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How to integrate mental health care into primary care
During my training as a child and adolescent psychiatry fellow, I “lived” down the hall from 10 other people just like me who had similar offices and training. Our pace was tailored to pediatric psychiatry. Appointments were 30 minutes or more. Our goal was to provide the most comprehensive mental health care for the families whom we grew to know and love.
The impetus to create an integrated mental health care approach has been well elucidated by the American Academy of Child and Adolescent Psychiatry (AACAP) in its report, Collaborative mental health care in pediatric primary care. It is based on some telling statistics: Fifty percent of all cases of mental illness begin before age 14 years and 75% begin by age 24. Half of all pediatric office visits involve behavioral, psychosocial, or educational concerns. The American Academy of Pediatrics’ Task Force on Mental Health similarly has stated that primary care clinicians can and should be able to provide mental health services to children and adolescents in a primary care setting.
Integrative psychiatry and primary care treatment comes in three forms: classic consultation, in which a specialist sees a patient and refers back to the PCP with recommendations; colocation, in which mental health specialists practice in the same office but essentially are “ships crossing in the night” with PCPs; and the most-lauded form, collaborative/integrative care, in which back-and-forth consultation and discussions of a case occur between mental health specialists and PCPs, with in-person follow-up as needed.
Several institutions offer programs to address the AACAP and AAP imperatives, most prominently the University of Washington, Seattle, and the University of Massachusetts, Worcester. Both offer resources on how to create an integrated care model (University of Washington AIMS Resource Center; The University of Massachusetts Center for Integrated Care).
What can one do in a busy pediatric primary care practice to address mental health imperatives on the individual provider level? Often PCPs can, as I do, offer families some resources by having a set of mental health handouts and resources. I have gathered useful handouts for families throughout my residency to use as shortcuts and visual aids to promote mental health. I use the AACAP Facts for Families for handouts on mental health diagnoses and topics. I use the National Sleep Foundation for its sleep hygiene tips. I also offer some low-cost mindfulness resources to help kids and parents with their anxiety, such as the Calm app and Headspace app. If parents have difficulty with access to parent management training (the first-line treatment to manage aggression in children), I often recommend “The Defiant Child: A Parent’s Guide to Oppositional Defiant Disorder” (Lanham, Md.: Taylor Trade Publishing, 1997), which shows how to create a rewards system in the home to promote positive behavior. “How to Talk So Kids Will Listen & Listen So Kids Will Talk” (New York: Scribner, 2012 ) is a beloved book for parents (and there is a teenager version) that I recommend when parents launch into questions about how to talk to kids and teens about difficult topics so that, ultimately, they can improve their relationship.
Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and an assistant professor of psychiatry at UVM, both in Burlington. Email her at [email protected].
Resources
The AACAP website has materials to help clinicians develop a collaborative mental health care model in the primary care setting: Search for “collaboration with primary care.”
The journal Pediatrics also has a useful resource: Improving mental health services in primary care: Reducing administrative and financial barriers to access and collaboration. (2009;123;1248-51).
During my training as a child and adolescent psychiatry fellow, I “lived” down the hall from 10 other people just like me who had similar offices and training. Our pace was tailored to pediatric psychiatry. Appointments were 30 minutes or more. Our goal was to provide the most comprehensive mental health care for the families whom we grew to know and love.
The impetus to create an integrated mental health care approach has been well elucidated by the American Academy of Child and Adolescent Psychiatry (AACAP) in its report, Collaborative mental health care in pediatric primary care. It is based on some telling statistics: Fifty percent of all cases of mental illness begin before age 14 years and 75% begin by age 24. Half of all pediatric office visits involve behavioral, psychosocial, or educational concerns. The American Academy of Pediatrics’ Task Force on Mental Health similarly has stated that primary care clinicians can and should be able to provide mental health services to children and adolescents in a primary care setting.
Integrative psychiatry and primary care treatment comes in three forms: classic consultation, in which a specialist sees a patient and refers back to the PCP with recommendations; colocation, in which mental health specialists practice in the same office but essentially are “ships crossing in the night” with PCPs; and the most-lauded form, collaborative/integrative care, in which back-and-forth consultation and discussions of a case occur between mental health specialists and PCPs, with in-person follow-up as needed.
Several institutions offer programs to address the AACAP and AAP imperatives, most prominently the University of Washington, Seattle, and the University of Massachusetts, Worcester. Both offer resources on how to create an integrated care model (University of Washington AIMS Resource Center; The University of Massachusetts Center for Integrated Care).
What can one do in a busy pediatric primary care practice to address mental health imperatives on the individual provider level? Often PCPs can, as I do, offer families some resources by having a set of mental health handouts and resources. I have gathered useful handouts for families throughout my residency to use as shortcuts and visual aids to promote mental health. I use the AACAP Facts for Families for handouts on mental health diagnoses and topics. I use the National Sleep Foundation for its sleep hygiene tips. I also offer some low-cost mindfulness resources to help kids and parents with their anxiety, such as the Calm app and Headspace app. If parents have difficulty with access to parent management training (the first-line treatment to manage aggression in children), I often recommend “The Defiant Child: A Parent’s Guide to Oppositional Defiant Disorder” (Lanham, Md.: Taylor Trade Publishing, 1997), which shows how to create a rewards system in the home to promote positive behavior. “How to Talk So Kids Will Listen & Listen So Kids Will Talk” (New York: Scribner, 2012 ) is a beloved book for parents (and there is a teenager version) that I recommend when parents launch into questions about how to talk to kids and teens about difficult topics so that, ultimately, they can improve their relationship.
Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and an assistant professor of psychiatry at UVM, both in Burlington. Email her at [email protected].
Resources
The AACAP website has materials to help clinicians develop a collaborative mental health care model in the primary care setting: Search for “collaboration with primary care.”
The journal Pediatrics also has a useful resource: Improving mental health services in primary care: Reducing administrative and financial barriers to access and collaboration. (2009;123;1248-51).
During my training as a child and adolescent psychiatry fellow, I “lived” down the hall from 10 other people just like me who had similar offices and training. Our pace was tailored to pediatric psychiatry. Appointments were 30 minutes or more. Our goal was to provide the most comprehensive mental health care for the families whom we grew to know and love.
The impetus to create an integrated mental health care approach has been well elucidated by the American Academy of Child and Adolescent Psychiatry (AACAP) in its report, Collaborative mental health care in pediatric primary care. It is based on some telling statistics: Fifty percent of all cases of mental illness begin before age 14 years and 75% begin by age 24. Half of all pediatric office visits involve behavioral, psychosocial, or educational concerns. The American Academy of Pediatrics’ Task Force on Mental Health similarly has stated that primary care clinicians can and should be able to provide mental health services to children and adolescents in a primary care setting.
Integrative psychiatry and primary care treatment comes in three forms: classic consultation, in which a specialist sees a patient and refers back to the PCP with recommendations; colocation, in which mental health specialists practice in the same office but essentially are “ships crossing in the night” with PCPs; and the most-lauded form, collaborative/integrative care, in which back-and-forth consultation and discussions of a case occur between mental health specialists and PCPs, with in-person follow-up as needed.
Several institutions offer programs to address the AACAP and AAP imperatives, most prominently the University of Washington, Seattle, and the University of Massachusetts, Worcester. Both offer resources on how to create an integrated care model (University of Washington AIMS Resource Center; The University of Massachusetts Center for Integrated Care).
What can one do in a busy pediatric primary care practice to address mental health imperatives on the individual provider level? Often PCPs can, as I do, offer families some resources by having a set of mental health handouts and resources. I have gathered useful handouts for families throughout my residency to use as shortcuts and visual aids to promote mental health. I use the AACAP Facts for Families for handouts on mental health diagnoses and topics. I use the National Sleep Foundation for its sleep hygiene tips. I also offer some low-cost mindfulness resources to help kids and parents with their anxiety, such as the Calm app and Headspace app. If parents have difficulty with access to parent management training (the first-line treatment to manage aggression in children), I often recommend “The Defiant Child: A Parent’s Guide to Oppositional Defiant Disorder” (Lanham, Md.: Taylor Trade Publishing, 1997), which shows how to create a rewards system in the home to promote positive behavior. “How to Talk So Kids Will Listen & Listen So Kids Will Talk” (New York: Scribner, 2012 ) is a beloved book for parents (and there is a teenager version) that I recommend when parents launch into questions about how to talk to kids and teens about difficult topics so that, ultimately, they can improve their relationship.
Dr. Pawlowski is an adult, adolescent, and child psychiatrist at the University of Vermont Medical Center and an assistant professor of psychiatry at UVM, both in Burlington. Email her at [email protected].
Resources
The AACAP website has materials to help clinicians develop a collaborative mental health care model in the primary care setting: Search for “collaboration with primary care.”
The journal Pediatrics also has a useful resource: Improving mental health services in primary care: Reducing administrative and financial barriers to access and collaboration. (2009;123;1248-51).
Teens are all about the sexting
More teenagers are sending and receiving sexts than in previous years, based on data from a meta-analysis of 39 studies including 110,380 individuals younger than 18 years.
Published rates of sexting in teens range from 1% to 60%, wrote Sheri Madigan, PhD, of the University of Calgary, Alberta, Canada, and her colleagues. “However, the true public health importance of youth sexting is unclear at present because the field is handicapped by inconsistent information regarding its prevalence.”
“Higher prevalence rates were found in more recent studies, with older youth, and with youth using a mobile device to sext,” the researchers said.
The increase in sexting among teens should inform sexting legislation, the researchers noted. However, given the increasing use of smartphones among children and the possibility that sexting may be a normal part of sexual behavior in the smartphone era, “efforts and resources to criminalize sexts should be redirected to educational programs on digital citizenship and healthy relationships,” they said. “Given that the mean age of first smartphone acquisition is 10.3 years, it is important for middle school educators, pediatricians, and parents to have ongoing conversations with tweens regarding sexting and digital citizenship.”
The meta-analysis’s results were limited by several factors, such as the focus on frequency of sexting alone and not on elements that might influence sexting behavior, as well as inclusion of relatively few studies on nonconsensual sexting.
The mean age was 15 years (range, 12-17 years). More than half of the studies were from the United States, followed by 12 from Europe, 2 from Australia, 1 from Canada, 1 from South Africa , and 1 study from South Korea.
The researchers had no relevant financial disclosures. The study was supported by the Alberta Children’s Hospital Foundation and the Canada Research Chairs Program.
SOURCE: Madigan S et al. JAMA Pediatr. 2018 Feb 26. doi: 10.1001/jamapediatrics.2017.5314.
“Sexting is a new behavior that is evolving rapidly, as technology changes and awareness increases,” Elizabeth Englander, PhD, and Meghan McCoy, EdD, wrote.
The current study adds to the limited knowledge about sexting in children and teens and also identifies areas in need of additional study, including the lack of a consistent definition of sexting and differences in sexting activity between males and females. Another challenge is determining the context of sexting, with the recognition that sexting within relationships is different than sexting between unattached individuals, they said. In addition, the study by Madigan et al. emphasized the concern for sexting behaviors among children younger than 12 years of age because children this age are increasingly likely to own cell phones.
