CASE Scratching, anxious, and hopeless

Ms. L, age 74, who is paraplegic and uses a wheelchair, presents to our hospital’s emergency department (ED) accompanied by staff from the nursing home where she resides. She reports that she can feel and see bugs crawling all over her skin, biting her, and burrowing into her body. She says that the bugs also stick to her clothes.

Ms. L experiences generalized pruritus with excoriations scattered over her upper and lower extremities and her trunk. She copes with the pruritus by scratching. She reports that the bugs are present throughout the day and are worse at night when she tries to go to bed. Nothing she does provides relief from the infestation. Earlier, at the nursing home, Ms. L had obtained a detergent powder and used it in an attempt to purge the bugs. She now has large swaths of irritated skin, mostly on her lower back and perineal region.

She says the bug infestation became unbearable 3 weeks ago, but she can’t identify any precipitants for her symptoms. Ms. L reports that the impact of the bugs on her daily activity, sleep, and quality of life is enormous. Despite her complaints, neither the nursing home staff nor the ED staff can find any evidence of bugs on Ms. L’s clothes or skin.

Because Ms. L resorted to such drastic measures in her attempt to rid her body of the bugs, she is considered a safety risk and is admitted to the psychiatric unit, although she vehemently denies any intention to harm herself.

On the psychiatric unit, Ms. L states that the infestation began approximately 2 years ago. She began to experience severe worsening of her symptoms a few weeks before presenting to the ED.

During evaluation, Ms. L is alert and oriented to person, place, and situation. She is also quite cooperative but guarded in describing her infestation. There is some degree of suspiciousness and paranoia with regards to her infestation; she is very sensitive to how the clinical staff respond to her condition. She appears worried, and exhibits anxiety, sadness, hopelessness, and tearfulness. Her thought process is goal-directed, but preoccupied by the bugs.

[polldaddy:10064801]

Continue to: The authors' observations

Delusional parasitosis is a rare disorder that is defined by an individual having a fixed, false belief that he or she is being infected or grossly invaded by a living organism. Karl A. Ekbom, a Swedish neurologist, was the first practitioner to definitively describe this affliction in 1938.¹

Primary delusional parasitosis is a disease defined by this single psychotic symptom without other classic symptoms of schizophrenia; this single symptom cannot be attributed to the effects of substance abuse or a medical condition. Many affected patients remain functional in their daily lives; only a minority of patients experience delusions that interfere with usual activity.² Secondary delusional parasitosis is a symptom of another psychiatric or medical disease.

Morgellons disease is characterized by symptoms similar to primary delusional parasitosis, but symptoms of this condition also include the delusional belief that inanimate objects, usually fibers, are in the skin as well as the parasites.³

A population-based study among individuals living in Olmsted County, Minnesota from 1976 to 2010 found that the incidence of delusional infestation was 1.9 cases (95% confidence interval, 1.5 to 2.4) per 100,000 person-years.⁴ In a retrospective study of 147 patients with delusional parasitosis, 33% of these patients described themselves as disabled, 28% were retired, and 26% were employed.⁵ In this study, the mean age of diagnosis was 57, with a female-to-male ratio of 2.89:1.⁵

Continue to: HISTORY Prior psychiatric hospitalization

HISTORY Prior psychiatric hospitalization

Ms. L, who is divorced and retired, lives in a nursing home and has no pets, no exposure to scabies, no recent travel, no allergies, and no difficulty with her hygiene except at the peak of her illness. She denies any alcohol or illicit drug use but reports a 6 pack year history of smoking. She has a son, 2 grandchildren, and 2 great grandchildren who all live in town and see her regularly. She reports no history of arrests or legal problems.

Ms. L has a history of depression and anxiety that culminated in a “nervous breakdown” in 1985 with a brief stay in a psychiatric hospital. She reports that she had seen a therapist for 6 years as part of her treatment following that event. During her hospitalization, she was treated with a tricyclic antidepressant and received electroconvulsive therapy. She denies being suicidal during the incident in 1985 or at any point in time before or since then. She now takes venlafaxine, 75 mg/d, for depression and anxiety.

Ms. L’s paraplegia resulted from her sixth corrective surgery for scoliosis, which occurred 6 years ago. She has had chronic pain since this surgery. Her medical history also includes hypertension, atrial fibrillation, mild neurocognitive changes, and gastroesophageal reflux disease.

EVALUATION Skin examination, blood analysis normal

On admission, Ms. L undergoes a skin examination, which yields no evidence consistent with infestation with Pediculus humanus corporis (body louse) or Sarcoptes scabiei (scabies).⁶ Blood analysis shows no iron deficiency, renal failure, hyperbilirubinemia, or eosinophilia. In the ED, the medical team examines Ms. L and explores other medical and dermatological causes of her condition. Because dermatological causes had been ruled out before Ms. L was admitted to the inpatient psychiatric unit, no dermatology consult is requested.

Continue to: TREATMENT A first-generation antipsychotic

When Ms. L is admitted to the psychiatric unit, she is started on oral perphenazine, 8 mg twice daily, and venlafaxine, 75 mg/d, which she was taking prior to hospital admission. Because she had tolerated venlafaxine with no adverse effects, it seems worthwhile to optimize the dose of this medication rather than start a new medication.

During the week, Ms. L’s perphenazine is titrated up to 24 mg twice daily and venlafaxine is titrated to 150 mg/d. A Montreal Cognitive Assessment (MoCA) is performed within the first 2 days of admission and she scores 16/30, indicating moderate cognitive impairment. On Friday, the attending physician explains that her medications should start to have therapeutic effect. During this time, this clinician engages in cognitive restructuring by providing validation of Ms. L’s suffering, verbal support, and medication compliance counseling. At this time, the treating team also suggests to Ms. L that she should expect the activity and effects of the bugs to dissipate. She is receptive to this suggestion. She also participates in the milieu, including unit activities, but is limited in her ability to engage in group therapy due to the intensity of her illness.

Throughout the weekend, the on-call physician also engages Ms. L and reports minor improvement.

OUTCOME Significant relief

On re-evaluation Monday morning—almost a week after Ms. L had been admitted to the inpatient psychiatric unit—she has achieved significant relief from her delusions. She says that she has no idea where the bugs have gone. Ms. L appears to be a completely different person. She no longer appears guarded. The suspiciousness, paranoia, hopelessness, and negative outlook she previously experienced have significantly diminished. Her MoCA score improves to 25/30, indicating no cognitive impairment (Table). She is discharged after a 7-night stay on the inpatient psychiatric unit.

Continue to: The authors' observations

During one of the clinical multidisciplinary treatment team meetings held for Ms. L, it was initially estimated that it would take at least 2 weeks for the delusional parasitosis to significantly respond to antipsychotic therapy. However, it is our professional opinion that the applied cognitive restructuring, with validation of her suffering, verbal support, and medication adherence counseling, expedited her recovery. This coincided with the aggressive titration of her antipsychotic and antidepressant, although the treatment team’s acknowledgment of Ms. L’s misery appeared to lower her guard and make her more susceptible to the power of cognitive restructuring. The efforts to validate the patient’s feelings and decrease hopelessness by telling her that the medication would make the bugs go away appeared to be the tipping point for her recovery. Patients with primary delusional parasitosis often are guarded and may feel alone in their predicament when they are met with perplexed responses from individuals with whom they discuss their symptoms. Compared with patients with schizophrenia, patients with delusional parasitosis maintain normal cognitive functioning, which may give them the insight to understand how their experience may be perceived as incompatible with reality.⁷ This understanding, coupled with some perceived helplessness, can lead a patient to fear having a severe mental decompensation, which can contribute to a delayed or complicated recovery.

The cognitive process described above might have been responsible for the difference in Ms. L’s MoCA scores because her performance in the initial test was hindered by her constant obsession with the bugs, which made her distracted during the test. By the time she responded to treatment, she gained significant clarity of thought, which enabled her to perform optimally in the test.

The difficulty in treating patients with delusional parasitosis may be further affected by lack of insight, and the fact that they often do not present to a psychiatrist for treatment in a timely manner because their delusion is impregnable and presents them with an alternate reality. These patients are more likely to seek out primary care physicians, dermatologists, infectious disease doctors, and entomologists because of the fervor of their delusion and the intensity of their discomfort. Because of this, a collaboration between these providers would likely lead to improved care and treatment acceptance for patients with delusional parasitosis.

Antipsychotics are the preferred medication for treating delusional parasitosis, and the literature supports their use for this purpose.^6,8 The overall response rate is 60% to 100%.⁶ Previously, in small placebo-­controlled trials, the first-generation antipsychotic (FGA) pimozide was considered first-line treatment for this disease.⁶ However, this antipsychotic is no longer favored because evidence is mounting that other FGAs result in comparable response rates with fewer tolerability issues.^8,9

The bulk of data on the use of antipsychotics for treating delusional parasitosis comes from retrospective case reports and case series.⁶ Multiple antipsychotics have been shown to be effective in treating delusional parasitosis, including both FGAs and second-generation antipsychotics (SGAs).^6,10 Published case reports and series have shown the effectiveness of the FGAs pimozide and haloperidol, among others. One review found that perphenazine, at doses up to 12 mg/d, resulted in partial remission for 2 patients and full remission for 1 patient.⁶

Continue to: The SGAs risperidone, olanzapine, aripiprazole...

The SGAs risperidone, olanzapine, aripiprazole, quetiapine, paliperidone, and ziprasidone have also been used in case reports.^6,8,10,11 Olanzapine and risperidone appear to have the most robust evidence supporting their use. Long-acting injectable antipsychotics, such as long-acting risperidone and paliperidone palmitate, have been used with success.^8,10 A systematic review did not find any evidence to support that any one antipsychotic was superior to another, nor was there a difference in response rate to FGAs or SGAs.⁶ In a case series, Boggild et al¹¹ found that combination therapy with an antidepressant and a low-dose high potency antipsychotic lead to improvements in symptom severity.

When selecting antipsychotic therapy for a patient diagnosed with delusional parasitosis, consider patient-specific factors, such as age, medication history, comorbidities, and the adverse-effect profile of the medication(s). These medications should be started at a low dose and titrated based on efficacy and safety. The optimal duration of therapy varies by patient. Patients should continually be assessed for possible treatment discontinuation, although if therapy is tapered off, patients need to be closely monitored for possible relapse or recurrence of symptoms.

Ms. L received perphenazine titrated up to 24 mg/d for the treatment of delusional parasitosis. The maximum dose used for Ms. L was higher than those used in previous reports, although she appeared to tolerate the medication well and respond rapidly. Her symptoms showed improvement within 1 week. Importantly, in published case reports, patients have been resistant to the use of psychotropic medications without other treatment modalities (eg, psychotherapy, various behavioral approaches). We conclude that Ms. L’s response was attributable to the use of the combination of psychotherapeutic techniques and the effectiveness of perphenazine and venlafaxine.

Bottom Line

Managing patients with primary delusional parasitosis can be challenging due to the fixed nature of the delusion. A combination of antipsychotics and psychotherapeutic techniques can benefit some patients. The optimal duration of treatment varies by patient.

Related Resource

• Trenton A, Pansare N, Tobia A, et al. Delusional parasitosis on the psychiatric consultation service-a longitudinal perspective: case study. BJPsych Open. 2017;3(3):154-158. 

Drug Brand Names

Aripiprazole • Abilify
Haloperidol • Haldol
Olanzapine • Zyprexa
Paliperidone • Invega
Paliperidone palmitate • Invega Sustenna
Perphenazine • Trilafon
Pimozide • Orap
Quetiapine • Seroquel
Risperidone • Risperdal
Venlafaxine • Effexor  
Ziprasidone • Geodon

CASE Scratching, anxious, and hopeless

Ms. L, age 74, who is paraplegic and uses a wheelchair, presents to our hospital’s emergency department (ED) accompanied by staff from the nursing home where she resides. She reports that she can feel and see bugs crawling all over her skin, biting her, and burrowing into her body. She says that the bugs also stick to her clothes.

Ms. L experiences generalized pruritus with excoriations scattered over her upper and lower extremities and her trunk. She copes with the pruritus by scratching. She reports that the bugs are present throughout the day and are worse at night when she tries to go to bed. Nothing she does provides relief from the infestation. Earlier, at the nursing home, Ms. L had obtained a detergent powder and used it in an attempt to purge the bugs. She now has large swaths of irritated skin, mostly on her lower back and perineal region.

She says the bug infestation became unbearable 3 weeks ago, but she can’t identify any precipitants for her symptoms. Ms. L reports that the impact of the bugs on her daily activity, sleep, and quality of life is enormous. Despite her complaints, neither the nursing home staff nor the ED staff can find any evidence of bugs on Ms. L’s clothes or skin.

Because Ms. L resorted to such drastic measures in her attempt to rid her body of the bugs, she is considered a safety risk and is admitted to the psychiatric unit, although she vehemently denies any intention to harm herself.

On the psychiatric unit, Ms. L states that the infestation began approximately 2 years ago. She began to experience severe worsening of her symptoms a few weeks before presenting to the ED.

During evaluation, Ms. L is alert and oriented to person, place, and situation. She is also quite cooperative but guarded in describing her infestation. There is some degree of suspiciousness and paranoia with regards to her infestation; she is very sensitive to how the clinical staff respond to her condition. She appears worried, and exhibits anxiety, sadness, hopelessness, and tearfulness. Her thought process is goal-directed, but preoccupied by the bugs.

[polldaddy:10064801]

Continue to: The authors' observations

Delusional parasitosis is a rare disorder that is defined by an individual having a fixed, false belief that he or she is being infected or grossly invaded by a living organism. Karl A. Ekbom, a Swedish neurologist, was the first practitioner to definitively describe this affliction in 1938.¹

Primary delusional parasitosis is a disease defined by this single psychotic symptom without other classic symptoms of schizophrenia; this single symptom cannot be attributed to the effects of substance abuse or a medical condition. Many affected patients remain functional in their daily lives; only a minority of patients experience delusions that interfere with usual activity.² Secondary delusional parasitosis is a symptom of another psychiatric or medical disease.

