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Early psychotherapy may predict buprenorphine treatment retention
SAN DIEGO – an observational study found.
“Opioid use disorder and overdose deaths are devastating many communities across the country,” lead study author Ajay Manhapra, MD, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. “We know that engagement in opioid agonist treatment with buprenorphine/methadone is associated with a two-thirds reduction in mortality and lower morbidity. However, 1-year retention rates are generally less than 50%.”
As part of a larger study on 3-year buprenorphine retention, Dr. Manhapra and his associates set out to investigate what factors predict long-term retention in buprenorphine treatment. From patients with an OUD diagnosis in the Marketscan database, they identified 16,190 individuals who filled their prescription of buprenorphine after the first 60 days of 2011 as new starts and calculated the treatment retention period as the time between the date of their first prescription to the last prescription until the end of 2014. The researchers used CPT codes to identify the receipt of any outpatient psychotherapy and multivariate Cox survival analysis to examine the effect of psychotherapy receipt on buprenorphine retention.
Dr. Manhapra reported that of the 16,190 patients, 15% were engaged in buprenorphine treatment for 30 days or fewer, 40% were engaged for 31 days to 1 year, 31% were engaged between 1 and 3 years, and 14% were engaged for more than 3 years. The mean duration of retention was 1.23 years. At the same time, the outpatient psychotherapy receipt rate in 2011 was 30.29% among those retained for 0-30 days, 35.30% among those retained for 31-364 days, 37.59% among those retained for 1-3 years, and 39.20% among those retained for more than 3 years.
Multivariate Cox survival analysis revealed that receipt of any psychotherapy in 2011 was associated with a lower risk of discontinuation of buprenorphine treatment (hazard ratio, 0.86; P less than .0001). “Is this a direct effect of psychotherapy? I don’t know,” said Dr. Manhapra, who also practices at the Hampton (Virginia) VA Medical Center. “Is this a selection bias not accounted for by the variables available? That is, those who have a better chance of sustained retention might have been selected for or chosen to receive psychotherapy. Those are possibilities. We need further observational and qualitative studies, and maybe more randomized trials.”
Dr. Manhapra disclosed that he has received support from the VA Interprofessional Fellowship in Addiction Treatment and from Research in Addiction Medicine Scholars.
SOURCE: Manhapra A et al. AAAP 2017. Paper session A5.
SAN DIEGO – an observational study found.
“Opioid use disorder and overdose deaths are devastating many communities across the country,” lead study author Ajay Manhapra, MD, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. “We know that engagement in opioid agonist treatment with buprenorphine/methadone is associated with a two-thirds reduction in mortality and lower morbidity. However, 1-year retention rates are generally less than 50%.”
As part of a larger study on 3-year buprenorphine retention, Dr. Manhapra and his associates set out to investigate what factors predict long-term retention in buprenorphine treatment. From patients with an OUD diagnosis in the Marketscan database, they identified 16,190 individuals who filled their prescription of buprenorphine after the first 60 days of 2011 as new starts and calculated the treatment retention period as the time between the date of their first prescription to the last prescription until the end of 2014. The researchers used CPT codes to identify the receipt of any outpatient psychotherapy and multivariate Cox survival analysis to examine the effect of psychotherapy receipt on buprenorphine retention.
Dr. Manhapra reported that of the 16,190 patients, 15% were engaged in buprenorphine treatment for 30 days or fewer, 40% were engaged for 31 days to 1 year, 31% were engaged between 1 and 3 years, and 14% were engaged for more than 3 years. The mean duration of retention was 1.23 years. At the same time, the outpatient psychotherapy receipt rate in 2011 was 30.29% among those retained for 0-30 days, 35.30% among those retained for 31-364 days, 37.59% among those retained for 1-3 years, and 39.20% among those retained for more than 3 years.
Multivariate Cox survival analysis revealed that receipt of any psychotherapy in 2011 was associated with a lower risk of discontinuation of buprenorphine treatment (hazard ratio, 0.86; P less than .0001). “Is this a direct effect of psychotherapy? I don’t know,” said Dr. Manhapra, who also practices at the Hampton (Virginia) VA Medical Center. “Is this a selection bias not accounted for by the variables available? That is, those who have a better chance of sustained retention might have been selected for or chosen to receive psychotherapy. Those are possibilities. We need further observational and qualitative studies, and maybe more randomized trials.”
Dr. Manhapra disclosed that he has received support from the VA Interprofessional Fellowship in Addiction Treatment and from Research in Addiction Medicine Scholars.
SOURCE: Manhapra A et al. AAAP 2017. Paper session A5.
