held steady over the 10-year period, elective use increased. Out of 89 instances of subacute relapse, elective rituximab was given twice from 2009 to 2010, compared with 26 times from 2017 to 2018.

Comparing features of survival, the investigators found that the median ADAMTS13 IgG antibody level was higher among those who died. Other factors related to increased mortality risk included raised troponin (sevenfold increased risk) and neurological abnormalities, defined by reduced Glasgow Coma Scale score (sixfold increased risk).

“Our data confirm other registries worldwide; in particular, increased susceptibility in women, the Afro-Caribbean population, and those who are middle-aged,” Dr. Shin said. “Our data also show that elevated cardiac troponin and neurological involvement are indicators of poor prognosis. Also, raised antibody levels appear to be associated with a worse clinical outcome and increased mortality rate. These are clearly valuable markers in clinical practice, allowing for intensive care of high-risk patients.”

The investigators reported having no conflicts of interest.
 

GLASGOW – Neurological abnormalities and elevated troponin predict mortality in patients with thrombotic thrombocytopenic purpura (TTP), according to retrospective analysis of 475 patients from the United Kingdom TTP registry.

Will Pass/MDedge News

In addition, low ADAMTS13 activity (less than 10%) was present in 92% of immune-mediated of TTP upon acute presentation, reported lead author Jin-Sup Shin, MD, of University College London Hospital, and colleagues.

Presenting at the annual meeting of the British Society for Haematology, Dr. Shin provided some background on TTP, a condition that most clinicians encounter infrequently.

“As recently as the 1980s and 90s, when etiology was not that well understood, TTP was associated with an untreated mortality of up to 90%,” Dr. Shin said. “However, based on improved understanding of pathophysiology, and through the creation of TTP registries worldwide, there have been major advances in diagnosis, treatment, and outcomes.”

To gain insight into diagnostic and prognostic characteristics of TTP, the investigators turned to data from 602 patients with clinically suspected TTP, based on an ADAMTS13 activity level less than 10% of normal and associated clinical signs. Out of these 602 patients, 475 consented to registry participation and data analysis.

The analysis revealed a mortality rate of 4%, although Dr. Shin said that “this is probably an underestimate of the true figure,” as it excludes those who died before treatment could be initiated.

Nearly three-quarters of patients were female. The median age at presentation was 43 years, with a range of 1-93 years. The most commonly represented racial/ethnic groups were white (60%) and Afro-Caribbean (22%). Some cases were congenital (16%), but the majority were immune mediated (84%).

The immune-mediated group was the primary focus of Dr. Shin’s report. In this cohort, 76% of cases were idiopathic, while the remainder had a defined precipitant; most common were infection, autoimmune disease, pregnancy, and HIV. The relapse rate among those with immune-mediated TTP was 19%, after a median time to relapse of 26 months.

In total, 71% of patients presented with neurological abnormalities, while slightly less than half (48%) had symptomatic thrombocytopenia (bleeding/petechiae).

Diagnostic tools showed that 64% of patients had an elevated troponin level, 92% had ADAMTS13 activity less than 10%, and 25% had a platelet count lower than 10 x 10⁹/L.

Median platelet count upon presentation was 15 x 10⁹/L, and median lactate dehydrogenase (LDH) exceeded 1,000 units/L. After 7 days of therapy, 58% of patients were still severely deficient in ADAMTS13 activity and 36% of patients still had a platelet count lower than 150 x 10⁹/L.

Where information was available, 30% of patients had positive auto-antibody screens, although not necessarily with signs or symptoms of autoimmune disease. A total of 93% of patients had elevated ADAMTS13 IgG antibody upon presentation. The median ADAMTS13 IgG antibody level at presentation was 37%, with a normal value being less than 6%.

Nearly half of patients with immune-mediated TTP (45%) required intensive care, and 10% of these patients were intubated and ventilated. Most patients were treated with steroids upon admission (81%). On average, 11 plasma exchanges (PEXs) were required before remission.

The investigators noted that “[t]he number of PEXs to remission appears to have decreased over the years.” As an example, a median of 14 PEXs were needed from 2009 to 2010, compared with 8 from 2017 to 2018.

Although rituximab usage in the acute setting held steady over the 10-year period, elective use increased. Out of 89 instances of subacute relapse, elective rituximab was given twice from 2009 to 2010, compared with 26 times from 2017 to 2018.

Comparing features of survival, the investigators found that the median ADAMTS13 IgG antibody level was higher among those who died. Other factors related to increased mortality risk included raised troponin (sevenfold increased risk) and neurological abnormalities, defined by reduced Glasgow Coma Scale score (sixfold increased risk).

“Our data confirm other registries worldwide; in particular, increased susceptibility in women, the Afro-Caribbean population, and those who are middle-aged,” Dr. Shin said. “Our data also show that elevated cardiac troponin and neurological involvement are indicators of poor prognosis. Also, raised antibody levels appear to be associated with a worse clinical outcome and increased mortality rate. These are clearly valuable markers in clinical practice, allowing for intensive care of high-risk patients.”

The investigators reported having no conflicts of interest.
 

GLASGOW – Neurological abnormalities and elevated troponin predict mortality in patients with thrombotic thrombocytopenic purpura (TTP), according to retrospective analysis of 475 patients from the United Kingdom TTP registry.

Will Pass/MDedge News

In addition, low ADAMTS13 activity (less than 10%) was present in 92% of immune-mediated of TTP upon acute presentation, reported lead author Jin-Sup Shin, MD, of University College London Hospital, and colleagues.

Presenting at the annual meeting of the British Society for Haematology, Dr. Shin provided some background on TTP, a condition that most clinicians encounter infrequently.

“As recently as the 1980s and 90s, when etiology was not that well understood, TTP was associated with an untreated mortality of up to 90%,” Dr. Shin said. “However, based on improved understanding of pathophysiology, and through the creation of TTP registries worldwide, there have been major advances in diagnosis, treatment, and outcomes.”

To gain insight into diagnostic and prognostic characteristics of TTP, the investigators turned to data from 602 patients with clinically suspected TTP, based on an ADAMTS13 activity level less than 10% of normal and associated clinical signs. Out of these 602 patients, 475 consented to registry participation and data analysis.