Morgellons disease is characterized by symptoms similar to primary delusional parasitosis, but symptoms of this condition also include the delusional belief that inanimate objects, usually fibers, are in the skin as well as the parasites.³

A population-based study among individuals living in Olmsted County, Minnesota from 1976 to 2010 found that the incidence of delusional infestation was 1.9 cases (95% confidence interval, 1.5 to 2.4) per 100,000 person-years.⁴ In a retrospective study of 147 patients with delusional parasitosis, 33% of these patients described themselves as disabled, 28% were retired, and 26% were employed.⁵ In this study, the mean age of diagnosis was 57, with a female-to-male ratio of 2.89:1.⁵

Continue to: HISTORY Prior psychiatric hospitalization

HISTORY Prior psychiatric hospitalization

Ms. L, who is divorced and retired, lives in a nursing home and has no pets, no exposure to scabies, no recent travel, no allergies, and no difficulty with her hygiene except at the peak of her illness. She denies any alcohol or illicit drug use but reports a 6 pack year history of smoking. She has a son, 2 grandchildren, and 2 great grandchildren who all live in town and see her regularly. She reports no history of arrests or legal problems.

Ms. L has a history of depression and anxiety that culminated in a “nervous breakdown” in 1985 with a brief stay in a psychiatric hospital. She reports that she had seen a therapist for 6 years as part of her treatment following that event. During her hospitalization, she was treated with a tricyclic antidepressant and received electroconvulsive therapy. She denies being suicidal during the incident in 1985 or at any point in time before or since then. She now takes venlafaxine, 75 mg/d, for depression and anxiety.

Ms. L’s paraplegia resulted from her sixth corrective surgery for scoliosis, which occurred 6 years ago. She has had chronic pain since this surgery. Her medical history also includes hypertension, atrial fibrillation, mild neurocognitive changes, and gastroesophageal reflux disease.

EVALUATION Skin examination, blood analysis normal

On admission, Ms. L undergoes a skin examination, which yields no evidence consistent with infestation with Pediculus humanus corporis (body louse) or Sarcoptes scabiei (scabies).⁶ Blood analysis shows no iron deficiency, renal failure, hyperbilirubinemia, or eosinophilia. In the ED, the medical team examines Ms. L and explores other medical and dermatological causes of her condition. Because dermatological causes had been ruled out before Ms. L was admitted to the inpatient psychiatric unit, no dermatology consult is requested.

Continue to: TREATMENT A first-generation antipsychotic

When Ms. L is admitted to the psychiatric unit, she is started on oral perphenazine, 8 mg twice daily, and venlafaxine, 75 mg/d, which she was taking prior to hospital admission. Because she had tolerated venlafaxine with no adverse effects, it seems worthwhile to optimize the dose of this medication rather than start a new medication.

During the week, Ms. L’s perphenazine is titrated up to 24 mg twice daily and venlafaxine is titrated to 150 mg/d. A Montreal Cognitive Assessment (MoCA) is performed within the first 2 days of admission and she scores 16/30, indicating moderate cognitive impairment. On Friday, the attending physician explains that her medications should start to have therapeutic effect. During this time, this clinician engages in cognitive restructuring by providing validation of Ms. L’s suffering, verbal support, and medication compliance counseling. At this time, the treating team also suggests to Ms. L that she should expect the activity and effects of the bugs to dissipate. She is receptive to this suggestion. She also participates in the milieu, including unit activities, but is limited in her ability to engage in group therapy due to the intensity of her illness.

Throughout the weekend, the on-call physician also engages Ms. L and reports minor improvement.

OUTCOME Significant relief

On re-evaluation Monday morning—almost a week after Ms. L had been admitted to the inpatient psychiatric unit—she has achieved significant relief from her delusions. She says that she has no idea where the bugs have gone. Ms. L appears to be a completely different person. She no longer appears guarded. The suspiciousness, paranoia, hopelessness, and negative outlook she previously experienced have significantly diminished. Her MoCA score improves to 25/30, indicating no cognitive impairment (Table). She is discharged after a 7-night stay on the inpatient psychiatric unit.

Continue to: The authors' observations

During one of the clinical multidisciplinary treatment team meetings held for Ms. L, it was initially estimated that it would take at least 2 weeks for the delusional parasitosis to significantly respond to antipsychotic therapy. However, it is our professional opinion that the applied cognitive restructuring, with validation of her suffering, verbal support, and medication adherence counseling, expedited her recovery. This coincided with the aggressive titration of her antipsychotic and antidepressant, although the treatment team’s acknowledgment of Ms. L’s misery appeared to lower her guard and make her more susceptible to the power of cognitive restructuring. The efforts to validate the patient’s feelings and decrease hopelessness by telling her that the medication would make the bugs go away appeared to be the tipping point for her recovery. Patients with primary delusional parasitosis often are guarded and may feel alone in their predicament when they are met with perplexed responses from individuals with whom they discuss their symptoms. Compared with patients with schizophrenia, patients with delusional parasitosis maintain normal cognitive functioning, which may give them the insight to understand how their experience may be perceived as incompatible with reality.⁷ This understanding, coupled with some perceived helplessness, can lead a patient to fear having a severe mental decompensation, which can contribute to a delayed or complicated recovery.

The cognitive process described above might have been responsible for the difference in Ms. L’s MoCA scores because her performance in the initial test was hindered by her constant obsession with the bugs, which made her distracted during the test. By the time she responded to treatment, she gained significant clarity of thought, which enabled her to perform optimally in the test.

The difficulty in treating patients with delusional parasitosis may be further affected by lack of insight, and the fact that they often do not present to a psychiatrist for treatment in a timely manner because their delusion is impregnable and presents them with an alternate reality. These patients are more likely to seek out primary care physicians, dermatologists, infectious disease doctors, and entomologists because of the fervor of their delusion and the intensity of their discomfort. Because of this, a collaboration between these providers would likely lead to improved care and treatment acceptance for patients with delusional parasitosis.

Antipsychotics are the preferred medication for treating delusional parasitosis, and the literature supports their use for this purpose.^6,8 The overall response rate is 60% to 100%.⁶ Previously, in small placebo-­controlled trials, the first-generation antipsychotic (FGA) pimozide was considered first-line treatment for this disease.⁶ However, this antipsychotic is no longer favored because evidence is mounting that other FGAs result in comparable response rates with fewer tolerability issues.^8,9

The bulk of data on the use of antipsychotics for treating delusional parasitosis comes from retrospective case reports and case series.⁶ Multiple antipsychotics have been shown to be effective in treating delusional parasitosis, including both FGAs and second-generation antipsychotics (SGAs).^6,10 Published case reports and series have shown the effectiveness of the FGAs pimozide and haloperidol, among others. One review found that perphenazine, at doses up to 12 mg/d, resulted in partial remission for 2 patients and full remission for 1 patient.⁶

Continue to: The SGAs risperidone, olanzapine, aripiprazole...

The SGAs risperidone, olanzapine, aripiprazole, quetiapine, paliperidone, and ziprasidone have also been used in case reports.^6,8,10,11 Olanzapine and risperidone appear to have the most robust evidence supporting their use. Long-acting injectable antipsychotics, such as long-acting risperidone and paliperidone palmitate, have been used with success.^8,10 A systematic review did not find any evidence to support that any one antipsychotic was superior to another, nor was there a difference in response rate to FGAs or SGAs.⁶ In a case series, Boggild et al¹¹ found that combination therapy with an antidepressant and a low-dose high potency antipsychotic lead to improvements in symptom severity.

When selecting antipsychotic therapy for a patient diagnosed with delusional parasitosis, consider patient-specific factors, such as age, medication history, comorbidities, and the adverse-effect profile of the medication(s). These medications should be started at a low dose and titrated based on efficacy and safety. The optimal duration of therapy varies by patient. Patients should continually be assessed for possible treatment discontinuation, although if therapy is tapered off, patients need to be closely monitored for possible relapse or recurrence of symptoms.

Ms. L received perphenazine titrated up to 24 mg/d for the treatment of delusional parasitosis. The maximum dose used for Ms. L was higher than those used in previous reports, although she appeared to tolerate the medication well and respond rapidly. Her symptoms showed improvement within 1 week. Importantly, in published case reports, patients have been resistant to the use of psychotropic medications without other treatment modalities (eg, psychotherapy, various behavioral approaches). We conclude that Ms. L’s response was attributable to the use of the combination of psychotherapeutic techniques and the effectiveness of perphenazine and venlafaxine.

Bottom Line

Managing patients with primary delusional parasitosis can be challenging due to the fixed nature of the delusion. A combination of antipsychotics and psychotherapeutic techniques can benefit some patients. The optimal duration of treatment varies by patient.

Related Resource

• Trenton A, Pansare N, Tobia A, et al. Delusional parasitosis on the psychiatric consultation service-a longitudinal perspective: case study. BJPsych Open. 2017;3(3):154-158. 

Drug Brand Names

Aripiprazole • Abilify
Haloperidol • Haldol
Olanzapine • Zyprexa
Paliperidone • Invega
Paliperidone palmitate • Invega Sustenna
Perphenazine • Trilafon
Pimozide • Orap
Quetiapine • Seroquel
Risperidone • Risperdal
Venlafaxine • Effexor  
Ziprasidone • Geodon

CASE Scratching, anxious, and hopeless

Ms. L, age 74, who is paraplegic and uses a wheelchair, presents to our hospital’s emergency department (ED) accompanied by staff from the nursing home where she resides. She reports that she can feel and see bugs crawling all over her skin, biting her, and burrowing into her body. She says that the bugs also stick to her clothes.

Ms. L experiences generalized pruritus with excoriations scattered over her upper and lower extremities and her trunk. She copes with the pruritus by scratching. She reports that the bugs are present throughout the day and are worse at night when she tries to go to bed. Nothing she does provides relief from the infestation. Earlier, at the nursing home, Ms. L had obtained a detergent powder and used it in an attempt to purge the bugs. She now has large swaths of irritated skin, mostly on her lower back and perineal region.

She says the bug infestation became unbearable 3 weeks ago, but she can’t identify any precipitants for her symptoms. Ms. L reports that the impact of the bugs on her daily activity, sleep, and quality of life is enormous. Despite her complaints, neither the nursing home staff nor the ED staff can find any evidence of bugs on Ms. L’s clothes or skin.

Because Ms. L resorted to such drastic measures in her attempt to rid her body of the bugs, she is considered a safety risk and is admitted to the psychiatric unit, although she vehemently denies any intention to harm herself.

On the psychiatric unit, Ms. L states that the infestation began approximately 2 years ago. She began to experience severe worsening of her symptoms a few weeks before presenting to the ED.

During evaluation, Ms. L is alert and oriented to person, place, and situation. She is also quite cooperative but guarded in describing her infestation. There is some degree of suspiciousness and paranoia with regards to her infestation; she is very sensitive to how the clinical staff respond to her condition. She appears worried, and exhibits anxiety, sadness, hopelessness, and tearfulness. Her thought process is goal-directed, but preoccupied by the bugs.

[polldaddy:10064801]

Continue to: The authors' observations

Delusional parasitosis is a rare disorder that is defined by an individual having a fixed, false belief that he or she is being infected or grossly invaded by a living organism. Karl A. Ekbom, a Swedish neurologist, was the first practitioner to definitively describe this affliction in 1938.¹

Primary delusional parasitosis is a disease defined by this single psychotic symptom without other classic symptoms of schizophrenia; this single symptom cannot be attributed to the effects of substance abuse or a medical condition. Many affected patients remain functional in their daily lives; only a minority of patients experience delusions that interfere with usual activity.² Secondary delusional parasitosis is a symptom of another psychiatric or medical disease.

Morgellons disease is characterized by symptoms similar to primary delusional parasitosis, but symptoms of this condition also include the delusional belief that inanimate objects, usually fibers, are in the skin as well as the parasites.³

A population-based study among individuals living in Olmsted County, Minnesota from 1976 to 2010 found that the incidence of delusional infestation was 1.9 cases (95% confidence interval, 1.5 to 2.4) per 100,000 person-years.⁴ In a retrospective study of 147 patients with delusional parasitosis, 33% of these patients described themselves as disabled, 28% were retired, and 26% were employed.⁵ In this study, the mean age of diagnosis was 57, with a female-to-male ratio of 2.89:1.⁵

Continue to: HISTORY Prior psychiatric hospitalization

HISTORY Prior psychiatric hospitalization

Ms. L, who is divorced and retired, lives in a nursing home and has no pets, no exposure to scabies, no recent travel, no allergies, and no difficulty with her hygiene except at the peak of her illness. She denies any alcohol or illicit drug use but reports a 6 pack year history of smoking. She has a son, 2 grandchildren, and 2 great grandchildren who all live in town and see her regularly. She reports no history of arrests or legal problems.

Ms. L has a history of depression and anxiety that culminated in a “nervous breakdown” in 1985 with a brief stay in a psychiatric hospital. She reports that she had seen a therapist for 6 years as part of her treatment following that event. During her hospitalization, she was treated with a tricyclic antidepressant and received electroconvulsive therapy. She denies being suicidal during the incident in 1985 or at any point in time before or since then. She now takes venlafaxine, 75 mg/d, for depression and anxiety.

Ms. L’s paraplegia resulted from her sixth corrective surgery for scoliosis, which occurred 6 years ago. She has had chronic pain since this surgery. Her medical history also includes hypertension, atrial fibrillation, mild neurocognitive changes, and gastroesophageal reflux disease.

EVALUATION Skin examination, blood analysis normal

On admission, Ms. L undergoes a skin examination, which yields no evidence consistent with infestation with Pediculus humanus corporis (body louse) or Sarcoptes scabiei (scabies).⁶ Blood analysis shows no iron deficiency, renal failure, hyperbilirubinemia, or eosinophilia. In the ED, the medical team examines Ms. L and explores other medical and dermatological causes of her condition. Because dermatological causes had been ruled out before Ms. L was admitted to the inpatient psychiatric unit, no dermatology consult is requested.