SAN DIEGO – an observational study found.
“Opioid use disorder and overdose deaths are devastating many communities across the country,” lead study author Ajay Manhapra, MD, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. “We know that engagement in opioid agonist treatment with buprenorphine/methadone is associated with a two-thirds reduction in mortality and lower morbidity. However, 1-year retention rates are generally less than 50%.”
As part of a larger study on 3-year buprenorphine retention, Dr. Manhapra and his associates set out to investigate what factors predict long-term retention in buprenorphine treatment. From patients with an OUD diagnosis in the Marketscan database, they identified 16,190 individuals who filled their prescription of buprenorphine after the first 60 days of 2011 as new starts and calculated the treatment retention period as the time between the date of their first prescription to the last prescription until the end of 2014. The researchers used CPT codes to identify the receipt of any outpatient psychotherapy and multivariate Cox survival analysis to examine the effect of psychotherapy receipt on buprenorphine retention.
Dr. Manhapra reported that of the 16,190 patients, 15% were engaged in buprenorphine treatment for 30 days or fewer, 40% were engaged for 31 days to 1 year, 31% were engaged between 1 and 3 years, and 14% were engaged for more than 3 years. The mean duration of retention was 1.23 years. At the same time, the outpatient psychotherapy receipt rate in 2011 was 30.29% among those retained for 0-30 days, 35.30% among those retained for 31-364 days, 37.59% among those retained for 1-3 years, and 39.20% among those retained for more than 3 years.
Multivariate Cox survival analysis revealed that receipt of any psychotherapy in 2011 was associated with a lower risk of discontinuation of buprenorphine treatment (hazard ratio, 0.86; P less than .0001). “Is this a direct effect of psychotherapy? I don’t know,” said Dr. Manhapra, who also practices at the Hampton (Virginia) VA Medical Center. “Is this a selection bias not accounted for by the variables available? That is, those who have a better chance of sustained retention might have been selected for or chosen to receive psychotherapy. Those are possibilities. We need further observational and qualitative studies, and maybe more randomized trials.”
Dr. Manhapra disclosed that he has received support from the VA Interprofessional Fellowship in Addiction Treatment and from Research in Addiction Medicine Scholars.
SOURCE: Manhapra A et al. AAAP 2017. Paper session A5.
REPORTING FROM AAAP
Key clinical point: Psychotherapy at the beginning of buprenorphine treatment may affect retention in patients with opioid use disorder.
Major finding: Receipt of any psychotherapy in 2011 was associated with a lower risk of discontinuation of buprenorphine treatment by 2014 (hazard ratio, 0.86; P less than .0001).
Study details: An observational study of 16,190 individuals with OUD.
Disclosures: Dr. Manhapra disclosed that he has received support from the VA Interprofessional Fellowship in Addiction Treatment and from Research in Addiction Medicine Scholars.
Source: Manhapra A et al. AAAP 2017. Paper session A5.
Review: Common gastrointestinal conditions in people living with HIV/AIDS
The two most common gastrointestinal conditions reported by people living with HIV/AIDS are diarrhea and nausea, according to Vincent Hall, PhD.
Diarrhea has been reported in up to 60% of people living with HIV/AIDS, and is generally classified as being infectious or noninfectious. While infectious causes of diarrhea, such as bacteria, fungi, viruses, and protozoa, have declined, noninfectious causes have increased. Common causes of noninfectious diarrhea include HIV enteropathy, diarrhea associated with highly active antiretroviral therapy (HAART), autonomic neuropathy, and chronic pancreatitis.
Prior to the development of HAART, nausea in people living with HIV/AIDS was usually caused by opportunistic infections; however, this has changed. Nausea can come from medication side effects, overlapping drug interactions, and from opportunistic infections in patients with poor immune health. The most common side effect of ART is nausea, and nausea is also the most common cause of ART discontinuation.
“It has been noted that HIV infection can be considered a disease of the GI tract because it is a significant target of infection and because of the side effects HAART can have on the GI system. Therefore, it is important that clinicians have an understanding of the causes of diarrhea and nausea and vomiting in people living with HIV/AIDS and educate patients about potential side effects and treatment options,” Mr. Hall concluded.
Find the full review in Critical Care Nursing Clinics of North America (doi: 10.1016/j.cnc.2017.10.009).
The two most common gastrointestinal conditions reported by people living with HIV/AIDS are diarrhea and nausea, according to Vincent Hall, PhD.