The analysis revealed a mortality rate of 4%, although Dr. Shin said that “this is probably an underestimate of the true figure,” as it excludes those who died before treatment could be initiated.

Nearly three-quarters of patients were female. The median age at presentation was 43 years, with a range of 1-93 years. The most commonly represented racial/ethnic groups were white (60%) and Afro-Caribbean (22%). Some cases were congenital (16%), but the majority were immune mediated (84%).

The immune-mediated group was the primary focus of Dr. Shin’s report. In this cohort, 76% of cases were idiopathic, while the remainder had a defined precipitant; most common were infection, autoimmune disease, pregnancy, and HIV. The relapse rate among those with immune-mediated TTP was 19%, after a median time to relapse of 26 months.

In total, 71% of patients presented with neurological abnormalities, while slightly less than half (48%) had symptomatic thrombocytopenia (bleeding/petechiae).

Diagnostic tools showed that 64% of patients had an elevated troponin level, 92% had ADAMTS13 activity less than 10%, and 25% had a platelet count lower than 10 x 10⁹/L.

Median platelet count upon presentation was 15 x 10⁹/L, and median lactate dehydrogenase (LDH) exceeded 1,000 units/L. After 7 days of therapy, 58% of patients were still severely deficient in ADAMTS13 activity and 36% of patients still had a platelet count lower than 150 x 10⁹/L.

Where information was available, 30% of patients had positive auto-antibody screens, although not necessarily with signs or symptoms of autoimmune disease. A total of 93% of patients had elevated ADAMTS13 IgG antibody upon presentation. The median ADAMTS13 IgG antibody level at presentation was 37%, with a normal value being less than 6%.

Nearly half of patients with immune-mediated TTP (45%) required intensive care, and 10% of these patients were intubated and ventilated. Most patients were treated with steroids upon admission (81%). On average, 11 plasma exchanges (PEXs) were required before remission.

The investigators noted that “[t]he number of PEXs to remission appears to have decreased over the years.” As an example, a median of 14 PEXs were needed from 2009 to 2010, compared with 8 from 2017 to 2018.

Although rituximab usage in the acute setting held steady over the 10-year period, elective use increased. Out of 89 instances of subacute relapse, elective rituximab was given twice from 2009 to 2010, compared with 26 times from 2017 to 2018.

Comparing features of survival, the investigators found that the median ADAMTS13 IgG antibody level was higher among those who died. Other factors related to increased mortality risk included raised troponin (sevenfold increased risk) and neurological abnormalities, defined by reduced Glasgow Coma Scale score (sixfold increased risk).

“Our data confirm other registries worldwide; in particular, increased susceptibility in women, the Afro-Caribbean population, and those who are middle-aged,” Dr. Shin said. “Our data also show that elevated cardiac troponin and neurological involvement are indicators of poor prognosis. Also, raised antibody levels appear to be associated with a worse clinical outcome and increased mortality rate. These are clearly valuable markers in clinical practice, allowing for intensive care of high-risk patients.”

The investigators reported having no conflicts of interest.
 

WASHINGTON – The prescription of oral antibiotics after benign excisions, malignant excisions, and Mohs surgery has increased over the past decade, according to an analysis presented at the annual meeting of the American Academy of Dermatology.

John Barbieri, MD, a dermatologist and postdoctoral research fellow at the University of Pennsylvania, Philadelphia, who presented the results, and colleagues examined data about antibiotic use in dermatology between 2008 and 2016. Overall, antibiotic use decreased during this period, primarily for chronic conditions such as acne and rosacea. On the other hand, antibiotic use associated with surgical visits increased by approximately 70%.

Using data from 2008 to 2016 in the Optum Clinformatics DataMart deidentified commercial claims database, the researchers performed a repeated cross-sectional analysis of oral antibiotic prescriptions associated with encounters for surgical procedures performed by dermatologists. They found that oral antibiotic prescriptions increased from 2.9% to 4.4% of visits for benign excisions, from 4.2% to 6.3% of visits for malignant excisions, and from 9.9% to 13.8% of visits for Mohs procedures during this time period. Oral antibiotic prescribing was more common for procedures that entailed a flap or graft and among patients with diabetes, female patients, and younger patients.


The investigators observed greater than twofold variation in antibiotic-prescribing rates across geographic census divisions. “If higher-prescribing divisions were to develop antibiotic prescribing rates similar to [those of] lower-prescribing divisions, antibiotic use could be decreased by over 50%,” Dr. Barbieri said. Before prescribing antibiotic prophylaxis, dermatologists should consider which patients benefit most from it, he added.

The investigators also examined the duration of antibiotic courses. The median course duration of postoperative antibiotics was 7 days. Randomized, controlled trials that collectively included more than 600 patients have failed to demonstrate a benefit of long postoperative courses of antibiotics, compared with perioperative antibiotics alone, said Dr. Barbieri. “While it may be hard to have true perioperative antibiotics available in a dermatology surgical clinic, there likely are opportunities to reduce these postoperative courses to a day or 3 days from this mean of 7 days that we observed in the study.” Reducing these courses would decrease the risk of antibiotic-associated complications such as nausea, diarrhea, and skin rashes, he added.

[email protected]

SOURCE: AAD 2019, Abstract 11356.

WASHINGTON – The prescription of oral antibiotics after benign excisions, malignant excisions, and Mohs surgery has increased over the past decade, according to an analysis presented at the annual meeting of the American Academy of Dermatology.

John Barbieri, MD, a dermatologist and postdoctoral research fellow at the University of Pennsylvania, Philadelphia, who presented the results, and colleagues examined data about antibiotic use in dermatology between 2008 and 2016. Overall, antibiotic use decreased during this period, primarily for chronic conditions such as acne and rosacea. On the other hand, antibiotic use associated with surgical visits increased by approximately 70%.

Using data from 2008 to 2016 in the Optum Clinformatics DataMart deidentified commercial claims database, the researchers performed a repeated cross-sectional analysis of oral antibiotic prescriptions associated with encounters for surgical procedures performed by dermatologists. They found that oral antibiotic prescriptions increased from 2.9% to 4.4% of visits for benign excisions, from 4.2% to 6.3% of visits for malignant excisions, and from 9.9% to 13.8% of visits for Mohs procedures during this time period. Oral antibiotic prescribing was more common for procedures that entailed a flap or graft and among patients with diabetes, female patients, and younger patients.


