Type 2 diabetes mellitus may be associated with an increased risk of Parkinson’s disease, according to a large retrospective cohort study published online June 13 in Neurology.

Researchers accessed the linked English national Hospital Episode Statistics and mortality data from 1999-2011 to compare data from 2,017,115 individuals admitted to hospital who had a diagnostic code for type 2 diabetes with data from a reference cohort of 6,173,208 individuals admitted for a range of other minor procedures.

They found a significant 32% higher incidence of Parkinson’s disease among individuals with type 2 diabetes, compared with the reference cohort (95% confidence interval, 1.29-1.35; P less than .001).

The incidence was particularly high among younger individuals with type 2 diabetes; those aged 25-44 years at the time of admission had a 3.8-fold higher rate of Parkinson’s disease, compared with the reference group (P less than .001). Individuals aged 45-64 years with type 2 diabetes had 71% greater rate of Parkinson, those aged 65-74 years had a 40% higher incidence, and those aged 75 years or over had an 18% higher rate.

Individuals with complicated type 2 diabetes, defined as the presence of diabetic neuropathy, nephropathy, or retinopathy, had a 49% higher incidence of Parkinson disease than did the reference cohort.

Eduardo De Pablo-Fernandez, MD, from the University College London Institute of Neurology, and his coauthors suggested that the interaction between the two, apparently unconnected, diseases may be a function of both genetics and shared pathogenic pathways.

“The magnitude of risk in our study was greater in younger individuals, whereby genetic factors may relatively exert more of an effect, and more than 400 genes, previously identified through genome-wide association studies, have been closely linked to both conditions using integrative network analysis,” the authors wrote.

“However, the association in elderly patients may be the consequence of disrupted insulin signaling secondary to additional lifestyle and environmental factors causing cumulative pathogenic brain changes.”

They proposed that disrupted brain insulin signaling could lead to neuroinflammation, mitochondrial dysfunction, and increased oxidative stress that could contribute to the development of Parkinson’s disease.

The findings were similar to those seen in a previous meta-analysis of five studies, although the authors commented that there was significant heterogeneity among the studies included in that analysis.

The authors of this study also noted that their study did not adjust for potential confounders such as smoking or antidiabetic medication use.

The study was supported by the National Institute for Health Research Biomedical Research Centre at the University of Oxford, England, and the NIHR Biomedical Research Centre at University College London. Two authors declared funding and payments from private industry outside the submitted work, but no other conflicts of interest were declared.

SOURCE: De Pablo Fernandez E et al. Neurology. 2018 June 13. doi: 10.1212/WNL.0000000000005771.

Type 2 diabetes mellitus may be associated with an increased risk of Parkinson’s disease, according to a large retrospective cohort study published online June 13 in Neurology.

Researchers accessed the linked English national Hospital Episode Statistics and mortality data from 1999-2011 to compare data from 2,017,115 individuals admitted to hospital who had a diagnostic code for type 2 diabetes with data from a reference cohort of 6,173,208 individuals admitted for a range of other minor procedures.

They found a significant 32% higher incidence of Parkinson’s disease among individuals with type 2 diabetes, compared with the reference cohort (95% confidence interval, 1.29-1.35; P less than .001).

The incidence was particularly high among younger individuals with type 2 diabetes; those aged 25-44 years at the time of admission had a 3.8-fold higher rate of Parkinson’s disease, compared with the reference group (P less than .001). Individuals aged 45-64 years with type 2 diabetes had 71% greater rate of Parkinson, those aged 65-74 years had a 40% higher incidence, and those aged 75 years or over had an 18% higher rate.

Individuals with complicated type 2 diabetes, defined as the presence of diabetic neuropathy, nephropathy, or retinopathy, had a 49% higher incidence of Parkinson disease than did the reference cohort.

Eduardo De Pablo-Fernandez, MD, from the University College London Institute of Neurology, and his coauthors suggested that the interaction between the two, apparently unconnected, diseases may be a function of both genetics and shared pathogenic pathways.

“The magnitude of risk in our study was greater in younger individuals, whereby genetic factors may relatively exert more of an effect, and more than 400 genes, previously identified through genome-wide association studies, have been closely linked to both conditions using integrative network analysis,” the authors wrote.

“However, the association in elderly patients may be the consequence of disrupted insulin signaling secondary to additional lifestyle and environmental factors causing cumulative pathogenic brain changes.”

They proposed that disrupted brain insulin signaling could lead to neuroinflammation, mitochondrial dysfunction, and increased oxidative stress that could contribute to the development of Parkinson’s disease.

The findings were similar to those seen in a previous meta-analysis of five studies, although the authors commented that there was significant heterogeneity among the studies included in that analysis.

The authors of this study also noted that their study did not adjust for potential confounders such as smoking or antidiabetic medication use.

The study was supported by the National Institute for Health Research Biomedical Research Centre at the University of Oxford, England, and the NIHR Biomedical Research Centre at University College London. Two authors declared funding and payments from private industry outside the submitted work, but no other conflicts of interest were declared.

SOURCE: De Pablo Fernandez E et al. Neurology. 2018 June 13. doi: 10.1212/WNL.0000000000005771.

Type 2 diabetes mellitus may be associated with an increased risk of Parkinson’s disease, according to a large retrospective cohort study published online June 13 in Neurology.

Researchers accessed the linked English national Hospital Episode Statistics and mortality data from 1999-2011 to compare data from 2,017,115 individuals admitted to hospital who had a diagnostic code for type 2 diabetes with data from a reference cohort of 6,173,208 individuals admitted for a range of other minor procedures.

They found a significant 32% higher incidence of Parkinson’s disease among individuals with type 2 diabetes, compared with the reference cohort (95% confidence interval, 1.29-1.35; P less than .001).

The incidence was particularly high among younger individuals with type 2 diabetes; those aged 25-44 years at the time of admission had a 3.8-fold higher rate of Parkinson’s disease, compared with the reference group (P less than .001). Individuals aged 45-64 years with type 2 diabetes had 71% greater rate of Parkinson, those aged 65-74 years had a 40% higher incidence, and those aged 75 years or over had an 18% higher rate.

Individuals with complicated type 2 diabetes, defined as the presence of diabetic neuropathy, nephropathy, or retinopathy, had a 49% higher incidence of Parkinson disease than did the reference cohort.

Eduardo De Pablo-Fernandez, MD, from the University College London Institute of Neurology, and his coauthors suggested that the interaction between the two, apparently unconnected, diseases may be a function of both genetics and shared pathogenic pathways.

“The magnitude of risk in our study was greater in younger individuals, whereby genetic factors may relatively exert more of an effect, and more than 400 genes, previously identified through genome-wide association studies, have been closely linked to both conditions using integrative network analysis,” the authors wrote.

“However, the association in elderly patients may be the consequence of disrupted insulin signaling secondary to additional lifestyle and environmental factors causing cumulative pathogenic brain changes.”

They proposed that disrupted brain insulin signaling could lead to neuroinflammation, mitochondrial dysfunction, and increased oxidative stress that could contribute to the development of Parkinson’s disease.

The findings were similar to those seen in a previous meta-analysis of five studies, although the authors commented that there was significant heterogeneity among the studies included in that analysis.

The authors of this study also noted that their study did not adjust for potential confounders such as smoking or antidiabetic medication use.

The study was supported by the National Institute for Health Research Biomedical Research Centre at the University of Oxford, England, and the NIHR Biomedical Research Centre at University College London. Two authors declared funding and payments from private industry outside the submitted work, but no other conflicts of interest were declared.

SOURCE: De Pablo Fernandez E et al. Neurology. 2018 June 13. doi: 10.1212/WNL.0000000000005771.

Case

A 40-year-old Indian immigrant presented to the emergency department with hemoptysis. He had had an intermittent productive cough for the past 4 weeks with increasing fatigue and lack of appetite. He also had intermittent fever with drenching night sweats. Chest radiograph and CT scan showed a left upper lobe cavitary lesion with infiltrate. He was admitted to the hospital with concern for pneumonia and to rule out possible active pulmonary tuberculosis.

Background

Active pulmonary tuberculosis (APTB) remains an important but often missed diagnosis in hospitalized patients in the Western world.^1,2 Because of its relative rarity, the diagnosis of APTB often is delayed in the United States, which can lead hospitalized patients to nosocomial transmission, unnecessary exposures, patient harm,³ and potentially avoidable cost to the health care system.⁴ The diagnosis and management can be challenging involving isolation needs, sputum clearance, treatment strategy, and criteria for discharge to home.

Diagnosis

Any patient with risk factors presenting with signs and/or symptoms of APTB such as productive cough for more than 4 weeks, night sweats, weight loss, low-grade fevers, upper lobe cavitary lesions, or hemoptysis should be suspected. The diagnostic work-up for APTB should always begin with a thorough medical and social history. A chest radiograph or a CT scan should always be obtained. Risk factors for infection and for progression to active pulmonary TB are listed below.
 

Risk factors for TB infection:

• Close contacts of a person with APTB.
• Health care workers.
• Immigrants from high-burden countries.
• Homeless people.
• Individuals who have been incarcerated.
• International travelers.
• HIV patients.
• Intravenous drug users.

Risk factors for progression to APTB:

• HIV infection.
• Intravenous drug use.
• Silicosis.
• Younger than 5 years of age.
• Immunosuppressed.

All patients with suspected or confirmed APTB who cannot be safely discharged home (see discharge considerations below) should be kept in negative-pressure airborne isolation rooms. Isolation can be discontinued once APTB has been ruled out or the patient is determined to be noninfectious based on three consecutive negative sputum smears.

Although rapid and inexpensive, acid-fast bacilli (AFB) smear microscopy has poor sensitivity (45%-80%, with culture-confirmed APTB cases) and poor positive predictive value (50%-80%) for TB in settings in which nontuberculous mycobacteria are commonly isolated. This makes an AFB smear nondiagnostic in the early diagnosis of APTB. The burden of mycobacteria seen in the sputum smear correlates with infectivity.