Continue to: TREATMENT A first-generation antipsychotic

When Ms. L is admitted to the psychiatric unit, she is started on oral perphenazine, 8 mg twice daily, and venlafaxine, 75 mg/d, which she was taking prior to hospital admission. Because she had tolerated venlafaxine with no adverse effects, it seems worthwhile to optimize the dose of this medication rather than start a new medication.

During the week, Ms. L’s perphenazine is titrated up to 24 mg twice daily and venlafaxine is titrated to 150 mg/d. A Montreal Cognitive Assessment (MoCA) is performed within the first 2 days of admission and she scores 16/30, indicating moderate cognitive impairment. On Friday, the attending physician explains that her medications should start to have therapeutic effect. During this time, this clinician engages in cognitive restructuring by providing validation of Ms. L’s suffering, verbal support, and medication compliance counseling. At this time, the treating team also suggests to Ms. L that she should expect the activity and effects of the bugs to dissipate. She is receptive to this suggestion. She also participates in the milieu, including unit activities, but is limited in her ability to engage in group therapy due to the intensity of her illness.

Throughout the weekend, the on-call physician also engages Ms. L and reports minor improvement.

OUTCOME Significant relief

On re-evaluation Monday morning—almost a week after Ms. L had been admitted to the inpatient psychiatric unit—she has achieved significant relief from her delusions. She says that she has no idea where the bugs have gone. Ms. L appears to be a completely different person. She no longer appears guarded. The suspiciousness, paranoia, hopelessness, and negative outlook she previously experienced have significantly diminished. Her MoCA score improves to 25/30, indicating no cognitive impairment (Table). She is discharged after a 7-night stay on the inpatient psychiatric unit.

Continue to: The authors' observations

During one of the clinical multidisciplinary treatment team meetings held for Ms. L, it was initially estimated that it would take at least 2 weeks for the delusional parasitosis to significantly respond to antipsychotic therapy. However, it is our professional opinion that the applied cognitive restructuring, with validation of her suffering, verbal support, and medication adherence counseling, expedited her recovery. This coincided with the aggressive titration of her antipsychotic and antidepressant, although the treatment team’s acknowledgment of Ms. L’s misery appeared to lower her guard and make her more susceptible to the power of cognitive restructuring. The efforts to validate the patient’s feelings and decrease hopelessness by telling her that the medication would make the bugs go away appeared to be the tipping point for her recovery. Patients with primary delusional parasitosis often are guarded and may feel alone in their predicament when they are met with perplexed responses from individuals with whom they discuss their symptoms. Compared with patients with schizophrenia, patients with delusional parasitosis maintain normal cognitive functioning, which may give them the insight to understand how their experience may be perceived as incompatible with reality.⁷ This understanding, coupled with some perceived helplessness, can lead a patient to fear having a severe mental decompensation, which can contribute to a delayed or complicated recovery.

The cognitive process described above might have been responsible for the difference in Ms. L’s MoCA scores because her performance in the initial test was hindered by her constant obsession with the bugs, which made her distracted during the test. By the time she responded to treatment, she gained significant clarity of thought, which enabled her to perform optimally in the test.

The difficulty in treating patients with delusional parasitosis may be further affected by lack of insight, and the fact that they often do not present to a psychiatrist for treatment in a timely manner because their delusion is impregnable and presents them with an alternate reality. These patients are more likely to seek out primary care physicians, dermatologists, infectious disease doctors, and entomologists because of the fervor of their delusion and the intensity of their discomfort. Because of this, a collaboration between these providers would likely lead to improved care and treatment acceptance for patients with delusional parasitosis.

Antipsychotics are the preferred medication for treating delusional parasitosis, and the literature supports their use for this purpose.^6,8 The overall response rate is 60% to 100%.⁶ Previously, in small placebo-­controlled trials, the first-generation antipsychotic (FGA) pimozide was considered first-line treatment for this disease.⁶ However, this antipsychotic is no longer favored because evidence is mounting that other FGAs result in comparable response rates with fewer tolerability issues.^8,9

The bulk of data on the use of antipsychotics for treating delusional parasitosis comes from retrospective case reports and case series.⁶ Multiple antipsychotics have been shown to be effective in treating delusional parasitosis, including both FGAs and second-generation antipsychotics (SGAs).^6,10 Published case reports and series have shown the effectiveness of the FGAs pimozide and haloperidol, among others. One review found that perphenazine, at doses up to 12 mg/d, resulted in partial remission for 2 patients and full remission for 1 patient.⁶

Continue to: The SGAs risperidone, olanzapine, aripiprazole...

The SGAs risperidone, olanzapine, aripiprazole, quetiapine, paliperidone, and ziprasidone have also been used in case reports.^6,8,10,11 Olanzapine and risperidone appear to have the most robust evidence supporting their use. Long-acting injectable antipsychotics, such as long-acting risperidone and paliperidone palmitate, have been used with success.^8,10 A systematic review did not find any evidence to support that any one antipsychotic was superior to another, nor was there a difference in response rate to FGAs or SGAs.⁶ In a case series, Boggild et al¹¹ found that combination therapy with an antidepressant and a low-dose high potency antipsychotic lead to improvements in symptom severity.

When selecting antipsychotic therapy for a patient diagnosed with delusional parasitosis, consider patient-specific factors, such as age, medication history, comorbidities, and the adverse-effect profile of the medication(s). These medications should be started at a low dose and titrated based on efficacy and safety. The optimal duration of therapy varies by patient. Patients should continually be assessed for possible treatment discontinuation, although if therapy is tapered off, patients need to be closely monitored for possible relapse or recurrence of symptoms.

Ms. L received perphenazine titrated up to 24 mg/d for the treatment of delusional parasitosis. The maximum dose used for Ms. L was higher than those used in previous reports, although she appeared to tolerate the medication well and respond rapidly. Her symptoms showed improvement within 1 week. Importantly, in published case reports, patients have been resistant to the use of psychotropic medications without other treatment modalities (eg, psychotherapy, various behavioral approaches). We conclude that Ms. L’s response was attributable to the use of the combination of psychotherapeutic techniques and the effectiveness of perphenazine and venlafaxine.

Bottom Line

Managing patients with primary delusional parasitosis can be challenging due to the fixed nature of the delusion. A combination of antipsychotics and psychotherapeutic techniques can benefit some patients. The optimal duration of treatment varies by patient.

Related Resource

• Trenton A, Pansare N, Tobia A, et al. Delusional parasitosis on the psychiatric consultation service-a longitudinal perspective: case study. BJPsych Open. 2017;3(3):154-158. 

Drug Brand Names

Aripiprazole • Abilify
Haloperidol • Haldol
Olanzapine • Zyprexa
Paliperidone • Invega
Paliperidone palmitate • Invega Sustenna
Perphenazine • Trilafon
Pimozide • Orap
Quetiapine • Seroquel
Risperidone • Risperdal
Venlafaxine • Effexor  
Ziprasidone • Geodon

ANSWER

The correct interpretation includes marked sinus bradycardia with sinus arrhythmia, biatrial enlargement, and an RSR’ pattern in lead V₁ suggestive of right ventricular conduction delay.

A heart rate below 60 beats/min is considered sinus bradycardia; below 50 beats/min, it may be called marked sinus bradycardia. Sinus arrhythmia is identified by comparing the RR intervals between the third/fourth and fourth/fifth beats on the rhythm strips with the others. This particular variation is most likely respiratory.

Biatrial enlargement is characterized by P waves ≥ 2.5 mm in lead II (right atrial enlargement), P waves > 120 ms in width in lead II, and a biphasic P wave in lead V₁ (> 40 ms wide, 1 mm deep). The criteria aren’t crystal clear in this example, but given the large P wave in leads II and aVF and the biphasic P waves in lead V₁, the finding is inferred.

Finally, the RSR’ pattern in V₁ suggests right ventricular conduction delay but does not meet the criteria (QRS duration > 120 ms) for a right bundle branch block.

ANSWER

The correct interpretation includes marked sinus bradycardia with sinus arrhythmia, biatrial enlargement, and an RSR’ pattern in lead V₁ suggestive of right ventricular conduction delay.

A heart rate below 60 beats/min is considered sinus bradycardia; below 50 beats/min, it may be called marked sinus bradycardia. Sinus arrhythmia is identified by comparing the RR intervals between the third/fourth and fourth/fifth beats on the rhythm strips with the others. This particular variation is most likely respiratory.

Biatrial enlargement is characterized by P waves ≥ 2.5 mm in lead II (right atrial enlargement), P waves > 120 ms in width in lead II, and a biphasic P wave in lead V₁ (> 40 ms wide, 1 mm deep). The criteria aren’t crystal clear in this example, but given the large P wave in leads II and aVF and the biphasic P waves in lead V₁, the finding is inferred.

Finally, the RSR’ pattern in V₁ suggests right ventricular conduction delay but does not meet the criteria (QRS duration > 120 ms) for a right bundle branch block.

ANSWER

The correct interpretation includes marked sinus bradycardia with sinus arrhythmia, biatrial enlargement, and an RSR’ pattern in lead V₁ suggestive of right ventricular conduction delay.

A heart rate below 60 beats/min is considered sinus bradycardia; below 50 beats/min, it may be called marked sinus bradycardia. Sinus arrhythmia is identified by comparing the RR intervals between the third/fourth and fourth/fifth beats on the rhythm strips with the others. This particular variation is most likely respiratory.

Biatrial enlargement is characterized by P waves ≥ 2.5 mm in lead II (right atrial enlargement), P waves > 120 ms in width in lead II, and a biphasic P wave in lead V₁ (> 40 ms wide, 1 mm deep). The criteria aren’t crystal clear in this example, but given the large P wave in leads II and aVF and the biphasic P waves in lead V₁, the finding is inferred.

Finally, the RSR’ pattern in V₁ suggests right ventricular conduction delay but does not meet the criteria (QRS duration > 120 ms) for a right bundle branch block.

Are you a clinician educator? Chances are, the answer is yes! Teaching is integral to the practice of chest medicine, whether the audience is medical students, residents, fellows, nurse practitioners, physician assistants, nurses, respiratory therapists, or patients. If you are interested in further developing this essential skill, CHEST 2018 has you covered! This year at the annual meeting, you will be offered more than 25 hours of content focused on enhancing your teaching.

If most of your teaching is in an academic setting, be sure to make time for the CHEST/APCCMPD Symposium on Sunday afternoon. Here you will learn from experienced program directors and faculty how to implement state-of-the art faculty development methods. You will also have the opportunity to discuss your own experience giving feedback to learners, as best practices are discussed and shared. And the Sunday content doesn’t stop there; we also have sessions on ICU burnout – an important factor for all of us – and the use of new mobile technologies to enhance your teaching.

Monday’s sessions will cover teaching in several different settings. First up, a session covering several techniques you can use to teach one-on-one or in a small group setting – perfect for enhancing your teaching during rounds! Next, learn practical tips to increase the impact of your teaching in a large group lecture or a small group session. The afternoon opens with the latest innovations in Pulmonary and Critical Care fellowship training, to keep you abreast of the newest opportunities for your learners, and a session at the end of the day reviews advances in the teaching of point-of-care ultrasound. Finally, don’t miss the 3:15 symposium on tips to get your CHEST Foundation Grant funded – this session will be pure gold for increasing your proposal’s chance for success!

Educators will also be interested in the Tuesday sessions on implicit bias. Although educators always have clear and defined curriculum that we teach to our learners, we can all recognize when a “hidden curriculum” exists. This hidden curriculum can influence our learning and working environment in positive or negative ways. Learning more about our implicit biases can help tilt the balance in the right direction!

Above and beyond the didactics, CHEST 2018 will offer many opportunities for clinician educators beyond what I’ve described here. While you are planning your personal meeting schedule, be sure to make time for networking with other clinician educators from around the globe. As is the case with so many other skills, we are better teachers together!

Looking forward to seeing you at CHEST 2018!

For more on CHEST Annual Meeting 2018— chestmeeting.chestnet.org.

Are you a clinician educator? Chances are, the answer is yes! Teaching is integral to the practice of chest medicine, whether the audience is medical students, residents, fellows, nurse practitioners, physician assistants, nurses, respiratory therapists, or patients. If you are interested in further developing this essential skill, CHEST 2018 has you covered! This year at the annual meeting, you will be offered more than 25 hours of content focused on enhancing your teaching.

If most of your teaching is in an academic setting, be sure to make time for the CHEST/APCCMPD Symposium on Sunday afternoon. Here you will learn from experienced program directors and faculty how to implement state-of-the art faculty development methods. You will also have the opportunity to discuss your own experience giving feedback to learners, as best practices are discussed and shared. And the Sunday content doesn’t stop there; we also have sessions on ICU burnout – an important factor for all of us – and the use of new mobile technologies to enhance your teaching.

Monday’s sessions will cover teaching in several different settings. First up, a session covering several techniques you can use to teach one-on-one or in a small group setting – perfect for enhancing your teaching during rounds! Next, learn practical tips to increase the impact of your teaching in a large group lecture or a small group session. The afternoon opens with the latest innovations in Pulmonary and Critical Care fellowship training, to keep you abreast of the newest opportunities for your learners, and a session at the end of the day reviews advances in the teaching of point-of-care ultrasound. Finally, don’t miss the 3:15 symposium on tips to get your CHEST Foundation Grant funded – this session will be pure gold for increasing your proposal’s chance for success!

Educators will also be interested in the Tuesday sessions on implicit bias. Although educators always have clear and defined curriculum that we teach to our learners, we can all recognize when a “hidden curriculum” exists. This hidden curriculum can influence our learning and working environment in positive or negative ways. Learning more about our implicit biases can help tilt the balance in the right direction!

Above and beyond the didactics, CHEST 2018 will offer many opportunities for clinician educators beyond what I’ve described here. While you are planning your personal meeting schedule, be sure to make time for networking with other clinician educators from around the globe. As is the case with so many other skills, we are better teachers together!

Looking forward to seeing you at CHEST 2018!

For more on CHEST Annual Meeting 2018— chestmeeting.chestnet.org.