The investigators observed greater than twofold variation in antibiotic-prescribing rates across geographic census divisions. “If higher-prescribing divisions were to develop antibiotic prescribing rates similar to [those of] lower-prescribing divisions, antibiotic use could be decreased by over 50%,” Dr. Barbieri said. Before prescribing antibiotic prophylaxis, dermatologists should consider which patients benefit most from it, he added.

The investigators also examined the duration of antibiotic courses. The median course duration of postoperative antibiotics was 7 days. Randomized, controlled trials that collectively included more than 600 patients have failed to demonstrate a benefit of long postoperative courses of antibiotics, compared with perioperative antibiotics alone, said Dr. Barbieri. “While it may be hard to have true perioperative antibiotics available in a dermatology surgical clinic, there likely are opportunities to reduce these postoperative courses to a day or 3 days from this mean of 7 days that we observed in the study.” Reducing these courses would decrease the risk of antibiotic-associated complications such as nausea, diarrhea, and skin rashes, he added.

[email protected]

SOURCE: AAD 2019, Abstract 11356.

WASHINGTON – The prescription of oral antibiotics after benign excisions, malignant excisions, and Mohs surgery has increased over the past decade, according to an analysis presented at the annual meeting of the American Academy of Dermatology.

John Barbieri, MD, a dermatologist and postdoctoral research fellow at the University of Pennsylvania, Philadelphia, who presented the results, and colleagues examined data about antibiotic use in dermatology between 2008 and 2016. Overall, antibiotic use decreased during this period, primarily for chronic conditions such as acne and rosacea. On the other hand, antibiotic use associated with surgical visits increased by approximately 70%.

Using data from 2008 to 2016 in the Optum Clinformatics DataMart deidentified commercial claims database, the researchers performed a repeated cross-sectional analysis of oral antibiotic prescriptions associated with encounters for surgical procedures performed by dermatologists. They found that oral antibiotic prescriptions increased from 2.9% to 4.4% of visits for benign excisions, from 4.2% to 6.3% of visits for malignant excisions, and from 9.9% to 13.8% of visits for Mohs procedures during this time period. Oral antibiotic prescribing was more common for procedures that entailed a flap or graft and among patients with diabetes, female patients, and younger patients.


The investigators observed greater than twofold variation in antibiotic-prescribing rates across geographic census divisions. “If higher-prescribing divisions were to develop antibiotic prescribing rates similar to [those of] lower-prescribing divisions, antibiotic use could be decreased by over 50%,” Dr. Barbieri said. Before prescribing antibiotic prophylaxis, dermatologists should consider which patients benefit most from it, he added.

The investigators also examined the duration of antibiotic courses. The median course duration of postoperative antibiotics was 7 days. Randomized, controlled trials that collectively included more than 600 patients have failed to demonstrate a benefit of long postoperative courses of antibiotics, compared with perioperative antibiotics alone, said Dr. Barbieri. “While it may be hard to have true perioperative antibiotics available in a dermatology surgical clinic, there likely are opportunities to reduce these postoperative courses to a day or 3 days from this mean of 7 days that we observed in the study.” Reducing these courses would decrease the risk of antibiotic-associated complications such as nausea, diarrhea, and skin rashes, he added.

[email protected]

SOURCE: AAD 2019, Abstract 11356.

Nearly 10 million people use indoor tanning (IT) even though it increases the risk of skin cancer. Young white women are particularly at risk—almost 1 in 3 reports using indoor tanning in the past year, and nearly 1 in 5 reports regular use (that is, > 10 times in the past year), according to researchers from Rutgers University in New Brunswick, New Jersey.

Research has already shown that most people use IT to enhance their appearance. But a tan is not only seen as attractive: It “plays an important part of youth culture,” the researchers note, especially when it comes to special events, like high school proms. Still, some IT users might remain “special event” users, not regular clients. What makes the difference? To find out, the researchers conducted 6 interviews with a salon employee who also used tanning beds. Their purpose was not to produce “generalizable knowledge of the experiences of many users” but to provide insights into the behavior and to propose working hypotheses for future examination.

The researchers found that the incentive to use IT mostly comes down to—as many health-related decisions do—how it is advertised. The first encounter is likely to be the most important one. That is when the sell begins, designed to “guide” the patron into coming back, and back again. For instance, the salon employee may be trained to establish rapport, to personalize the interaction, and to ask about “tan goals,” setting the stage for a process, rather than a 1-time purchase. The employee describes the steps of creating a “base tan,” maintaining the tan, deepening the tan. Framing tanning as a process sends the message that frequent visits are needed. The researchers cite self-regulation theories that posit for a habit to take hold, the individual must develop a mental model or plans for how to use the habitual behavior to achieve desired goals.

The US Federal Trade Commission and other agencies have enacted restrictions on IT industry advertisements, the researchers say. But the policy efforts have not addressed greater regulation at the point-of-purchase, other than requiring the provision of standardized risk warnings. The interview findings suggest ways to help reduce IT use. Pricing controls, for instance: If patrons had to buy single sessions—instead of in bulk—they might feel less pressured to “get their money’s worth.” Restrictions on advertisement might require salon employees also to provide information on unnecessary exposure. The researchers contrast the salon employee to a convenience store clerk who “simply serves as a cashier for purchasing cigarettes or unhealthy food options.”

The researchers suggest that their findings be followed up in larger, more representational samples.

Nearly 10 million people use indoor tanning (IT) even though it increases the risk of skin cancer. Young white women are particularly at risk—almost 1 in 3 reports using indoor tanning in the past year, and nearly 1 in 5 reports regular use (that is, > 10 times in the past year), according to researchers from Rutgers University in New Brunswick, New Jersey.

Research has already shown that most people use IT to enhance their appearance. But a tan is not only seen as attractive: It “plays an important part of youth culture,” the researchers note, especially when it comes to special events, like high school proms. Still, some IT users might remain “special event” users, not regular clients. What makes the difference? To find out, the researchers conducted 6 interviews with a salon employee who also used tanning beds. Their purpose was not to produce “generalizable knowledge of the experiences of many users” but to provide insights into the behavior and to propose working hypotheses for future examination.