To improve sensitivity of testing, it is strongly recommended that three AFB smears be completed in 8- to 24-hour intervals and positive smears be accompanied by nucleic acid amplification (NAA) testing.⁵ If APTB is suspected, but the patient is unable to expectorate, induced sputum samples should be obtained, and, if unable to induce sputum samples, flexible bronchoscopy sampling should be pursued especially for the high-risk populations described above.

The Centers for Disease Control and Prevention recommends that at least one sputum specimen be tested with NAA to expedite the time to diagnosis of APTB. A negative NAA does NOT rule out TB. The turnaround time for this test is about 24-48 hours. NAA has better positive predictive value (greater than 95%) with AFB smear-positive specimens in settings in which nontuberculous mycobacteria are common. The ability to confirm rapidly the presence of Mycobacterium tuberculosis is 50%-80% in AFB smear-negative, culture-positive specimens.⁶

In patients with clinical or radiologic suspicion of APTB who are unable to produce sputum or have negative sputum smear microscopy results, bronchoscopy is a safe and reliable method for the diagnosis of pulmonary tuberculosis. For the diagnosis of tuberculosis, bronchoalveolar lavage has a sensitivity and specificity of 60% and 100%, respectively. Adding transbronchial biopsy further increases the sensitivity to 84%, and post-bronchoscopy sputum smear microscopy increases the sensitivity to 94%.⁶

In 2005, the CDC released guidelines for using interferon-gamma release assays (IGRA) to test for M. tuberculosis infection.⁷ Both tuberculin skin testing (TST) and IGRAs assess lymphocytes’ response to M. tuberculosis. Although these tests can be supportive of a previous tuberculosis infection, they are not diagnostic tests for APTB. Neither an IGRA nor a TST can distinguish latent from active tuberculosis.

Sputum AFB culture remains the preferred method for laboratory confirmation of APTB. Once APTB is confirmed, it is essential for susceptibility testing and genotyping. However, in the absence of a positive culture, APTB can be diagnosed based on signs and symptoms alone in a high-risk patient.
 

Treatment

A multidisciplinary, patient-centered approach involving the patient, providers, and public health officials is required to accomplish the following treatment goals: eradicating Mycobacterium infection, eliminating the risk of transmission, avoiding the disease, and preventing drug resistance.⁸

Infectious disease consultation is mandatory in all HIV-positive and suspected or confirmed multidrug-resistant cases. Directly observed therapy is an essential component of APTB treatment to ensure compliance in many situations.
 

Admission and discharge

Admission to a hospital is not required unless a patient meets criteria for admission independent of APTB diagnosis, or proper risk stratification and assessment cannot be completed in a timely manner. A patient with suspected APTB should be placed in airborne isolation. All staff should wear N95 disposable masks or respirators while inside the patient’s room.⁹

Discharge considerations are listed below:

• Inform the department of health (DOH).
• Establish proper isolation precautions to minimize exposure.
• Ensure ability to stay at home until DOH and physician determines noninfectivity.
• Educate the patient about length of therapy, directly observed therapy, side effects and importance of compliance.
• Coordinate discharge with the DOH.
• Make sure proper follow-up is scheduled.

Back to the case

Our patient was placed on airborne respiratory isolation immediately upon admission and sputum was sent for AFB. Sputum smear was positive for AFB as well as a positive nucleic acid testing for Mycobacterium tuberculosis. HIV antibody testing was negative. Once the sputum AFB was determined to be positive, the department of health was informed. He was started on the intensive phase of therapy with pyrazinamide, rifampin, ethambutol, and isoniazid along with pyridoxine. He tolerated his medications well and had no immediate reactions. His family and close contacts were screened and advised to be tested.

The patient was discharged after proper follow-up with primary care doctor was scheduled. The department of health arranged for directly observed therapy. He received information about the importance of taking all of his medications and staying at home except for medical visits until the DOH had deemed him to be noninfectious.
 

Bottom line

APTB in the hospital is an uncommon but serious problem in certain populations. It requires a high index of suspicion and a multidisciplinary approach for effective treatment and prevention of transmission.

Dr. Mallampalli is an attending physician in hospital medicine at Geisinger in Danville, Pa., and clinical assistant professor at Temple University, Philadelphia. Dr. Velidi is an attending physician in hospital medicine at Geisinger. Dr. Courtney is associate director of the department of hospital medicine at Geisinger.

References

1. Miller AC et al. Missed opportunities to diagnose tuberculosis are common among hospitalized patients and patients seen in emergency departments. Open Forum Infectious Diseases. 2015. doi. org/10.1093/ofid/ofv171.

2. Greenaway C et al and the Canadian Collaborative Group in Nosocomial Transmission of Tuberculosis. Delay in diagnosis among hospitalized patients with active tuberculosis–predictors and outcomes. Am J Respir Crit Care Med. 2002 Apr;165:927-33.

3. Medrano BA et al. A missed tuberculosis diagnosis resulting in hospital transmission. Infect Control Hosp Epidemiol. 2014 May;35(5):534-7.

4. Kelly AM et al. Delayed tuberculosis diagnosis and costs of contact investigations for hospital exposure: New York City, 2010-2014. Am J Infect Control. 2017 May 1;45(5):483-6.

5. Lewinsohn DM et al. Official ATS/IDSA/CDC Clinical Practice Guidelines: Diagnosis of tuberculosis in adults and children. Clin Infect Dis. 2017 Jan;64:111-5.

6. Mazurek GH et al. Guidelines for using the QuantiFERON-TB Gold test for detecting Mycobacterium tuberculosis infection, United States. MMWR Recomm Rep. 2005 Dec 16;54(RR-15):49-55.

7. CDC. Trends in tuberculosis – United States, 2010. MMWR Morb Mortal Wkly Rep. 2011 Mar 25;60(11):333-7.

8. Jensen PA et al. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. 2005 Dec 30;54(RR-17):1-141.

9. Siegel JD et al and the Health Care Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007 Dec;35(10 Suppl 2):S65-164.

Case

A 40-year-old Indian immigrant presented to the emergency department with hemoptysis. He had had an intermittent productive cough for the past 4 weeks with increasing fatigue and lack of appetite. He also had intermittent fever with drenching night sweats. Chest radiograph and CT scan showed a left upper lobe cavitary lesion with infiltrate. He was admitted to the hospital with concern for pneumonia and to rule out possible active pulmonary tuberculosis.

Background

Active pulmonary tuberculosis (APTB) remains an important but often missed diagnosis in hospitalized patients in the Western world.^1,2 Because of its relative rarity, the diagnosis of APTB often is delayed in the United States, which can lead hospitalized patients to nosocomial transmission, unnecessary exposures, patient harm,³ and potentially avoidable cost to the health care system.⁴ The diagnosis and management can be challenging involving isolation needs, sputum clearance, treatment strategy, and criteria for discharge to home.

Diagnosis

Any patient with risk factors presenting with signs and/or symptoms of APTB such as productive cough for more than 4 weeks, night sweats, weight loss, low-grade fevers, upper lobe cavitary lesions, or hemoptysis should be suspected. The diagnostic work-up for APTB should always begin with a thorough medical and social history. A chest radiograph or a CT scan should always be obtained. Risk factors for infection and for progression to active pulmonary TB are listed below.
 

Risk factors for TB infection:

• Close contacts of a person with APTB.
• Health care workers.
• Immigrants from high-burden countries.
• Homeless people.
• Individuals who have been incarcerated.
• International travelers.
• HIV patients.
• Intravenous drug users.

Risk factors for progression to APTB:

• HIV infection.
• Intravenous drug use.
• Silicosis.
• Younger than 5 years of age.
• Immunosuppressed.

All patients with suspected or confirmed APTB who cannot be safely discharged home (see discharge considerations below) should be kept in negative-pressure airborne isolation rooms. Isolation can be discontinued once APTB has been ruled out or the patient is determined to be noninfectious based on three consecutive negative sputum smears.

Although rapid and inexpensive, acid-fast bacilli (AFB) smear microscopy has poor sensitivity (45%-80%, with culture-confirmed APTB cases) and poor positive predictive value (50%-80%) for TB in settings in which nontuberculous mycobacteria are commonly isolated. This makes an AFB smear nondiagnostic in the early diagnosis of APTB. The burden of mycobacteria seen in the sputum smear correlates with infectivity.

To improve sensitivity of testing, it is strongly recommended that three AFB smears be completed in 8- to 24-hour intervals and positive smears be accompanied by nucleic acid amplification (NAA) testing.⁵ If APTB is suspected, but the patient is unable to expectorate, induced sputum samples should be obtained, and, if unable to induce sputum samples, flexible bronchoscopy sampling should be pursued especially for the high-risk populations described above.

The Centers for Disease Control and Prevention recommends that at least one sputum specimen be tested with NAA to expedite the time to diagnosis of APTB. A negative NAA does NOT rule out TB. The turnaround time for this test is about 24-48 hours. NAA has better positive predictive value (greater than 95%) with AFB smear-positive specimens in settings in which nontuberculous mycobacteria are common. The ability to confirm rapidly the presence of Mycobacterium tuberculosis is 50%-80% in AFB smear-negative, culture-positive specimens.⁶

In patients with clinical or radiologic suspicion of APTB who are unable to produce sputum or have negative sputum smear microscopy results, bronchoscopy is a safe and reliable method for the diagnosis of pulmonary tuberculosis. For the diagnosis of tuberculosis, bronchoalveolar lavage has a sensitivity and specificity of 60% and 100%, respectively. Adding transbronchial biopsy further increases the sensitivity to 84%, and post-bronchoscopy sputum smear microscopy increases the sensitivity to 94%.⁶

In 2005, the CDC released guidelines for using interferon-gamma release assays (IGRA) to test for M. tuberculosis infection.⁷ Both tuberculin skin testing (TST) and IGRAs assess lymphocytes’ response to M. tuberculosis. Although these tests can be supportive of a previous tuberculosis infection, they are not diagnostic tests for APTB. Neither an IGRA nor a TST can distinguish latent from active tuberculosis.

Sputum AFB culture remains the preferred method for laboratory confirmation of APTB. Once APTB is confirmed, it is essential for susceptibility testing and genotyping. However, in the absence of a positive culture, APTB can be diagnosed based on signs and symptoms alone in a high-risk patient.
 