Diarrhea has been reported in up to 60% of people living with HIV/AIDS, and is generally classified as being infectious or noninfectious. While infectious causes of diarrhea, such as bacteria, fungi, viruses, and protozoa, have declined, noninfectious causes have increased. Common causes of noninfectious diarrhea include HIV enteropathy, diarrhea associated with highly active antiretroviral therapy (HAART), autonomic neuropathy, and chronic pancreatitis.
Prior to the development of HAART, nausea in people living with HIV/AIDS was usually caused by opportunistic infections; however, this has changed. Nausea can come from medication side effects, overlapping drug interactions, and from opportunistic infections in patients with poor immune health. The most common side effect of ART is nausea, and nausea is also the most common cause of ART discontinuation.
“It has been noted that HIV infection can be considered a disease of the GI tract because it is a significant target of infection and because of the side effects HAART can have on the GI system. Therefore, it is important that clinicians have an understanding of the causes of diarrhea and nausea and vomiting in people living with HIV/AIDS and educate patients about potential side effects and treatment options,” Mr. Hall concluded.
Find the full review in Critical Care Nursing Clinics of North America (doi: 10.1016/j.cnc.2017.10.009).
The two most common gastrointestinal conditions reported by people living with HIV/AIDS are diarrhea and nausea, according to Vincent Hall, PhD.
Diarrhea has been reported in up to 60% of people living with HIV/AIDS, and is generally classified as being infectious or noninfectious. While infectious causes of diarrhea, such as bacteria, fungi, viruses, and protozoa, have declined, noninfectious causes have increased. Common causes of noninfectious diarrhea include HIV enteropathy, diarrhea associated with highly active antiretroviral therapy (HAART), autonomic neuropathy, and chronic pancreatitis.
Prior to the development of HAART, nausea in people living with HIV/AIDS was usually caused by opportunistic infections; however, this has changed. Nausea can come from medication side effects, overlapping drug interactions, and from opportunistic infections in patients with poor immune health. The most common side effect of ART is nausea, and nausea is also the most common cause of ART discontinuation.
“It has been noted that HIV infection can be considered a disease of the GI tract because it is a significant target of infection and because of the side effects HAART can have on the GI system. Therefore, it is important that clinicians have an understanding of the causes of diarrhea and nausea and vomiting in people living with HIV/AIDS and educate patients about potential side effects and treatment options,” Mr. Hall concluded.
Find the full review in Critical Care Nursing Clinics of North America (doi: 10.1016/j.cnc.2017.10.009).
FROM CRITICAL CARE NURSING CLINICS OF NORTH AMERICA
Disparities persist in infant safe sleep practices
Sleep-related deaths among infants in the United States decreased during the 1990s as a result of recommendations to place babies on their backs to sleep. However, the decline has leveled off in recent years, and health care providers should proactively counsel caregivers about safe sleep practices, wrote Jennifer M. Bombard, MSPH, of the Centers for Disease Control and Prevention and her colleagues in a study published online in the Morbidity and Mortality Weekly Report.
Overall, 22% of respondents from 32 states and New York City in 2015 reported placing babies in a position other than their backs to sleep. In addition, 61% of respondents from 14 states reported bed sharing, and 39% from 13 states and New York City reported using soft bedding, including bumper pads and thick blankets.
Unsafe sleep practices varied by maternal demographics; nonsupine sleep positioning was more likely among non-Hispanic blacks, individuals aged 25 years or younger, those with 12 years or less of education, and those participating in the Special Supplemental Nutrition Program for Women, Infants, and Children.
“These findings highlight the need to implement and evaluate interventions to continue improving safe sleep practices,” Ms. Bombard and her associates said.
They cited the Study of Attitudes and Factors Effecting Infant Care Practices, in which caregivers who received appropriate advice on safe sleep practices were significantly less likely to place infants in a nonsupine position to sleep. “Evidence-based approaches to increase use of safe sleep practices include developing health messages and educational tools for caregivers and educating health and child care professionals on safe sleep practices,” they noted.
The study was limited by several factors, including reliance on self reports and inclusion of only states with Pregnancy Risk Assessment Monitoring System records, the researchers said.
Ms. Bombard and her associates had no relevant financial disclosures.
SOURCE: Bombard J et al. MMWR. 2018 Jan 9. doi: 10.15585/mmwr.mm6701e1.
Sleep-related deaths among infants in the United States decreased during the 1990s as a result of recommendations to place babies on their backs to sleep. However, the decline has leveled off in recent years, and health care providers should proactively counsel caregivers about safe sleep practices, wrote Jennifer M. Bombard, MSPH, of the Centers for Disease Control and Prevention and her colleagues in a study published online in the Morbidity and Mortality Weekly Report.