Are you a clinician educator? Chances are, the answer is yes! Teaching is integral to the practice of chest medicine, whether the audience is medical students, residents, fellows, nurse practitioners, physician assistants, nurses, respiratory therapists, or patients. If you are interested in further developing this essential skill, CHEST 2018 has you covered! This year at the annual meeting, you will be offered more than 25 hours of content focused on enhancing your teaching.

If most of your teaching is in an academic setting, be sure to make time for the CHEST/APCCMPD Symposium on Sunday afternoon. Here you will learn from experienced program directors and faculty how to implement state-of-the art faculty development methods. You will also have the opportunity to discuss your own experience giving feedback to learners, as best practices are discussed and shared. And the Sunday content doesn’t stop there; we also have sessions on ICU burnout – an important factor for all of us – and the use of new mobile technologies to enhance your teaching.

Monday’s sessions will cover teaching in several different settings. First up, a session covering several techniques you can use to teach one-on-one or in a small group setting – perfect for enhancing your teaching during rounds! Next, learn practical tips to increase the impact of your teaching in a large group lecture or a small group session. The afternoon opens with the latest innovations in Pulmonary and Critical Care fellowship training, to keep you abreast of the newest opportunities for your learners, and a session at the end of the day reviews advances in the teaching of point-of-care ultrasound. Finally, don’t miss the 3:15 symposium on tips to get your CHEST Foundation Grant funded – this session will be pure gold for increasing your proposal’s chance for success!

Educators will also be interested in the Tuesday sessions on implicit bias. Although educators always have clear and defined curriculum that we teach to our learners, we can all recognize when a “hidden curriculum” exists. This hidden curriculum can influence our learning and working environment in positive or negative ways. Learning more about our implicit biases can help tilt the balance in the right direction!

Above and beyond the didactics, CHEST 2018 will offer many opportunities for clinician educators beyond what I’ve described here. While you are planning your personal meeting schedule, be sure to make time for networking with other clinician educators from around the globe. As is the case with so many other skills, we are better teachers together!

Looking forward to seeing you at CHEST 2018!

For more on CHEST Annual Meeting 2018— chestmeeting.chestnet.org.

The Board of Regents met at CHEST headquarters in June to review our work and progress with the 2018-2022 Strategic Plan. As President of CHEST, Dr. John Studdard leads these meetings and shared the great progress toward our goals.

Editor’s Note

One of the missions of CHEST Physician is to keep you—our members, colleagues, and friends—apprised of ongoing actions of your CHEST Board of Regents. Thanks to Dr. Buckley for penning this column. We plan to run quarterly updates from the Board, and hope to have regular updates from the CHEST Foundation’s Board of Trustees, as well! If there are additional items that you’d like to see related to the function of the College or the Foundation, please let us know at [email protected].

David A. Schulman, MD, FCCP

The Board of Regents met at CHEST headquarters in June to review our work and progress with the 2018-2022 Strategic Plan. As President of CHEST, Dr. John Studdard leads these meetings and shared the great progress toward our goals.

Editor’s Note

One of the missions of CHEST Physician is to keep you—our members, colleagues, and friends—apprised of ongoing actions of your CHEST Board of Regents. Thanks to Dr. Buckley for penning this column. We plan to run quarterly updates from the Board, and hope to have regular updates from the CHEST Foundation’s Board of Trustees, as well! If there are additional items that you’d like to see related to the function of the College or the Foundation, please let us know at [email protected].

David A. Schulman, MD, FCCP

The Board of Regents met at CHEST headquarters in June to review our work and progress with the 2018-2022 Strategic Plan. As President of CHEST, Dr. John Studdard leads these meetings and shared the great progress toward our goals.

Editor’s Note

One of the missions of CHEST Physician is to keep you—our members, colleagues, and friends—apprised of ongoing actions of your CHEST Board of Regents. Thanks to Dr. Buckley for penning this column. We plan to run quarterly updates from the Board, and hope to have regular updates from the CHEST Foundation’s Board of Trustees, as well! If there are additional items that you’d like to see related to the function of the College or the Foundation, please let us know at [email protected].

David A. Schulman, MD, FCCP

San Antonio is known for its sports teams, the River Walk, and, of course, the Alamo, but one thing that doesn’t get the recognition it deserves is the food. San Antonio offers a variety of must-try food items that you simply can’t find anywhere else. Ready to get your grub on? Here are just a few picks to try out while visiting the Alamo City.
 

Bella on the River

A 13-minute walk from the Convention Center along the River Walk will land you at this San Antonio hotspot. Bella on the River is known for its “Texas Style Italian food,” which means bigger, flavor-packed portions with an Italian twist. From antipasto to paella, you’re sure to find something on the menu to feast on. Be sure to take a look at their extensive wine list, as well.
 

Cookhouse

Who says you can’t get a little taste of New Orleans while in Texas? The Cookhouse is serving up cajun favorites just a 6-minute drive from the Convention Center. Known for its New Orleans barbequed shrimp, fried boudin balls, and Po’ Boys, it’ll be hard to pick which one to feast on for dinner.
 

El Mirador

Just a 4-minute Uber from the Convention Center, you’ll find El Mirador, known for its deliciously authentic Mexican food. El Mirador has been serving up chicharrones, fresh breakfast tacos, and other savory dishes to the San Antonio community since 1968. Be sure to grab a seat on their outdoor patio, and take a look at the nearby shops and bars while enjoying your delicious meal.
 

La Fonda on Main

Take a trip to the Alta Vista neighborhood post-CHEST and visit the oldest Mexican restaurant in San Antonio, open since 1932. La Fonda on Main is known for its lively atmosphere and its traditional Tex-Mex food options. Be sure to take your dinner outside, and sit along their tree-lined patio. As this is one of San Antonio’s most recommended restaurants, we suggest making reservations.
 

Restaurant Gwendolyn

Tired out from the latest in medical advancements and tech? Kick it old school and grab a seat at Restaurant Gwendolyn along the River Walk and feast on local, seasonal, and handmade food from around the San Antonio area. This restaurant’s mission is to serve food entirely old school, which means using what they had and creating food like it was prepared prior to the industrial revolution in 1850. If you like surprises, you’re in luck, as the menu constantly changes based on what is available at that time!



Keep in mind, these are just some of the San Antonio restaurants serving up delicious dishes. If you find 0other restaurants we should add to our list, tag us on social media (@accpchest) with your picks!

San Antonio is known for its sports teams, the River Walk, and, of course, the Alamo, but one thing that doesn’t get the recognition it deserves is the food. San Antonio offers a variety of must-try food items that you simply can’t find anywhere else. Ready to get your grub on? Here are just a few picks to try out while visiting the Alamo City.
 

Bella on the River

A 13-minute walk from the Convention Center along the River Walk will land you at this San Antonio hotspot. Bella on the River is known for its “Texas Style Italian food,” which means bigger, flavor-packed portions with an Italian twist. From antipasto to paella, you’re sure to find something on the menu to feast on. Be sure to take a look at their extensive wine list, as well.
 

Cookhouse

Who says you can’t get a little taste of New Orleans while in Texas? The Cookhouse is serving up cajun favorites just a 6-minute drive from the Convention Center. Known for its New Orleans barbequed shrimp, fried boudin balls, and Po’ Boys, it’ll be hard to pick which one to feast on for dinner.
 

El Mirador

Just a 4-minute Uber from the Convention Center, you’ll find El Mirador, known for its deliciously authentic Mexican food. El Mirador has been serving up chicharrones, fresh breakfast tacos, and other savory dishes to the San Antonio community since 1968. Be sure to grab a seat on their outdoor patio, and take a look at the nearby shops and bars while enjoying your delicious meal.
 

La Fonda on Main

Take a trip to the Alta Vista neighborhood post-CHEST and visit the oldest Mexican restaurant in San Antonio, open since 1932. La Fonda on Main is known for its lively atmosphere and its traditional Tex-Mex food options. Be sure to take your dinner outside, and sit along their tree-lined patio. As this is one of San Antonio’s most recommended restaurants, we suggest making reservations.
 

Restaurant Gwendolyn

Tired out from the latest in medical advancements and tech? Kick it old school and grab a seat at Restaurant Gwendolyn along the River Walk and feast on local, seasonal, and handmade food from around the San Antonio area. This restaurant’s mission is to serve food entirely old school, which means using what they had and creating food like it was prepared prior to the industrial revolution in 1850. If you like surprises, you’re in luck, as the menu constantly changes based on what is available at that time!



Keep in mind, these are just some of the San Antonio restaurants serving up delicious dishes. If you find 0other restaurants we should add to our list, tag us on social media (@accpchest) with your picks!

San Antonio is known for its sports teams, the River Walk, and, of course, the Alamo, but one thing that doesn’t get the recognition it deserves is the food. San Antonio offers a variety of must-try food items that you simply can’t find anywhere else. Ready to get your grub on? Here are just a few picks to try out while visiting the Alamo City.
 

Bella on the River

A 13-minute walk from the Convention Center along the River Walk will land you at this San Antonio hotspot. Bella on the River is known for its “Texas Style Italian food,” which means bigger, flavor-packed portions with an Italian twist. From antipasto to paella, you’re sure to find something on the menu to feast on. Be sure to take a look at their extensive wine list, as well.
 

Cookhouse

Who says you can’t get a little taste of New Orleans while in Texas? The Cookhouse is serving up cajun favorites just a 6-minute drive from the Convention Center. Known for its New Orleans barbequed shrimp, fried boudin balls, and Po’ Boys, it’ll be hard to pick which one to feast on for dinner.
 

El Mirador

Just a 4-minute Uber from the Convention Center, you’ll find El Mirador, known for its deliciously authentic Mexican food. El Mirador has been serving up chicharrones, fresh breakfast tacos, and other savory dishes to the San Antonio community since 1968. Be sure to grab a seat on their outdoor patio, and take a look at the nearby shops and bars while enjoying your delicious meal.
 

La Fonda on Main

Take a trip to the Alta Vista neighborhood post-CHEST and visit the oldest Mexican restaurant in San Antonio, open since 1932. La Fonda on Main is known for its lively atmosphere and its traditional Tex-Mex food options. Be sure to take your dinner outside, and sit along their tree-lined patio. As this is one of San Antonio’s most recommended restaurants, we suggest making reservations.
 

Restaurant Gwendolyn

Tired out from the latest in medical advancements and tech? Kick it old school and grab a seat at Restaurant Gwendolyn along the River Walk and feast on local, seasonal, and handmade food from around the San Antonio area. This restaurant’s mission is to serve food entirely old school, which means using what they had and creating food like it was prepared prior to the industrial revolution in 1850. If you like surprises, you’re in luck, as the menu constantly changes based on what is available at that time!



Keep in mind, these are just some of the San Antonio restaurants serving up delicious dishes. If you find 0other restaurants we should add to our list, tag us on social media (@accpchest) with your picks!

In June 2018, the CHEST Foundation was approved to participate as a National Organization in the 2018 Combined Federal Campaign (CFC). The CFC is the only authorized solicitation of employees in the federal workplace on behalf of charitable organizations. As an approved organization, we will be listed on the 2018 CFC Charity List and receive our own code to promote to donors. Receiving this approval to participate in the CFC is a wonderful honor for the CHEST Foundation, and we are excited to share our news with you!

CHEST Foundation President, Lisa K. Moores, MD, FCCP, shares her insight and value about this new opportunity to engage and support the foundation’s mission of clinical research, community service, and patient education. “As a long-time federal employee, I am extremely excited that I can now show my support of the CHEST Foundation through employee giving during the annual CFC campaign. This will also allow me to share the story of the CHEST Foundation with colleagues. When they choose who they want to give to for their work place giving, they can support the CHEST Foundation, as well. This is a great opportunity for the CHEST Foundation, as I know each year during the CFC campaign (September -January), it is highly encouraged and promoted to employees. This increased exposure is very exciting and will hopefully allow us to strengthen the philanthropic work we do with the Foundation.”

Stay tuned for more information as we kick off the Combined Federal Campaign in September 2018!

In June 2018, the CHEST Foundation was approved to participate as a National Organization in the 2018 Combined Federal Campaign (CFC). The CFC is the only authorized solicitation of employees in the federal workplace on behalf of charitable organizations. As an approved organization, we will be listed on the 2018 CFC Charity List and receive our own code to promote to donors. Receiving this approval to participate in the CFC is a wonderful honor for the CHEST Foundation, and we are excited to share our news with you!

CHEST Foundation President, Lisa K. Moores, MD, FCCP, shares her insight and value about this new opportunity to engage and support the foundation’s mission of clinical research, community service, and patient education. “As a long-time federal employee, I am extremely excited that I can now show my support of the CHEST Foundation through employee giving during the annual CFC campaign. This will also allow me to share the story of the CHEST Foundation with colleagues. When they choose who they want to give to for their work place giving, they can support the CHEST Foundation, as well. This is a great opportunity for the CHEST Foundation, as I know each year during the CFC campaign (September -January), it is highly encouraged and promoted to employees. This increased exposure is very exciting and will hopefully allow us to strengthen the philanthropic work we do with the Foundation.”

Stay tuned for more information as we kick off the Combined Federal Campaign in September 2018!

In June 2018, the CHEST Foundation was approved to participate as a National Organization in the 2018 Combined Federal Campaign (CFC). The CFC is the only authorized solicitation of employees in the federal workplace on behalf of charitable organizations. As an approved organization, we will be listed on the 2018 CFC Charity List and receive our own code to promote to donors. Receiving this approval to participate in the CFC is a wonderful honor for the CHEST Foundation, and we are excited to share our news with you!

CHEST Foundation President, Lisa K. Moores, MD, FCCP, shares her insight and value about this new opportunity to engage and support the foundation’s mission of clinical research, community service, and patient education. “As a long-time federal employee, I am extremely excited that I can now show my support of the CHEST Foundation through employee giving during the annual CFC campaign. This will also allow me to share the story of the CHEST Foundation with colleagues. When they choose who they want to give to for their work place giving, they can support the CHEST Foundation, as well. This is a great opportunity for the CHEST Foundation, as I know each year during the CFC campaign (September -January), it is highly encouraged and promoted to employees. This increased exposure is very exciting and will hopefully allow us to strengthen the philanthropic work we do with the Foundation.”