The researchers found that the incentive to use IT mostly comes down to—as many health-related decisions do—how it is advertised. The first encounter is likely to be the most important one. That is when the sell begins, designed to “guide” the patron into coming back, and back again. For instance, the salon employee may be trained to establish rapport, to personalize the interaction, and to ask about “tan goals,” setting the stage for a process, rather than a 1-time purchase. The employee describes the steps of creating a “base tan,” maintaining the tan, deepening the tan. Framing tanning as a process sends the message that frequent visits are needed. The researchers cite self-regulation theories that posit for a habit to take hold, the individual must develop a mental model or plans for how to use the habitual behavior to achieve desired goals.

The US Federal Trade Commission and other agencies have enacted restrictions on IT industry advertisements, the researchers say. But the policy efforts have not addressed greater regulation at the point-of-purchase, other than requiring the provision of standardized risk warnings. The interview findings suggest ways to help reduce IT use. Pricing controls, for instance: If patrons had to buy single sessions—instead of in bulk—they might feel less pressured to “get their money’s worth.” Restrictions on advertisement might require salon employees also to provide information on unnecessary exposure. The researchers contrast the salon employee to a convenience store clerk who “simply serves as a cashier for purchasing cigarettes or unhealthy food options.”

The researchers suggest that their findings be followed up in larger, more representational samples.

Nearly 10 million people use indoor tanning (IT) even though it increases the risk of skin cancer. Young white women are particularly at risk—almost 1 in 3 reports using indoor tanning in the past year, and nearly 1 in 5 reports regular use (that is, > 10 times in the past year), according to researchers from Rutgers University in New Brunswick, New Jersey.

Research has already shown that most people use IT to enhance their appearance. But a tan is not only seen as attractive: It “plays an important part of youth culture,” the researchers note, especially when it comes to special events, like high school proms. Still, some IT users might remain “special event” users, not regular clients. What makes the difference? To find out, the researchers conducted 6 interviews with a salon employee who also used tanning beds. Their purpose was not to produce “generalizable knowledge of the experiences of many users” but to provide insights into the behavior and to propose working hypotheses for future examination.

The researchers found that the incentive to use IT mostly comes down to—as many health-related decisions do—how it is advertised. The first encounter is likely to be the most important one. That is when the sell begins, designed to “guide” the patron into coming back, and back again. For instance, the salon employee may be trained to establish rapport, to personalize the interaction, and to ask about “tan goals,” setting the stage for a process, rather than a 1-time purchase. The employee describes the steps of creating a “base tan,” maintaining the tan, deepening the tan. Framing tanning as a process sends the message that frequent visits are needed. The researchers cite self-regulation theories that posit for a habit to take hold, the individual must develop a mental model or plans for how to use the habitual behavior to achieve desired goals.

The US Federal Trade Commission and other agencies have enacted restrictions on IT industry advertisements, the researchers say. But the policy efforts have not addressed greater regulation at the point-of-purchase, other than requiring the provision of standardized risk warnings. The interview findings suggest ways to help reduce IT use. Pricing controls, for instance: If patrons had to buy single sessions—instead of in bulk—they might feel less pressured to “get their money’s worth.” Restrictions on advertisement might require salon employees also to provide information on unnecessary exposure. The researchers contrast the salon employee to a convenience store clerk who “simply serves as a cashier for purchasing cigarettes or unhealthy food options.”

The researchers suggest that their findings be followed up in larger, more representational samples.

More than a quarter of U.S. children aged 19-35 months are not fully vaccinated for rotavirus, falling short of the Healthy People 2020 goal of 80% complete vaccination, according to Bethany K. Sederdahl, MPH, and her associates at Emory University, Atlanta.

Yarinca/istockphoto

In an analysis published in Pediatrics of data from 14,571 children included in the 2014 National Immunization Survey, 71% of children received full vaccination for rotavirus, 15% received partial vaccination, and 14% received no vaccination. Children whose mothers were not college graduates, lived in households with at least four children, or were uninsured at any point had an increased likelihood of being unvaccinated; African American children also faced an increased risk of being unvaccinated.

Among the unvaccinated, 72% had at least one missed opportunity according to the Advisory Committee on Immunization Practices schedule, and 83% had at least one missed opportunity according to the World Health Organization schedule. For the partially vaccinated, 54% at least one missed opportunity according to the ACIP schedule, and 96% had at least one missed opportunity according to the WHO schedule. While poorer socioeconomic conditions were associated with the risk of being unvaccinated, children who were partially vaccinated and who missed vaccination opportunities according to the ACIP-recommended schedule were more likely to have mothers with a college degree or an income of more than $75,000.

According to the investigators, if all missed opportunities for vaccination according to the ACIP schedule were addressed, coverage would improve from 71% to 81%; if all opportunities according to the WHO schedule were addressed, coverage would increase to 94%.

“Low rotavirus vaccine uptake may be attributable to both socioeconomic barriers and possibly vaccine hesitancy. Understanding the barriers to rotavirus vaccine uptake and developing effective public health measures to promote vaccine use will be essential to reducing rotavirus morbidity in the United States,” Ms. Sederdahl and her associates wrote.

The study received no external funding. One coauthor reported receiving personal fees from AbbVie, funds to conduct clinical research from Merck, and that his institution receives funds to conduct clinical research from MedImmune, Regeneron, PaxVax, Pfizer, Merck, Novavax, Sanofi Pasteur, and Micron Technology.

[email protected]

SOURCE: Sederdahl BK et al. Pediatrics. 2019 Apr 25. doi: 10.1542/peds.2018-2498.

More than a quarter of U.S. children aged 19-35 months are not fully vaccinated for rotavirus, falling short of the Healthy People 2020 goal of 80% complete vaccination, according to Bethany K. Sederdahl, MPH, and her associates at Emory University, Atlanta.

Yarinca/istockphoto

In an analysis published in Pediatrics of data from 14,571 children included in the 2014 National Immunization Survey, 71% of children received full vaccination for rotavirus, 15% received partial vaccination, and 14% received no vaccination. Children whose mothers were not college graduates, lived in households with at least four children, or were uninsured at any point had an increased likelihood of being unvaccinated; African American children also faced an increased risk of being unvaccinated.