Overall, 22% of respondents from 32 states and New York City in 2015 reported placing babies in a position other than their backs to sleep. In addition, 61% of respondents from 14 states reported bed sharing, and 39% from 13 states and New York City reported using soft bedding, including bumper pads and thick blankets.
Unsafe sleep practices varied by maternal demographics; nonsupine sleep positioning was more likely among non-Hispanic blacks, individuals aged 25 years or younger, those with 12 years or less of education, and those participating in the Special Supplemental Nutrition Program for Women, Infants, and Children.
“These findings highlight the need to implement and evaluate interventions to continue improving safe sleep practices,” Ms. Bombard and her associates said.
They cited the Study of Attitudes and Factors Effecting Infant Care Practices, in which caregivers who received appropriate advice on safe sleep practices were significantly less likely to place infants in a nonsupine position to sleep. “Evidence-based approaches to increase use of safe sleep practices include developing health messages and educational tools for caregivers and educating health and child care professionals on safe sleep practices,” they noted.
The study was limited by several factors, including reliance on self reports and inclusion of only states with Pregnancy Risk Assessment Monitoring System records, the researchers said.
Ms. Bombard and her associates had no relevant financial disclosures.
SOURCE: Bombard J et al. MMWR. 2018 Jan 9. doi: 10.15585/mmwr.mm6701e1.
Sleep-related deaths among infants in the United States decreased during the 1990s as a result of recommendations to place babies on their backs to sleep. However, the decline has leveled off in recent years, and health care providers should proactively counsel caregivers about safe sleep practices, wrote Jennifer M. Bombard, MSPH, of the Centers for Disease Control and Prevention and her colleagues in a study published online in the Morbidity and Mortality Weekly Report.
Overall, 22% of respondents from 32 states and New York City in 2015 reported placing babies in a position other than their backs to sleep. In addition, 61% of respondents from 14 states reported bed sharing, and 39% from 13 states and New York City reported using soft bedding, including bumper pads and thick blankets.
Unsafe sleep practices varied by maternal demographics; nonsupine sleep positioning was more likely among non-Hispanic blacks, individuals aged 25 years or younger, those with 12 years or less of education, and those participating in the Special Supplemental Nutrition Program for Women, Infants, and Children.
“These findings highlight the need to implement and evaluate interventions to continue improving safe sleep practices,” Ms. Bombard and her associates said.
They cited the Study of Attitudes and Factors Effecting Infant Care Practices, in which caregivers who received appropriate advice on safe sleep practices were significantly less likely to place infants in a nonsupine position to sleep. “Evidence-based approaches to increase use of safe sleep practices include developing health messages and educational tools for caregivers and educating health and child care professionals on safe sleep practices,” they noted.
The study was limited by several factors, including reliance on self reports and inclusion of only states with Pregnancy Risk Assessment Monitoring System records, the researchers said.
Ms. Bombard and her associates had no relevant financial disclosures.
SOURCE: Bombard J et al. MMWR. 2018 Jan 9. doi: 10.15585/mmwr.mm6701e1.
FROM MMWR
Key clinical point: Health care providers can improve safe sleep for babies by counseling caregivers.
Major finding: Of respondents from 32 states and New York City in 2015, 22% reported placing babies in a position other than their backs to sleep.
Study details: The data come from the 2009-2015 Pregnancy Risk Assessment Monitoring System.
Disclosures: The researchers had no relevant financial disclosures.
Source: Bombard J et al. MMWR 2018 Jan 9. doi: 10.15585/mmwr.mm6701e1.
Prepregnancy obesity linked to bump in severe morbidity
Having a high or low prepregnancy body mass index was associated with a small absolute increase in severe maternal morbidity and mortality in a large, retrospective cohort study.
Some studies have suggested a link between obesity and pregnancy complications such as preeclampsia, gestational diabetes, thromboembolism, and cesarean delivery. But one study suggested no link between higher BMI and risk of severe morbidity.
Adjustment for weight gain had no significant effect on the observed associations, Sarka Lisonkova, MD, PhD, of B.C. Women’s Hospital & Health Centre in Vancouver and her colleagues reported in JAMA.
Compared with normal weight women (BMI 18.5-24.9), women considered underweight (BMI less than 18.5) had an adjusted odds ratio (aOR) for mortality or severity morbidity of 1.2 (95% confidence interval, 1.0-1.3). Women who were overweight (BMI of 25.0-29.9) had an aOR of 1.1 (95% CI, 1.1-1.2).