Stay tuned for more information as we kick off the Combined Federal Campaign in September 2018!

One of the great educational opportunities that comes with each annual CHEST meeting is the slate of postgraduate courses that kicks the meeting off. I have always found them to be in-depth, clinically relevant reviews on specific aspects of pulmonary, critical care, and sleep medicine, as delivered by the best educators and clinical experts CHEST has to offer. And, this year is no exception. We have a total of 11 courses offered this go around, including four dedicated full-day sessions on subjects as wide-ranging as lung and pleural ultrasonography, state-of-the-art practices in the diagnosis and management of interstitial lung diseases, and a year-in-review of the best of the pulmonary literature. The American Association for Bronchology and Interventional Pulmonology will hold its annual 1-day meeting at this time, as well.

For those of you who prefer our half-day courses, we have seven of those queued up for you; morning sessions focus on pulmonary hypertension, asthma, and sleep medicine, while our afternoon courses cover updates in lung cancer, critical care medicine, use of noninvasive ventilation, and our always-popular InPHOCUS case-based hands-on simulation course for pulmonary vascular disease.

It has been a little while since I attended my first CHEST meeting as a pulmonary and critical care medicine fellow, but I vividly remember thinking how incredibly valuable these courses were, how engaging and welcoming the faculty was, and how much knowledge CHEST was able to cram into a single day. Those opinions have not changed over the last 2 decades. While we think we’ve got some pretty cool stuff going on throughout the San Antonio meeting, I hope you won’t miss the chance to sign up for these incredible learning opportunities.

Looking forward to seeing you all in Texas!
 

One of the great educational opportunities that comes with each annual CHEST meeting is the slate of postgraduate courses that kicks the meeting off. I have always found them to be in-depth, clinically relevant reviews on specific aspects of pulmonary, critical care, and sleep medicine, as delivered by the best educators and clinical experts CHEST has to offer. And, this year is no exception. We have a total of 11 courses offered this go around, including four dedicated full-day sessions on subjects as wide-ranging as lung and pleural ultrasonography, state-of-the-art practices in the diagnosis and management of interstitial lung diseases, and a year-in-review of the best of the pulmonary literature. The American Association for Bronchology and Interventional Pulmonology will hold its annual 1-day meeting at this time, as well.

For those of you who prefer our half-day courses, we have seven of those queued up for you; morning sessions focus on pulmonary hypertension, asthma, and sleep medicine, while our afternoon courses cover updates in lung cancer, critical care medicine, use of noninvasive ventilation, and our always-popular InPHOCUS case-based hands-on simulation course for pulmonary vascular disease.

It has been a little while since I attended my first CHEST meeting as a pulmonary and critical care medicine fellow, but I vividly remember thinking how incredibly valuable these courses were, how engaging and welcoming the faculty was, and how much knowledge CHEST was able to cram into a single day. Those opinions have not changed over the last 2 decades. While we think we’ve got some pretty cool stuff going on throughout the San Antonio meeting, I hope you won’t miss the chance to sign up for these incredible learning opportunities.

Looking forward to seeing you all in Texas!
 

One of the great educational opportunities that comes with each annual CHEST meeting is the slate of postgraduate courses that kicks the meeting off. I have always found them to be in-depth, clinically relevant reviews on specific aspects of pulmonary, critical care, and sleep medicine, as delivered by the best educators and clinical experts CHEST has to offer. And, this year is no exception. We have a total of 11 courses offered this go around, including four dedicated full-day sessions on subjects as wide-ranging as lung and pleural ultrasonography, state-of-the-art practices in the diagnosis and management of interstitial lung diseases, and a year-in-review of the best of the pulmonary literature. The American Association for Bronchology and Interventional Pulmonology will hold its annual 1-day meeting at this time, as well.

For those of you who prefer our half-day courses, we have seven of those queued up for you; morning sessions focus on pulmonary hypertension, asthma, and sleep medicine, while our afternoon courses cover updates in lung cancer, critical care medicine, use of noninvasive ventilation, and our always-popular InPHOCUS case-based hands-on simulation course for pulmonary vascular disease.

It has been a little while since I attended my first CHEST meeting as a pulmonary and critical care medicine fellow, but I vividly remember thinking how incredibly valuable these courses were, how engaging and welcoming the faculty was, and how much knowledge CHEST was able to cram into a single day. Those opinions have not changed over the last 2 decades. While we think we’ve got some pretty cool stuff going on throughout the San Antonio meeting, I hope you won’t miss the chance to sign up for these incredible learning opportunities.

Looking forward to seeing you all in Texas!
 

If you work in an ICU, chances are good that you frequently order IV fluids (IVF). Between resuscitation, maintenance, and medication carriers, nearly all ICU patients receive IVF. Historically, much of this IVF has been 0.9% sodium chloride (“saline” or “normal saline”). Providers in the United States alone administer more than 200 million liters of saline each year (Myburgh JA, et al. N Engl J Med. 2013;369[13]:1243). New evidence, however, suggests that treating your ICU patients with so-called “balanced crystalloids,” rather than saline, may improve patient outcomes.

For over a century, clinicians ordering IV isotonic crystalloids have had two basic options: saline or balanced crystalloids (BC). Saline contains water and 154 mmol/L of sodium chloride (around 50% more chloride than human extracellular fluid). In contrast, BCs, like lactated Ringer’s (LR), Hartman’s solution, and others, contain an amount of chloride resembling human plasma (Table 1). BC substitute an organic anion such as bicarbonate, lactate, acetate, or gluconate, in place of chloride – resulting in lower chloride level and a more neutral pH.

Over the last 2 decades, evidence has slowly accumulated that the different compositions of saline and BC might translate into differences in patient physiology and outcomes. Research in the operating room and ICU found that saline administration caused hyperchloremia and metabolic acidosis. Studies of healthy volunteers found that saline decreased blood flow to the kidney (Chowdhury AH, et al. Ann Surg. 2012;256[1]:18). Animal sepsis models suggested that saline might cause inflammation, low blood pressure, and kidney injury (Zhou F, et al. Crit Care Med. 2014;42[4]:e270). Large observational studies among ICU patients found saline to be associated with increased risk of kidney injury, dialysis, or death (Raghunathan K, et al. Crit Care Med. 2014 Jul;42[7]:1585). These preliminary studies set the stage for a large randomized clinical trial comparing clinical outcomes between BC and saline among acutely ill adults.

Between June 2015 and April 2017, our research group conducted the Isotonic Solutions and Major Adverse Renal Events Trial (SMART) (Semler MW, et al. N Engl J Med. 2018;378[9]:819). SMART was a pragmatic trial in which 15,802 adults in five ICUs were assigned to receive either saline (0.9% sodium chloride) or BC (LR or another branded BC [PlasmaLyte A]). The goal was to determine whether using BC rather than saline would decrease the rates of death, new dialysis, or renal dysfunction lasting through hospital discharge. Patients in the BC group received primarily BC (44% LR and 56% another branded BC [PlasmaLyte A]), whereas patients in the saline group received primarily saline. The rate of death, new dialysis, or renal dysfunction lasting through hospital discharge was lower in the BC group (14.3%) than the saline group (15.4%) (OR: 0.90; 95% CI, 0.82-0.99; P=0.04). The difference between groups was primarily in death and new dialysis, not changes in creatinine. For every 100 patients admitted to an ICU, using BC rather than saline would spare one patient from experiencing death, dialysis, or renal dysfunction lasting to hospital discharge (number needed to treat). The benefits of BC appeared to be greater among patients who received larger volumes of IVF and patients with sepsis. In fact, among patients with sepsis, mortality was significantly lower with BC (25.2%) than with saline (29.4%) (P=.02).

Another trial was conducted in parallel. Saline against LR or another branded BC (PlasmaLyte) in the ED (SALT-ED) compared BC with saline among 13,347 non-critically ill adults treated with IVF in the ED (Self WH, et al. N Engl J Med. 2018;378[9]:829). Like the SMART trial, the SALT-ED trial found a 1% absolute reduction in the risk of death, new dialysis, or renal dysfunction lasting to hospital discharge favoring BC.

The SMART and SALT-ED trials have important limitations. They were conducted at a single academic center, and treating clinicians were not blinded to the assigned fluid. The key outcome was a composite of death, new dialysis, and renal dysfunction lasting to hospital discharge – and the trials were not powered to show differences in each of the individual components of the composite.

Despite these limitations, we now have data from two trials enrolling nearly 30,000 acutely ill patients suggesting that BC may result in better clinical outcomes than saline for acutely ill adults. For clinicians who were already using primarily BC solutions, these results will reinforce their current practice. For clinicians whose default IVF has been saline, these new findings raise challenging questions. Prior to these trials, the ICU in which I practice had always used primarily saline. Some of the questions we faced in considering how to apply the results of the SMART and SALT-ED trials to our practice included:

1. Recent data suggest BC may produce better clinical outcomes than saline for acutely ill adults. Are there any data that saline may produce better clinical outcomes than BC? Currently, there are not.

2. Cost is an important consideration in critical care, are BC more expensive than saline? The cost to produce saline and BC is similar. At our hospital, the cost for a 1L bag of saline, LR, and another branded BC (PlasmaLyte A ) is the exactly the same.

3. Is there a specific population for whom BC might have important adverse effects? Because some BC are hypotonic, the safety of administration of BC to patients with elevated intracranial pressure (e.g., traumatic brain injury) is unknown.

4. Are there practical considerations to using BC in the ICU? Compatibility with medications can pose a challenge. For example, the calcium in LR may be incompatible with ceftriaxone infusion. Although BC are compatible with many of the medication infusions used in the ICU for which testing has been performed, less data on compatibility exist for BC than for saline.

5. Are BC as readily available as saline? The three companies that make the majority of IVF used in the United States produce both saline and BC. Recent damage to production facilities has contributed to shortages in the supply of all of them. Over the long term, however, saline and BC are similar in their availability to hospital pharmacies.

After discussing each of these considerations with our ICU physicians and nurses, consultants, and pharmacists, our ICU collectively decided to switch from using primarily saline to BC. This involved (1) our pharmacy team stocking the medication dispensing cabinets in the ICU with 90% LR and 10% saline; and (2) making BC rather than saline the default in order sets within our electronic order entry system. Based on the results of the SMART trial, making the change from saline to BC might be expected to prevent around 100 deaths in our ICU each year.

Many questions regarding the effect of IV crystalloid solutions on clinical outcomes for critically ill adults remain unanswered. The mechanism by which BC may produce better clinical outcomes than saline is uncertain. Whether acetate-containing BC (eg, PlasmaLyte) produced better outcomes than non-acetate-containing BC (eg, LR) is unknown. The safety and efficacy of BC for specific subgroups of patients (eg, those with hyperkalemia) requires further study. Two ongoing trials comparing BC to saline among critically ill adults are expected to finish in 2021 and may provide additional insights into the best approach to IVF management for critically ill adults. An ongoing pilot trial comparing LR to other branded BC (Plasmalyte/Normosol )may inform the choice between BC.

In summary, IVF administration is ubiquitous in critical care. For decades, much of that fluid has been saline. BC are similar to saline in availability and cost. Two large trials now demonstrate better patient outcomes with BC compared with saline. These data challenge ICU providers, pharmacies, and hospital systems primarily using saline to evaluate the available data, their current IVF prescribing practices, and the logistical barriers to change, to determine whether there are legitimate reasons to continue using saline, or whether the time has come to make BC the first-line fluid therapy for acutely ill adults.

Dr. Semler is with the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine –Vanderbilt University Medical Center, Nashville, Tennessee.

If you work in an ICU, chances are good that you frequently order IV fluids (IVF). Between resuscitation, maintenance, and medication carriers, nearly all ICU patients receive IVF. Historically, much of this IVF has been 0.9% sodium chloride (“saline” or “normal saline”). Providers in the United States alone administer more than 200 million liters of saline each year (Myburgh JA, et al. N Engl J Med. 2013;369[13]:1243). New evidence, however, suggests that treating your ICU patients with so-called “balanced crystalloids,” rather than saline, may improve patient outcomes.

For over a century, clinicians ordering IV isotonic crystalloids have had two basic options: saline or balanced crystalloids (BC). Saline contains water and 154 mmol/L of sodium chloride (around 50% more chloride than human extracellular fluid). In contrast, BCs, like lactated Ringer’s (LR), Hartman’s solution, and others, contain an amount of chloride resembling human plasma (Table 1). BC substitute an organic anion such as bicarbonate, lactate, acetate, or gluconate, in place of chloride – resulting in lower chloride level and a more neutral pH.

Over the last 2 decades, evidence has slowly accumulated that the different compositions of saline and BC might translate into differences in patient physiology and outcomes. Research in the operating room and ICU found that saline administration caused hyperchloremia and metabolic acidosis. Studies of healthy volunteers found that saline decreased blood flow to the kidney (Chowdhury AH, et al. Ann Surg. 2012;256[1]:18). Animal sepsis models suggested that saline might cause inflammation, low blood pressure, and kidney injury (Zhou F, et al. Crit Care Med. 2014;42[4]:e270). Large observational studies among ICU patients found saline to be associated with increased risk of kidney injury, dialysis, or death (Raghunathan K, et al. Crit Care Med. 2014 Jul;42[7]:1585). These preliminary studies set the stage for a large randomized clinical trial comparing clinical outcomes between BC and saline among acutely ill adults.