Among the unvaccinated, 72% had at least one missed opportunity according to the Advisory Committee on Immunization Practices schedule, and 83% had at least one missed opportunity according to the World Health Organization schedule. For the partially vaccinated, 54% at least one missed opportunity according to the ACIP schedule, and 96% had at least one missed opportunity according to the WHO schedule. While poorer socioeconomic conditions were associated with the risk of being unvaccinated, children who were partially vaccinated and who missed vaccination opportunities according to the ACIP-recommended schedule were more likely to have mothers with a college degree or an income of more than $75,000.

According to the investigators, if all missed opportunities for vaccination according to the ACIP schedule were addressed, coverage would improve from 71% to 81%; if all opportunities according to the WHO schedule were addressed, coverage would increase to 94%.

“Low rotavirus vaccine uptake may be attributable to both socioeconomic barriers and possibly vaccine hesitancy. Understanding the barriers to rotavirus vaccine uptake and developing effective public health measures to promote vaccine use will be essential to reducing rotavirus morbidity in the United States,” Ms. Sederdahl and her associates wrote.

The study received no external funding. One coauthor reported receiving personal fees from AbbVie, funds to conduct clinical research from Merck, and that his institution receives funds to conduct clinical research from MedImmune, Regeneron, PaxVax, Pfizer, Merck, Novavax, Sanofi Pasteur, and Micron Technology.

[email protected]

SOURCE: Sederdahl BK et al. Pediatrics. 2019 Apr 25. doi: 10.1542/peds.2018-2498.

More than a quarter of U.S. children aged 19-35 months are not fully vaccinated for rotavirus, falling short of the Healthy People 2020 goal of 80% complete vaccination, according to Bethany K. Sederdahl, MPH, and her associates at Emory University, Atlanta.

Yarinca/istockphoto

In an analysis published in Pediatrics of data from 14,571 children included in the 2014 National Immunization Survey, 71% of children received full vaccination for rotavirus, 15% received partial vaccination, and 14% received no vaccination. Children whose mothers were not college graduates, lived in households with at least four children, or were uninsured at any point had an increased likelihood of being unvaccinated; African American children also faced an increased risk of being unvaccinated.

Among the unvaccinated, 72% had at least one missed opportunity according to the Advisory Committee on Immunization Practices schedule, and 83% had at least one missed opportunity according to the World Health Organization schedule. For the partially vaccinated, 54% at least one missed opportunity according to the ACIP schedule, and 96% had at least one missed opportunity according to the WHO schedule. While poorer socioeconomic conditions were associated with the risk of being unvaccinated, children who were partially vaccinated and who missed vaccination opportunities according to the ACIP-recommended schedule were more likely to have mothers with a college degree or an income of more than $75,000.

According to the investigators, if all missed opportunities for vaccination according to the ACIP schedule were addressed, coverage would improve from 71% to 81%; if all opportunities according to the WHO schedule were addressed, coverage would increase to 94%.

“Low rotavirus vaccine uptake may be attributable to both socioeconomic barriers and possibly vaccine hesitancy. Understanding the barriers to rotavirus vaccine uptake and developing effective public health measures to promote vaccine use will be essential to reducing rotavirus morbidity in the United States,” Ms. Sederdahl and her associates wrote.

The study received no external funding. One coauthor reported receiving personal fees from AbbVie, funds to conduct clinical research from Merck, and that his institution receives funds to conduct clinical research from MedImmune, Regeneron, PaxVax, Pfizer, Merck, Novavax, Sanofi Pasteur, and Micron Technology.

[email protected]

SOURCE: Sederdahl BK et al. Pediatrics. 2019 Apr 25. doi: 10.1542/peds.2018-2498.

I have been ruminating about the Bai et al article on independent billing in the emergency department (ED) for weeks.¹ I keep wondering why the data analysis seems so off base. Don’t get me wrong: The data gathered from Medicare is what it is—but a key piece of information is not present in the pure numbers input to the Medicare database.

So, I continued to probe this study with my colleagues. To a person, their comments supported that the intent of the study is unclear. The authors posit their objective to be an examination of the “involvement of NPs and PAs” in emergency services, using billing data. But to use billing data as a measure of “involvement” does not tell the whole story.

Independence in billing does not mean that the care NPs and PAs are providing is “beyond their scope of practice.” Moreover, the billing does not capture whether, or to what extent, physician consultation or assistance was involved. If the NP or PA dictated the chart, then they are by default the “only” (independent) provider. However, billing independently does not mean a physician (or other provider) was not consulted about the plan of care. 

Case in point: Years ago, I had a young woman present to the ED with a sore throat. Her presenting complaint was a symptom of a peritonsillar abscess. So I phoned an ENT colleague (a physician) and asked him about the best treatment and follow-up in this case. Did he make a note in or sign the chart? No. Was I the only provider of record? Yes. Was that care “independent,” if you only look at the billing (done by a coder, for the record)? Yes. 

Admittedly, Bai and colleagues do add in their conclusion that “independence in billing … does not necessarily indicate [NPs’/PAs’] independence in care delivery.”1 And they do note that the true challenge in the ED is determining how best to “blend” the expertise of the three professions (MD, NP, and PA) to provide efficient and cost-effective care.

However, throughout the article, there is an underpinning of inference that NPs and PAs are potentially practicing beyond their scope. Their comment that the increase in billing for NP and PA services results in a “reduction of the proportion of emergency physicians” speaks volumes.¹ Perhaps there is more concern here about ED physician job security than about independent billing!

Regardless of the intention by Bai et al—and acknowledging that the analysis they presented is somewhat interesting—I see two missed opportunities to “actionalize” the data.² One is to use the information to identify whether a problem with billing exists (ie, is there upcharging as a result of more details contained within the electronic health record?). The second is to use the data to investigate innovative ways to improve access to care across the continuum. Essentially, how do we use the results of any data analysis in a way that can be useful? That is the real challenge. 

Continue to: The biggest conclusion I've drawn...