Dr. Englander and Dr. McCoy concluded that the current study represents “an important step forward in understanding prevalence, including the prevalence of unauthorized distribution of sexts.”
Dr. Englander and Dr. McCoy are affiliated with the Massachusetts Aggression Reduction Center at Bridgewater (Mass.) State University. They commented in an editorial accompanying the meta-analysis by Madigan et al. (JAMA Pediatr. 2018 Feb 26. doi: 10.1001/jamapediatrics.2017.5682). They had no relevant financial disclosures.
“Sexting is a new behavior that is evolving rapidly, as technology changes and awareness increases,” Elizabeth Englander, PhD, and Meghan McCoy, EdD, wrote.
The current study adds to the limited knowledge about sexting in children and teens and also identifies areas in need of additional study, including the lack of a consistent definition of sexting and differences in sexting activity between males and females. Another challenge is determining the context of sexting, with the recognition that sexting within relationships is different than sexting between unattached individuals, they said. In addition, the study by Madigan et al. emphasized the concern for sexting behaviors among children younger than 12 years of age because children this age are increasingly likely to own cell phones.
Dr. Englander and Dr. McCoy concluded that the current study represents “an important step forward in understanding prevalence, including the prevalence of unauthorized distribution of sexts.”
Dr. Englander and Dr. McCoy are affiliated with the Massachusetts Aggression Reduction Center at Bridgewater (Mass.) State University. They commented in an editorial accompanying the meta-analysis by Madigan et al. (JAMA Pediatr. 2018 Feb 26. doi: 10.1001/jamapediatrics.2017.5682). They had no relevant financial disclosures.
“Sexting is a new behavior that is evolving rapidly, as technology changes and awareness increases,” Elizabeth Englander, PhD, and Meghan McCoy, EdD, wrote.
The current study adds to the limited knowledge about sexting in children and teens and also identifies areas in need of additional study, including the lack of a consistent definition of sexting and differences in sexting activity between males and females. Another challenge is determining the context of sexting, with the recognition that sexting within relationships is different than sexting between unattached individuals, they said. In addition, the study by Madigan et al. emphasized the concern for sexting behaviors among children younger than 12 years of age because children this age are increasingly likely to own cell phones.
Dr. Englander and Dr. McCoy concluded that the current study represents “an important step forward in understanding prevalence, including the prevalence of unauthorized distribution of sexts.”
Dr. Englander and Dr. McCoy are affiliated with the Massachusetts Aggression Reduction Center at Bridgewater (Mass.) State University. They commented in an editorial accompanying the meta-analysis by Madigan et al. (JAMA Pediatr. 2018 Feb 26. doi: 10.1001/jamapediatrics.2017.5682). They had no relevant financial disclosures.
More teenagers are sending and receiving sexts than in previous years, based on data from a meta-analysis of 39 studies including 110,380 individuals younger than 18 years.
Published rates of sexting in teens range from 1% to 60%, wrote Sheri Madigan, PhD, of the University of Calgary, Alberta, Canada, and her colleagues. “However, the true public health importance of youth sexting is unclear at present because the field is handicapped by inconsistent information regarding its prevalence.”
“Higher prevalence rates were found in more recent studies, with older youth, and with youth using a mobile device to sext,” the researchers said.
The increase in sexting among teens should inform sexting legislation, the researchers noted. However, given the increasing use of smartphones among children and the possibility that sexting may be a normal part of sexual behavior in the smartphone era, “efforts and resources to criminalize sexts should be redirected to educational programs on digital citizenship and healthy relationships,” they said. “Given that the mean age of first smartphone acquisition is 10.3 years, it is important for middle school educators, pediatricians, and parents to have ongoing conversations with tweens regarding sexting and digital citizenship.”
The meta-analysis’s results were limited by several factors, such as the focus on frequency of sexting alone and not on elements that might influence sexting behavior, as well as inclusion of relatively few studies on nonconsensual sexting.
The mean age was 15 years (range, 12-17 years). More than half of the studies were from the United States, followed by 12 from Europe, 2 from Australia, 1 from Canada, 1 from South Africa , and 1 study from South Korea.
The researchers had no relevant financial disclosures. The study was supported by the Alberta Children’s Hospital Foundation and the Canada Research Chairs Program.
SOURCE: Madigan S et al. JAMA Pediatr. 2018 Feb 26. doi: 10.1001/jamapediatrics.2017.5314.
More teenagers are sending and receiving sexts than in previous years, based on data from a meta-analysis of 39 studies including 110,380 individuals younger than 18 years.
Published rates of sexting in teens range from 1% to 60%, wrote Sheri Madigan, PhD, of the University of Calgary, Alberta, Canada, and her colleagues. “However, the true public health importance of youth sexting is unclear at present because the field is handicapped by inconsistent information regarding its prevalence.”
“Higher prevalence rates were found in more recent studies, with older youth, and with youth using a mobile device to sext,” the researchers said.
The increase in sexting among teens should inform sexting legislation, the researchers noted. However, given the increasing use of smartphones among children and the possibility that sexting may be a normal part of sexual behavior in the smartphone era, “efforts and resources to criminalize sexts should be redirected to educational programs on digital citizenship and healthy relationships,” they said. “Given that the mean age of first smartphone acquisition is 10.3 years, it is important for middle school educators, pediatricians, and parents to have ongoing conversations with tweens regarding sexting and digital citizenship.”
The meta-analysis’s results were limited by several factors, such as the focus on frequency of sexting alone and not on elements that might influence sexting behavior, as well as inclusion of relatively few studies on nonconsensual sexting.
The mean age was 15 years (range, 12-17 years). More than half of the studies were from the United States, followed by 12 from Europe, 2 from Australia, 1 from Canada, 1 from South Africa , and 1 study from South Korea.
The researchers had no relevant financial disclosures. The study was supported by the Alberta Children’s Hospital Foundation and the Canada Research Chairs Program.
SOURCE: Madigan S et al. JAMA Pediatr. 2018 Feb 26. doi: 10.1001/jamapediatrics.2017.5314.
FROM JAMA PEDIATRICS
Key clinical point: Sexting frequency has increased among teens in recent years, and this frequency increases with age.
Major finding:
Study details: The data come from a meta-analysis of 39 studies with 110,380 participants.
Disclosures: The researchers had no financial conflicts to disclose. The study was supported by the Alberta Children’s Hospital Foundation and the Canada Research Chairs Program.
Source: Madigan S et al. JAMA Pediatr. 2018 Feb 26. doi: 10.1001/jamapediatrics.2017.5314.
How to direct refer for GI endoscopy
MAUI, HAWAII – Rheumatologists can save their patients time and the inconvenience of an unnecessary preprocedural office visit with a gastroenterologist by making a direct referral for GI endoscopy when appropriate, according to Uma Mahadevan, MD, professor of medicine at the University of California, San Francisco.
“Many health systems have access issues, and in most accountable care organizations, there’s a need to see patients within 14 days. the gastroenterologist explained at the 2018 Rheumatology Winter Clinical Symposium.
“We’re an open-access endoscopy center at UCSF, and I can’t tell you how many times a patient gets direct referred to us and – the night before the procedure, when we’re preparing for the case – we see that this patient can’t have a procedure tomorrow. Those patients have already done the bowel prep, they’re taking the day off work, they’ve arranged for someone to drive them, and they’re really mad,” said Dr. Mahadevan, who is also the medical director of the UCSF Center for Colitis and Crohn’s Disease.
Sometimes the procedure gets called off because the gastroenterologist sees that it would be inappropriate. For example, it would be inappropriate to perform an endoscopy on a patient with irritable bowel syndrome or fibromyalgia who has already had three negative endoscopic procedures in the past 5 years; alternatively, a screening colonoscopy would be inappropriate for an 80-year-old because the U.S. Preventive Services Task Force gives a class A recommendation for screening colonoscopy only during ages 50-75 years.
Sometimes the physician who made the direct referral failed to include other key information the gastroenterologist needed to have in advance of the procedure. For example, a morbidly obese patient or an individual with significant cardiovascular or pulmonary disease generally needs to have an anesthesiologist present for GI endoscopy, rather than a nurse anesthetist, since the airway is suspect. Similarly, a patient with a severe anxiety disorder or tolerance to pain medication is unlikely to be adequately sedated with the fentanyl and midazolam (Versed) used for moderate sedation in most upper endoscopy and colonoscopy procedures; those individuals are going to require deep sedation with propofol (Diprivan) and assistance in maintaining a patent airway.
“Your patient taking Oxycodone every day is not going to get sedated with fentanyl and midazolam. So you need to put that information on your direct request,” she stressed.
“If your patient has obstructive sleep apnea and is on CPAP at home, or if your patient is on home oxygen, your gastroenterologist needs to know that because those are the patients we bring into the office to evaluate the airway ahead of time,” according to the gastroenterologist.
Also, while routine direct referral for colonoscopy to rule out comorbid inflammatory bowel disease is entirely appropriate in patients with ankylosing spondylitis or other spondyloarthropathies, if they had ankylosing spondylitis in the prebiologic era, then it’s important to include that information.
“If they did, their neck is often dangerous for sedation. They’re very difficult to intubate. That’s something we need to know,” Dr. Mahadevan continued.
Other patient information gastroenterologists want included in the direct referral: Is the patient on daily aspirin and/or a thienopyridine antiplatelet agent or on oral anticoagulation with warfarin or one of the newer direct-acting oral anticoagulants? American Society for Gastrointestinal Endoscopy guidelines have detailed how to manage antithrombotic agents in patients undergoing GI endoscopy, including when and how to bridge with low-molecular-weight heparin in the days prior to the procedure (Gastrointest Endosc. 2016 Jan;83[1]:3-16). Of note, the guidelines rate diagnostic esophagogastroduodenoscopy (EGD) and colonoscopy, even with biopsies taken, as low-bleeding-risk procedures that therefore don’t require stopping antithrombotic therapy.
In addition to screening or surveillance colonoscopy, rheumatologists might also direct refer patients for GI endoscopy because they have iron-deficiency anemia, in which case evaluation by both EGD and colonoscopy is necessary. Direct referral for EGD in patients with celiac disease is appropriate. Acute GI bleeding is best handled via direct referral for colonoscopy in a patient with hematochezia and for EGD in the setting of melena. Direct referral for endoscopy is also warranted in patients with polymyalgia rheumatica or dermatomyositis, where the indication is to rule out associated malignancy.
Dr. Mahadevan reported having no financial conflicts regarding her presentation.
MAUI, HAWAII – Rheumatologists can save their patients time and the inconvenience of an unnecessary preprocedural office visit with a gastroenterologist by making a direct referral for GI endoscopy when appropriate, according to Uma Mahadevan, MD, professor of medicine at the University of California, San Francisco.
“Many health systems have access issues, and in most accountable care organizations, there’s a need to see patients within 14 days. the gastroenterologist explained at the 2018 Rheumatology Winter Clinical Symposium.
“We’re an open-access endoscopy center at UCSF, and I can’t tell you how many times a patient gets direct referred to us and – the night before the procedure, when we’re preparing for the case – we see that this patient can’t have a procedure tomorrow. Those patients have already done the bowel prep, they’re taking the day off work, they’ve arranged for someone to drive them, and they’re really mad,” said Dr. Mahadevan, who is also the medical director of the UCSF Center for Colitis and Crohn’s Disease.