The risk was also greater for women with class 1 obesity (BMI, 30.0-34.9; aOR, 1.1; 95% CI, 1.1-1.2), class 2 obesity (BMI, 35.0-39.9; aOR, 1.2; 95% CI, 1.1-1.3), and class 3 obesity (BMI, 40 or greater; aOR, 1.4; 95% CI, 1.3-1.5).
In all cases, the absolute increases in mortality and severe morbidity, compared with normal weight women, were small, ranging from adjusted rated differences of 17.6 per 10,000 for overweight women to 61.1 per 10,000 women with class 3 obesity. Underweight women had an increase of 28.8 per 10,000.
Specifically, underweight women had a higher risk for antepartum and postpartum hemorrhage and acute renal failure, whereas women who were obese had increased risks for respiratory morbidity and thromboembolism, the researchers reported.
The study was funded by the Canadian Institutes of Health Research. Dr. Lisonkova is supported by an award from the Michael Smith Foundation for Health Research. No other financial disclosures were reported.
SOURCE: Lisonkova S et al. JAMA. 2017 Nov 14;318(18):1777-86.
Having a high or low prepregnancy body mass index was associated with a small absolute increase in severe maternal morbidity and mortality in a large, retrospective cohort study.
Some studies have suggested a link between obesity and pregnancy complications such as preeclampsia, gestational diabetes, thromboembolism, and cesarean delivery. But one study suggested no link between higher BMI and risk of severe morbidity.
Adjustment for weight gain had no significant effect on the observed associations, Sarka Lisonkova, MD, PhD, of B.C. Women’s Hospital & Health Centre in Vancouver and her colleagues reported in JAMA.
Compared with normal weight women (BMI 18.5-24.9), women considered underweight (BMI less than 18.5) had an adjusted odds ratio (aOR) for mortality or severity morbidity of 1.2 (95% confidence interval, 1.0-1.3). Women who were overweight (BMI of 25.0-29.9) had an aOR of 1.1 (95% CI, 1.1-1.2).
The risk was also greater for women with class 1 obesity (BMI, 30.0-34.9; aOR, 1.1; 95% CI, 1.1-1.2), class 2 obesity (BMI, 35.0-39.9; aOR, 1.2; 95% CI, 1.1-1.3), and class 3 obesity (BMI, 40 or greater; aOR, 1.4; 95% CI, 1.3-1.5).
In all cases, the absolute increases in mortality and severe morbidity, compared with normal weight women, were small, ranging from adjusted rated differences of 17.6 per 10,000 for overweight women to 61.1 per 10,000 women with class 3 obesity. Underweight women had an increase of 28.8 per 10,000.
Specifically, underweight women had a higher risk for antepartum and postpartum hemorrhage and acute renal failure, whereas women who were obese had increased risks for respiratory morbidity and thromboembolism, the researchers reported.
The study was funded by the Canadian Institutes of Health Research. Dr. Lisonkova is supported by an award from the Michael Smith Foundation for Health Research. No other financial disclosures were reported.
SOURCE: Lisonkova S et al. JAMA. 2017 Nov 14;318(18):1777-86.
Having a high or low prepregnancy body mass index was associated with a small absolute increase in severe maternal morbidity and mortality in a large, retrospective cohort study.
Some studies have suggested a link between obesity and pregnancy complications such as preeclampsia, gestational diabetes, thromboembolism, and cesarean delivery. But one study suggested no link between higher BMI and risk of severe morbidity.
Adjustment for weight gain had no significant effect on the observed associations, Sarka Lisonkova, MD, PhD, of B.C. Women’s Hospital & Health Centre in Vancouver and her colleagues reported in JAMA.
Compared with normal weight women (BMI 18.5-24.9), women considered underweight (BMI less than 18.5) had an adjusted odds ratio (aOR) for mortality or severity morbidity of 1.2 (95% confidence interval, 1.0-1.3). Women who were overweight (BMI of 25.0-29.9) had an aOR of 1.1 (95% CI, 1.1-1.2).
The risk was also greater for women with class 1 obesity (BMI, 30.0-34.9; aOR, 1.1; 95% CI, 1.1-1.2), class 2 obesity (BMI, 35.0-39.9; aOR, 1.2; 95% CI, 1.1-1.3), and class 3 obesity (BMI, 40 or greater; aOR, 1.4; 95% CI, 1.3-1.5).
In all cases, the absolute increases in mortality and severe morbidity, compared with normal weight women, were small, ranging from adjusted rated differences of 17.6 per 10,000 for overweight women to 61.1 per 10,000 women with class 3 obesity. Underweight women had an increase of 28.8 per 10,000.