The biggest conclusion I’ve drawn from my exploration of these study findings? The opportunity to investigate the competencies of all ED providers, with the goal of improving access and controlling costs, is there. And as the NPs and PAs providing the care, we should undertake the next research study or data analysis and not leave the research on us to other professions!

I’d love to hear your thoughts on the Bai et al study or any aspect of this 4-part discussion! Drop me a line at [email protected].

I have been ruminating about the Bai et al article on independent billing in the emergency department (ED) for weeks.¹ I keep wondering why the data analysis seems so off base. Don’t get me wrong: The data gathered from Medicare is what it is—but a key piece of information is not present in the pure numbers input to the Medicare database.

So, I continued to probe this study with my colleagues. To a person, their comments supported that the intent of the study is unclear. The authors posit their objective to be an examination of the “involvement of NPs and PAs” in emergency services, using billing data. But to use billing data as a measure of “involvement” does not tell the whole story.

Independence in billing does not mean that the care NPs and PAs are providing is “beyond their scope of practice.” Moreover, the billing does not capture whether, or to what extent, physician consultation or assistance was involved. If the NP or PA dictated the chart, then they are by default the “only” (independent) provider. However, billing independently does not mean a physician (or other provider) was not consulted about the plan of care. 

Case in point: Years ago, I had a young woman present to the ED with a sore throat. Her presenting complaint was a symptom of a peritonsillar abscess. So I phoned an ENT colleague (a physician) and asked him about the best treatment and follow-up in this case. Did he make a note in or sign the chart? No. Was I the only provider of record? Yes. Was that care “independent,” if you only look at the billing (done by a coder, for the record)? Yes. 

Admittedly, Bai and colleagues do add in their conclusion that “independence in billing … does not necessarily indicate [NPs’/PAs’] independence in care delivery.”1 And they do note that the true challenge in the ED is determining how best to “blend” the expertise of the three professions (MD, NP, and PA) to provide efficient and cost-effective care.

However, throughout the article, there is an underpinning of inference that NPs and PAs are potentially practicing beyond their scope. Their comment that the increase in billing for NP and PA services results in a “reduction of the proportion of emergency physicians” speaks volumes.¹ Perhaps there is more concern here about ED physician job security than about independent billing!

Regardless of the intention by Bai et al—and acknowledging that the analysis they presented is somewhat interesting—I see two missed opportunities to “actionalize” the data.² One is to use the information to identify whether a problem with billing exists (ie, is there upcharging as a result of more details contained within the electronic health record?). The second is to use the data to investigate innovative ways to improve access to care across the continuum. Essentially, how do we use the results of any data analysis in a way that can be useful? That is the real challenge. 

Continue to: The biggest conclusion I've drawn...

The biggest conclusion I’ve drawn from my exploration of these study findings? The opportunity to investigate the competencies of all ED providers, with the goal of improving access and controlling costs, is there. And as the NPs and PAs providing the care, we should undertake the next research study or data analysis and not leave the research on us to other professions!

I’d love to hear your thoughts on the Bai et al study or any aspect of this 4-part discussion! Drop me a line at [email protected].

I have been ruminating about the Bai et al article on independent billing in the emergency department (ED) for weeks.¹ I keep wondering why the data analysis seems so off base. Don’t get me wrong: The data gathered from Medicare is what it is—but a key piece of information is not present in the pure numbers input to the Medicare database.

So, I continued to probe this study with my colleagues. To a person, their comments supported that the intent of the study is unclear. The authors posit their objective to be an examination of the “involvement of NPs and PAs” in emergency services, using billing data. But to use billing data as a measure of “involvement” does not tell the whole story.

Independence in billing does not mean that the care NPs and PAs are providing is “beyond their scope of practice.” Moreover, the billing does not capture whether, or to what extent, physician consultation or assistance was involved. If the NP or PA dictated the chart, then they are by default the “only” (independent) provider. However, billing independently does not mean a physician (or other provider) was not consulted about the plan of care. 

Case in point: Years ago, I had a young woman present to the ED with a sore throat. Her presenting complaint was a symptom of a peritonsillar abscess. So I phoned an ENT colleague (a physician) and asked him about the best treatment and follow-up in this case. Did he make a note in or sign the chart? No. Was I the only provider of record? Yes. Was that care “independent,” if you only look at the billing (done by a coder, for the record)? Yes. 

Admittedly, Bai and colleagues do add in their conclusion that “independence in billing … does not necessarily indicate [NPs’/PAs’] independence in care delivery.”1 And they do note that the true challenge in the ED is determining how best to “blend” the expertise of the three professions (MD, NP, and PA) to provide efficient and cost-effective care.

However, throughout the article, there is an underpinning of inference that NPs and PAs are potentially practicing beyond their scope. Their comment that the increase in billing for NP and PA services results in a “reduction of the proportion of emergency physicians” speaks volumes.¹ Perhaps there is more concern here about ED physician job security than about independent billing!

Regardless of the intention by Bai et al—and acknowledging that the analysis they presented is somewhat interesting—I see two missed opportunities to “actionalize” the data.² One is to use the information to identify whether a problem with billing exists (ie, is there upcharging as a result of more details contained within the electronic health record?). The second is to use the data to investigate innovative ways to improve access to care across the continuum. Essentially, how do we use the results of any data analysis in a way that can be useful? That is the real challenge. 

Continue to: The biggest conclusion I've drawn...

The biggest conclusion I’ve drawn from my exploration of these study findings? The opportunity to investigate the competencies of all ED providers, with the goal of improving access and controlling costs, is there. And as the NPs and PAs providing the care, we should undertake the next research study or data analysis and not leave the research on us to other professions!

I’d love to hear your thoughts on the Bai et al study or any aspect of this 4-part discussion! Drop me a line at [email protected].

The FP suspected that this could be a nodular melanoma that was mostly hypomelanotic (with minimal melanin visible, which explained why it was so pink). It looked like there was a flat nevus with brown coloration at one side of the base. The FP asked the patient whether she had a mole there in the past. The patient thought she did have a mole there since childhood, but had not thought about it. The light brown hyperpigmentation lateral to the lesion was likely secondary to scratching.