Sometimes the procedure gets called off because the gastroenterologist sees that it would be inappropriate. For example, it would be inappropriate to perform an endoscopy on a patient with irritable bowel syndrome or fibromyalgia who has already had three negative endoscopic procedures in the past 5 years; alternatively, a screening colonoscopy would be inappropriate for an 80-year-old because the U.S. Preventive Services Task Force gives a class A recommendation for screening colonoscopy only during ages 50-75 years.
Sometimes the physician who made the direct referral failed to include other key information the gastroenterologist needed to have in advance of the procedure. For example, a morbidly obese patient or an individual with significant cardiovascular or pulmonary disease generally needs to have an anesthesiologist present for GI endoscopy, rather than a nurse anesthetist, since the airway is suspect. Similarly, a patient with a severe anxiety disorder or tolerance to pain medication is unlikely to be adequately sedated with the fentanyl and midazolam (Versed) used for moderate sedation in most upper endoscopy and colonoscopy procedures; those individuals are going to require deep sedation with propofol (Diprivan) and assistance in maintaining a patent airway.
“Your patient taking Oxycodone every day is not going to get sedated with fentanyl and midazolam. So you need to put that information on your direct request,” she stressed.
“If your patient has obstructive sleep apnea and is on CPAP at home, or if your patient is on home oxygen, your gastroenterologist needs to know that because those are the patients we bring into the office to evaluate the airway ahead of time,” according to the gastroenterologist.
Also, while routine direct referral for colonoscopy to rule out comorbid inflammatory bowel disease is entirely appropriate in patients with ankylosing spondylitis or other spondyloarthropathies, if they had ankylosing spondylitis in the prebiologic era, then it’s important to include that information.
“If they did, their neck is often dangerous for sedation. They’re very difficult to intubate. That’s something we need to know,” Dr. Mahadevan continued.
Other patient information gastroenterologists want included in the direct referral: Is the patient on daily aspirin and/or a thienopyridine antiplatelet agent or on oral anticoagulation with warfarin or one of the newer direct-acting oral anticoagulants? American Society for Gastrointestinal Endoscopy guidelines have detailed how to manage antithrombotic agents in patients undergoing GI endoscopy, including when and how to bridge with low-molecular-weight heparin in the days prior to the procedure (Gastrointest Endosc. 2016 Jan;83[1]:3-16). Of note, the guidelines rate diagnostic esophagogastroduodenoscopy (EGD) and colonoscopy, even with biopsies taken, as low-bleeding-risk procedures that therefore don’t require stopping antithrombotic therapy.
In addition to screening or surveillance colonoscopy, rheumatologists might also direct refer patients for GI endoscopy because they have iron-deficiency anemia, in which case evaluation by both EGD and colonoscopy is necessary. Direct referral for EGD in patients with celiac disease is appropriate. Acute GI bleeding is best handled via direct referral for colonoscopy in a patient with hematochezia and for EGD in the setting of melena. Direct referral for endoscopy is also warranted in patients with polymyalgia rheumatica or dermatomyositis, where the indication is to rule out associated malignancy.
Dr. Mahadevan reported having no financial conflicts regarding her presentation.
MAUI, HAWAII – Rheumatologists can save their patients time and the inconvenience of an unnecessary preprocedural office visit with a gastroenterologist by making a direct referral for GI endoscopy when appropriate, according to Uma Mahadevan, MD, professor of medicine at the University of California, San Francisco.
“Many health systems have access issues, and in most accountable care organizations, there’s a need to see patients within 14 days. the gastroenterologist explained at the 2018 Rheumatology Winter Clinical Symposium.
“We’re an open-access endoscopy center at UCSF, and I can’t tell you how many times a patient gets direct referred to us and – the night before the procedure, when we’re preparing for the case – we see that this patient can’t have a procedure tomorrow. Those patients have already done the bowel prep, they’re taking the day off work, they’ve arranged for someone to drive them, and they’re really mad,” said Dr. Mahadevan, who is also the medical director of the UCSF Center for Colitis and Crohn’s Disease.
Sometimes the procedure gets called off because the gastroenterologist sees that it would be inappropriate. For example, it would be inappropriate to perform an endoscopy on a patient with irritable bowel syndrome or fibromyalgia who has already had three negative endoscopic procedures in the past 5 years; alternatively, a screening colonoscopy would be inappropriate for an 80-year-old because the U.S. Preventive Services Task Force gives a class A recommendation for screening colonoscopy only during ages 50-75 years.
Sometimes the physician who made the direct referral failed to include other key information the gastroenterologist needed to have in advance of the procedure. For example, a morbidly obese patient or an individual with significant cardiovascular or pulmonary disease generally needs to have an anesthesiologist present for GI endoscopy, rather than a nurse anesthetist, since the airway is suspect. Similarly, a patient with a severe anxiety disorder or tolerance to pain medication is unlikely to be adequately sedated with the fentanyl and midazolam (Versed) used for moderate sedation in most upper endoscopy and colonoscopy procedures; those individuals are going to require deep sedation with propofol (Diprivan) and assistance in maintaining a patent airway.
“Your patient taking Oxycodone every day is not going to get sedated with fentanyl and midazolam. So you need to put that information on your direct request,” she stressed.
“If your patient has obstructive sleep apnea and is on CPAP at home, or if your patient is on home oxygen, your gastroenterologist needs to know that because those are the patients we bring into the office to evaluate the airway ahead of time,” according to the gastroenterologist.
Also, while routine direct referral for colonoscopy to rule out comorbid inflammatory bowel disease is entirely appropriate in patients with ankylosing spondylitis or other spondyloarthropathies, if they had ankylosing spondylitis in the prebiologic era, then it’s important to include that information.
“If they did, their neck is often dangerous for sedation. They’re very difficult to intubate. That’s something we need to know,” Dr. Mahadevan continued.
Other patient information gastroenterologists want included in the direct referral: Is the patient on daily aspirin and/or a thienopyridine antiplatelet agent or on oral anticoagulation with warfarin or one of the newer direct-acting oral anticoagulants? American Society for Gastrointestinal Endoscopy guidelines have detailed how to manage antithrombotic agents in patients undergoing GI endoscopy, including when and how to bridge with low-molecular-weight heparin in the days prior to the procedure (Gastrointest Endosc. 2016 Jan;83[1]:3-16). Of note, the guidelines rate diagnostic esophagogastroduodenoscopy (EGD) and colonoscopy, even with biopsies taken, as low-bleeding-risk procedures that therefore don’t require stopping antithrombotic therapy.
In addition to screening or surveillance colonoscopy, rheumatologists might also direct refer patients for GI endoscopy because they have iron-deficiency anemia, in which case evaluation by both EGD and colonoscopy is necessary. Direct referral for EGD in patients with celiac disease is appropriate. Acute GI bleeding is best handled via direct referral for colonoscopy in a patient with hematochezia and for EGD in the setting of melena. Direct referral for endoscopy is also warranted in patients with polymyalgia rheumatica or dermatomyositis, where the indication is to rule out associated malignancy.
Dr. Mahadevan reported having no financial conflicts regarding her presentation.
EXPERT ANALYSIS FROM RWCS 2018
Free testosterone linked to frailty in older men
A new study provides more evidence of a link between lower free testosterone levels and higher levels of frailty in older men, but a researcher says proof of a causal connection remains elusive.
“Our study demonstrates clear associations between testosterone and frailty progression, and, although causality and directionality of the hormone/frailty relationships require clarification, the results presented here make a strong case for large interventional trials of testosterone therapy in frail men to determine whether such treatment would be beneficial,” lead author Agnieszka Swiecicka, MD, of the andrology research unit in the division of diabetes, endocrinology, and gastroenterology at the University of Manchester (England), said in an interview.
As Dr. Swiecicka noted, “in men, testosterone levels decline with age, and it has been suggested that this phenomenon might play a role in the development of frailty.”
However, evidence is limited, and studies have offered conflicting results Dr. Swiecicka said.
For the new study, the researchers prospectively tracked 3,369 community-dwelling men aged 40-79 years from eight European centers. Hundreds were excluded for various reasons or lost to follow-up, and 2,278 men were ultimately included.
The average age was 58 years, and the average body mass index was 28 kg/m2.
Hormone measurements were performed, and frailty was tracked via frailty status (FS, n = 2,278) and frailty phenotype (FP, n = 1,980).
After adjusting their statistics to account for various factors, the researchers were able to link only free testosterone – and not testosterone or dihydrotestosterone – to changes in frailty index (FI). They linked each standard deviation improvement in free testosterone level at baseline to a –2.8% change in FI over 4 years (95% confidence interval, –4.9 to –0.3, P = .030).
“Higher free testosterone levels were associated with a lower risk of worsening frailty status. The direction of this association was consistent regardless of the frailty construct used (FI and FP),” Dr. Swiecicka said. “Higher androgen remained significantly associated with improving frailty status, as assessed by FI, despite age adjustment, suggesting that these relationships cannot be explained by age-related differences in androgen levels.”
Overall, “sex hormones are associated with the development/worsening of frailty in middle-aged and older men, but these relationships vary between different constructs of frailty assessment,” Dr. Swiecicka said. “In light of the findings, a therapeutic role for testosterone in the context of physical frailty prevention or alleviation remains an attractive possibility that should be further explored.”
The study was published in the Journal of Clinical Endocrinology and Metabolism.
In an interview, Steve Borst, PhD, of the University of Florida, questioned the study’s approach because it looks only at baseline hormone levels. “What would be much more interesting to study would be changes in hormone levels vs. changes in frailty,” he said.
Dr. Borst added that researchers already know that “the relationship between testosterone and frailty is both large in magnitude and causal in nature.”
He pointed to his group’s research that linked testosterone injections to an increase in muscle strength, and he said others have linked testosterone administration to an increase in bone density. “While these measures are not exactly the same as frailty index,” he said, “it is well established that lower body muscle strength keeps older people in an independent living state and that the changes in bone mineral density are enough to account for protection against fracture.”
John Morley, MBBCh, of Saint Louis University, said in an interview that testosterone has a role in combating frailty. “But it’s not like it’s going to turn people into super people,” he said.
He added that “we shouldn’t say ‘Let’s do testosterone before we do exercise.’ It’s better to do resistance exercise than it is to take testosterone. But most older males are loath to do any physical work to make themselves better. That’s just human nature.”
The study was funded by various European research-based organizations. The study authors reported multiple disclosures. Dr. Morley reports no disclosures.
SOURCE: Swiecicka A et al. J Clin Endocrinol Metab. 2018 Feb;103(2):701-9.
A new study provides more evidence of a link between lower free testosterone levels and higher levels of frailty in older men, but a researcher says proof of a causal connection remains elusive.
“Our study demonstrates clear associations between testosterone and frailty progression, and, although causality and directionality of the hormone/frailty relationships require clarification, the results presented here make a strong case for large interventional trials of testosterone therapy in frail men to determine whether such treatment would be beneficial,” lead author Agnieszka Swiecicka, MD, of the andrology research unit in the division of diabetes, endocrinology, and gastroenterology at the University of Manchester (England), said in an interview.