Treatment

A multidisciplinary, patient-centered approach involving the patient, providers, and public health officials is required to accomplish the following treatment goals: eradicating Mycobacterium infection, eliminating the risk of transmission, avoiding the disease, and preventing drug resistance.⁸

Infectious disease consultation is mandatory in all HIV-positive and suspected or confirmed multidrug-resistant cases. Directly observed therapy is an essential component of APTB treatment to ensure compliance in many situations.
 

Admission and discharge

Admission to a hospital is not required unless a patient meets criteria for admission independent of APTB diagnosis, or proper risk stratification and assessment cannot be completed in a timely manner. A patient with suspected APTB should be placed in airborne isolation. All staff should wear N95 disposable masks or respirators while inside the patient’s room.⁹

Discharge considerations are listed below:

• Inform the department of health (DOH).
• Establish proper isolation precautions to minimize exposure.
• Ensure ability to stay at home until DOH and physician determines noninfectivity.
• Educate the patient about length of therapy, directly observed therapy, side effects and importance of compliance.
• Coordinate discharge with the DOH.
• Make sure proper follow-up is scheduled.

Back to the case

Our patient was placed on airborne respiratory isolation immediately upon admission and sputum was sent for AFB. Sputum smear was positive for AFB as well as a positive nucleic acid testing for Mycobacterium tuberculosis. HIV antibody testing was negative. Once the sputum AFB was determined to be positive, the department of health was informed. He was started on the intensive phase of therapy with pyrazinamide, rifampin, ethambutol, and isoniazid along with pyridoxine. He tolerated his medications well and had no immediate reactions. His family and close contacts were screened and advised to be tested.

The patient was discharged after proper follow-up with primary care doctor was scheduled. The department of health arranged for directly observed therapy. He received information about the importance of taking all of his medications and staying at home except for medical visits until the DOH had deemed him to be noninfectious.
 

Bottom line

APTB in the hospital is an uncommon but serious problem in certain populations. It requires a high index of suspicion and a multidisciplinary approach for effective treatment and prevention of transmission.

Dr. Mallampalli is an attending physician in hospital medicine at Geisinger in Danville, Pa., and clinical assistant professor at Temple University, Philadelphia. Dr. Velidi is an attending physician in hospital medicine at Geisinger. Dr. Courtney is associate director of the department of hospital medicine at Geisinger.

References

1. Miller AC et al. Missed opportunities to diagnose tuberculosis are common among hospitalized patients and patients seen in emergency departments. Open Forum Infectious Diseases. 2015. doi. org/10.1093/ofid/ofv171.

2. Greenaway C et al and the Canadian Collaborative Group in Nosocomial Transmission of Tuberculosis. Delay in diagnosis among hospitalized patients with active tuberculosis–predictors and outcomes. Am J Respir Crit Care Med. 2002 Apr;165:927-33.

3. Medrano BA et al. A missed tuberculosis diagnosis resulting in hospital transmission. Infect Control Hosp Epidemiol. 2014 May;35(5):534-7.

4. Kelly AM et al. Delayed tuberculosis diagnosis and costs of contact investigations for hospital exposure: New York City, 2010-2014. Am J Infect Control. 2017 May 1;45(5):483-6.

5. Lewinsohn DM et al. Official ATS/IDSA/CDC Clinical Practice Guidelines: Diagnosis of tuberculosis in adults and children. Clin Infect Dis. 2017 Jan;64:111-5.

6. Mazurek GH et al. Guidelines for using the QuantiFERON-TB Gold test for detecting Mycobacterium tuberculosis infection, United States. MMWR Recomm Rep. 2005 Dec 16;54(RR-15):49-55.

7. CDC. Trends in tuberculosis – United States, 2010. MMWR Morb Mortal Wkly Rep. 2011 Mar 25;60(11):333-7.

8. Jensen PA et al. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. 2005 Dec 30;54(RR-17):1-141.

9. Siegel JD et al and the Health Care Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007 Dec;35(10 Suppl 2):S65-164.

Case

A 40-year-old Indian immigrant presented to the emergency department with hemoptysis. He had had an intermittent productive cough for the past 4 weeks with increasing fatigue and lack of appetite. He also had intermittent fever with drenching night sweats. Chest radiograph and CT scan showed a left upper lobe cavitary lesion with infiltrate. He was admitted to the hospital with concern for pneumonia and to rule out possible active pulmonary tuberculosis.

Background

Active pulmonary tuberculosis (APTB) remains an important but often missed diagnosis in hospitalized patients in the Western world.^1,2 Because of its relative rarity, the diagnosis of APTB often is delayed in the United States, which can lead hospitalized patients to nosocomial transmission, unnecessary exposures, patient harm,³ and potentially avoidable cost to the health care system.⁴ The diagnosis and management can be challenging involving isolation needs, sputum clearance, treatment strategy, and criteria for discharge to home.

Diagnosis

Any patient with risk factors presenting with signs and/or symptoms of APTB such as productive cough for more than 4 weeks, night sweats, weight loss, low-grade fevers, upper lobe cavitary lesions, or hemoptysis should be suspected. The diagnostic work-up for APTB should always begin with a thorough medical and social history. A chest radiograph or a CT scan should always be obtained. Risk factors for infection and for progression to active pulmonary TB are listed below.
 

Risk factors for TB infection:

• Close contacts of a person with APTB.
• Health care workers.
• Immigrants from high-burden countries.
• Homeless people.
• Individuals who have been incarcerated.
• International travelers.
• HIV patients.
• Intravenous drug users.

Risk factors for progression to APTB:

• HIV infection.
• Intravenous drug use.
• Silicosis.
• Younger than 5 years of age.
• Immunosuppressed.

All patients with suspected or confirmed APTB who cannot be safely discharged home (see discharge considerations below) should be kept in negative-pressure airborne isolation rooms. Isolation can be discontinued once APTB has been ruled out or the patient is determined to be noninfectious based on three consecutive negative sputum smears.

Although rapid and inexpensive, acid-fast bacilli (AFB) smear microscopy has poor sensitivity (45%-80%, with culture-confirmed APTB cases) and poor positive predictive value (50%-80%) for TB in settings in which nontuberculous mycobacteria are commonly isolated. This makes an AFB smear nondiagnostic in the early diagnosis of APTB. The burden of mycobacteria seen in the sputum smear correlates with infectivity.

To improve sensitivity of testing, it is strongly recommended that three AFB smears be completed in 8- to 24-hour intervals and positive smears be accompanied by nucleic acid amplification (NAA) testing.⁵ If APTB is suspected, but the patient is unable to expectorate, induced sputum samples should be obtained, and, if unable to induce sputum samples, flexible bronchoscopy sampling should be pursued especially for the high-risk populations described above.

The Centers for Disease Control and Prevention recommends that at least one sputum specimen be tested with NAA to expedite the time to diagnosis of APTB. A negative NAA does NOT rule out TB. The turnaround time for this test is about 24-48 hours. NAA has better positive predictive value (greater than 95%) with AFB smear-positive specimens in settings in which nontuberculous mycobacteria are common. The ability to confirm rapidly the presence of Mycobacterium tuberculosis is 50%-80% in AFB smear-negative, culture-positive specimens.⁶

In patients with clinical or radiologic suspicion of APTB who are unable to produce sputum or have negative sputum smear microscopy results, bronchoscopy is a safe and reliable method for the diagnosis of pulmonary tuberculosis. For the diagnosis of tuberculosis, bronchoalveolar lavage has a sensitivity and specificity of 60% and 100%, respectively. Adding transbronchial biopsy further increases the sensitivity to 84%, and post-bronchoscopy sputum smear microscopy increases the sensitivity to 94%.⁶

In 2005, the CDC released guidelines for using interferon-gamma release assays (IGRA) to test for M. tuberculosis infection.⁷ Both tuberculin skin testing (TST) and IGRAs assess lymphocytes’ response to M. tuberculosis. Although these tests can be supportive of a previous tuberculosis infection, they are not diagnostic tests for APTB. Neither an IGRA nor a TST can distinguish latent from active tuberculosis.

Sputum AFB culture remains the preferred method for laboratory confirmation of APTB. Once APTB is confirmed, it is essential for susceptibility testing and genotyping. However, in the absence of a positive culture, APTB can be diagnosed based on signs and symptoms alone in a high-risk patient.
 

Treatment

A multidisciplinary, patient-centered approach involving the patient, providers, and public health officials is required to accomplish the following treatment goals: eradicating Mycobacterium infection, eliminating the risk of transmission, avoiding the disease, and preventing drug resistance.⁸

Infectious disease consultation is mandatory in all HIV-positive and suspected or confirmed multidrug-resistant cases. Directly observed therapy is an essential component of APTB treatment to ensure compliance in many situations.
 

Admission and discharge

Admission to a hospital is not required unless a patient meets criteria for admission independent of APTB diagnosis, or proper risk stratification and assessment cannot be completed in a timely manner. A patient with suspected APTB should be placed in airborne isolation. All staff should wear N95 disposable masks or respirators while inside the patient’s room.⁹

Discharge considerations are listed below:

• Inform the department of health (DOH).
• Establish proper isolation precautions to minimize exposure.
• Ensure ability to stay at home until DOH and physician determines noninfectivity.
• Educate the patient about length of therapy, directly observed therapy, side effects and importance of compliance.
• Coordinate discharge with the DOH.
• Make sure proper follow-up is scheduled.

Back to the case

Our patient was placed on airborne respiratory isolation immediately upon admission and sputum was sent for AFB. Sputum smear was positive for AFB as well as a positive nucleic acid testing for Mycobacterium tuberculosis. HIV antibody testing was negative. Once the sputum AFB was determined to be positive, the department of health was informed. He was started on the intensive phase of therapy with pyrazinamide, rifampin, ethambutol, and isoniazid along with pyridoxine. He tolerated his medications well and had no immediate reactions. His family and close contacts were screened and advised to be tested.

The patient was discharged after proper follow-up with primary care doctor was scheduled. The department of health arranged for directly observed therapy. He received information about the importance of taking all of his medications and staying at home except for medical visits until the DOH had deemed him to be noninfectious.
 