Specifically, underweight women had a higher risk for antepartum and postpartum hemorrhage and acute renal failure, whereas women who were obese had increased risks for respiratory morbidity and thromboembolism, the researchers reported.
The study was funded by the Canadian Institutes of Health Research. Dr. Lisonkova is supported by an award from the Michael Smith Foundation for Health Research. No other financial disclosures were reported.
SOURCE: Lisonkova S et al. JAMA. 2017 Nov 14;318(18):1777-86.
FROM JAMA
Key clinical point: Major finding: Severe morbidity and mortality risk was increased by 20% in women with prepregnancy class 2 obesity and 40% in women with class 3 obesity.
Study details: Retrospective analysis of 743,630 singleton pregnancies in Washington state between 2004 and 2013.
Disclosures: The study was funded by the Canadian Institutes of Health Research. Dr. Lisonkova is supported by an award from the Michael Smith Foundation for Health Research. No other financial disclosures were reported.
Source: Lisonkova S et al. JAMA. 2017 Nov 14;318(18):1777-86.
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There is a link between obesity and maternal complications during pregnancy, but a causal relationship has not been established. It could be that obese women are inherently at greater risk of mortality, or it could be that physicians have a harder time managing severe conditions in women who are obese.
One way to better understand the problem is to study obesity and severe maternal morbidity in pregnant women because the severe morbidity may precede and add to the increased mortality rates that are being seen among obese pregnant women.
The results of the current study support the idea that the association between class 3 obesity and severe complications in pregnancy may play a role in the increased risk of maternal mortality that was also observed.
The results also suggest that physicians caring for women of childbearing age should emphasize the importance of achieving optimal body mass index in reducing pregnancy complications.
Aaron B. Caughey, MD, PhD, is the chair of the department of obstetrics and gynecology at Oregon Health and Science University, Portland. His comments are adapted from an accompanying editorial (JAMA. 2017;318[18]:1765-6). Dr. Caughey reported having no financial disclosures.
APA guideline backs naltrexone, acamprosate for alcohol use disorder
Naltrexone or acamprosate should be offered as first-line pharmacologic therapy to patients with moderate to severe alcohol use disorder (AUD) who do not respond to nonpharmacologic therapy alone, according to a practice guideline published by the American Psychiatric Association.
if naltrexone and acamprosate are not effective or well tolerated, the report said.
The APA guideline recommends against the use of antidepressants and benzodiazepines for patients with alcohol use disorder, except for situations where a co-occurring disorder requires treatment. In addition, the guideline recommends against the use of acamprosate in patients with renal impairment, and specifies that naltrexone should not be used by patients with acute hepatitis, hepatic failure, or opioid dependence.
“Naltrexone and acamprosate have the best available evidence as pharmacotherapy for patients with AUD,” wrote Victor I. Reus, MD, and his coauthors in the APA Guideline Writing Group, which formed the guideline using a systematic review of current literature in accordance with Institute of Medicine (now called the National Academy of Medicine) and Agency for Healthcare Research and Quality standards.
Naltrexone, an opioid receptor antagonist, is effective in treating both AUD and opioid use disorder. Studies have shown that it may decrease cravings, and is associated with fewer drinking days and a reduced likelihood of return to drinking, the authors reported. In patients with a history of renal impairment, serum creatinine should be measured, and results should be reviewed before initiating treatment with acamprosate – a synthetic amino acid.
Disulfiram breaks down acetaldehyde, an ethanol byproduct, and should be used only to treat patients with a goal of abstinence. It is not recommended as a first-line therapy because of the side effects of concurrent alcohol use, including tachycardia, flushing, headache, nausea, and vomiting, reported Dr. Reus of the psychiatry department at the University of California, San Francisco, and his coauthors.
“Patients should be fully informed of the physiological consequences of consuming alcohol while taking disulfiram and should agree to taking the medication,” the authors wrote. “They should be instructed to abstain from drinking alcohol for at least 12 hours before taking a dose of the medication and be advised that reactions with alcohol can occur up to 14 days after taking disulfiram.”
Lastly, topiramate and gabapentin may be used in patients for whom naltrexone and acamprosate are ineffective, though topiramate may have side effects of concern to the patient, including cognitive dysfunction and numbness, tingling, paresthesias, dizziness, taste abnormalities, and decreased appetite or weight loss, the report said.
Although the APA guideline acknowledges the importance of psychiatric evaluation and nonpharmacologic treatments such as cognitive-behavioral therapy and 12-step programs, it does not provide recommendations on those treatment options.