As Dr. Swiecicka noted, “in men, testosterone levels decline with age, and it has been suggested that this phenomenon might play a role in the development of frailty.”
However, evidence is limited, and studies have offered conflicting results Dr. Swiecicka said.
For the new study, the researchers prospectively tracked 3,369 community-dwelling men aged 40-79 years from eight European centers. Hundreds were excluded for various reasons or lost to follow-up, and 2,278 men were ultimately included.
The average age was 58 years, and the average body mass index was 28 kg/m2.
Hormone measurements were performed, and frailty was tracked via frailty status (FS, n = 2,278) and frailty phenotype (FP, n = 1,980).
After adjusting their statistics to account for various factors, the researchers were able to link only free testosterone – and not testosterone or dihydrotestosterone – to changes in frailty index (FI). They linked each standard deviation improvement in free testosterone level at baseline to a –2.8% change in FI over 4 years (95% confidence interval, –4.9 to –0.3, P = .030).
“Higher free testosterone levels were associated with a lower risk of worsening frailty status. The direction of this association was consistent regardless of the frailty construct used (FI and FP),” Dr. Swiecicka said. “Higher androgen remained significantly associated with improving frailty status, as assessed by FI, despite age adjustment, suggesting that these relationships cannot be explained by age-related differences in androgen levels.”
Overall, “sex hormones are associated with the development/worsening of frailty in middle-aged and older men, but these relationships vary between different constructs of frailty assessment,” Dr. Swiecicka said. “In light of the findings, a therapeutic role for testosterone in the context of physical frailty prevention or alleviation remains an attractive possibility that should be further explored.”
The study was published in the Journal of Clinical Endocrinology and Metabolism.
In an interview, Steve Borst, PhD, of the University of Florida, questioned the study’s approach because it looks only at baseline hormone levels. “What would be much more interesting to study would be changes in hormone levels vs. changes in frailty,” he said.
Dr. Borst added that researchers already know that “the relationship between testosterone and frailty is both large in magnitude and causal in nature.”
He pointed to his group’s research that linked testosterone injections to an increase in muscle strength, and he said others have linked testosterone administration to an increase in bone density. “While these measures are not exactly the same as frailty index,” he said, “it is well established that lower body muscle strength keeps older people in an independent living state and that the changes in bone mineral density are enough to account for protection against fracture.”
John Morley, MBBCh, of Saint Louis University, said in an interview that testosterone has a role in combating frailty. “But it’s not like it’s going to turn people into super people,” he said.
He added that “we shouldn’t say ‘Let’s do testosterone before we do exercise.’ It’s better to do resistance exercise than it is to take testosterone. But most older males are loath to do any physical work to make themselves better. That’s just human nature.”
The study was funded by various European research-based organizations. The study authors reported multiple disclosures. Dr. Morley reports no disclosures.
SOURCE: Swiecicka A et al. J Clin Endocrinol Metab. 2018 Feb;103(2):701-9.
A new study provides more evidence of a link between lower free testosterone levels and higher levels of frailty in older men, but a researcher says proof of a causal connection remains elusive.
“Our study demonstrates clear associations between testosterone and frailty progression, and, although causality and directionality of the hormone/frailty relationships require clarification, the results presented here make a strong case for large interventional trials of testosterone therapy in frail men to determine whether such treatment would be beneficial,” lead author Agnieszka Swiecicka, MD, of the andrology research unit in the division of diabetes, endocrinology, and gastroenterology at the University of Manchester (England), said in an interview.
As Dr. Swiecicka noted, “in men, testosterone levels decline with age, and it has been suggested that this phenomenon might play a role in the development of frailty.”
However, evidence is limited, and studies have offered conflicting results Dr. Swiecicka said.
For the new study, the researchers prospectively tracked 3,369 community-dwelling men aged 40-79 years from eight European centers. Hundreds were excluded for various reasons or lost to follow-up, and 2,278 men were ultimately included.
The average age was 58 years, and the average body mass index was 28 kg/m2.
Hormone measurements were performed, and frailty was tracked via frailty status (FS, n = 2,278) and frailty phenotype (FP, n = 1,980).
After adjusting their statistics to account for various factors, the researchers were able to link only free testosterone – and not testosterone or dihydrotestosterone – to changes in frailty index (FI). They linked each standard deviation improvement in free testosterone level at baseline to a –2.8% change in FI over 4 years (95% confidence interval, –4.9 to –0.3, P = .030).
“Higher free testosterone levels were associated with a lower risk of worsening frailty status. The direction of this association was consistent regardless of the frailty construct used (FI and FP),” Dr. Swiecicka said. “Higher androgen remained significantly associated with improving frailty status, as assessed by FI, despite age adjustment, suggesting that these relationships cannot be explained by age-related differences in androgen levels.”
Overall, “sex hormones are associated with the development/worsening of frailty in middle-aged and older men, but these relationships vary between different constructs of frailty assessment,” Dr. Swiecicka said. “In light of the findings, a therapeutic role for testosterone in the context of physical frailty prevention or alleviation remains an attractive possibility that should be further explored.”
The study was published in the Journal of Clinical Endocrinology and Metabolism.
In an interview, Steve Borst, PhD, of the University of Florida, questioned the study’s approach because it looks only at baseline hormone levels. “What would be much more interesting to study would be changes in hormone levels vs. changes in frailty,” he said.
Dr. Borst added that researchers already know that “the relationship between testosterone and frailty is both large in magnitude and causal in nature.”
He pointed to his group’s research that linked testosterone injections to an increase in muscle strength, and he said others have linked testosterone administration to an increase in bone density. “While these measures are not exactly the same as frailty index,” he said, “it is well established that lower body muscle strength keeps older people in an independent living state and that the changes in bone mineral density are enough to account for protection against fracture.”
John Morley, MBBCh, of Saint Louis University, said in an interview that testosterone has a role in combating frailty. “But it’s not like it’s going to turn people into super people,” he said.
He added that “we shouldn’t say ‘Let’s do testosterone before we do exercise.’ It’s better to do resistance exercise than it is to take testosterone. But most older males are loath to do any physical work to make themselves better. That’s just human nature.”
The study was funded by various European research-based organizations. The study authors reported multiple disclosures. Dr. Morley reports no disclosures.
SOURCE: Swiecicka A et al. J Clin Endocrinol Metab. 2018 Feb;103(2):701-9.
FROM THE JOURNAL OF CLINICAL ENDOCRINOLOGY AND METABOLISM
Key clinical point: Free testosterone levels are linked to frailty in older men.
Major finding: For each standard deviation improvement in free testosterone level at baseline, frailty index was 2.8% lower at 4 years. (95% CI, –4.9% to –0.3%, P = .030)
Study details: Prospective cohort study of 3,369 men aged 40-79 years at eight European centers.
Disclosures: The study was funded by various European research-based organizations. The investigators reported multiple disclosures.
Source: Swiecicka A et al. J Clin Endocrinol Metab. 2018 Feb;103(2):701-9.
Breast cancer deaths projected for 2018
Female breast cancer mortality is expected to be about 25.3 per 100,000 women in 2018, with the highest rate in the District of Columbia and the lowest in Utah.
Approximately 40,920 deaths from invasive female breast cancer are predicted in the United States by the American Cancer Society (ACS) in its Cancer Facts & Figures 2018, which is based on analysis of 2001-2015 data from the National Center for Health Statistics. The death rate has declined 39% since its peak in 1989, and over the last 10 years, the annual decline has been 1.8% for white women and 1.5% for black women per year, the ACS said.
Breast cancer is the most common cancer in women, as it is expected to account for 30% of the almost 880,000 new cancer cases in 2018, compared with 13% for lung cancer, which is second. Lung cancer, however, is projected to cause more deaths among women – 70,500 – than any other cancer, the ACS reported.
Female breast cancer mortality is expected to be about 25.3 per 100,000 women in 2018, with the highest rate in the District of Columbia and the lowest in Utah.
Approximately 40,920 deaths from invasive female breast cancer are predicted in the United States by the American Cancer Society (ACS) in its Cancer Facts & Figures 2018, which is based on analysis of 2001-2015 data from the National Center for Health Statistics. The death rate has declined 39% since its peak in 1989, and over the last 10 years, the annual decline has been 1.8% for white women and 1.5% for black women per year, the ACS said.
Breast cancer is the most common cancer in women, as it is expected to account for 30% of the almost 880,000 new cancer cases in 2018, compared with 13% for lung cancer, which is second. Lung cancer, however, is projected to cause more deaths among women – 70,500 – than any other cancer, the ACS reported.
Female breast cancer mortality is expected to be about 25.3 per 100,000 women in 2018, with the highest rate in the District of Columbia and the lowest in Utah.
Approximately 40,920 deaths from invasive female breast cancer are predicted in the United States by the American Cancer Society (ACS) in its Cancer Facts & Figures 2018, which is based on analysis of 2001-2015 data from the National Center for Health Statistics. The death rate has declined 39% since its peak in 1989, and over the last 10 years, the annual decline has been 1.8% for white women and 1.5% for black women per year, the ACS said.
Breast cancer is the most common cancer in women, as it is expected to account for 30% of the almost 880,000 new cancer cases in 2018, compared with 13% for lung cancer, which is second. Lung cancer, however, is projected to cause more deaths among women – 70,500 – than any other cancer, the ACS reported.
Fluarix Quadrivalent effective in very young, simplifies flu shots for all ages
Fluarix Quadrivalent is highly effective against moderate and severe flu strains in children aged 6-35 months, and has the potential to simplify influenza vaccinations for all ages, according the results of a phase 3 clinical trial presented at a meeting of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.
“Fluarix Quadrivalent, at the 0.5-mL dose in young children 6 to 35 months of age, demonstrated efficacy of 63.2% against moderate to severe influenza and 49.8% against any severity influenza disease” stated Leonard Friedland, MD, director of scientific affairs and public health, Vaccines North America, GlaxoSmithKline. Dr. Friedland, a pediatrician in Pennsylvania, said that a standard 0.5-mL dose of Fluarix Quadrivalent has practice-changing implications for physicians. “The use of a 0.5-mL dose (15 mcg per strain) for all persons aged 6 months and older potentially simplifies influenza vaccination by allowing the same vaccine dose to be used for all eligible individuals.”
The high efficacy of Fluarix against almost half of all influenza strains, regardless of severity, and in preventing moderate to severe influenza, correlated with a reduction in health care utilization by pediatric influenza patients, he said. Visits to general practitioners and emergency departments decreased by 47% and 79%, respectively, in children aged 6-35 months. Influenza-associated antibiotic use in these pediatric influenza patients also decreased by 50%.
These findings were the result of D-QIV-004, a phase 3, observer-blinded, randomized trial of 12,018 children aged 6-35 months. These children were split into five cohorts, each in a different influenza season. The study spanned 13 countries and ran from October 2011 to December 2014. To determine the safety of Fluarix, the study utilized noninfluenza vaccine comparator vaccines that were age appropriate, including Prevnar 13, Havrix, and Varivax.