Bottom line

APTB in the hospital is an uncommon but serious problem in certain populations. It requires a high index of suspicion and a multidisciplinary approach for effective treatment and prevention of transmission.

Dr. Mallampalli is an attending physician in hospital medicine at Geisinger in Danville, Pa., and clinical assistant professor at Temple University, Philadelphia. Dr. Velidi is an attending physician in hospital medicine at Geisinger. Dr. Courtney is associate director of the department of hospital medicine at Geisinger.

References

1. Miller AC et al. Missed opportunities to diagnose tuberculosis are common among hospitalized patients and patients seen in emergency departments. Open Forum Infectious Diseases. 2015. doi. org/10.1093/ofid/ofv171.

2. Greenaway C et al and the Canadian Collaborative Group in Nosocomial Transmission of Tuberculosis. Delay in diagnosis among hospitalized patients with active tuberculosis–predictors and outcomes. Am J Respir Crit Care Med. 2002 Apr;165:927-33.

3. Medrano BA et al. A missed tuberculosis diagnosis resulting in hospital transmission. Infect Control Hosp Epidemiol. 2014 May;35(5):534-7.

4. Kelly AM et al. Delayed tuberculosis diagnosis and costs of contact investigations for hospital exposure: New York City, 2010-2014. Am J Infect Control. 2017 May 1;45(5):483-6.

5. Lewinsohn DM et al. Official ATS/IDSA/CDC Clinical Practice Guidelines: Diagnosis of tuberculosis in adults and children. Clin Infect Dis. 2017 Jan;64:111-5.

6. Mazurek GH et al. Guidelines for using the QuantiFERON-TB Gold test for detecting Mycobacterium tuberculosis infection, United States. MMWR Recomm Rep. 2005 Dec 16;54(RR-15):49-55.

7. CDC. Trends in tuberculosis – United States, 2010. MMWR Morb Mortal Wkly Rep. 2011 Mar 25;60(11):333-7.

8. Jensen PA et al. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. 2005 Dec 30;54(RR-17):1-141.

9. Siegel JD et al and the Health Care Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007 Dec;35(10 Suppl 2):S65-164.

PARIS – Removal of circulating C-reactive protein (CRP) via selective extracorporeal apheresis shows considerable promise as a safe and effective adjunctive therapy for ST-segment elevation MI in an interim analysis of an ongoing, multicenter, German, randomized, proof-of-concept trial, Christoph D. Garlichs, MD, reported at the annual meeting of the European Association of Percutaneous Cardiovascular Interventions.

In the first 64 of 80 scheduled, randomized ST-segment elevation MI (STEMI) patients participating in the CRP Apheresis in the Acute Myocardial Infarction (CAMI 1) trial, CRP apheresis plus standard European Society of Cardiology guideline-recommended STEMI therapy, including complete coronary revascularization, resulted in a 47% reduction in infarct area by cardiac MRI performed 2-7 days post infarct, compared with standard therapy alone, which is the primary study endpoint, reported Dr. Garlichs, a cardiologist and head of the internal medicine clinic at Deaconess Hospital in Flensburg, Germany.

Bruce Jancin/MDedge News

[email protected]

PARIS – Removal of circulating C-reactive protein (CRP) via selective extracorporeal apheresis shows considerable promise as a safe and effective adjunctive therapy for ST-segment elevation MI in an interim analysis of an ongoing, multicenter, German, randomized, proof-of-concept trial, Christoph D. Garlichs, MD, reported at the annual meeting of the European Association of Percutaneous Cardiovascular Interventions.

In the first 64 of 80 scheduled, randomized ST-segment elevation MI (STEMI) patients participating in the CRP Apheresis in the Acute Myocardial Infarction (CAMI 1) trial, CRP apheresis plus standard European Society of Cardiology guideline-recommended STEMI therapy, including complete coronary revascularization, resulted in a 47% reduction in infarct area by cardiac MRI performed 2-7 days post infarct, compared with standard therapy alone, which is the primary study endpoint, reported Dr. Garlichs, a cardiologist and head of the internal medicine clinic at Deaconess Hospital in Flensburg, Germany.

Bruce Jancin/MDedge News

[email protected]

PARIS – Removal of circulating C-reactive protein (CRP) via selective extracorporeal apheresis shows considerable promise as a safe and effective adjunctive therapy for ST-segment elevation MI in an interim analysis of an ongoing, multicenter, German, randomized, proof-of-concept trial, Christoph D. Garlichs, MD, reported at the annual meeting of the European Association of Percutaneous Cardiovascular Interventions.

In the first 64 of 80 scheduled, randomized ST-segment elevation MI (STEMI) patients participating in the CRP Apheresis in the Acute Myocardial Infarction (CAMI 1) trial, CRP apheresis plus standard European Society of Cardiology guideline-recommended STEMI therapy, including complete coronary revascularization, resulted in a 47% reduction in infarct area by cardiac MRI performed 2-7 days post infarct, compared with standard therapy alone, which is the primary study endpoint, reported Dr. Garlichs, a cardiologist and head of the internal medicine clinic at Deaconess Hospital in Flensburg, Germany.

Bruce Jancin/MDedge News

[email protected]

CHICAGO – Preoperative chemotherapy improves outcomes in patients with resectable or borderline resectable pancreatic cancer, preliminary findings from the phase 3 PREOPANC-1 trial suggest.

Overall survival in 127 patients randomized to immediate surgery followed by adjuvant chemotherapy was 13.7 months vs. 17.1 months in 119 patients randomized to receive preoperative chemoradiotherapy and postoperative adjuvant chemotherapy, Geertjan van Tienhoven, MD, PhD, reported at the annual meeting of the American Society of Clinical Oncology.

The difference did not quite reach statistical significance, but final analysis requires an additional 26 events, Dr. van Tienhoven of Academic Medical Center, Amsterdam explained in a video interview at the meeting.

Other differences between the groups, which included disease-free survival, local control, and metastasis-free survival, did differ significantly in favor of preoperative chemotherapy, he said.

Of note, 72% and 62% of patients in the immediate surgery and preoperative chemoradiotherapy groups, respectively, underwent resection and a greater proportion of patients in the latter group achieved microscopically complete resection, he said (63% vs. 31%).

Should these results hold up in the final analysis, particularly if the difference in overall survival reaches statistical significance, “then this is a proof of principle and practice-changing trial,” Dr. van Tienhoven said.

Dr. van Tienhoven reported having no disclosures.

SOURCE: van Tienhoven et al. ASCO 2108, Abstract LBA4002.

CHICAGO – Preoperative chemotherapy improves outcomes in patients with resectable or borderline resectable pancreatic cancer, preliminary findings from the phase 3 PREOPANC-1 trial suggest.

Overall survival in 127 patients randomized to immediate surgery followed by adjuvant chemotherapy was 13.7 months vs. 17.1 months in 119 patients randomized to receive preoperative chemoradiotherapy and postoperative adjuvant chemotherapy, Geertjan van Tienhoven, MD, PhD, reported at the annual meeting of the American Society of Clinical Oncology.

The difference did not quite reach statistical significance, but final analysis requires an additional 26 events, Dr. van Tienhoven of Academic Medical Center, Amsterdam explained in a video interview at the meeting.

Other differences between the groups, which included disease-free survival, local control, and metastasis-free survival, did differ significantly in favor of preoperative chemotherapy, he said.

Of note, 72% and 62% of patients in the immediate surgery and preoperative chemoradiotherapy groups, respectively, underwent resection and a greater proportion of patients in the latter group achieved microscopically complete resection, he said (63% vs. 31%).

Should these results hold up in the final analysis, particularly if the difference in overall survival reaches statistical significance, “then this is a proof of principle and practice-changing trial,” Dr. van Tienhoven said.

Dr. van Tienhoven reported having no disclosures.

SOURCE: van Tienhoven et al. ASCO 2108, Abstract LBA4002.

CHICAGO – Preoperative chemotherapy improves outcomes in patients with resectable or borderline resectable pancreatic cancer, preliminary findings from the phase 3 PREOPANC-1 trial suggest.

Overall survival in 127 patients randomized to immediate surgery followed by adjuvant chemotherapy was 13.7 months vs. 17.1 months in 119 patients randomized to receive preoperative chemoradiotherapy and postoperative adjuvant chemotherapy, Geertjan van Tienhoven, MD, PhD, reported at the annual meeting of the American Society of Clinical Oncology.

The difference did not quite reach statistical significance, but final analysis requires an additional 26 events, Dr. van Tienhoven of Academic Medical Center, Amsterdam explained in a video interview at the meeting.

Other differences between the groups, which included disease-free survival, local control, and metastasis-free survival, did differ significantly in favor of preoperative chemotherapy, he said.

Of note, 72% and 62% of patients in the immediate surgery and preoperative chemoradiotherapy groups, respectively, underwent resection and a greater proportion of patients in the latter group achieved microscopically complete resection, he said (63% vs. 31%).

Should these results hold up in the final analysis, particularly if the difference in overall survival reaches statistical significance, “then this is a proof of principle and practice-changing trial,” Dr. van Tienhoven said.

Dr. van Tienhoven reported having no disclosures.

SOURCE: van Tienhoven et al. ASCO 2108, Abstract LBA4002.

The introduction of the new high-sensitivity cardiac troponin T (hs-cTnT) test was linked with an 11% decrease in reinfarctions but showed no evidence of improving survival in a large longitudinal cohort study.

Over an average of 3.9 years of follow-up, the adjusted risk of all-cause mortality was identical whether patients’ initial MI was diagnosed with the new troponin test or the conventional one, reported Maria Odqvist, MD, of South Alvsborg Hospital, Boras, Sweden, and her associates. “As hs-cTn assays become widely available and clinicians gain experience interpreting the results, more work is needed to enhance clinical reasoning and implementation to improve patient outcomes,” the researchers wrote in the Journal of the American College of Cardiology.

High-sensitivity cardiac troponin T assays detect acute coronary syndrome more rapidly than their conventional predecessors. However, hs-cTnT’s higher sensitivity comes with lost specificity and hence has raised concerns about potentially wasting health care resources. Some clinicians have asked whether the new test is worthwhile and how to maximize its benefits.