The differential diagnosis included melanoma, squamous cell carcinoma, and basal cell carcinoma. Suspecting that it was most likely a nodular melanoma, the FP knew that a rapid diagnosis would be essential to an improved prognosis. Nodular melanomas are fast-growing melanomas that grow vertically, thereby making them one of the deadliest melanomas. A delay in the diagnosis of a nodular melanoma by even 3 to 6 months can change the prognosis from favorable to fatal.

The FP considered the options for biopsy but realized that cutting out the whole lesion would be time-consuming and require rescheduling for a different time. Getting a good sampling of the tumor with either a deep shave or a large punch biopsy would most likely provide the diagnosis. The FP presented the options to the patient, who indicated that the FP should do whatever he thought would be best. The FP performed a deep shave biopsy below the pigment on the edge and acquired a good-sized portion of the tumor. Aluminum chloride was initially used for hemostasis, but electrosurgery was ultimately required because of the vascular nature of the tumor. (See the Watch & Learn video on “Shave biopsy.”)

The pathology report came back as a nodular melanoma with a depth of 4.1 mm. The patient was referred to Surgical Oncology for a wide local excision and a sentinel lymph node biopsy. The sentinel node biopsy was positive for metastasis. The patient was then sent to Medical Oncology to discuss further evaluation and treatment of her melanoma. The FP was saddened by the worrisome prognosis for this young mother.

He reflected that this nodular melanoma should have been diagnosed at least 6 to 12 months earlier when this patient was seeing an obstetrician regularly for health care. It was unfortunate that no one in the health care team during her pregnancy, labor, delivery, or postpartum care noted the melanoma and encouraged her to get evaluated. This supports the practice that we should not listen to lungs over the shirt. While every health care provider is not a dermatologist, the skin should not be ignored.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.

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 Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The FP suspected that this could be a nodular melanoma that was mostly hypomelanotic (with minimal melanin visible, which explained why it was so pink). It looked like there was a flat nevus with brown coloration at one side of the base. The FP asked the patient whether she had a mole there in the past. The patient thought she did have a mole there since childhood, but had not thought about it. The light brown hyperpigmentation lateral to the lesion was likely secondary to scratching.

The differential diagnosis included melanoma, squamous cell carcinoma, and basal cell carcinoma. Suspecting that it was most likely a nodular melanoma, the FP knew that a rapid diagnosis would be essential to an improved prognosis. Nodular melanomas are fast-growing melanomas that grow vertically, thereby making them one of the deadliest melanomas. A delay in the diagnosis of a nodular melanoma by even 3 to 6 months can change the prognosis from favorable to fatal.

The FP considered the options for biopsy but realized that cutting out the whole lesion would be time-consuming and require rescheduling for a different time. Getting a good sampling of the tumor with either a deep shave or a large punch biopsy would most likely provide the diagnosis. The FP presented the options to the patient, who indicated that the FP should do whatever he thought would be best. The FP performed a deep shave biopsy below the pigment on the edge and acquired a good-sized portion of the tumor. Aluminum chloride was initially used for hemostasis, but electrosurgery was ultimately required because of the vascular nature of the tumor. (See the Watch & Learn video on “Shave biopsy.”)

The pathology report came back as a nodular melanoma with a depth of 4.1 mm. The patient was referred to Surgical Oncology for a wide local excision and a sentinel lymph node biopsy. The sentinel node biopsy was positive for metastasis. The patient was then sent to Medical Oncology to discuss further evaluation and treatment of her melanoma. The FP was saddened by the worrisome prognosis for this young mother.

He reflected that this nodular melanoma should have been diagnosed at least 6 to 12 months earlier when this patient was seeing an obstetrician regularly for health care. It was unfortunate that no one in the health care team during her pregnancy, labor, delivery, or postpartum care noted the melanoma and encouraged her to get evaluated. This supports the practice that we should not listen to lungs over the shirt. While every health care provider is not a dermatologist, the skin should not be ignored.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.

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 Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The FP suspected that this could be a nodular melanoma that was mostly hypomelanotic (with minimal melanin visible, which explained why it was so pink). It looked like there was a flat nevus with brown coloration at one side of the base. The FP asked the patient whether she had a mole there in the past. The patient thought she did have a mole there since childhood, but had not thought about it. The light brown hyperpigmentation lateral to the lesion was likely secondary to scratching.

The differential diagnosis included melanoma, squamous cell carcinoma, and basal cell carcinoma. Suspecting that it was most likely a nodular melanoma, the FP knew that a rapid diagnosis would be essential to an improved prognosis. Nodular melanomas are fast-growing melanomas that grow vertically, thereby making them one of the deadliest melanomas. A delay in the diagnosis of a nodular melanoma by even 3 to 6 months can change the prognosis from favorable to fatal.

The FP considered the options for biopsy but realized that cutting out the whole lesion would be time-consuming and require rescheduling for a different time. Getting a good sampling of the tumor with either a deep shave or a large punch biopsy would most likely provide the diagnosis. The FP presented the options to the patient, who indicated that the FP should do whatever he thought would be best. The FP performed a deep shave biopsy below the pigment on the edge and acquired a good-sized portion of the tumor. Aluminum chloride was initially used for hemostasis, but electrosurgery was ultimately required because of the vascular nature of the tumor. (See the Watch & Learn video on “Shave biopsy.”)

The pathology report came back as a nodular melanoma with a depth of 4.1 mm. The patient was referred to Surgical Oncology for a wide local excision and a sentinel lymph node biopsy. The sentinel node biopsy was positive for metastasis. The patient was then sent to Medical Oncology to discuss further evaluation and treatment of her melanoma. The FP was saddened by the worrisome prognosis for this young mother.

He reflected that this nodular melanoma should have been diagnosed at least 6 to 12 months earlier when this patient was seeing an obstetrician regularly for health care. It was unfortunate that no one in the health care team during her pregnancy, labor, delivery, or postpartum care noted the melanoma and encouraged her to get evaluated. This supports the practice that we should not listen to lungs over the shirt. While every health care provider is not a dermatologist, the skin should not be ignored.

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Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Melanoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill;2019:1112-1123.

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 Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

Officials at the Centers for Disease Control and Prevention are warning against the misapplication of the agency’s 2016 guidelines on opioid prescribing, as well as clarifying dosage recommendations for patients starting or stopping pain medications.