A majority of the children in the study (98%) were vaccine unprimed (had never received two doses of seasonal influenza vaccine) and received two doses of Fluarix. The remaining children received one dose.
On Jan. 11, 2018, the Food and Drug Administration expanded the indication of Fluarix Quadrivalent to include use in persons 6 months and older. Previously, it was approved only for persons 3 years and older.
“These study results support universal vaccination of all individuals from 6 months of age [with Fluarix] to prevent influenza.” Dr. Friedland concluded.
For live updates and information concerning influenza, visit the CDC website.
[email protected]
SOURCE: D-QIV-004.
Fluarix Quadrivalent is highly effective against moderate and severe flu strains in children aged 6-35 months, and has the potential to simplify influenza vaccinations for all ages, according the results of a phase 3 clinical trial presented at a meeting of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.
“Fluarix Quadrivalent, at the 0.5-mL dose in young children 6 to 35 months of age, demonstrated efficacy of 63.2% against moderate to severe influenza and 49.8% against any severity influenza disease” stated Leonard Friedland, MD, director of scientific affairs and public health, Vaccines North America, GlaxoSmithKline. Dr. Friedland, a pediatrician in Pennsylvania, said that a standard 0.5-mL dose of Fluarix Quadrivalent has practice-changing implications for physicians. “The use of a 0.5-mL dose (15 mcg per strain) for all persons aged 6 months and older potentially simplifies influenza vaccination by allowing the same vaccine dose to be used for all eligible individuals.”
The high efficacy of Fluarix against almost half of all influenza strains, regardless of severity, and in preventing moderate to severe influenza, correlated with a reduction in health care utilization by pediatric influenza patients, he said. Visits to general practitioners and emergency departments decreased by 47% and 79%, respectively, in children aged 6-35 months. Influenza-associated antibiotic use in these pediatric influenza patients also decreased by 50%.
These findings were the result of D-QIV-004, a phase 3, observer-blinded, randomized trial of 12,018 children aged 6-35 months. These children were split into five cohorts, each in a different influenza season. The study spanned 13 countries and ran from October 2011 to December 2014. To determine the safety of Fluarix, the study utilized noninfluenza vaccine comparator vaccines that were age appropriate, including Prevnar 13, Havrix, and Varivax.
A majority of the children in the study (98%) were vaccine unprimed (had never received two doses of seasonal influenza vaccine) and received two doses of Fluarix. The remaining children received one dose.
On Jan. 11, 2018, the Food and Drug Administration expanded the indication of Fluarix Quadrivalent to include use in persons 6 months and older. Previously, it was approved only for persons 3 years and older.
“These study results support universal vaccination of all individuals from 6 months of age [with Fluarix] to prevent influenza.” Dr. Friedland concluded.
For live updates and information concerning influenza, visit the CDC website.
[email protected]
SOURCE: D-QIV-004.
Fluarix Quadrivalent is highly effective against moderate and severe flu strains in children aged 6-35 months, and has the potential to simplify influenza vaccinations for all ages, according the results of a phase 3 clinical trial presented at a meeting of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.
“Fluarix Quadrivalent, at the 0.5-mL dose in young children 6 to 35 months of age, demonstrated efficacy of 63.2% against moderate to severe influenza and 49.8% against any severity influenza disease” stated Leonard Friedland, MD, director of scientific affairs and public health, Vaccines North America, GlaxoSmithKline. Dr. Friedland, a pediatrician in Pennsylvania, said that a standard 0.5-mL dose of Fluarix Quadrivalent has practice-changing implications for physicians. “The use of a 0.5-mL dose (15 mcg per strain) for all persons aged 6 months and older potentially simplifies influenza vaccination by allowing the same vaccine dose to be used for all eligible individuals.”
The high efficacy of Fluarix against almost half of all influenza strains, regardless of severity, and in preventing moderate to severe influenza, correlated with a reduction in health care utilization by pediatric influenza patients, he said. Visits to general practitioners and emergency departments decreased by 47% and 79%, respectively, in children aged 6-35 months. Influenza-associated antibiotic use in these pediatric influenza patients also decreased by 50%.
These findings were the result of D-QIV-004, a phase 3, observer-blinded, randomized trial of 12,018 children aged 6-35 months. These children were split into five cohorts, each in a different influenza season. The study spanned 13 countries and ran from October 2011 to December 2014. To determine the safety of Fluarix, the study utilized noninfluenza vaccine comparator vaccines that were age appropriate, including Prevnar 13, Havrix, and Varivax.
A majority of the children in the study (98%) were vaccine unprimed (had never received two doses of seasonal influenza vaccine) and received two doses of Fluarix. The remaining children received one dose.
On Jan. 11, 2018, the Food and Drug Administration expanded the indication of Fluarix Quadrivalent to include use in persons 6 months and older. Previously, it was approved only for persons 3 years and older.
“These study results support universal vaccination of all individuals from 6 months of age [with Fluarix] to prevent influenza.” Dr. Friedland concluded.
For live updates and information concerning influenza, visit the CDC website.
[email protected]
SOURCE: D-QIV-004.
FROM AN ACIP MEETING
Key clinical point: The high efficacy of Fluarix against almost half of all influenza strains, regardless of severity, as well as preventing moderate to severe influenza, reduced health care utilization by pediatric influenza patients.
Major finding: Fluarix Quadrivalent was effective against moderate to severe influenza in 63.2% and against any severity of influenza in 49.8% of children aged 6-35 months.
Study details: A phase 3, observer-blinded, randomized trial of 12,018 children aged 6-35 months, in which the children were split into five cohorts, each in a different influenza season from October 2011 to December 2014.
Disclosures: No disclosures were reported.
Source: The D-QIV-004 study.
Guidelines update best practices for hemorrhoid treatment
Each year, more than 2.2 million patients in the United States undergo evaluations for symptoms of hemorrhoids, according to updated guidelines on the management of hemorrhoids issued by the American Society of Colon and Rectal Surgeons.
“As a result, it is important to identify symptomatic hemorrhoids as the underlying source of the anorectal symptom and to have a clear understanding of the evaluation and management of this disease process,” wrote Bradley R. Davis, MD, FACS, chief of colon and rectal surgery at the Carolinas Medical Center, Charlotte, N.C., and the fellow members of the Clinical Practice Guidelines Committee of the ASCRS.
The guidelines are based on the ASCRS Practice Parameters for the Management of Hemorrhoids published in 2011. The 2018 update was published in the Diseases of the Colon & Rectum.
The guidelines recommend evaluation of hemorrhoids based on a disease-specific history, and a physical that emphasizes the degree and duration of symptoms and identifies risk factors. But the guideline writers note that the recommendation is a grade 1C because the supporting data mainly come from observational or case studies.
“The cardinal signs of internal hemorrhoids are painless bleeding with bowel movements with intermittent protrusion,” the committee said, also emphasizing that patients should be evaluated for fecal incontinence, which could inform surgical decision making.
In addition, the guidelines call for a complete endoscopic evaluation of the colon for patients who present with symptomatic hemorrhoids and rectal bleeding; this recommendation is based on moderately strong evidence, and presented with a grade of 1B.
Medical management of hemorrhoids may include office-based procedures or surgery, according to the guidelines.
“Most patients with grade I and II and select patients with grade III internal hemorrhoidal disease who fail medical treatment can be effectively treated with office-based procedures, such as banding, sclerotherapy, and infrared coagulation,” the committee wrote, and medical office treatment received a strong grade 1A recommendation based on high-quality evidence. Although office procedures are generally well tolerated, the condition can recur. Bleeding is the most common complication, and it is more likely after rubber-band ligation than other office-based options, the guidelines state.
The guidelines offer a weak recommendation of 2C, based on the lack of quality evidence, for the use of early surgical excision to treat patients with thrombosed external hemorrhoids. “Although most patients treated nonoperatively will experience eventual resolution of their symptoms, excision of thrombosed external hemorrhoids may result in more rapid symptom resolution, lower incidence of recurrence, and longer remission intervals,” the committee noted.
Surgical hemorrhoidectomy received the strongest possible recommendation (1A, based on high-quality evidence) for the treatment of patients with external hemorrhoids or a combination of internal and external hemorrhoids with prolapse.
Surgical options described in the recommendations include surgical excision (hemorrhoidectomy), hemorrhoidopexy, and Doppler-guided hemorrhoidectomy, with citations of studies on each procedure. Data from a meta-analysis of 18 randomized prospective studies comparing hemorrhoidectomy with office-based procedures showed that hemorrhoidectomy was “the most effective treatment for patients with grade III hemorrhoids,” but it was associated with greater pain and complication rates, according to the guidelines.
However, complications in general are low after surgical hemorrhoidectomy, with reported complication rates of 1%-2% for the most common complication of postprocedure hemorrhage, the guidelines state. After surgery, the guidelines recommend with a 1B grade (moderate quality evidence) that patients use “a multimodality pain regimen to reduce narcotic usage and promote a faster recovery.”
The committee members had no financial conflicts to disclose.
AGA offers information for your patients about hemorrhoids at http://www.gastro.org/patient-care/conditions-diseases/hemorrhoids.
SOURCE: Davis BR et al. Dis Colon Rectum. 2018; 61:284-92.
Each year, more than 2.2 million patients in the United States undergo evaluations for symptoms of hemorrhoids, according to updated guidelines on the management of hemorrhoids issued by the American Society of Colon and Rectal Surgeons.
“As a result, it is important to identify symptomatic hemorrhoids as the underlying source of the anorectal symptom and to have a clear understanding of the evaluation and management of this disease process,” wrote Bradley R. Davis, MD, FACS, chief of colon and rectal surgery at the Carolinas Medical Center, Charlotte, N.C., and the fellow members of the Clinical Practice Guidelines Committee of the ASCRS.
The guidelines are based on the ASCRS Practice Parameters for the Management of Hemorrhoids published in 2011. The 2018 update was published in the Diseases of the Colon & Rectum.
The guidelines recommend evaluation of hemorrhoids based on a disease-specific history, and a physical that emphasizes the degree and duration of symptoms and identifies risk factors. But the guideline writers note that the recommendation is a grade 1C because the supporting data mainly come from observational or case studies.
“The cardinal signs of internal hemorrhoids are painless bleeding with bowel movements with intermittent protrusion,” the committee said, also emphasizing that patients should be evaluated for fecal incontinence, which could inform surgical decision making.
In addition, the guidelines call for a complete endoscopic evaluation of the colon for patients who present with symptomatic hemorrhoids and rectal bleeding; this recommendation is based on moderately strong evidence, and presented with a grade of 1B.
Medical management of hemorrhoids may include office-based procedures or surgery, according to the guidelines.
“Most patients with grade I and II and select patients with grade III internal hemorrhoidal disease who fail medical treatment can be effectively treated with office-based procedures, such as banding, sclerotherapy, and infrared coagulation,” the committee wrote, and medical office treatment received a strong grade 1A recommendation based on high-quality evidence. Although office procedures are generally well tolerated, the condition can recur. Bleeding is the most common complication, and it is more likely after rubber-band ligation than other office-based options, the guidelines state.