The study, which included nearly 88,000 patients with initial MI from the Swedish National Patient Registry, spanned 2009-2013, when 73% of Swedish acute care hospitals transitioned from conventional troponin tests (cTn) to hs-cTnT. After adjustment for factors such as age, sex, location, chronic kidney disease, cardiovascular history, and prescriptions, Dr. Odqvist and her associates compared each test types’ risks of death, reinfarction, coronary angiography, and revascularization among patients diagnosed.

In all, 47,133 (54%) patients’ initial MI was diagnosed with cTn while 46% were diagnosed with hs-cTnT. Overall, the rate of MI rose by 5% during the 90 days after hospitals implemented hs-cTnT, compared with the 90 days before. But hospitals used varying hs-cTnT thresholds for MI, which might explain why some hospitals initially observed a marked initial decrease in MI while others saw a relatively large increase, the investigators wrote.

There were 15,766 reinfarctions over an average of 3.1 years of follow-up. Although there was no difference in all-cause mortality, risk of reinfarction was 11% lower among patients diagnosed using hs-cTnT, compared with those diagnosed by cTn.

At the hospital level, coronary angiography and revascularization became only slightly more common during the 3 months after hospitals switched to hs-cTnT, the researchers wrote. However, patients whose MIs were diagnosed with hs-cTnT were 16% more likely to undergo coronary angiography and 13% more likely to undergo revascularization within the next 30 days, compared with patients diagnosed with cTn. Patients diagnosed with hs-cTnT also were more likely to receive statins, but trends in other prescriptions did not change.

The Swedish Heart-Lung Foundation funded one investigator. Dr. Odqvist and one coinvestigator reported having no relevant conflicts of interest. Senior author Martin J. Holzmann, MD, PhD, disclosed ties to Actelion and Pfizer. Two other coinvestigators disclosed ties to Roche, Gilead, Janssen, Abbvie, CTI Bipharma, GlaxoSmithKline, Abbott Laboratories, and AstraZeneca, and Fiomi Diagnostics.

SOURCE: Odqvist M et al. J Am Coll Cardiol. 2018 Jun 12;71(23):2616-24

The introduction of the new high-sensitivity cardiac troponin T (hs-cTnT) test was linked with an 11% decrease in reinfarctions but showed no evidence of improving survival in a large longitudinal cohort study.

Over an average of 3.9 years of follow-up, the adjusted risk of all-cause mortality was identical whether patients’ initial MI was diagnosed with the new troponin test or the conventional one, reported Maria Odqvist, MD, of South Alvsborg Hospital, Boras, Sweden, and her associates. “As hs-cTn assays become widely available and clinicians gain experience interpreting the results, more work is needed to enhance clinical reasoning and implementation to improve patient outcomes,” the researchers wrote in the Journal of the American College of Cardiology.

High-sensitivity cardiac troponin T assays detect acute coronary syndrome more rapidly than their conventional predecessors. However, hs-cTnT’s higher sensitivity comes with lost specificity and hence has raised concerns about potentially wasting health care resources. Some clinicians have asked whether the new test is worthwhile and how to maximize its benefits.

The study, which included nearly 88,000 patients with initial MI from the Swedish National Patient Registry, spanned 2009-2013, when 73% of Swedish acute care hospitals transitioned from conventional troponin tests (cTn) to hs-cTnT. After adjustment for factors such as age, sex, location, chronic kidney disease, cardiovascular history, and prescriptions, Dr. Odqvist and her associates compared each test types’ risks of death, reinfarction, coronary angiography, and revascularization among patients diagnosed.

In all, 47,133 (54%) patients’ initial MI was diagnosed with cTn while 46% were diagnosed with hs-cTnT. Overall, the rate of MI rose by 5% during the 90 days after hospitals implemented hs-cTnT, compared with the 90 days before. But hospitals used varying hs-cTnT thresholds for MI, which might explain why some hospitals initially observed a marked initial decrease in MI while others saw a relatively large increase, the investigators wrote.

There were 15,766 reinfarctions over an average of 3.1 years of follow-up. Although there was no difference in all-cause mortality, risk of reinfarction was 11% lower among patients diagnosed using hs-cTnT, compared with those diagnosed by cTn.

At the hospital level, coronary angiography and revascularization became only slightly more common during the 3 months after hospitals switched to hs-cTnT, the researchers wrote. However, patients whose MIs were diagnosed with hs-cTnT were 16% more likely to undergo coronary angiography and 13% more likely to undergo revascularization within the next 30 days, compared with patients diagnosed with cTn. Patients diagnosed with hs-cTnT also were more likely to receive statins, but trends in other prescriptions did not change.

The Swedish Heart-Lung Foundation funded one investigator. Dr. Odqvist and one coinvestigator reported having no relevant conflicts of interest. Senior author Martin J. Holzmann, MD, PhD, disclosed ties to Actelion and Pfizer. Two other coinvestigators disclosed ties to Roche, Gilead, Janssen, Abbvie, CTI Bipharma, GlaxoSmithKline, Abbott Laboratories, and AstraZeneca, and Fiomi Diagnostics.

SOURCE: Odqvist M et al. J Am Coll Cardiol. 2018 Jun 12;71(23):2616-24

The introduction of the new high-sensitivity cardiac troponin T (hs-cTnT) test was linked with an 11% decrease in reinfarctions but showed no evidence of improving survival in a large longitudinal cohort study.

Over an average of 3.9 years of follow-up, the adjusted risk of all-cause mortality was identical whether patients’ initial MI was diagnosed with the new troponin test or the conventional one, reported Maria Odqvist, MD, of South Alvsborg Hospital, Boras, Sweden, and her associates. “As hs-cTn assays become widely available and clinicians gain experience interpreting the results, more work is needed to enhance clinical reasoning and implementation to improve patient outcomes,” the researchers wrote in the Journal of the American College of Cardiology.

High-sensitivity cardiac troponin T assays detect acute coronary syndrome more rapidly than their conventional predecessors. However, hs-cTnT’s higher sensitivity comes with lost specificity and hence has raised concerns about potentially wasting health care resources. Some clinicians have asked whether the new test is worthwhile and how to maximize its benefits.

The study, which included nearly 88,000 patients with initial MI from the Swedish National Patient Registry, spanned 2009-2013, when 73% of Swedish acute care hospitals transitioned from conventional troponin tests (cTn) to hs-cTnT. After adjustment for factors such as age, sex, location, chronic kidney disease, cardiovascular history, and prescriptions, Dr. Odqvist and her associates compared each test types’ risks of death, reinfarction, coronary angiography, and revascularization among patients diagnosed.

In all, 47,133 (54%) patients’ initial MI was diagnosed with cTn while 46% were diagnosed with hs-cTnT. Overall, the rate of MI rose by 5% during the 90 days after hospitals implemented hs-cTnT, compared with the 90 days before. But hospitals used varying hs-cTnT thresholds for MI, which might explain why some hospitals initially observed a marked initial decrease in MI while others saw a relatively large increase, the investigators wrote.

There were 15,766 reinfarctions over an average of 3.1 years of follow-up. Although there was no difference in all-cause mortality, risk of reinfarction was 11% lower among patients diagnosed using hs-cTnT, compared with those diagnosed by cTn.

At the hospital level, coronary angiography and revascularization became only slightly more common during the 3 months after hospitals switched to hs-cTnT, the researchers wrote. However, patients whose MIs were diagnosed with hs-cTnT were 16% more likely to undergo coronary angiography and 13% more likely to undergo revascularization within the next 30 days, compared with patients diagnosed with cTn. Patients diagnosed with hs-cTnT also were more likely to receive statins, but trends in other prescriptions did not change.

The Swedish Heart-Lung Foundation funded one investigator. Dr. Odqvist and one coinvestigator reported having no relevant conflicts of interest. Senior author Martin J. Holzmann, MD, PhD, disclosed ties to Actelion and Pfizer. Two other coinvestigators disclosed ties to Roche, Gilead, Janssen, Abbvie, CTI Bipharma, GlaxoSmithKline, Abbott Laboratories, and AstraZeneca, and Fiomi Diagnostics.

SOURCE: Odqvist M et al. J Am Coll Cardiol. 2018 Jun 12;71(23):2616-24

For as long as I have been writing this column, I have stressed that aggressive management of accounts receivable (AR) is the key to any practice’s financial health; and yet, all these years later, AR is still the subject that generates the most questions.

Okay; let’s go over it one more time: Basically, physicians extend more credit than any business except banks. Despite what you may have read recently, banks are good at it, and they charge interest (and a myriad of fees) to do it. Doctors do it for free. Are we crazy? No business owner in his or her right mind allows customers to take away goods or services without paying for them; but doctors do it every day.

What to do? Common sense tells you to collect everything you can at the time of service; but some patients inevitably brandish the old “I forgot my checkbook” excuse and escape without paying. And the patient-owed portion of most insurance charges is often unknown, and unknowable, at the time of service.

That means you’ll need to send a bill; and every bill you send (or hire somebody to send) costs you a bundle. And when it arrives, it goes right to the bottom of your patient’s payment priority list. That is, each month your patients will pay their electric, water, gas, and telephone bills … and just about any other bill ... before getting around to yours. If there is no more money when your bill finally surfaces, that’s just too bad. The electric company can shut off their power; what can you do?

What we do is what every hotel, rental car agency, and many other businesses have done for years: We ask for a credit card number, keep it on file, and bill balances to it as they come in. Plastic runs the show everywhere you go – except in most medical offices.

New patients in my office receive a letter at their first visit explaining our policy. At the bottom is a brief consent for the patient to sign, and a place to write the credit card number and expiration date. (See below for a copy of our letter; feel free to use it as a template for creating your own.)

Do patients object? Some do – mostly older people, and fewer each year. But when we explain that we’re doing nothing different than a hotel does at each check-in, and that it will work to their advantage as well by decreasing the bills they will receive and the checks they must write, most come around. Make it an option at first if you wish; then, when everyone is accustomed to it, you can make it mandatory.