In a perspective published in the New England Journal of Medicine on April 24, lead author Deborah Dowell, MD, chief medical officer for the CDC’s National Center for Injury Prevention and Control, conveyed concern that some policies and practices derived from the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain are inconsistent with the recommendations and often go beyond their scope.

Misapplication examples include inappropriately applying the guideline to patients in active cancer treatment, patients experiencing acute sickle cell crises, or patients experiencing postsurgical pain, Dr. Dowell wrote.

The guideline offers guidance to clinicians treating chronic pain in adults who are already receiving opioids long-term at high dosages, she noted. It includes advice on maximizing nonopioid treatment, reviewing risks associated with continuing high-dose opioids, and collaborating with patients who agree to taper dosage, among other guidance.

Any application of the guideline’s dosage recommendation that results in hard limits or “cutting off” opioids is also an incorrect use of the recommendations, according to Dr. Dowell.

While the guideline advises clinicians to start opioids at the lowest effective dosage and avoid increasing dosage to 90 morphine milligram equivalents per day or more, that statement does not suggest discontinuation of opioids already prescribed at high dosages, according to the CDC’s clarification.

The guidance also does not apply to patients receiving or starting medication-assisted treatment for opioid use disorder.

The commentary comes after a trio of organizations raised concerns that insurers are inappropriately applying the recommendations to active cancer patients when making coverage determinations.

The American Society of Clinical Oncology, the National Comprehensive Cancer Network, and the American Society of Hematology, raised the issue in a letter to the CDC in February. In response, Dr. Dowell clarified that the recommendations are not intended to deny clinically appropriate opioid therapy to any patients who suffer chronic pain, but rather to ensure that physicians and patients consider all safe and effective treatment options.

In the perspective, Dr. Dowell wrote that the CDC is evaluating the intended and unintended impact of the 2016 opioid-prescribing guideline on clinician and patient outcomes and that the agency is committed to updating the recommendations when new evidence is available.
 

[email protected]

Officials at the Centers for Disease Control and Prevention are warning against the misapplication of the agency’s 2016 guidelines on opioid prescribing, as well as clarifying dosage recommendations for patients starting or stopping pain medications.

In a perspective published in the New England Journal of Medicine on April 24, lead author Deborah Dowell, MD, chief medical officer for the CDC’s National Center for Injury Prevention and Control, conveyed concern that some policies and practices derived from the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain are inconsistent with the recommendations and often go beyond their scope.

Misapplication examples include inappropriately applying the guideline to patients in active cancer treatment, patients experiencing acute sickle cell crises, or patients experiencing postsurgical pain, Dr. Dowell wrote.

The guideline offers guidance to clinicians treating chronic pain in adults who are already receiving opioids long-term at high dosages, she noted. It includes advice on maximizing nonopioid treatment, reviewing risks associated with continuing high-dose opioids, and collaborating with patients who agree to taper dosage, among other guidance.

Any application of the guideline’s dosage recommendation that results in hard limits or “cutting off” opioids is also an incorrect use of the recommendations, according to Dr. Dowell.

While the guideline advises clinicians to start opioids at the lowest effective dosage and avoid increasing dosage to 90 morphine milligram equivalents per day or more, that statement does not suggest discontinuation of opioids already prescribed at high dosages, according to the CDC’s clarification.

The guidance also does not apply to patients receiving or starting medication-assisted treatment for opioid use disorder.

The commentary comes after a trio of organizations raised concerns that insurers are inappropriately applying the recommendations to active cancer patients when making coverage determinations.

The American Society of Clinical Oncology, the National Comprehensive Cancer Network, and the American Society of Hematology, raised the issue in a letter to the CDC in February. In response, Dr. Dowell clarified that the recommendations are not intended to deny clinically appropriate opioid therapy to any patients who suffer chronic pain, but rather to ensure that physicians and patients consider all safe and effective treatment options.

In the perspective, Dr. Dowell wrote that the CDC is evaluating the intended and unintended impact of the 2016 opioid-prescribing guideline on clinician and patient outcomes and that the agency is committed to updating the recommendations when new evidence is available.
 

[email protected]

Officials at the Centers for Disease Control and Prevention are warning against the misapplication of the agency’s 2016 guidelines on opioid prescribing, as well as clarifying dosage recommendations for patients starting or stopping pain medications.

In a perspective published in the New England Journal of Medicine on April 24, lead author Deborah Dowell, MD, chief medical officer for the CDC’s National Center for Injury Prevention and Control, conveyed concern that some policies and practices derived from the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain are inconsistent with the recommendations and often go beyond their scope.

Misapplication examples include inappropriately applying the guideline to patients in active cancer treatment, patients experiencing acute sickle cell crises, or patients experiencing postsurgical pain, Dr. Dowell wrote.

The guideline offers guidance to clinicians treating chronic pain in adults who are already receiving opioids long-term at high dosages, she noted. It includes advice on maximizing nonopioid treatment, reviewing risks associated with continuing high-dose opioids, and collaborating with patients who agree to taper dosage, among other guidance.

Any application of the guideline’s dosage recommendation that results in hard limits or “cutting off” opioids is also an incorrect use of the recommendations, according to Dr. Dowell.

While the guideline advises clinicians to start opioids at the lowest effective dosage and avoid increasing dosage to 90 morphine milligram equivalents per day or more, that statement does not suggest discontinuation of opioids already prescribed at high dosages, according to the CDC’s clarification.

The guidance also does not apply to patients receiving or starting medication-assisted treatment for opioid use disorder.

The commentary comes after a trio of organizations raised concerns that insurers are inappropriately applying the recommendations to active cancer patients when making coverage determinations.

The American Society of Clinical Oncology, the National Comprehensive Cancer Network, and the American Society of Hematology, raised the issue in a letter to the CDC in February. In response, Dr. Dowell clarified that the recommendations are not intended to deny clinically appropriate opioid therapy to any patients who suffer chronic pain, but rather to ensure that physicians and patients consider all safe and effective treatment options.

In the perspective, Dr. Dowell wrote that the CDC is evaluating the intended and unintended impact of the 2016 opioid-prescribing guideline on clinician and patient outcomes and that the agency is committed to updating the recommendations when new evidence is available.
 

[email protected]