The guidelines offer a weak recommendation of 2C, based on the lack of quality evidence, for the use of early surgical excision to treat patients with thrombosed external hemorrhoids. “Although most patients treated nonoperatively will experience eventual resolution of their symptoms, excision of thrombosed external hemorrhoids may result in more rapid symptom resolution, lower incidence of recurrence, and longer remission intervals,” the committee noted.
Surgical hemorrhoidectomy received the strongest possible recommendation (1A, based on high-quality evidence) for the treatment of patients with external hemorrhoids or a combination of internal and external hemorrhoids with prolapse.
Surgical options described in the recommendations include surgical excision (hemorrhoidectomy), hemorrhoidopexy, and Doppler-guided hemorrhoidectomy, with citations of studies on each procedure. Data from a meta-analysis of 18 randomized prospective studies comparing hemorrhoidectomy with office-based procedures showed that hemorrhoidectomy was “the most effective treatment for patients with grade III hemorrhoids,” but it was associated with greater pain and complication rates, according to the guidelines.
However, complications in general are low after surgical hemorrhoidectomy, with reported complication rates of 1%-2% for the most common complication of postprocedure hemorrhage, the guidelines state. After surgery, the guidelines recommend with a 1B grade (moderate quality evidence) that patients use “a multimodality pain regimen to reduce narcotic usage and promote a faster recovery.”
The committee members had no financial conflicts to disclose.
AGA offers information for your patients about hemorrhoids at http://www.gastro.org/patient-care/conditions-diseases/hemorrhoids.
SOURCE: Davis BR et al. Dis Colon Rectum. 2018; 61:284-92.
Each year, more than 2.2 million patients in the United States undergo evaluations for symptoms of hemorrhoids, according to updated guidelines on the management of hemorrhoids issued by the American Society of Colon and Rectal Surgeons.
“As a result, it is important to identify symptomatic hemorrhoids as the underlying source of the anorectal symptom and to have a clear understanding of the evaluation and management of this disease process,” wrote Bradley R. Davis, MD, FACS, chief of colon and rectal surgery at the Carolinas Medical Center, Charlotte, N.C., and the fellow members of the Clinical Practice Guidelines Committee of the ASCRS.
The guidelines are based on the ASCRS Practice Parameters for the Management of Hemorrhoids published in 2011. The 2018 update was published in the Diseases of the Colon & Rectum.
The guidelines recommend evaluation of hemorrhoids based on a disease-specific history, and a physical that emphasizes the degree and duration of symptoms and identifies risk factors. But the guideline writers note that the recommendation is a grade 1C because the supporting data mainly come from observational or case studies.
“The cardinal signs of internal hemorrhoids are painless bleeding with bowel movements with intermittent protrusion,” the committee said, also emphasizing that patients should be evaluated for fecal incontinence, which could inform surgical decision making.
In addition, the guidelines call for a complete endoscopic evaluation of the colon for patients who present with symptomatic hemorrhoids and rectal bleeding; this recommendation is based on moderately strong evidence, and presented with a grade of 1B.
Medical management of hemorrhoids may include office-based procedures or surgery, according to the guidelines.
“Most patients with grade I and II and select patients with grade III internal hemorrhoidal disease who fail medical treatment can be effectively treated with office-based procedures, such as banding, sclerotherapy, and infrared coagulation,” the committee wrote, and medical office treatment received a strong grade 1A recommendation based on high-quality evidence. Although office procedures are generally well tolerated, the condition can recur. Bleeding is the most common complication, and it is more likely after rubber-band ligation than other office-based options, the guidelines state.
The guidelines offer a weak recommendation of 2C, based on the lack of quality evidence, for the use of early surgical excision to treat patients with thrombosed external hemorrhoids. “Although most patients treated nonoperatively will experience eventual resolution of their symptoms, excision of thrombosed external hemorrhoids may result in more rapid symptom resolution, lower incidence of recurrence, and longer remission intervals,” the committee noted.
Surgical hemorrhoidectomy received the strongest possible recommendation (1A, based on high-quality evidence) for the treatment of patients with external hemorrhoids or a combination of internal and external hemorrhoids with prolapse.
Surgical options described in the recommendations include surgical excision (hemorrhoidectomy), hemorrhoidopexy, and Doppler-guided hemorrhoidectomy, with citations of studies on each procedure. Data from a meta-analysis of 18 randomized prospective studies comparing hemorrhoidectomy with office-based procedures showed that hemorrhoidectomy was “the most effective treatment for patients with grade III hemorrhoids,” but it was associated with greater pain and complication rates, according to the guidelines.
However, complications in general are low after surgical hemorrhoidectomy, with reported complication rates of 1%-2% for the most common complication of postprocedure hemorrhage, the guidelines state. After surgery, the guidelines recommend with a 1B grade (moderate quality evidence) that patients use “a multimodality pain regimen to reduce narcotic usage and promote a faster recovery.”
The committee members had no financial conflicts to disclose.
AGA offers information for your patients about hemorrhoids at http://www.gastro.org/patient-care/conditions-diseases/hemorrhoids.
SOURCE: Davis BR et al. Dis Colon Rectum. 2018; 61:284-92.
FROM DISEASES OF THE COLON & RECTUM
How to lower occupational radiation exposure in the cath lab
Adding some lead shielding in cardiac catheterization labs can cut the amount of radiation that nurse circulators and scrub technologists are exposed to, according to a single-center study of more than 750 patients.
“The simple and relatively inexpensive approach of providing staff members with a dedicated accessory lead shield during cardiac catheterization was associated with a nearly two-thirds reduction in radiation exposure among both nurses and technologists” according to Ryan Madder, MD, and his associates. “The present study is the first, to our knowledge, to observe a similar benefit among nonphysician staff members, an observation that may have important implications for occupational safety in the cardiac catheterization laboratory.”
The report was published in JACC: Cardiovascular Interventions.
SHIELD (Combining Robotic-Stenting and Proactive Shielding Techniques in the Catheterization Laboratory to Achieve Lowest Possible Radiation Exposure to Physicians and Staff) was a single-center, prospective, observational designed study to research radiation exposure levels among physicians and other staff members in cardiac catheterization labs. Dr. Madder, a cardiologist at Spectrum Health in Grand Rapids, Mich., and his colleagues collected radiation exposure information for staff members such as nurse circulators and scrub technologists during August 2015–February 2016 and measured radiation exposure in 764 consecutive cases. Radiation exposure was monitored for these staff members by dosimeters worn on either the left anterior side of the glasses or thyroid collar, and a body dosimeter underneath the lead apparel on the V-neck of their scrub shirt.
The radiation protection used in the study followed standard institutional operating procedures, which includes two shields between the patient and physician, a ceiling mounted upper body shield with a patient contour cutout, and a lower body shield attached to the side of the operating table, extending from the table to the floor. Staff members wore traditional lead garments, consisting of a lead skirt, apron, and thyroid collar. Additional radiation absorbing disposable pads were used as desired by the staff members.
The study was split into two phases to evaluate the effectiveness of accessory shields with phase 1 (401 cases) utilizing traditional protective measures. Phase 2 (363 cases) used the same material as phase I, but a dedicated accessory lead shield was used. For nurse circulators, this shield was placed between the patient and the intravenous medication pole. For scrub technologists, the shield was placed at the foot of the patient’s bed.
Radiation exposure was higher in phase 1 than phase 2 for all workers. In phase I, technologists faced an effective dose normalized to the dose-area product (EDAP) of 2.4 mcSv/(mGy x cm2) x 10-5 per case. This dropped significantly in phase 2 to an EDAP of 0.9per case, a 62.5% lower dose per case (P less than .0001).
Nurses experienced a similar decrease in exposure per case from phase 1 (EDAP 1.1) and phase 2 (EDAP 0.4). This accounted for a 63.6% lower dose per case (P less than .0001).
The contrast delivery system used at the lab did not allow technologists to maximize their distance from radiation sources, so it is unclear whether the results of this study can be extrapolated to centers where technologists do not perform contrast injections.
Dr. Madder and his colleagues pointed out that this research only begins to scratch the surface of the occupational hazards that catheterization laboratory personnel face.“The use of accessory lead shields, which might be effective to reduce staff radiation exposure, will not likely reduce other occupational hazards of working in the catheterization laboratory related to wearing heavy lead garments, including the risks for orthopedic injuries and experiencing chronic work-related pain.”
Corindus Vascular Robotics partially funded this study and has provided research support to Dr. Madder. All other researchers have no financial conflicts to report.
SOURCE: Madder R. JACC: Cardiovasc Interven. 2018 Jan 22;11[2]:206-12.
While concerns about occupational radiation exposure to cardiologists has prompted equipment, shielding, and behavioral modifications to reduce radiation exposure in cardiologists, exposure to staff members such as nurses and technologists has not received this same attention.
Considering that the shield should also absorb approximately 98% of the scatter radiation, the only real issue about its effectiveness is whether technologists and nurses can remain behind the wall while still being able to assist during a procedure.
All cardiology labs should be equipped with these shields to provide adequate radiation protection to those who work there. The work of Madder et al. should provide confidence to nurses and technologists that their occupational radiation exposure can be expected to be low, as well as their cancer risk.
Kenneth A. Fetterly, PhD , a radiologist, and Malcolm R. Bell, MD , a cardiologist and director of the ischemic heart disease program at the Mayo Clinic in Rochester, Minn., made these comments in an editorial ( JACC: Cardiovasc Interven. 2018 Jan 22;11[2]:213-4 ).
While concerns about occupational radiation exposure to cardiologists has prompted equipment, shielding, and behavioral modifications to reduce radiation exposure in cardiologists, exposure to staff members such as nurses and technologists has not received this same attention.
Considering that the shield should also absorb approximately 98% of the scatter radiation, the only real issue about its effectiveness is whether technologists and nurses can remain behind the wall while still being able to assist during a procedure.
All cardiology labs should be equipped with these shields to provide adequate radiation protection to those who work there. The work of Madder et al. should provide confidence to nurses and technologists that their occupational radiation exposure can be expected to be low, as well as their cancer risk.
Kenneth A. Fetterly, PhD , a radiologist, and Malcolm R. Bell, MD , a cardiologist and director of the ischemic heart disease program at the Mayo Clinic in Rochester, Minn., made these comments in an editorial ( JACC: Cardiovasc Interven. 2018 Jan 22;11[2]:213-4 ).
While concerns about occupational radiation exposure to cardiologists has prompted equipment, shielding, and behavioral modifications to reduce radiation exposure in cardiologists, exposure to staff members such as nurses and technologists has not received this same attention.
Considering that the shield should also absorb approximately 98% of the scatter radiation, the only real issue about its effectiveness is whether technologists and nurses can remain behind the wall while still being able to assist during a procedure.
All cardiology labs should be equipped with these shields to provide adequate radiation protection to those who work there. The work of Madder et al. should provide confidence to nurses and technologists that their occupational radiation exposure can be expected to be low, as well as their cancer risk.
Kenneth A. Fetterly, PhD , a radiologist, and Malcolm R. Bell, MD , a cardiologist and director of the ischemic heart disease program at the Mayo Clinic in Rochester, Minn., made these comments in an editorial ( JACC: Cardiovasc Interven. 2018 Jan 22;11[2]:213-4 ).