Do patients worry about confidentiality, or unauthorized use? They don’t anywhere else. They think nothing of handing a card to a waiter or waitress in a restaurant with no thought of what he or she might do with it in the kitchen. They hand cards over to hotel clerks, and never think to ask how long they keep the information or who has access to it. They blithely shoot their numbers into black holes on the Internet. We explain that we guard our patients’ financial information as carefully as we do their medical information. (If you have EHR, it can go in the chart with everything else; if not, I suggest a separate portable Rolodex-type file that can be locked up each night.)

Does it work? In only a year, our accounts receivable totals dropped by nearly 50%; after another year, they stabilized at 30%-35% of previous levels and have remained there ever since. When my accountant retired a few years ago, I hired a new one. Something must be wrong, he said nervously, after his first look at our books; AR totals are “never” that low in a practice with our level of volume. His eyes widened as I explained our system. “Why doesn’t every medical office do that?” he asked.

Why indeed? The business of health care delivery is being rocked to its very foundations as we speak. In my humble opinion, private practice will only survive those changes if physicians learn to do more of what we do best – treating patients – and leave the business of extending credit to the banks.
 

Patient consent form

This generic letter is intended to be used as an example for a letter you might draft for a similar purpose. We take no responsibility for your use of its content, either verbatim or altered, or for any inappropriate usage. Click on the attachment below for a printable copy of the letter.

To Our Patients:

As you know if you have ever checked into a hotel or rented a car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage for both you and the hotel or rental company, since it makes checkout easier, faster, and more efficient.

We have implemented a similar policy. You will be asked for a credit card number at the time you check in and the information will be held securely until your insurances have paid their portion and notified us of the amount of your share. At that time, any remaining balance owed by you will be charged to your credit card, and a copy of the charge will be mailed to you.

This will be an advantage to you, since you will no longer have to write out and mail us checks. It will be an advantage to us as well, since it will greatly decrease the number of statements that we have to generate and send out. The combination will benefit everybody in helping to keep the cost of health care down.

This in no way will compromise your ability to dispute a charge or question your insurance company’s determination of payment.

Copays due at the time of the visit will, of course, still be due at the time of the visit.

If you have any questions about this payment method, do not hesitate to ask.



Sincerely yours,



I authorize ********************, PA to charge outstanding balances on my account to the following credit card:



Visa Mastercard American Express Other: ____________________________



Account number _______________________Expiration Date ____________CVV_____



Name on card (please print) _________________________________________________



Signature _____________________________________ Date ______________________
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected]

For as long as I have been writing this column, I have stressed that aggressive management of accounts receivable (AR) is the key to any practice’s financial health; and yet, all these years later, AR is still the subject that generates the most questions.

Okay; let’s go over it one more time: Basically, physicians extend more credit than any business except banks. Despite what you may have read recently, banks are good at it, and they charge interest (and a myriad of fees) to do it. Doctors do it for free. Are we crazy? No business owner in his or her right mind allows customers to take away goods or services without paying for them; but doctors do it every day.

What to do? Common sense tells you to collect everything you can at the time of service; but some patients inevitably brandish the old “I forgot my checkbook” excuse and escape without paying. And the patient-owed portion of most insurance charges is often unknown, and unknowable, at the time of service.

That means you’ll need to send a bill; and every bill you send (or hire somebody to send) costs you a bundle. And when it arrives, it goes right to the bottom of your patient’s payment priority list. That is, each month your patients will pay their electric, water, gas, and telephone bills … and just about any other bill ... before getting around to yours. If there is no more money when your bill finally surfaces, that’s just too bad. The electric company can shut off their power; what can you do?

What we do is what every hotel, rental car agency, and many other businesses have done for years: We ask for a credit card number, keep it on file, and bill balances to it as they come in. Plastic runs the show everywhere you go – except in most medical offices.

New patients in my office receive a letter at their first visit explaining our policy. At the bottom is a brief consent for the patient to sign, and a place to write the credit card number and expiration date. (See below for a copy of our letter; feel free to use it as a template for creating your own.)

Do patients object? Some do – mostly older people, and fewer each year. But when we explain that we’re doing nothing different than a hotel does at each check-in, and that it will work to their advantage as well by decreasing the bills they will receive and the checks they must write, most come around. Make it an option at first if you wish; then, when everyone is accustomed to it, you can make it mandatory.

Do patients worry about confidentiality, or unauthorized use? They don’t anywhere else. They think nothing of handing a card to a waiter or waitress in a restaurant with no thought of what he or she might do with it in the kitchen. They hand cards over to hotel clerks, and never think to ask how long they keep the information or who has access to it. They blithely shoot their numbers into black holes on the Internet. We explain that we guard our patients’ financial information as carefully as we do their medical information. (If you have EHR, it can go in the chart with everything else; if not, I suggest a separate portable Rolodex-type file that can be locked up each night.)

Does it work? In only a year, our accounts receivable totals dropped by nearly 50%; after another year, they stabilized at 30%-35% of previous levels and have remained there ever since. When my accountant retired a few years ago, I hired a new one. Something must be wrong, he said nervously, after his first look at our books; AR totals are “never” that low in a practice with our level of volume. His eyes widened as I explained our system. “Why doesn’t every medical office do that?” he asked.

Why indeed? The business of health care delivery is being rocked to its very foundations as we speak. In my humble opinion, private practice will only survive those changes if physicians learn to do more of what we do best – treating patients – and leave the business of extending credit to the banks.
 

Patient consent form

This generic letter is intended to be used as an example for a letter you might draft for a similar purpose. We take no responsibility for your use of its content, either verbatim or altered, or for any inappropriate usage. Click on the attachment below for a printable copy of the letter.

To Our Patients:

As you know if you have ever checked into a hotel or rented a car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage for both you and the hotel or rental company, since it makes checkout easier, faster, and more efficient.

We have implemented a similar policy. You will be asked for a credit card number at the time you check in and the information will be held securely until your insurances have paid their portion and notified us of the amount of your share. At that time, any remaining balance owed by you will be charged to your credit card, and a copy of the charge will be mailed to you.

This will be an advantage to you, since you will no longer have to write out and mail us checks. It will be an advantage to us as well, since it will greatly decrease the number of statements that we have to generate and send out. The combination will benefit everybody in helping to keep the cost of health care down.

This in no way will compromise your ability to dispute a charge or question your insurance company’s determination of payment.

Copays due at the time of the visit will, of course, still be due at the time of the visit.

If you have any questions about this payment method, do not hesitate to ask.



Sincerely yours,



I authorize ********************, PA to charge outstanding balances on my account to the following credit card:



Visa Mastercard American Express Other: ____________________________



Account number _______________________Expiration Date ____________CVV_____



Name on card (please print) _________________________________________________



Signature _____________________________________ Date ______________________
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected]

For as long as I have been writing this column, I have stressed that aggressive management of accounts receivable (AR) is the key to any practice’s financial health; and yet, all these years later, AR is still the subject that generates the most questions.

Okay; let’s go over it one more time: Basically, physicians extend more credit than any business except banks. Despite what you may have read recently, banks are good at it, and they charge interest (and a myriad of fees) to do it. Doctors do it for free. Are we crazy? No business owner in his or her right mind allows customers to take away goods or services without paying for them; but doctors do it every day.

What to do? Common sense tells you to collect everything you can at the time of service; but some patients inevitably brandish the old “I forgot my checkbook” excuse and escape without paying. And the patient-owed portion of most insurance charges is often unknown, and unknowable, at the time of service.

That means you’ll need to send a bill; and every bill you send (or hire somebody to send) costs you a bundle. And when it arrives, it goes right to the bottom of your patient’s payment priority list. That is, each month your patients will pay their electric, water, gas, and telephone bills … and just about any other bill ... before getting around to yours. If there is no more money when your bill finally surfaces, that’s just too bad. The electric company can shut off their power; what can you do?

What we do is what every hotel, rental car agency, and many other businesses have done for years: We ask for a credit card number, keep it on file, and bill balances to it as they come in. Plastic runs the show everywhere you go – except in most medical offices.

New patients in my office receive a letter at their first visit explaining our policy. At the bottom is a brief consent for the patient to sign, and a place to write the credit card number and expiration date. (See below for a copy of our letter; feel free to use it as a template for creating your own.)

Do patients object? Some do – mostly older people, and fewer each year. But when we explain that we’re doing nothing different than a hotel does at each check-in, and that it will work to their advantage as well by decreasing the bills they will receive and the checks they must write, most come around. Make it an option at first if you wish; then, when everyone is accustomed to it, you can make it mandatory.

Do patients worry about confidentiality, or unauthorized use? They don’t anywhere else. They think nothing of handing a card to a waiter or waitress in a restaurant with no thought of what he or she might do with it in the kitchen. They hand cards over to hotel clerks, and never think to ask how long they keep the information or who has access to it. They blithely shoot their numbers into black holes on the Internet. We explain that we guard our patients’ financial information as carefully as we do their medical information. (If you have EHR, it can go in the chart with everything else; if not, I suggest a separate portable Rolodex-type file that can be locked up each night.)

Does it work? In only a year, our accounts receivable totals dropped by nearly 50%; after another year, they stabilized at 30%-35% of previous levels and have remained there ever since. When my accountant retired a few years ago, I hired a new one. Something must be wrong, he said nervously, after his first look at our books; AR totals are “never” that low in a practice with our level of volume. His eyes widened as I explained our system. “Why doesn’t every medical office do that?” he asked.

Why indeed? The business of health care delivery is being rocked to its very foundations as we speak. In my humble opinion, private practice will only survive those changes if physicians learn to do more of what we do best – treating patients – and leave the business of extending credit to the banks.
 

Patient consent form

This generic letter is intended to be used as an example for a letter you might draft for a similar purpose. We take no responsibility for your use of its content, either verbatim or altered, or for any inappropriate usage. Click on the attachment below for a printable copy of the letter.

To Our Patients:

As you know if you have ever checked into a hotel or rented a car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage for both you and the hotel or rental company, since it makes checkout easier, faster, and more efficient.

We have implemented a similar policy. You will be asked for a credit card number at the time you check in and the information will be held securely until your insurances have paid their portion and notified us of the amount of your share. At that time, any remaining balance owed by you will be charged to your credit card, and a copy of the charge will be mailed to you.