Further research on alcohol use disorder should include study of quantitative measures for longitudinal monitoring, co-occurring medical and psychiatric conditions, and the effectiveness of naltrexone versus combination therapy for patients with both AUD and opioid use disorder, the authors said.
“The overall goal of this guideline is to enhance the treatment of AUD for millions of affected individuals, thereby reducing the significant psychosocial and public health consequences of this important psychiatric condition,” the report concluded. An executive summary of the guideline was published in the American Journal of Psychiatry.
The guideline authors disclosed no conflicts of interest with their work on the guideline.
SOURCE: Reus VI et al. Am J Psychiatry. 2018;175:86-90.
Naltrexone or acamprosate should be offered as first-line pharmacologic therapy to patients with moderate to severe alcohol use disorder (AUD) who do not respond to nonpharmacologic therapy alone, according to a practice guideline published by the American Psychiatric Association.
if naltrexone and acamprosate are not effective or well tolerated, the report said.
The APA guideline recommends against the use of antidepressants and benzodiazepines for patients with alcohol use disorder, except for situations where a co-occurring disorder requires treatment. In addition, the guideline recommends against the use of acamprosate in patients with renal impairment, and specifies that naltrexone should not be used by patients with acute hepatitis, hepatic failure, or opioid dependence.
“Naltrexone and acamprosate have the best available evidence as pharmacotherapy for patients with AUD,” wrote Victor I. Reus, MD, and his coauthors in the APA Guideline Writing Group, which formed the guideline using a systematic review of current literature in accordance with Institute of Medicine (now called the National Academy of Medicine) and Agency for Healthcare Research and Quality standards.
Naltrexone, an opioid receptor antagonist, is effective in treating both AUD and opioid use disorder. Studies have shown that it may decrease cravings, and is associated with fewer drinking days and a reduced likelihood of return to drinking, the authors reported. In patients with a history of renal impairment, serum creatinine should be measured, and results should be reviewed before initiating treatment with acamprosate – a synthetic amino acid.
Disulfiram breaks down acetaldehyde, an ethanol byproduct, and should be used only to treat patients with a goal of abstinence. It is not recommended as a first-line therapy because of the side effects of concurrent alcohol use, including tachycardia, flushing, headache, nausea, and vomiting, reported Dr. Reus of the psychiatry department at the University of California, San Francisco, and his coauthors.
“Patients should be fully informed of the physiological consequences of consuming alcohol while taking disulfiram and should agree to taking the medication,” the authors wrote. “They should be instructed to abstain from drinking alcohol for at least 12 hours before taking a dose of the medication and be advised that reactions with alcohol can occur up to 14 days after taking disulfiram.”
Lastly, topiramate and gabapentin may be used in patients for whom naltrexone and acamprosate are ineffective, though topiramate may have side effects of concern to the patient, including cognitive dysfunction and numbness, tingling, paresthesias, dizziness, taste abnormalities, and decreased appetite or weight loss, the report said.
Although the APA guideline acknowledges the importance of psychiatric evaluation and nonpharmacologic treatments such as cognitive-behavioral therapy and 12-step programs, it does not provide recommendations on those treatment options.
Further research on alcohol use disorder should include study of quantitative measures for longitudinal monitoring, co-occurring medical and psychiatric conditions, and the effectiveness of naltrexone versus combination therapy for patients with both AUD and opioid use disorder, the authors said.
“The overall goal of this guideline is to enhance the treatment of AUD for millions of affected individuals, thereby reducing the significant psychosocial and public health consequences of this important psychiatric condition,” the report concluded. An executive summary of the guideline was published in the American Journal of Psychiatry.
The guideline authors disclosed no conflicts of interest with their work on the guideline.
SOURCE: Reus VI et al. Am J Psychiatry. 2018;175:86-90.
Naltrexone or acamprosate should be offered as first-line pharmacologic therapy to patients with moderate to severe alcohol use disorder (AUD) who do not respond to nonpharmacologic therapy alone, according to a practice guideline published by the American Psychiatric Association.
if naltrexone and acamprosate are not effective or well tolerated, the report said.
The APA guideline recommends against the use of antidepressants and benzodiazepines for patients with alcohol use disorder, except for situations where a co-occurring disorder requires treatment. In addition, the guideline recommends against the use of acamprosate in patients with renal impairment, and specifies that naltrexone should not be used by patients with acute hepatitis, hepatic failure, or opioid dependence.
“Naltrexone and acamprosate have the best available evidence as pharmacotherapy for patients with AUD,” wrote Victor I. Reus, MD, and his coauthors in the APA Guideline Writing Group, which formed the guideline using a systematic review of current literature in accordance with Institute of Medicine (now called the National Academy of Medicine) and Agency for Healthcare Research and Quality standards.