Between June 2015 and April 2017, our research group conducted the Isotonic Solutions and Major Adverse Renal Events Trial (SMART) (Semler MW, et al. N Engl J Med. 2018;378[9]:819). SMART was a pragmatic trial in which 15,802 adults in five ICUs were assigned to receive either saline (0.9% sodium chloride) or BC (LR or another branded BC [PlasmaLyte A]). The goal was to determine whether using BC rather than saline would decrease the rates of death, new dialysis, or renal dysfunction lasting through hospital discharge. Patients in the BC group received primarily BC (44% LR and 56% another branded BC [PlasmaLyte A]), whereas patients in the saline group received primarily saline. The rate of death, new dialysis, or renal dysfunction lasting through hospital discharge was lower in the BC group (14.3%) than the saline group (15.4%) (OR: 0.90; 95% CI, 0.82-0.99; P=0.04). The difference between groups was primarily in death and new dialysis, not changes in creatinine. For every 100 patients admitted to an ICU, using BC rather than saline would spare one patient from experiencing death, dialysis, or renal dysfunction lasting to hospital discharge (number needed to treat). The benefits of BC appeared to be greater among patients who received larger volumes of IVF and patients with sepsis. In fact, among patients with sepsis, mortality was significantly lower with BC (25.2%) than with saline (29.4%) (P=.02).

Another trial was conducted in parallel. Saline against LR or another branded BC (PlasmaLyte) in the ED (SALT-ED) compared BC with saline among 13,347 non-critically ill adults treated with IVF in the ED (Self WH, et al. N Engl J Med. 2018;378[9]:829). Like the SMART trial, the SALT-ED trial found a 1% absolute reduction in the risk of death, new dialysis, or renal dysfunction lasting to hospital discharge favoring BC.

The SMART and SALT-ED trials have important limitations. They were conducted at a single academic center, and treating clinicians were not blinded to the assigned fluid. The key outcome was a composite of death, new dialysis, and renal dysfunction lasting to hospital discharge – and the trials were not powered to show differences in each of the individual components of the composite.

Despite these limitations, we now have data from two trials enrolling nearly 30,000 acutely ill patients suggesting that BC may result in better clinical outcomes than saline for acutely ill adults. For clinicians who were already using primarily BC solutions, these results will reinforce their current practice. For clinicians whose default IVF has been saline, these new findings raise challenging questions. Prior to these trials, the ICU in which I practice had always used primarily saline. Some of the questions we faced in considering how to apply the results of the SMART and SALT-ED trials to our practice included:

1. Recent data suggest BC may produce better clinical outcomes than saline for acutely ill adults. Are there any data that saline may produce better clinical outcomes than BC? Currently, there are not.

2. Cost is an important consideration in critical care, are BC more expensive than saline? The cost to produce saline and BC is similar. At our hospital, the cost for a 1L bag of saline, LR, and another branded BC (PlasmaLyte A ) is the exactly the same.

3. Is there a specific population for whom BC might have important adverse effects? Because some BC are hypotonic, the safety of administration of BC to patients with elevated intracranial pressure (e.g., traumatic brain injury) is unknown.

4. Are there practical considerations to using BC in the ICU? Compatibility with medications can pose a challenge. For example, the calcium in LR may be incompatible with ceftriaxone infusion. Although BC are compatible with many of the medication infusions used in the ICU for which testing has been performed, less data on compatibility exist for BC than for saline.

5. Are BC as readily available as saline? The three companies that make the majority of IVF used in the United States produce both saline and BC. Recent damage to production facilities has contributed to shortages in the supply of all of them. Over the long term, however, saline and BC are similar in their availability to hospital pharmacies.

After discussing each of these considerations with our ICU physicians and nurses, consultants, and pharmacists, our ICU collectively decided to switch from using primarily saline to BC. This involved (1) our pharmacy team stocking the medication dispensing cabinets in the ICU with 90% LR and 10% saline; and (2) making BC rather than saline the default in order sets within our electronic order entry system. Based on the results of the SMART trial, making the change from saline to BC might be expected to prevent around 100 deaths in our ICU each year.

Many questions regarding the effect of IV crystalloid solutions on clinical outcomes for critically ill adults remain unanswered. The mechanism by which BC may produce better clinical outcomes than saline is uncertain. Whether acetate-containing BC (eg, PlasmaLyte) produced better outcomes than non-acetate-containing BC (eg, LR) is unknown. The safety and efficacy of BC for specific subgroups of patients (eg, those with hyperkalemia) requires further study. Two ongoing trials comparing BC to saline among critically ill adults are expected to finish in 2021 and may provide additional insights into the best approach to IVF management for critically ill adults. An ongoing pilot trial comparing LR to other branded BC (Plasmalyte/Normosol )may inform the choice between BC.

In summary, IVF administration is ubiquitous in critical care. For decades, much of that fluid has been saline. BC are similar to saline in availability and cost. Two large trials now demonstrate better patient outcomes with BC compared with saline. These data challenge ICU providers, pharmacies, and hospital systems primarily using saline to evaluate the available data, their current IVF prescribing practices, and the logistical barriers to change, to determine whether there are legitimate reasons to continue using saline, or whether the time has come to make BC the first-line fluid therapy for acutely ill adults.

Dr. Semler is with the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine –Vanderbilt University Medical Center, Nashville, Tennessee.

If you work in an ICU, chances are good that you frequently order IV fluids (IVF). Between resuscitation, maintenance, and medication carriers, nearly all ICU patients receive IVF. Historically, much of this IVF has been 0.9% sodium chloride (“saline” or “normal saline”). Providers in the United States alone administer more than 200 million liters of saline each year (Myburgh JA, et al. N Engl J Med. 2013;369[13]:1243). New evidence, however, suggests that treating your ICU patients with so-called “balanced crystalloids,” rather than saline, may improve patient outcomes.

For over a century, clinicians ordering IV isotonic crystalloids have had two basic options: saline or balanced crystalloids (BC). Saline contains water and 154 mmol/L of sodium chloride (around 50% more chloride than human extracellular fluid). In contrast, BCs, like lactated Ringer’s (LR), Hartman’s solution, and others, contain an amount of chloride resembling human plasma (Table 1). BC substitute an organic anion such as bicarbonate, lactate, acetate, or gluconate, in place of chloride – resulting in lower chloride level and a more neutral pH.

Over the last 2 decades, evidence has slowly accumulated that the different compositions of saline and BC might translate into differences in patient physiology and outcomes. Research in the operating room and ICU found that saline administration caused hyperchloremia and metabolic acidosis. Studies of healthy volunteers found that saline decreased blood flow to the kidney (Chowdhury AH, et al. Ann Surg. 2012;256[1]:18). Animal sepsis models suggested that saline might cause inflammation, low blood pressure, and kidney injury (Zhou F, et al. Crit Care Med. 2014;42[4]:e270). Large observational studies among ICU patients found saline to be associated with increased risk of kidney injury, dialysis, or death (Raghunathan K, et al. Crit Care Med. 2014 Jul;42[7]:1585). These preliminary studies set the stage for a large randomized clinical trial comparing clinical outcomes between BC and saline among acutely ill adults.

Between June 2015 and April 2017, our research group conducted the Isotonic Solutions and Major Adverse Renal Events Trial (SMART) (Semler MW, et al. N Engl J Med. 2018;378[9]:819). SMART was a pragmatic trial in which 15,802 adults in five ICUs were assigned to receive either saline (0.9% sodium chloride) or BC (LR or another branded BC [PlasmaLyte A]). The goal was to determine whether using BC rather than saline would decrease the rates of death, new dialysis, or renal dysfunction lasting through hospital discharge. Patients in the BC group received primarily BC (44% LR and 56% another branded BC [PlasmaLyte A]), whereas patients in the saline group received primarily saline. The rate of death, new dialysis, or renal dysfunction lasting through hospital discharge was lower in the BC group (14.3%) than the saline group (15.4%) (OR: 0.90; 95% CI, 0.82-0.99; P=0.04). The difference between groups was primarily in death and new dialysis, not changes in creatinine. For every 100 patients admitted to an ICU, using BC rather than saline would spare one patient from experiencing death, dialysis, or renal dysfunction lasting to hospital discharge (number needed to treat). The benefits of BC appeared to be greater among patients who received larger volumes of IVF and patients with sepsis. In fact, among patients with sepsis, mortality was significantly lower with BC (25.2%) than with saline (29.4%) (P=.02).

Another trial was conducted in parallel. Saline against LR or another branded BC (PlasmaLyte) in the ED (SALT-ED) compared BC with saline among 13,347 non-critically ill adults treated with IVF in the ED (Self WH, et al. N Engl J Med. 2018;378[9]:829). Like the SMART trial, the SALT-ED trial found a 1% absolute reduction in the risk of death, new dialysis, or renal dysfunction lasting to hospital discharge favoring BC.

The SMART and SALT-ED trials have important limitations. They were conducted at a single academic center, and treating clinicians were not blinded to the assigned fluid. The key outcome was a composite of death, new dialysis, and renal dysfunction lasting to hospital discharge – and the trials were not powered to show differences in each of the individual components of the composite.

Despite these limitations, we now have data from two trials enrolling nearly 30,000 acutely ill patients suggesting that BC may result in better clinical outcomes than saline for acutely ill adults. For clinicians who were already using primarily BC solutions, these results will reinforce their current practice. For clinicians whose default IVF has been saline, these new findings raise challenging questions. Prior to these trials, the ICU in which I practice had always used primarily saline. Some of the questions we faced in considering how to apply the results of the SMART and SALT-ED trials to our practice included:

1. Recent data suggest BC may produce better clinical outcomes than saline for acutely ill adults. Are there any data that saline may produce better clinical outcomes than BC? Currently, there are not.

2. Cost is an important consideration in critical care, are BC more expensive than saline? The cost to produce saline and BC is similar. At our hospital, the cost for a 1L bag of saline, LR, and another branded BC (PlasmaLyte A ) is the exactly the same.

3. Is there a specific population for whom BC might have important adverse effects? Because some BC are hypotonic, the safety of administration of BC to patients with elevated intracranial pressure (e.g., traumatic brain injury) is unknown.

4. Are there practical considerations to using BC in the ICU? Compatibility with medications can pose a challenge. For example, the calcium in LR may be incompatible with ceftriaxone infusion. Although BC are compatible with many of the medication infusions used in the ICU for which testing has been performed, less data on compatibility exist for BC than for saline.

5. Are BC as readily available as saline? The three companies that make the majority of IVF used in the United States produce both saline and BC. Recent damage to production facilities has contributed to shortages in the supply of all of them. Over the long term, however, saline and BC are similar in their availability to hospital pharmacies.

After discussing each of these considerations with our ICU physicians and nurses, consultants, and pharmacists, our ICU collectively decided to switch from using primarily saline to BC. This involved (1) our pharmacy team stocking the medication dispensing cabinets in the ICU with 90% LR and 10% saline; and (2) making BC rather than saline the default in order sets within our electronic order entry system. Based on the results of the SMART trial, making the change from saline to BC might be expected to prevent around 100 deaths in our ICU each year.

Many questions regarding the effect of IV crystalloid solutions on clinical outcomes for critically ill adults remain unanswered. The mechanism by which BC may produce better clinical outcomes than saline is uncertain. Whether acetate-containing BC (eg, PlasmaLyte) produced better outcomes than non-acetate-containing BC (eg, LR) is unknown. The safety and efficacy of BC for specific subgroups of patients (eg, those with hyperkalemia) requires further study. Two ongoing trials comparing BC to saline among critically ill adults are expected to finish in 2021 and may provide additional insights into the best approach to IVF management for critically ill adults. An ongoing pilot trial comparing LR to other branded BC (Plasmalyte/Normosol )may inform the choice between BC.

In summary, IVF administration is ubiquitous in critical care. For decades, much of that fluid has been saline. BC are similar to saline in availability and cost. Two large trials now demonstrate better patient outcomes with BC compared with saline. These data challenge ICU providers, pharmacies, and hospital systems primarily using saline to evaluate the available data, their current IVF prescribing practices, and the logistical barriers to change, to determine whether there are legitimate reasons to continue using saline, or whether the time has come to make BC the first-line fluid therapy for acutely ill adults.

Dr. Semler is with the Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine –Vanderbilt University Medical Center, Nashville, Tennessee.

Disaster Response

Ebola virus outbreak preparedness

The 2014-2016 Ebola virus disease (EVD) outbreak in West Africa highlighted the global reach of emerging infectious diseases and shattered a sense of complacency in an increasingly interconnected world. Consequently, a subsequent outbreak of EVD in the Democratic Republic of the Congo (DRC) in early May 2018 triggered a swift response. International agencies and workers benefited from increased experience with the disease, new investigational vaccines, including the rVSV-ZEBOV vaccine, and novel therapies, including ZMapp, favipiravir, and remdesivir (GS-5734).

However, are health-care providers and facilities outside of outbreak areas truly more prepared to handle high-risk pathogens today than they were in 2014? The answer, at least in the United States, seems to be “yes,” due to a regional concentration of funding and resources. The US Department of Health and Human Services (HHS) has identified treatment centers for Ebola and other special pathogens nationwide.¹ The National Ebola Training and Education Center (NETEC) trains health systems to implement disease management plans.² The Centers for Disease Control and Prevention (CDC) has prepared recommendations for public health planners.³

In nonreferral centers, providers should always obtain a travel history, remain cognizant of emerging diseases,⁴ and optimize supportive care. Early collaboration with public health authorities and appropriate infection control precautions are necessary for rapid confirmation of a suspected high-risk pathogen and for ensuring patient and staff safety. Most centers will not need to care for a patient with EVD for an extended period, but the ability to recognize, contain, and refer is essential for good outcomes.

Ryan Maves, MD, FCCP
Cristian Madar, MD
Steering Committee Members

References

1. www.hhs.gov/about/news/2016/06/14/hhs-selects-regional-ebola-treatment-center-southwestern-us.html. Accessed July 18, 2018.

2. www.netec.org. Accessed July 18, 2018.

3. www.cdc.gov/vhf/ebola/public-health-planners. Accessed July 18, 2018.

4. www.cdc.gov/travel/notices. Accessed July 18, 2018.
 

Practice Operations

Current impact of social media on health care

In an age of connectivity, social media websites pose many challenges. Not immune to this are the physicians and their health-care practices, particularly their online presence to their patients. Many of these sites publish user-submitted patient appreciation or complaints. These postings are generally viewable to the public and often not moderated or restricted in content. With value-based care at the front lines, these posts may be detrimental to the success of the practice. Public postings exist regardless of providers’ awareness or management of them.