This will be an advantage to you, since you will no longer have to write out and mail us checks. It will be an advantage to us as well, since it will greatly decrease the number of statements that we have to generate and send out. The combination will benefit everybody in helping to keep the cost of health care down.

This in no way will compromise your ability to dispute a charge or question your insurance company’s determination of payment.

Copays due at the time of the visit will, of course, still be due at the time of the visit.

If you have any questions about this payment method, do not hesitate to ask.



Sincerely yours,



I authorize ********************, PA to charge outstanding balances on my account to the following credit card:



Visa Mastercard American Express Other: ____________________________



Account number _______________________Expiration Date ____________CVV_____



Name on card (please print) _________________________________________________



Signature _____________________________________ Date ______________________
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected]

Something old, something new, something improved.

The old is providing a schedule of VAM’s myriad events. This year, find that schedule on “something new,” our interactive VAM Planner (vsweb.org/VAMPlanner), which not only includes the lineup but also lets attendees create their own VAM schedules from beginning to end.

And something improved is the VAM Mobile App, which has been redesigned to be more intuitive, more useful, and to more easily integrate with the VAM Planner.

As its name suggests, the VAM Planner permits users to plan their own VAM experience. See a session you want to attend? Mark it as a favorite. The Planner will add it to your calendar and remind you of what you planned to attend. Then, when you install the app and fire it up, those favorites, and other details you entered in the Planner, will be right there on your phone or other mobile device.

The Planner lets attendees seek out information easily: a presenter, a topic, the kind of session, an area of interest, intended audience. Perhaps someone wants to view all the sessions of interest to academics. Done. Want to know which sessions offer Continuing Medical Education credits? That information is easily found as well.

Pop-ups provide pertinent information on a given program with date and time, location, moderators, learning objectives, and more. People can read presenter biographies and mark various events as favorites, “like” them, post them to Facebook, or tweet about them.

Single sign-on adds convenience: To save information on the Planner, users must create a log-in. That “single sign-on” log-in, with just one password, is used for registration and syncing with the mobile app and Planner. Only one log-in and one password, during any VAM process, will open the door to navigating all platforms. SVS nonmembers or VQI attendees will need to create a guest account in order to take advantage of this functionality.

Online integration: If you’ve already registered for VAM, your ticketed courses such as breakfast sessions, workshops, or postgraduate courses as well as special events, will automatically transfer to the Planner after you log in.

It all adds up to an improved and easier VAM experience. 

Something old, something new, something improved.

The old is providing a schedule of VAM’s myriad events. This year, find that schedule on “something new,” our interactive VAM Planner (vsweb.org/VAMPlanner), which not only includes the lineup but also lets attendees create their own VAM schedules from beginning to end.

And something improved is the VAM Mobile App, which has been redesigned to be more intuitive, more useful, and to more easily integrate with the VAM Planner.

As its name suggests, the VAM Planner permits users to plan their own VAM experience. See a session you want to attend? Mark it as a favorite. The Planner will add it to your calendar and remind you of what you planned to attend. Then, when you install the app and fire it up, those favorites, and other details you entered in the Planner, will be right there on your phone or other mobile device.

The Planner lets attendees seek out information easily: a presenter, a topic, the kind of session, an area of interest, intended audience. Perhaps someone wants to view all the sessions of interest to academics. Done. Want to know which sessions offer Continuing Medical Education credits? That information is easily found as well.

Pop-ups provide pertinent information on a given program with date and time, location, moderators, learning objectives, and more. People can read presenter biographies and mark various events as favorites, “like” them, post them to Facebook, or tweet about them.

Single sign-on adds convenience: To save information on the Planner, users must create a log-in. That “single sign-on” log-in, with just one password, is used for registration and syncing with the mobile app and Planner. Only one log-in and one password, during any VAM process, will open the door to navigating all platforms. SVS nonmembers or VQI attendees will need to create a guest account in order to take advantage of this functionality.

Online integration: If you’ve already registered for VAM, your ticketed courses such as breakfast sessions, workshops, or postgraduate courses as well as special events, will automatically transfer to the Planner after you log in.

It all adds up to an improved and easier VAM experience. 

Something old, something new, something improved.

The old is providing a schedule of VAM’s myriad events. This year, find that schedule on “something new,” our interactive VAM Planner (vsweb.org/VAMPlanner), which not only includes the lineup but also lets attendees create their own VAM schedules from beginning to end.

And something improved is the VAM Mobile App, which has been redesigned to be more intuitive, more useful, and to more easily integrate with the VAM Planner.

As its name suggests, the VAM Planner permits users to plan their own VAM experience. See a session you want to attend? Mark it as a favorite. The Planner will add it to your calendar and remind you of what you planned to attend. Then, when you install the app and fire it up, those favorites, and other details you entered in the Planner, will be right there on your phone or other mobile device.

The Planner lets attendees seek out information easily: a presenter, a topic, the kind of session, an area of interest, intended audience. Perhaps someone wants to view all the sessions of interest to academics. Done. Want to know which sessions offer Continuing Medical Education credits? That information is easily found as well.

Pop-ups provide pertinent information on a given program with date and time, location, moderators, learning objectives, and more. People can read presenter biographies and mark various events as favorites, “like” them, post them to Facebook, or tweet about them.

Single sign-on adds convenience: To save information on the Planner, users must create a log-in. That “single sign-on” log-in, with just one password, is used for registration and syncing with the mobile app and Planner. Only one log-in and one password, during any VAM process, will open the door to navigating all platforms. SVS nonmembers or VQI attendees will need to create a guest account in order to take advantage of this functionality.

Online integration: If you’ve already registered for VAM, your ticketed courses such as breakfast sessions, workshops, or postgraduate courses as well as special events, will automatically transfer to the Planner after you log in.

It all adds up to an improved and easier VAM experience. 

The importance of early diagnosis and proper treatment for tinea capitis cannot be overstated, given the psychosocial impact of permanent baldness in children and the substantially reduced overall quality of health, reported Aditya K. Gupta, MD, PhD, of Mediprobe Research and the University of Toronto, and his associates.

In a systematic review of both randomized, controlled trials and clinical trials published before June 1, 2017, the authors sought to identify differences between treatment medications and significant adverse side effects, and to evaluate the most effective methods for diagnosis. The study criteria included trials with clinical and mycologic diagnosis of tinea capitis, evaluation of efficacy rates and/or safety measures in participants aged 18 years or younger, yielded a total of 4,190 studies in this article published in Pediatric Dermatology.

Courtesy RegionalDerm.com

Adverse events

Altogether, 295 drug-related adverse effects were reported: 51.2% from terbinafine, 26.8% from griseofulvin, 12.2% from fluconazole, 8.5% from itraconazole, and 1.4% from ketoconazole; all were transient and mild to moderate in severity.

Of the total population observed, just 50 children (1.3% of 3,998) ceased treatment because of adverse effects of the medication.
 

Therapy choices

Of the 75 antifungal treatment combinations identified, cure rates were highest with continuous itraconazole and terbinafine (mycologic), griseofulvin and terbinafine (clinical), and griseofulvin and terbinafine (complete). Griseofulvin was more effective at treating Microsporum than Trichophyton infections, fluconazole was comparably effective in treating both Microsporum and Trichophyton infections, and continuous itraconazole and terbinafine were more effective at curing Trichophyton infections than Microsporum, noted Dr. Gupta and his associates.

Terbinafine treatment for Trichophyton infections was found to be effective at just 4 weeks, however, oral terbinafine was singularly responsible for more than half of adverse events reported. The authors suggested that this might be from its extensive biodistribution. In such cases, the authors recommended baseline monitoring of transaminase.

Although griseofulvin is the most widely prescribed medication for pediatric tinea capitis, primarily because of its cost effectiveness and accessibility, a 2016 Cochrane review found that newer treatments – terbinafine, itraconazole and fluconazole – offer comparative effectiveness in cases of Trichophyton infection. The relatively higher cost of these treatments and the prevalence of tinea capitis in lower socioeconomic populations, however, may render them impractical, the authors noted. As recent clinical trials have suggested significantly larger, weight-normalized doses are required in children to approximate the exposure estimates of adults, this should be of key consideration when choosing appropriate, cost-effective treatments.
 

Diagnostic issues

T. tonsurans cases of tinea capitis are most prevalent in North America, and recent data suggest they are on the rise. The organism typically infects human skin and hair, and can to survive for lengthy periods on inanimate objects, including combs, brushes, sheets, and blankets. Researchers credit the growing number of cases in North America to several factors. Infections from the fungus have become increasingly common in the United States and Canada as a consequence of changing travel and immigration patterns. In addition, many physicians still turn to fluorescence (Wood’s light examination) in diagnosing tinea capitis, but T. tonsurans does not show up with fluorescence and typically does not present with the classic black dots characteristic of other fungal species. As a result, many cases in North America are misdiagnosed as seborrhea, dandruff, and impetigo, and subsequently undertreated, leading to spread of the infection. It was noted that more than half of the included studies used some form of Wood’s light examination.

Of all the techniques addressed, microscopy was found to be the fastest, but not always the most accurate, means of diagnosing tinea capitis. Dr. Gupta and his associates advised that diagnosis confirmation and precise species identification is best obtained with cultured scrapings, but this process can take 3 weeks or longer.

While fomites and hair care practices play a key role in tinea capitis infection, large family size, crowded living conditions, and low socioeconomic status are predisposing factors. Those who come in contact with infected patients should be considered possible asymptomatic carriers and be evaluated accordingly for treatment and to prevent spread of infection, the authors advised. Furthermore, recent studies recognized the impracticality of isolating children recently treated with oral therapy from classrooms since shedding of spores can continue for months.

The researchers had no relevant financial disclosures to report.

SOURCE: Gupta AK et al. Ped Dermatol. 2018 May 24. doi: 10.1111/jdv.15088.

The importance of early diagnosis and proper treatment for tinea capitis cannot be overstated, given the psychosocial impact of permanent baldness in children and the substantially reduced overall quality of health, reported Aditya K. Gupta, MD, PhD, of Mediprobe Research and the University of Toronto, and his associates.