Adding some lead shielding in cardiac catheterization labs can cut the amount of radiation that nurse circulators and scrub technologists are exposed to, according to a single-center study of more than 750 patients.
“The simple and relatively inexpensive approach of providing staff members with a dedicated accessory lead shield during cardiac catheterization was associated with a nearly two-thirds reduction in radiation exposure among both nurses and technologists” according to Ryan Madder, MD, and his associates. “The present study is the first, to our knowledge, to observe a similar benefit among nonphysician staff members, an observation that may have important implications for occupational safety in the cardiac catheterization laboratory.”
The report was published in JACC: Cardiovascular Interventions.
SHIELD (Combining Robotic-Stenting and Proactive Shielding Techniques in the Catheterization Laboratory to Achieve Lowest Possible Radiation Exposure to Physicians and Staff) was a single-center, prospective, observational designed study to research radiation exposure levels among physicians and other staff members in cardiac catheterization labs. Dr. Madder, a cardiologist at Spectrum Health in Grand Rapids, Mich., and his colleagues collected radiation exposure information for staff members such as nurse circulators and scrub technologists during August 2015–February 2016 and measured radiation exposure in 764 consecutive cases. Radiation exposure was monitored for these staff members by dosimeters worn on either the left anterior side of the glasses or thyroid collar, and a body dosimeter underneath the lead apparel on the V-neck of their scrub shirt.
The radiation protection used in the study followed standard institutional operating procedures, which includes two shields between the patient and physician, a ceiling mounted upper body shield with a patient contour cutout, and a lower body shield attached to the side of the operating table, extending from the table to the floor. Staff members wore traditional lead garments, consisting of a lead skirt, apron, and thyroid collar. Additional radiation absorbing disposable pads were used as desired by the staff members.
The study was split into two phases to evaluate the effectiveness of accessory shields with phase 1 (401 cases) utilizing traditional protective measures. Phase 2 (363 cases) used the same material as phase I, but a dedicated accessory lead shield was used. For nurse circulators, this shield was placed between the patient and the intravenous medication pole. For scrub technologists, the shield was placed at the foot of the patient’s bed.
Radiation exposure was higher in phase 1 than phase 2 for all workers. In phase I, technologists faced an effective dose normalized to the dose-area product (EDAP) of 2.4 mcSv/(mGy x cm2) x 10-5 per case. This dropped significantly in phase 2 to an EDAP of 0.9per case, a 62.5% lower dose per case (P less than .0001).
Nurses experienced a similar decrease in exposure per case from phase 1 (EDAP 1.1) and phase 2 (EDAP 0.4). This accounted for a 63.6% lower dose per case (P less than .0001).
The contrast delivery system used at the lab did not allow technologists to maximize their distance from radiation sources, so it is unclear whether the results of this study can be extrapolated to centers where technologists do not perform contrast injections.
Dr. Madder and his colleagues pointed out that this research only begins to scratch the surface of the occupational hazards that catheterization laboratory personnel face.“The use of accessory lead shields, which might be effective to reduce staff radiation exposure, will not likely reduce other occupational hazards of working in the catheterization laboratory related to wearing heavy lead garments, including the risks for orthopedic injuries and experiencing chronic work-related pain.”
Corindus Vascular Robotics partially funded this study and has provided research support to Dr. Madder. All other researchers have no financial conflicts to report.
SOURCE: Madder R. JACC: Cardiovasc Interven. 2018 Jan 22;11[2]:206-12.
Adding some lead shielding in cardiac catheterization labs can cut the amount of radiation that nurse circulators and scrub technologists are exposed to, according to a single-center study of more than 750 patients.
“The simple and relatively inexpensive approach of providing staff members with a dedicated accessory lead shield during cardiac catheterization was associated with a nearly two-thirds reduction in radiation exposure among both nurses and technologists” according to Ryan Madder, MD, and his associates. “The present study is the first, to our knowledge, to observe a similar benefit among nonphysician staff members, an observation that may have important implications for occupational safety in the cardiac catheterization laboratory.”
The report was published in JACC: Cardiovascular Interventions.
SHIELD (Combining Robotic-Stenting and Proactive Shielding Techniques in the Catheterization Laboratory to Achieve Lowest Possible Radiation Exposure to Physicians and Staff) was a single-center, prospective, observational designed study to research radiation exposure levels among physicians and other staff members in cardiac catheterization labs. Dr. Madder, a cardiologist at Spectrum Health in Grand Rapids, Mich., and his colleagues collected radiation exposure information for staff members such as nurse circulators and scrub technologists during August 2015–February 2016 and measured radiation exposure in 764 consecutive cases. Radiation exposure was monitored for these staff members by dosimeters worn on either the left anterior side of the glasses or thyroid collar, and a body dosimeter underneath the lead apparel on the V-neck of their scrub shirt.
The radiation protection used in the study followed standard institutional operating procedures, which includes two shields between the patient and physician, a ceiling mounted upper body shield with a patient contour cutout, and a lower body shield attached to the side of the operating table, extending from the table to the floor. Staff members wore traditional lead garments, consisting of a lead skirt, apron, and thyroid collar. Additional radiation absorbing disposable pads were used as desired by the staff members.
The study was split into two phases to evaluate the effectiveness of accessory shields with phase 1 (401 cases) utilizing traditional protective measures. Phase 2 (363 cases) used the same material as phase I, but a dedicated accessory lead shield was used. For nurse circulators, this shield was placed between the patient and the intravenous medication pole. For scrub technologists, the shield was placed at the foot of the patient’s bed.
Radiation exposure was higher in phase 1 than phase 2 for all workers. In phase I, technologists faced an effective dose normalized to the dose-area product (EDAP) of 2.4 mcSv/(mGy x cm2) x 10-5 per case. This dropped significantly in phase 2 to an EDAP of 0.9per case, a 62.5% lower dose per case (P less than .0001).
Nurses experienced a similar decrease in exposure per case from phase 1 (EDAP 1.1) and phase 2 (EDAP 0.4). This accounted for a 63.6% lower dose per case (P less than .0001).
The contrast delivery system used at the lab did not allow technologists to maximize their distance from radiation sources, so it is unclear whether the results of this study can be extrapolated to centers where technologists do not perform contrast injections.
Dr. Madder and his colleagues pointed out that this research only begins to scratch the surface of the occupational hazards that catheterization laboratory personnel face.“The use of accessory lead shields, which might be effective to reduce staff radiation exposure, will not likely reduce other occupational hazards of working in the catheterization laboratory related to wearing heavy lead garments, including the risks for orthopedic injuries and experiencing chronic work-related pain.”
Corindus Vascular Robotics partially funded this study and has provided research support to Dr. Madder. All other researchers have no financial conflicts to report.
SOURCE: Madder R. JACC: Cardiovasc Interven. 2018 Jan 22;11[2]:206-12.
FROM JACC: CARDIOVASCULAR INTERVENTIONS
Key clinical point: Accessory lead shielding reduces radiation exposure for nurses and technologists.
Major finding: Accessory lead shielding reduced radiation exposure by over two-thirds.
Study details: A single-center, prospective, observational study of 764 cases.
Disclosures: Corindus Vascular Robotics partially funded this study and has provided research support to Dr. Madder. All other researchers have no financial conflicts to report.
Source: Madder R. JACC: Cardiovasc Interven. 2018 Jan 22;11[2]:206-12.
Dexmedetomidine: ‘Silver bullet’ for ventilator liberation?
SAN ANTONIO – Among medications to facilitate extubation, dexmedetomidine offers favorable attributes, but whether it’s the best choice for patients who have difficulty being liberated from the ventilator remains to be proven, said Gilles L. Fraser, BS Pharm, PharmD.
The current CHEST/ATS guidelines on liberation from mechanical ventilation in critically ill adults strongly suggest extubation to noninvasive mechanical ventilation in high-risk patients (Chest. 2017 Jan;151[1]:160-5. doi: 10.1016/j.chest.2016.10.037). Guideline authors also suggested protocols attempting to minimize sedation for acutely hospitalized patients ventilated for more than 24 hours, based on some evidence showing a trend toward shorter ventilation time and ICU stay, as well as lower short-term mortality.
, one of the coauthors of the guidelines, during his presentation at the Critical Care Congress sponsored by the Society for Critical Care Medicine.
“I’ll leave you up to your own devices,” he told attendees at a session on conundrums in critical care that are not addressed in current guidelines. “We use it all the time, frankly, but I don’t have any firm data to support that contention.”
Despite best practices, extubation attempts are not always successful: “If you follow the rules of the road, success is going to occur about 85% of the time,” said Dr. Fraser, who is a clinical pharmacist at Maine Medical Center, Portland, and professor of medicine at Tufts University, Boston. “That means that about 15% of our patients have difficulties in being liberated from the ventilator.”
In terms of medications to facilitate ventilator liberation, benzodiazepines, dexmedetomidine, and propofol all have roles to play, according to Dr. Fraser. Clinicians have to consider agent-specific side effects, pharmacokinetics and dynamics, and “econotoxicity,” or the cost of care, he added.
Although there are few comparative data available to guide choice of medication, Dr. Fraser and his colleagues have published a systematic review and meta-analysis of randomized trials of benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adult patients (Crit Care Med. 2013 Sep;41[9 Suppl 1]:S30-8. doi: 10.1097/CCM.0b013e3182a16898).
They found that dexmedetomidine- or propofol-based sedation regimens appeared to reduce mechanical ventilation duration and length of ICU stay versus benzodiazepine-based sedation, but they stated that larger controlled studies would be needed to further define outcomes in this setting.
More recently, other investigators reported an evaluation of 9,603 consecutive mechanical ventilation episodes (Chest. 2016 Jun;149[6]:1373-9. doi: 10.1378/chest.15-1389). In this large, real-world experience, propofol and dexmedetomidine were both associated with less time to extubation versus benzodiazepines, and dexmedetomidine was associated with less time to extubation versus propofol.
Relatively few patients (about 12%), however, received dexmedetomidine in that large series, and that was mostly in the setting of cardiac surgery, Dr. Fraser noted. Moreover, the investigators reported finding no differences between any two agents in hospital discharge or mortality hazard ratio.
“We’re not suggesting the benzodiazepines as routine sedative agents in our patient populations,” Dr. Fraser said in his presentation. “The primary reason is that they result in a longer time on the vent, typically between 1 and 2 days.”
But this doesn’t mean that the benzodiazepines are the “devil’s handiwork,” he added, noting that they may be useful in patients with anxiety related to ventilator weaning and those recovering from hemodynamic instability or at risk for GABA-agonist withdrawal.
Dexmedetomidine is opioid sparing and has a minimal effect on respiratory drive, among other advantages; however, some potential drawbacks include its hemodynamic effects and its cost, according to Dr. Fraser.
Dr. Fraser said that his institution’s daily acquisition cost for dexmedetomidine is $500, compared with $120 for propofol and $40 for benzodiazepines, but some pharmacoeconomic evaluations suggest use of dexmedetomidine may actually save between $3,000 and $9,000 per ICU admission. “At least in our place, one day in the ICU costs about $5,000, so that all makes sense … and I can argue fairly effectively that dexmedetomidine really isn’t that expensive compared to midazolam,” he said.