There is limited training on social media presence, handling negative reviews, addressing patient-specific posts online, or mediating conflicts. This includes legal issues related to licensing, privacy, litigation, and fraud. Compliance to ethical requirements and protecting patient privacy online still remains crucial in the heavily regulated health-care industry. The burden of social media remains a widely unacknowledged impediment to growing physicians’ practice. While several organizations have published guidelines to help ensure success and to better inform physicians, these are not widely practiced or well known.

However, significant potential benefits to social media include marketing opportunities, education, and connection with patients. Social media has been key for support group networks amongst patients. Similar to professionals in other fields, it is recommended that providers separate their public and private social media accounts or use alternate names. For more information about social media and answers to many legal questions, attend the Practice Operations NetWork Featured Lecture at the CHEST Annual Meeting on Monday, October 8, at 1:30 PM.

Megan Sisk, DO
Fellow-in-Training Member

Humayun Anjum, MD
Steering Committee Member
 

Transplant

Implications of the opioid crisis on organ donation for lung transplantation

The opioid epidemic in the United States claims a substantial number of lives annually, with overdose-related deaths increasing five times between 2000 and2016.¹ In the midst of this national crisis, perhaps one solace is an increase in organ donation for thoracic transplantation. In fact, data show that patients dying of overdose have the highest donation rates,² and a staggering 10 times increase in the proportion of eligible donors dying of overdose has been witnessed over this period (1.2% of donors in 2000, 13.7% in 2016),³ with a parallel increase in transplants performed.⁴

Despite this, transplant program organ utilization in overdose deaths falls well short of expected, in part due to disease transmission concerns, supported by the observation that these donors are two to five times more likely designated as “PHS-Increased-Risk” Criteria for transmission of HBV, HCV, and HIV.^2,5 In lung transplantation, additional concerns over donor quality often exist, including aspiration, edema, or other opioid-induced injuries. Although a disturbing premise, as the health-care community and lawmakers attempt to curtail the opioid epidemic, it is important to recognize opportunities for improvement in organ utilization, which offers potential to help many patients with cardiopulmonary disease. In addition to community-wide organ donation campaigns, this may stem from dissemination of knowledge of the low infectious risks in PHS-increased-risk donors,⁵ as well as analyses showing similar survival among recipients of allografts from overdose-death donors compared with donors from other causes.³ Use of HCV-positive organs, particularly in the modern era of infectious testing and therapies, offers additional potential,⁶ as does fine-tuning technologies such as ex-vivo lung perfusion, which may enhance organ quality making lungs suitable for transplant.

Anupam Kumar, MD
Fellow-in-Training Member

Siddhartha G. Kapnadak, MD
Steering Committee Member

References

1. Rudd RA, et al. MMWR Morb Mortal Wkly Rep. 2016;Dec 30;65(5051):1445.

2. Goldberg DS, et al. Am J Transplant. 2016 Oct; 16(10): 2836.

3. Mehra MR, et al. N Engl J Med. 2018 May 17;378(20):1943.

4. Durand CM, et al. Ann Intern Med. 2018 May 15;168(10):702.

5. Sibulesky L, et al. Clin Transplant. 2015 Sep;29(9):724.

6. Abdelbasit A, et al. Am J Respir Crit Care Med. 2018 Jun 1;197(11):1492.
 

Women’s Health

Sex and gender in pulmonary disease

On September 18-19, 2017, the National Heart, Lung, and Blood Institute convened a workshop of investigators with the National Institutes of Health, the Office of Research on Women’s Health, and the Office of Rare Diseases Research to discuss the role of sex and gender in pulmonary disease. The findings of this workshop, published online ahead of print (Han MK, et al. Am J Respir Crit Care Med. 2018 May 10. doi: 10.1164/rccm.201801-0168WS. [Epub ahead of print]), outline important future directions for research in pulmonary medicine.

The group identified several areas in which there are substantial sex-specific differences in clinical presentation and treatment outcomes in pulmonary diseases, including tobacco cessation, circadian rhythms and sleep-disordered breathing, COPD, asthma, cystic fibrosis, and interstitial lung disease.

In addition to defining the terms sex and gender, the committee called for standardization of the reporting of sex as a variable in animal and cellular models. Given the observed relationship between sex hormones and the development of lung disease, a collaboration across disciplines, including endocrinology, would be useful to understand this relationship at a basic and clinical science level. Furthermore, in the era of big data research, sex and gender should be included as co-variates when possible to better clarify the contributions of these variables in pulmonary disease.

The workshop also highlighted the need to educate clinicians about these differences. Just as trainees are taught that women can present with atypical symptoms for a heart attack, so should they be taught about the differences in management of chronic lung disease and tobacco dependence between men and women.

Nikita Desai, MD
Fellow-in-Training Member


 

Disaster Response

Ebola virus outbreak preparedness

The 2014-2016 Ebola virus disease (EVD) outbreak in West Africa highlighted the global reach of emerging infectious diseases and shattered a sense of complacency in an increasingly interconnected world. Consequently, a subsequent outbreak of EVD in the Democratic Republic of the Congo (DRC) in early May 2018 triggered a swift response. International agencies and workers benefited from increased experience with the disease, new investigational vaccines, including the rVSV-ZEBOV vaccine, and novel therapies, including ZMapp, favipiravir, and remdesivir (GS-5734).

However, are health-care providers and facilities outside of outbreak areas truly more prepared to handle high-risk pathogens today than they were in 2014? The answer, at least in the United States, seems to be “yes,” due to a regional concentration of funding and resources. The US Department of Health and Human Services (HHS) has identified treatment centers for Ebola and other special pathogens nationwide.¹ The National Ebola Training and Education Center (NETEC) trains health systems to implement disease management plans.² The Centers for Disease Control and Prevention (CDC) has prepared recommendations for public health planners.³

In nonreferral centers, providers should always obtain a travel history, remain cognizant of emerging diseases,⁴ and optimize supportive care. Early collaboration with public health authorities and appropriate infection control precautions are necessary for rapid confirmation of a suspected high-risk pathogen and for ensuring patient and staff safety. Most centers will not need to care for a patient with EVD for an extended period, but the ability to recognize, contain, and refer is essential for good outcomes.

Ryan Maves, MD, FCCP
Cristian Madar, MD
Steering Committee Members

References

1. www.hhs.gov/about/news/2016/06/14/hhs-selects-regional-ebola-treatment-center-southwestern-us.html. Accessed July 18, 2018.

2. www.netec.org. Accessed July 18, 2018.

3. www.cdc.gov/vhf/ebola/public-health-planners. Accessed July 18, 2018.

4. www.cdc.gov/travel/notices. Accessed July 18, 2018.
 

Practice Operations

Current impact of social media on health care

In an age of connectivity, social media websites pose many challenges. Not immune to this are the physicians and their health-care practices, particularly their online presence to their patients. Many of these sites publish user-submitted patient appreciation or complaints. These postings are generally viewable to the public and often not moderated or restricted in content. With value-based care at the front lines, these posts may be detrimental to the success of the practice. Public postings exist regardless of providers’ awareness or management of them.

There is limited training on social media presence, handling negative reviews, addressing patient-specific posts online, or mediating conflicts. This includes legal issues related to licensing, privacy, litigation, and fraud. Compliance to ethical requirements and protecting patient privacy online still remains crucial in the heavily regulated health-care industry. The burden of social media remains a widely unacknowledged impediment to growing physicians’ practice. While several organizations have published guidelines to help ensure success and to better inform physicians, these are not widely practiced or well known.

However, significant potential benefits to social media include marketing opportunities, education, and connection with patients. Social media has been key for support group networks amongst patients. Similar to professionals in other fields, it is recommended that providers separate their public and private social media accounts or use alternate names. For more information about social media and answers to many legal questions, attend the Practice Operations NetWork Featured Lecture at the CHEST Annual Meeting on Monday, October 8, at 1:30 PM.

Megan Sisk, DO
Fellow-in-Training Member

Humayun Anjum, MD
Steering Committee Member
 

Transplant

Implications of the opioid crisis on organ donation for lung transplantation

The opioid epidemic in the United States claims a substantial number of lives annually, with overdose-related deaths increasing five times between 2000 and2016.¹ In the midst of this national crisis, perhaps one solace is an increase in organ donation for thoracic transplantation. In fact, data show that patients dying of overdose have the highest donation rates,² and a staggering 10 times increase in the proportion of eligible donors dying of overdose has been witnessed over this period (1.2% of donors in 2000, 13.7% in 2016),³ with a parallel increase in transplants performed.⁴

Despite this, transplant program organ utilization in overdose deaths falls well short of expected, in part due to disease transmission concerns, supported by the observation that these donors are two to five times more likely designated as “PHS-Increased-Risk” Criteria for transmission of HBV, HCV, and HIV.^2,5 In lung transplantation, additional concerns over donor quality often exist, including aspiration, edema, or other opioid-induced injuries. Although a disturbing premise, as the health-care community and lawmakers attempt to curtail the opioid epidemic, it is important to recognize opportunities for improvement in organ utilization, which offers potential to help many patients with cardiopulmonary disease. In addition to community-wide organ donation campaigns, this may stem from dissemination of knowledge of the low infectious risks in PHS-increased-risk donors,⁵ as well as analyses showing similar survival among recipients of allografts from overdose-death donors compared with donors from other causes.³ Use of HCV-positive organs, particularly in the modern era of infectious testing and therapies, offers additional potential,⁶ as does fine-tuning technologies such as ex-vivo lung perfusion, which may enhance organ quality making lungs suitable for transplant.

Anupam Kumar, MD
Fellow-in-Training Member

Siddhartha G. Kapnadak, MD
Steering Committee Member

References

1. Rudd RA, et al. MMWR Morb Mortal Wkly Rep. 2016;Dec 30;65(5051):1445.

2. Goldberg DS, et al. Am J Transplant. 2016 Oct; 16(10): 2836.

3. Mehra MR, et al. N Engl J Med. 2018 May 17;378(20):1943.

4. Durand CM, et al. Ann Intern Med. 2018 May 15;168(10):702.

5. Sibulesky L, et al. Clin Transplant. 2015 Sep;29(9):724.

6. Abdelbasit A, et al. Am J Respir Crit Care Med. 2018 Jun 1;197(11):1492.
 

Women’s Health

Sex and gender in pulmonary disease

On September 18-19, 2017, the National Heart, Lung, and Blood Institute convened a workshop of investigators with the National Institutes of Health, the Office of Research on Women’s Health, and the Office of Rare Diseases Research to discuss the role of sex and gender in pulmonary disease. The findings of this workshop, published online ahead of print (Han MK, et al. Am J Respir Crit Care Med. 2018 May 10. doi: 10.1164/rccm.201801-0168WS. [Epub ahead of print]), outline important future directions for research in pulmonary medicine.

The group identified several areas in which there are substantial sex-specific differences in clinical presentation and treatment outcomes in pulmonary diseases, including tobacco cessation, circadian rhythms and sleep-disordered breathing, COPD, asthma, cystic fibrosis, and interstitial lung disease.

In addition to defining the terms sex and gender, the committee called for standardization of the reporting of sex as a variable in animal and cellular models. Given the observed relationship between sex hormones and the development of lung disease, a collaboration across disciplines, including endocrinology, would be useful to understand this relationship at a basic and clinical science level. Furthermore, in the era of big data research, sex and gender should be included as co-variates when possible to better clarify the contributions of these variables in pulmonary disease.

The workshop also highlighted the need to educate clinicians about these differences. Just as trainees are taught that women can present with atypical symptoms for a heart attack, so should they be taught about the differences in management of chronic lung disease and tobacco dependence between men and women.

Nikita Desai, MD
Fellow-in-Training Member


 

Disaster Response

Ebola virus outbreak preparedness

The 2014-2016 Ebola virus disease (EVD) outbreak in West Africa highlighted the global reach of emerging infectious diseases and shattered a sense of complacency in an increasingly interconnected world. Consequently, a subsequent outbreak of EVD in the Democratic Republic of the Congo (DRC) in early May 2018 triggered a swift response. International agencies and workers benefited from increased experience with the disease, new investigational vaccines, including the rVSV-ZEBOV vaccine, and novel therapies, including ZMapp, favipiravir, and remdesivir (GS-5734).

However, are health-care providers and facilities outside of outbreak areas truly more prepared to handle high-risk pathogens today than they were in 2014? The answer, at least in the United States, seems to be “yes,” due to a regional concentration of funding and resources. The US Department of Health and Human Services (HHS) has identified treatment centers for Ebola and other special pathogens nationwide.¹ The National Ebola Training and Education Center (NETEC) trains health systems to implement disease management plans.² The Centers for Disease Control and Prevention (CDC) has prepared recommendations for public health planners.³

In nonreferral centers, providers should always obtain a travel history, remain cognizant of emerging diseases,⁴ and optimize supportive care. Early collaboration with public health authorities and appropriate infection control precautions are necessary for rapid confirmation of a suspected high-risk pathogen and for ensuring patient and staff safety. Most centers will not need to care for a patient with EVD for an extended period, but the ability to recognize, contain, and refer is essential for good outcomes.

Ryan Maves, MD, FCCP
Cristian Madar, MD
Steering Committee Members

References

1. www.hhs.gov/about/news/2016/06/14/hhs-selects-regional-ebola-treatment-center-southwestern-us.html. Accessed July 18, 2018.

2. www.netec.org. Accessed July 18, 2018.

3. www.cdc.gov/vhf/ebola/public-health-planners. Accessed July 18, 2018.

4. www.cdc.gov/travel/notices. Accessed July 18, 2018.
 

Practice Operations

Current impact of social media on health care

In an age of connectivity, social media websites pose many challenges. Not immune to this are the physicians and their health-care practices, particularly their online presence to their patients. Many of these sites publish user-submitted patient appreciation or complaints. These postings are generally viewable to the public and often not moderated or restricted in content. With value-based care at the front lines, these posts may be detrimental to the success of the practice. Public postings exist regardless of providers’ awareness or management of them.