In a systematic review of both randomized, controlled trials and clinical trials published before June 1, 2017, the authors sought to identify differences between treatment medications and significant adverse side effects, and to evaluate the most effective methods for diagnosis. The study criteria included trials with clinical and mycologic diagnosis of tinea capitis, evaluation of efficacy rates and/or safety measures in participants aged 18 years or younger, yielded a total of 4,190 studies in this article published in Pediatric Dermatology.

Courtesy RegionalDerm.com

Adverse events

Altogether, 295 drug-related adverse effects were reported: 51.2% from terbinafine, 26.8% from griseofulvin, 12.2% from fluconazole, 8.5% from itraconazole, and 1.4% from ketoconazole; all were transient and mild to moderate in severity.

Of the total population observed, just 50 children (1.3% of 3,998) ceased treatment because of adverse effects of the medication.
 

Therapy choices

Of the 75 antifungal treatment combinations identified, cure rates were highest with continuous itraconazole and terbinafine (mycologic), griseofulvin and terbinafine (clinical), and griseofulvin and terbinafine (complete). Griseofulvin was more effective at treating Microsporum than Trichophyton infections, fluconazole was comparably effective in treating both Microsporum and Trichophyton infections, and continuous itraconazole and terbinafine were more effective at curing Trichophyton infections than Microsporum, noted Dr. Gupta and his associates.

Terbinafine treatment for Trichophyton infections was found to be effective at just 4 weeks, however, oral terbinafine was singularly responsible for more than half of adverse events reported. The authors suggested that this might be from its extensive biodistribution. In such cases, the authors recommended baseline monitoring of transaminase.

Although griseofulvin is the most widely prescribed medication for pediatric tinea capitis, primarily because of its cost effectiveness and accessibility, a 2016 Cochrane review found that newer treatments – terbinafine, itraconazole and fluconazole – offer comparative effectiveness in cases of Trichophyton infection. The relatively higher cost of these treatments and the prevalence of tinea capitis in lower socioeconomic populations, however, may render them impractical, the authors noted. As recent clinical trials have suggested significantly larger, weight-normalized doses are required in children to approximate the exposure estimates of adults, this should be of key consideration when choosing appropriate, cost-effective treatments.
 

Diagnostic issues

T. tonsurans cases of tinea capitis are most prevalent in North America, and recent data suggest they are on the rise. The organism typically infects human skin and hair, and can to survive for lengthy periods on inanimate objects, including combs, brushes, sheets, and blankets. Researchers credit the growing number of cases in North America to several factors. Infections from the fungus have become increasingly common in the United States and Canada as a consequence of changing travel and immigration patterns. In addition, many physicians still turn to fluorescence (Wood’s light examination) in diagnosing tinea capitis, but T. tonsurans does not show up with fluorescence and typically does not present with the classic black dots characteristic of other fungal species. As a result, many cases in North America are misdiagnosed as seborrhea, dandruff, and impetigo, and subsequently undertreated, leading to spread of the infection. It was noted that more than half of the included studies used some form of Wood’s light examination.

Of all the techniques addressed, microscopy was found to be the fastest, but not always the most accurate, means of diagnosing tinea capitis. Dr. Gupta and his associates advised that diagnosis confirmation and precise species identification is best obtained with cultured scrapings, but this process can take 3 weeks or longer.

While fomites and hair care practices play a key role in tinea capitis infection, large family size, crowded living conditions, and low socioeconomic status are predisposing factors. Those who come in contact with infected patients should be considered possible asymptomatic carriers and be evaluated accordingly for treatment and to prevent spread of infection, the authors advised. Furthermore, recent studies recognized the impracticality of isolating children recently treated with oral therapy from classrooms since shedding of spores can continue for months.

The researchers had no relevant financial disclosures to report.

SOURCE: Gupta AK et al. Ped Dermatol. 2018 May 24. doi: 10.1111/jdv.15088.

The importance of early diagnosis and proper treatment for tinea capitis cannot be overstated, given the psychosocial impact of permanent baldness in children and the substantially reduced overall quality of health, reported Aditya K. Gupta, MD, PhD, of Mediprobe Research and the University of Toronto, and his associates.

In a systematic review of both randomized, controlled trials and clinical trials published before June 1, 2017, the authors sought to identify differences between treatment medications and significant adverse side effects, and to evaluate the most effective methods for diagnosis. The study criteria included trials with clinical and mycologic diagnosis of tinea capitis, evaluation of efficacy rates and/or safety measures in participants aged 18 years or younger, yielded a total of 4,190 studies in this article published in Pediatric Dermatology.

Courtesy RegionalDerm.com

Adverse events

Altogether, 295 drug-related adverse effects were reported: 51.2% from terbinafine, 26.8% from griseofulvin, 12.2% from fluconazole, 8.5% from itraconazole, and 1.4% from ketoconazole; all were transient and mild to moderate in severity.

Of the total population observed, just 50 children (1.3% of 3,998) ceased treatment because of adverse effects of the medication.
 

Therapy choices

Of the 75 antifungal treatment combinations identified, cure rates were highest with continuous itraconazole and terbinafine (mycologic), griseofulvin and terbinafine (clinical), and griseofulvin and terbinafine (complete). Griseofulvin was more effective at treating Microsporum than Trichophyton infections, fluconazole was comparably effective in treating both Microsporum and Trichophyton infections, and continuous itraconazole and terbinafine were more effective at curing Trichophyton infections than Microsporum, noted Dr. Gupta and his associates.

Terbinafine treatment for Trichophyton infections was found to be effective at just 4 weeks, however, oral terbinafine was singularly responsible for more than half of adverse events reported. The authors suggested that this might be from its extensive biodistribution. In such cases, the authors recommended baseline monitoring of transaminase.

Although griseofulvin is the most widely prescribed medication for pediatric tinea capitis, primarily because of its cost effectiveness and accessibility, a 2016 Cochrane review found that newer treatments – terbinafine, itraconazole and fluconazole – offer comparative effectiveness in cases of Trichophyton infection. The relatively higher cost of these treatments and the prevalence of tinea capitis in lower socioeconomic populations, however, may render them impractical, the authors noted. As recent clinical trials have suggested significantly larger, weight-normalized doses are required in children to approximate the exposure estimates of adults, this should be of key consideration when choosing appropriate, cost-effective treatments.
 

Diagnostic issues

T. tonsurans cases of tinea capitis are most prevalent in North America, and recent data suggest they are on the rise. The organism typically infects human skin and hair, and can to survive for lengthy periods on inanimate objects, including combs, brushes, sheets, and blankets. Researchers credit the growing number of cases in North America to several factors. Infections from the fungus have become increasingly common in the United States and Canada as a consequence of changing travel and immigration patterns. In addition, many physicians still turn to fluorescence (Wood’s light examination) in diagnosing tinea capitis, but T. tonsurans does not show up with fluorescence and typically does not present with the classic black dots characteristic of other fungal species. As a result, many cases in North America are misdiagnosed as seborrhea, dandruff, and impetigo, and subsequently undertreated, leading to spread of the infection. It was noted that more than half of the included studies used some form of Wood’s light examination.

Of all the techniques addressed, microscopy was found to be the fastest, but not always the most accurate, means of diagnosing tinea capitis. Dr. Gupta and his associates advised that diagnosis confirmation and precise species identification is best obtained with cultured scrapings, but this process can take 3 weeks or longer.

While fomites and hair care practices play a key role in tinea capitis infection, large family size, crowded living conditions, and low socioeconomic status are predisposing factors. Those who come in contact with infected patients should be considered possible asymptomatic carriers and be evaluated accordingly for treatment and to prevent spread of infection, the authors advised. Furthermore, recent studies recognized the impracticality of isolating children recently treated with oral therapy from classrooms since shedding of spores can continue for months.

The researchers had no relevant financial disclosures to report.

SOURCE: Gupta AK et al. Ped Dermatol. 2018 May 24. doi: 10.1111/jdv.15088.

E. Albert Reece, MD, PhD, MBA, the dean of the University of Maryland School of Medicine, Baltimore, and medical editor of Ob.Gyn. News, has spoken often in the newspaper’s pages about how the fetus has become a visible and intimate patient – one who, “like the mother, can be interrogated, monitored, and sometimes treated before birth.”

Physician-scientists have been instrumental in lifting the cloud of mystery that surrounded the fetus and fetal outcomes. Yet today, in a trend that Dr. Reece and his colleagues call deeply concerning, the number of physician-scientists is declining. “We’re missing out on a workforce that is dedicated to exploring the biologic basis of disease – knowledge that enables the development of targeted therapeutic interventions,” he said in an interview.

Courtesy of Yale School of Medicine

Courtesy of Yale School of Medicine

E. Albert Reece, MD, PhD, MBA, the dean of the University of Maryland School of Medicine, Baltimore, and medical editor of Ob.Gyn. News, has spoken often in the newspaper’s pages about how the fetus has become a visible and intimate patient – one who, “like the mother, can be interrogated, monitored, and sometimes treated before birth.”

Physician-scientists have been instrumental in lifting the cloud of mystery that surrounded the fetus and fetal outcomes. Yet today, in a trend that Dr. Reece and his colleagues call deeply concerning, the number of physician-scientists is declining. “We’re missing out on a workforce that is dedicated to exploring the biologic basis of disease – knowledge that enables the development of targeted therapeutic interventions,” he said in an interview.

Courtesy of Yale School of Medicine

Courtesy of Yale School of Medicine

E. Albert Reece, MD, PhD, MBA, the dean of the University of Maryland School of Medicine, Baltimore, and medical editor of Ob.Gyn. News, has spoken often in the newspaper’s pages about how the fetus has become a visible and intimate patient – one who, “like the mother, can be interrogated, monitored, and sometimes treated before birth.”

Physician-scientists have been instrumental in lifting the cloud of mystery that surrounded the fetus and fetal outcomes. Yet today, in a trend that Dr. Reece and his colleagues call deeply concerning, the number of physician-scientists is declining. “We’re missing out on a workforce that is dedicated to exploring the biologic basis of disease – knowledge that enables the development of targeted therapeutic interventions,” he said in an interview.

Courtesy of Yale School of Medicine

Courtesy of Yale School of Medicine