Dr. Fraser said that he had no disclosures related to his presentation.
SAN ANTONIO – Among medications to facilitate extubation, dexmedetomidine offers favorable attributes, but whether it’s the best choice for patients who have difficulty being liberated from the ventilator remains to be proven, said Gilles L. Fraser, BS Pharm, PharmD.
The current CHEST/ATS guidelines on liberation from mechanical ventilation in critically ill adults strongly suggest extubation to noninvasive mechanical ventilation in high-risk patients (Chest. 2017 Jan;151[1]:160-5. doi: 10.1016/j.chest.2016.10.037). Guideline authors also suggested protocols attempting to minimize sedation for acutely hospitalized patients ventilated for more than 24 hours, based on some evidence showing a trend toward shorter ventilation time and ICU stay, as well as lower short-term mortality.
, one of the coauthors of the guidelines, during his presentation at the Critical Care Congress sponsored by the Society for Critical Care Medicine.
“I’ll leave you up to your own devices,” he told attendees at a session on conundrums in critical care that are not addressed in current guidelines. “We use it all the time, frankly, but I don’t have any firm data to support that contention.”
Despite best practices, extubation attempts are not always successful: “If you follow the rules of the road, success is going to occur about 85% of the time,” said Dr. Fraser, who is a clinical pharmacist at Maine Medical Center, Portland, and professor of medicine at Tufts University, Boston. “That means that about 15% of our patients have difficulties in being liberated from the ventilator.”
In terms of medications to facilitate ventilator liberation, benzodiazepines, dexmedetomidine, and propofol all have roles to play, according to Dr. Fraser. Clinicians have to consider agent-specific side effects, pharmacokinetics and dynamics, and “econotoxicity,” or the cost of care, he added.
Although there are few comparative data available to guide choice of medication, Dr. Fraser and his colleagues have published a systematic review and meta-analysis of randomized trials of benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adult patients (Crit Care Med. 2013 Sep;41[9 Suppl 1]:S30-8. doi: 10.1097/CCM.0b013e3182a16898).
They found that dexmedetomidine- or propofol-based sedation regimens appeared to reduce mechanical ventilation duration and length of ICU stay versus benzodiazepine-based sedation, but they stated that larger controlled studies would be needed to further define outcomes in this setting.
More recently, other investigators reported an evaluation of 9,603 consecutive mechanical ventilation episodes (Chest. 2016 Jun;149[6]:1373-9. doi: 10.1378/chest.15-1389). In this large, real-world experience, propofol and dexmedetomidine were both associated with less time to extubation versus benzodiazepines, and dexmedetomidine was associated with less time to extubation versus propofol.
Relatively few patients (about 12%), however, received dexmedetomidine in that large series, and that was mostly in the setting of cardiac surgery, Dr. Fraser noted. Moreover, the investigators reported finding no differences between any two agents in hospital discharge or mortality hazard ratio.
“We’re not suggesting the benzodiazepines as routine sedative agents in our patient populations,” Dr. Fraser said in his presentation. “The primary reason is that they result in a longer time on the vent, typically between 1 and 2 days.”
But this doesn’t mean that the benzodiazepines are the “devil’s handiwork,” he added, noting that they may be useful in patients with anxiety related to ventilator weaning and those recovering from hemodynamic instability or at risk for GABA-agonist withdrawal.
Dexmedetomidine is opioid sparing and has a minimal effect on respiratory drive, among other advantages; however, some potential drawbacks include its hemodynamic effects and its cost, according to Dr. Fraser.
Dr. Fraser said that his institution’s daily acquisition cost for dexmedetomidine is $500, compared with $120 for propofol and $40 for benzodiazepines, but some pharmacoeconomic evaluations suggest use of dexmedetomidine may actually save between $3,000 and $9,000 per ICU admission. “At least in our place, one day in the ICU costs about $5,000, so that all makes sense … and I can argue fairly effectively that dexmedetomidine really isn’t that expensive compared to midazolam,” he said.
Dr. Fraser said that he had no disclosures related to his presentation.
SAN ANTONIO – Among medications to facilitate extubation, dexmedetomidine offers favorable attributes, but whether it’s the best choice for patients who have difficulty being liberated from the ventilator remains to be proven, said Gilles L. Fraser, BS Pharm, PharmD.
The current CHEST/ATS guidelines on liberation from mechanical ventilation in critically ill adults strongly suggest extubation to noninvasive mechanical ventilation in high-risk patients (Chest. 2017 Jan;151[1]:160-5. doi: 10.1016/j.chest.2016.10.037). Guideline authors also suggested protocols attempting to minimize sedation for acutely hospitalized patients ventilated for more than 24 hours, based on some evidence showing a trend toward shorter ventilation time and ICU stay, as well as lower short-term mortality.
, one of the coauthors of the guidelines, during his presentation at the Critical Care Congress sponsored by the Society for Critical Care Medicine.
“I’ll leave you up to your own devices,” he told attendees at a session on conundrums in critical care that are not addressed in current guidelines. “We use it all the time, frankly, but I don’t have any firm data to support that contention.”
Despite best practices, extubation attempts are not always successful: “If you follow the rules of the road, success is going to occur about 85% of the time,” said Dr. Fraser, who is a clinical pharmacist at Maine Medical Center, Portland, and professor of medicine at Tufts University, Boston. “That means that about 15% of our patients have difficulties in being liberated from the ventilator.”
In terms of medications to facilitate ventilator liberation, benzodiazepines, dexmedetomidine, and propofol all have roles to play, according to Dr. Fraser. Clinicians have to consider agent-specific side effects, pharmacokinetics and dynamics, and “econotoxicity,” or the cost of care, he added.
Although there are few comparative data available to guide choice of medication, Dr. Fraser and his colleagues have published a systematic review and meta-analysis of randomized trials of benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adult patients (Crit Care Med. 2013 Sep;41[9 Suppl 1]:S30-8. doi: 10.1097/CCM.0b013e3182a16898).
They found that dexmedetomidine- or propofol-based sedation regimens appeared to reduce mechanical ventilation duration and length of ICU stay versus benzodiazepine-based sedation, but they stated that larger controlled studies would be needed to further define outcomes in this setting.
More recently, other investigators reported an evaluation of 9,603 consecutive mechanical ventilation episodes (Chest. 2016 Jun;149[6]:1373-9. doi: 10.1378/chest.15-1389). In this large, real-world experience, propofol and dexmedetomidine were both associated with less time to extubation versus benzodiazepines, and dexmedetomidine was associated with less time to extubation versus propofol.
Relatively few patients (about 12%), however, received dexmedetomidine in that large series, and that was mostly in the setting of cardiac surgery, Dr. Fraser noted. Moreover, the investigators reported finding no differences between any two agents in hospital discharge or mortality hazard ratio.
“We’re not suggesting the benzodiazepines as routine sedative agents in our patient populations,” Dr. Fraser said in his presentation. “The primary reason is that they result in a longer time on the vent, typically between 1 and 2 days.”
But this doesn’t mean that the benzodiazepines are the “devil’s handiwork,” he added, noting that they may be useful in patients with anxiety related to ventilator weaning and those recovering from hemodynamic instability or at risk for GABA-agonist withdrawal.
Dexmedetomidine is opioid sparing and has a minimal effect on respiratory drive, among other advantages; however, some potential drawbacks include its hemodynamic effects and its cost, according to Dr. Fraser.
Dr. Fraser said that his institution’s daily acquisition cost for dexmedetomidine is $500, compared with $120 for propofol and $40 for benzodiazepines, but some pharmacoeconomic evaluations suggest use of dexmedetomidine may actually save between $3,000 and $9,000 per ICU admission. “At least in our place, one day in the ICU costs about $5,000, so that all makes sense … and I can argue fairly effectively that dexmedetomidine really isn’t that expensive compared to midazolam,” he said.
Dr. Fraser said that he had no disclosures related to his presentation.
EXPERT ANALYSIS FROM CCC47
Combo therapy does not improve outcomes for A. Baumannii
, based on data from 406 patients.
In a study published online in The Lancet Infectious Diseases, Mical Paul, MD, of Rambam Health Care Campus, Haifa, Israel, and colleagues randomized 198 patients to colistin alone and 208 to colistin plus meropenem (Lancet Infect Dis. 2018 Feb 15. doi: 10.1016/S1473-3099[18]30099-9).
The demographics were similar between the groups and approximately 77% of patients in each group were infected with A. baumannii.
The results highlight “the necessity of assessing combination therapy in randomized trials before adopting it into clinical use,” the researchers said.
The study was not designed to examine the effect of the two types of therapy on bacteria other than A. baumannii, the researchers noted. However, based on the findings, “we recommend against the routine use of carbapenems for the treatment of carbapenem-resistant A. baumannii infections,” they said.
The study was supported by EU AIDA grant Health-F3-2011-278348. Dr. Paul had no financial conflicts to disclose.
SOURCE: Paul M et al. Lancet Infect Dis. 2018 Feb 15. doi: 10.1016/S1473-3099(18)30099-9.
, based on data from 406 patients.
In a study published online in The Lancet Infectious Diseases, Mical Paul, MD, of Rambam Health Care Campus, Haifa, Israel, and colleagues randomized 198 patients to colistin alone and 208 to colistin plus meropenem (Lancet Infect Dis. 2018 Feb 15. doi: 10.1016/S1473-3099[18]30099-9).
The demographics were similar between the groups and approximately 77% of patients in each group were infected with A. baumannii.
The results highlight “the necessity of assessing combination therapy in randomized trials before adopting it into clinical use,” the researchers said.
The study was not designed to examine the effect of the two types of therapy on bacteria other than A. baumannii, the researchers noted. However, based on the findings, “we recommend against the routine use of carbapenems for the treatment of carbapenem-resistant A. baumannii infections,” they said.
The study was supported by EU AIDA grant Health-F3-2011-278348. Dr. Paul had no financial conflicts to disclose.
SOURCE: Paul M et al. Lancet Infect Dis. 2018 Feb 15. doi: 10.1016/S1473-3099(18)30099-9.
, based on data from 406 patients.
In a study published online in The Lancet Infectious Diseases, Mical Paul, MD, of Rambam Health Care Campus, Haifa, Israel, and colleagues randomized 198 patients to colistin alone and 208 to colistin plus meropenem (Lancet Infect Dis. 2018 Feb 15. doi: 10.1016/S1473-3099[18]30099-9).
The demographics were similar between the groups and approximately 77% of patients in each group were infected with A. baumannii.
The results highlight “the necessity of assessing combination therapy in randomized trials before adopting it into clinical use,” the researchers said.
The study was not designed to examine the effect of the two types of therapy on bacteria other than A. baumannii, the researchers noted. However, based on the findings, “we recommend against the routine use of carbapenems for the treatment of carbapenem-resistant A. baumannii infections,” they said.
The study was supported by EU AIDA grant Health-F3-2011-278348. Dr. Paul had no financial conflicts to disclose.
SOURCE: Paul M et al. Lancet Infect Dis. 2018 Feb 15. doi: 10.1016/S1473-3099(18)30099-9.
FROM THE LANCET INFECTIOUS DISEASES