There is limited training on social media presence, handling negative reviews, addressing patient-specific posts online, or mediating conflicts. This includes legal issues related to licensing, privacy, litigation, and fraud. Compliance to ethical requirements and protecting patient privacy online still remains crucial in the heavily regulated health-care industry. The burden of social media remains a widely unacknowledged impediment to growing physicians’ practice. While several organizations have published guidelines to help ensure success and to better inform physicians, these are not widely practiced or well known.

However, significant potential benefits to social media include marketing opportunities, education, and connection with patients. Social media has been key for support group networks amongst patients. Similar to professionals in other fields, it is recommended that providers separate their public and private social media accounts or use alternate names. For more information about social media and answers to many legal questions, attend the Practice Operations NetWork Featured Lecture at the CHEST Annual Meeting on Monday, October 8, at 1:30 PM.

Megan Sisk, DO
Fellow-in-Training Member

Humayun Anjum, MD
Steering Committee Member
 

Transplant

Implications of the opioid crisis on organ donation for lung transplantation

The opioid epidemic in the United States claims a substantial number of lives annually, with overdose-related deaths increasing five times between 2000 and2016.¹ In the midst of this national crisis, perhaps one solace is an increase in organ donation for thoracic transplantation. In fact, data show that patients dying of overdose have the highest donation rates,² and a staggering 10 times increase in the proportion of eligible donors dying of overdose has been witnessed over this period (1.2% of donors in 2000, 13.7% in 2016),³ with a parallel increase in transplants performed.⁴

Despite this, transplant program organ utilization in overdose deaths falls well short of expected, in part due to disease transmission concerns, supported by the observation that these donors are two to five times more likely designated as “PHS-Increased-Risk” Criteria for transmission of HBV, HCV, and HIV.^2,5 In lung transplantation, additional concerns over donor quality often exist, including aspiration, edema, or other opioid-induced injuries. Although a disturbing premise, as the health-care community and lawmakers attempt to curtail the opioid epidemic, it is important to recognize opportunities for improvement in organ utilization, which offers potential to help many patients with cardiopulmonary disease. In addition to community-wide organ donation campaigns, this may stem from dissemination of knowledge of the low infectious risks in PHS-increased-risk donors,⁵ as well as analyses showing similar survival among recipients of allografts from overdose-death donors compared with donors from other causes.³ Use of HCV-positive organs, particularly in the modern era of infectious testing and therapies, offers additional potential,⁶ as does fine-tuning technologies such as ex-vivo lung perfusion, which may enhance organ quality making lungs suitable for transplant.

Anupam Kumar, MD
Fellow-in-Training Member

Siddhartha G. Kapnadak, MD
Steering Committee Member

References

1. Rudd RA, et al. MMWR Morb Mortal Wkly Rep. 2016;Dec 30;65(5051):1445.

2. Goldberg DS, et al. Am J Transplant. 2016 Oct; 16(10): 2836.

3. Mehra MR, et al. N Engl J Med. 2018 May 17;378(20):1943.

4. Durand CM, et al. Ann Intern Med. 2018 May 15;168(10):702.

5. Sibulesky L, et al. Clin Transplant. 2015 Sep;29(9):724.

6. Abdelbasit A, et al. Am J Respir Crit Care Med. 2018 Jun 1;197(11):1492.
 

Women’s Health

Sex and gender in pulmonary disease

On September 18-19, 2017, the National Heart, Lung, and Blood Institute convened a workshop of investigators with the National Institutes of Health, the Office of Research on Women’s Health, and the Office of Rare Diseases Research to discuss the role of sex and gender in pulmonary disease. The findings of this workshop, published online ahead of print (Han MK, et al. Am J Respir Crit Care Med. 2018 May 10. doi: 10.1164/rccm.201801-0168WS. [Epub ahead of print]), outline important future directions for research in pulmonary medicine.

The group identified several areas in which there are substantial sex-specific differences in clinical presentation and treatment outcomes in pulmonary diseases, including tobacco cessation, circadian rhythms and sleep-disordered breathing, COPD, asthma, cystic fibrosis, and interstitial lung disease.

In addition to defining the terms sex and gender, the committee called for standardization of the reporting of sex as a variable in animal and cellular models. Given the observed relationship between sex hormones and the development of lung disease, a collaboration across disciplines, including endocrinology, would be useful to understand this relationship at a basic and clinical science level. Furthermore, in the era of big data research, sex and gender should be included as co-variates when possible to better clarify the contributions of these variables in pulmonary disease.

The workshop also highlighted the need to educate clinicians about these differences. Just as trainees are taught that women can present with atypical symptoms for a heart attack, so should they be taught about the differences in management of chronic lung disease and tobacco dependence between men and women.

Nikita Desai, MD
Fellow-in-Training Member


 

Methylphenidate appears to be the safest and most effective treatment option for attention-deficit/hyperactivity disorder in children and adolescents, while amphetamines are the preferred first-line choice in adults, a systematic review and meta-analysis have found.

Researchers reported the results of a network meta-analysis of 133 double-blind randomized controlled trials – 81 in children and adolescents, 51 in adults, and 1 in both – involving a total of 10,068 children and adolescents, and 8,131 adults. The included studies all compared a range of medications to placebo or in head-to-head trials. The meta-analysis was published online Aug. 7 in The Lancet Psychiatry.

At 12 weeks, all the medications, which included amphetamines, atomoxetine, bupropion, clonidine, guanfacine, methylphenidate, and modafinil, were found to be better than placebo in reducing core ADHD symptoms in children and adolescents, according to clinicians’ ratings. However, when teachers’ ratings were used, only methylphenidate and modafinil were better than placebo.

In adults, clinicians’ ratings found that amphetamines, methylphenidate, bupropion, and atomoxetine – but not modafinil – were better than placebo.

In head-to-head trials, clinicians’ ratings favored amphetamines over modafinil, atomoxetine, and methylphenidate in children, adolescents, and adults.

On the Clinical Global Impression–Improvement scale, all drugs except clonidine were better than placebo in children. But in adults, amphetamines, bupropion, and methylphenidate all beat placebo.

When it came to tolerability in children and adolescents, guanfacine and amphetamines were the only two treatments that were less well tolerated than placebo. However, a post hoc analysis suggested lisdexamfetamine had a lower tolerability relative to other amphetamines, at least in children and adolescents. In adults, modafinil, amphetamines, methylphenidate, and atomoxetine were beaten by placebo for tolerability.

“Overall, all medications, except modafinil in adults, were more efficacious than placebo for the short-term treatment of ADHD, and they were less efficacious and less well tolerated in adults than in children and adolescents,” wrote Samuele Cortese, MD, PhD, of the University of Southampton (England), and his coauthors. “However, the included medications were not equivalent in relation to their mean effect size, which ranged from moderate to high and varied according to the type of rater.”

For example, while atomoxetine had the lowest mean effect size in children and adolescents based on clinicians’ ratings, in adults, it was on par with methylphenidate. Amphetamines increased diastolic blood pressure in children but not in adults.

“Taking into account both efficacy and safety, evidence from this meta-analysis supports methylphenidate in children and adolescents, and amphetamines in adults, as preferred first-choice medications for the short-term treatment of ADHD,” the authors wrote.

Dr. Cortese and his coauthors cited a few limitations. One is that the most recent study included in their meta-analysis was published in April 2017. When the researchers conducted a PubMed search in May 2018, they found three additional studies that met their criteria. “Since we already had 133 included studies, we decided that adding these three studies would not have changed the final results materially,” they wrote.

The study was supported by the Stichting Eunethydis (European Network for Hyperkinetic Disorders), and the U.K. National Institute for Health Research Oxford Health Biomedical Research Centre. Nine authors declared support, funding, or advisory roles with a range of organizations or the pharmaceutical industry.

SOURCE: Cortese S et al. Lancet Psychiatry. 2018 Aug 7. doi: 10.1016/S2215-0366(18)30269-4.

Methylphenidate appears to be the safest and most effective treatment option for attention-deficit/hyperactivity disorder in children and adolescents, while amphetamines are the preferred first-line choice in adults, a systematic review and meta-analysis have found.

Researchers reported the results of a network meta-analysis of 133 double-blind randomized controlled trials – 81 in children and adolescents, 51 in adults, and 1 in both – involving a total of 10,068 children and adolescents, and 8,131 adults. The included studies all compared a range of medications to placebo or in head-to-head trials. The meta-analysis was published online Aug. 7 in The Lancet Psychiatry.

At 12 weeks, all the medications, which included amphetamines, atomoxetine, bupropion, clonidine, guanfacine, methylphenidate, and modafinil, were found to be better than placebo in reducing core ADHD symptoms in children and adolescents, according to clinicians’ ratings. However, when teachers’ ratings were used, only methylphenidate and modafinil were better than placebo.

In adults, clinicians’ ratings found that amphetamines, methylphenidate, bupropion, and atomoxetine – but not modafinil – were better than placebo.

In head-to-head trials, clinicians’ ratings favored amphetamines over modafinil, atomoxetine, and methylphenidate in children, adolescents, and adults.

On the Clinical Global Impression–Improvement scale, all drugs except clonidine were better than placebo in children. But in adults, amphetamines, bupropion, and methylphenidate all beat placebo.

When it came to tolerability in children and adolescents, guanfacine and amphetamines were the only two treatments that were less well tolerated than placebo. However, a post hoc analysis suggested lisdexamfetamine had a lower tolerability relative to other amphetamines, at least in children and adolescents. In adults, modafinil, amphetamines, methylphenidate, and atomoxetine were beaten by placebo for tolerability.

“Overall, all medications, except modafinil in adults, were more efficacious than placebo for the short-term treatment of ADHD, and they were less efficacious and less well tolerated in adults than in children and adolescents,” wrote Samuele Cortese, MD, PhD, of the University of Southampton (England), and his coauthors. “However, the included medications were not equivalent in relation to their mean effect size, which ranged from moderate to high and varied according to the type of rater.”

For example, while atomoxetine had the lowest mean effect size in children and adolescents based on clinicians’ ratings, in adults, it was on par with methylphenidate. Amphetamines increased diastolic blood pressure in children but not in adults.

“Taking into account both efficacy and safety, evidence from this meta-analysis supports methylphenidate in children and adolescents, and amphetamines in adults, as preferred first-choice medications for the short-term treatment of ADHD,” the authors wrote.

Dr. Cortese and his coauthors cited a few limitations. One is that the most recent study included in their meta-analysis was published in April 2017. When the researchers conducted a PubMed search in May 2018, they found three additional studies that met their criteria. “Since we already had 133 included studies, we decided that adding these three studies would not have changed the final results materially,” they wrote.

The study was supported by the Stichting Eunethydis (European Network for Hyperkinetic Disorders), and the U.K. National Institute for Health Research Oxford Health Biomedical Research Centre. Nine authors declared support, funding, or advisory roles with a range of organizations or the pharmaceutical industry.

SOURCE: Cortese S et al. Lancet Psychiatry. 2018 Aug 7. doi: 10.1016/S2215-0366(18)30269-4.

Methylphenidate appears to be the safest and most effective treatment option for attention-deficit/hyperactivity disorder in children and adolescents, while amphetamines are the preferred first-line choice in adults, a systematic review and meta-analysis have found.

Researchers reported the results of a network meta-analysis of 133 double-blind randomized controlled trials – 81 in children and adolescents, 51 in adults, and 1 in both – involving a total of 10,068 children and adolescents, and 8,131 adults. The included studies all compared a range of medications to placebo or in head-to-head trials. The meta-analysis was published online Aug. 7 in The Lancet Psychiatry.

At 12 weeks, all the medications, which included amphetamines, atomoxetine, bupropion, clonidine, guanfacine, methylphenidate, and modafinil, were found to be better than placebo in reducing core ADHD symptoms in children and adolescents, according to clinicians’ ratings. However, when teachers’ ratings were used, only methylphenidate and modafinil were better than placebo.

In adults, clinicians’ ratings found that amphetamines, methylphenidate, bupropion, and atomoxetine – but not modafinil – were better than placebo.

In head-to-head trials, clinicians’ ratings favored amphetamines over modafinil, atomoxetine, and methylphenidate in children, adolescents, and adults.

On the Clinical Global Impression–Improvement scale, all drugs except clonidine were better than placebo in children. But in adults, amphetamines, bupropion, and methylphenidate all beat placebo.

When it came to tolerability in children and adolescents, guanfacine and amphetamines were the only two treatments that were less well tolerated than placebo. However, a post hoc analysis suggested lisdexamfetamine had a lower tolerability relative to other amphetamines, at least in children and adolescents. In adults, modafinil, amphetamines, methylphenidate, and atomoxetine were beaten by placebo for tolerability.

“Overall, all medications, except modafinil in adults, were more efficacious than placebo for the short-term treatment of ADHD, and they were less efficacious and less well tolerated in adults than in children and adolescents,” wrote Samuele Cortese, MD, PhD, of the University of Southampton (England), and his coauthors. “However, the included medications were not equivalent in relation to their mean effect size, which ranged from moderate to high and varied according to the type of rater.”

For example, while atomoxetine had the lowest mean effect size in children and adolescents based on clinicians’ ratings, in adults, it was on par with methylphenidate. Amphetamines increased diastolic blood pressure in children but not in adults.

“Taking into account both efficacy and safety, evidence from this meta-analysis supports methylphenidate in children and adolescents, and amphetamines in adults, as preferred first-choice medications for the short-term treatment of ADHD,” the authors wrote.

Dr. Cortese and his coauthors cited a few limitations. One is that the most recent study included in their meta-analysis was published in April 2017. When the researchers conducted a PubMed search in May 2018, they found three additional studies that met their criteria. “Since we already had 133 included studies, we decided that adding these three studies would not have changed the final results materially,” they wrote.

The study was supported by the Stichting Eunethydis (European Network for Hyperkinetic Disorders), and the U.K. National Institute for Health Research Oxford Health Biomedical Research Centre. Nine authors declared support, funding, or advisory roles with a range of organizations or the pharmaceutical industry.

SOURCE: Cortese S et al. Lancet Psychiatry. 2018 Aug 7. doi: 10.1016/S2215-0366(18)30269-4.