Naltrexone, an opioid receptor antagonist, is effective in treating both AUD and opioid use disorder. Studies have shown that it may decrease cravings, and is associated with fewer drinking days and a reduced likelihood of return to drinking, the authors reported. In patients with a history of renal impairment, serum creatinine should be measured, and results should be reviewed before initiating treatment with acamprosate – a synthetic amino acid.
Disulfiram breaks down acetaldehyde, an ethanol byproduct, and should be used only to treat patients with a goal of abstinence. It is not recommended as a first-line therapy because of the side effects of concurrent alcohol use, including tachycardia, flushing, headache, nausea, and vomiting, reported Dr. Reus of the psychiatry department at the University of California, San Francisco, and his coauthors.
“Patients should be fully informed of the physiological consequences of consuming alcohol while taking disulfiram and should agree to taking the medication,” the authors wrote. “They should be instructed to abstain from drinking alcohol for at least 12 hours before taking a dose of the medication and be advised that reactions with alcohol can occur up to 14 days after taking disulfiram.”
Lastly, topiramate and gabapentin may be used in patients for whom naltrexone and acamprosate are ineffective, though topiramate may have side effects of concern to the patient, including cognitive dysfunction and numbness, tingling, paresthesias, dizziness, taste abnormalities, and decreased appetite or weight loss, the report said.
Although the APA guideline acknowledges the importance of psychiatric evaluation and nonpharmacologic treatments such as cognitive-behavioral therapy and 12-step programs, it does not provide recommendations on those treatment options.
Further research on alcohol use disorder should include study of quantitative measures for longitudinal monitoring, co-occurring medical and psychiatric conditions, and the effectiveness of naltrexone versus combination therapy for patients with both AUD and opioid use disorder, the authors said.
“The overall goal of this guideline is to enhance the treatment of AUD for millions of affected individuals, thereby reducing the significant psychosocial and public health consequences of this important psychiatric condition,” the report concluded. An executive summary of the guideline was published in the American Journal of Psychiatry.
The guideline authors disclosed no conflicts of interest with their work on the guideline.
SOURCE: Reus VI et al. Am J Psychiatry. 2018;175:86-90.
FROM THE AMERICAN JOURNAL OF PSYCHIATRY
Mutations on LRRK2 gene modify risks for both Crohn’s and Parkinson’s
Crohn’s and Parkinson’s diseases seem to share a common genetic risk pathway, mediated by mutations in a gene that modify disease risk in both directions.
A multidisciplinary collaboration of researchers have discovered that the Crohn’s risk variant N2081D in the leucine-rich repeat kinase 2 (LRRK2) gene lies close to variant G2019S, the major genetic risk factor for both sporadic and familial Parkinson’s. However, protective mutations also occur in the LRRK2 gene, and Ken Y. Hui, MD, of Yale University, New Haven, Conn., and his associates identified two that, when combined, significantly decrease the risk of Crohn’s.
The team first discovered the association in an exome sequencing study of 50 Crohn’s patients of Ashkenazi Jewish descent. This identified more than 4,000 potentially high-yield mutations, which they then examined in a pure Ashkenazi cohort of 1,477 Crohn’s patients and 2,614 healthy controls.
In this phase, the researchers found that N2081D in LRRK2 was associated with a 73% increased odds of Crohn’s. The LRRK2 N551K variant was associated with protection against Crohn’s, reducing odds for the disease by 35% (odds ratio, 0.65), as was R1398H, which conferred a 29% reduction in the likelihood of developing the disease (OR, 0.71). It has been known that these two mutations can combine to provide a protective genetic signature, and the team investigated this compound interaction as well.
After repeated analyses in large, unique case-control cohorts and tissue samples, they determined that the N2081D allele increased the odds of Crohn’s by 70% in the Ashkenazi subjects and by 60% in non-Ashkenazi subjects. The allele was associated with a 10% increased likelihood of Parkinson’s among the Ashkenazi cohort and a 30% increased likelihood among the non-Ashkenazi cohort.
The researchers also examined the two protective alleles, N551K and R1398H, in these further analyses. In the Ashkenazi cohort, N551K decreased the likelihood of Crohn’s by 33%, and it decreased the likelihood of Parkinson’s by 23% in non-Ashkenazi subjects (OR, 0.67 and 0.77, respectively).
In the Ashkenazi cohort, R1398H reduced the odds of Crohn’s by 29% and the odds of Parkinson’s by 16% (OR, 0.71 and 0.84, respectively). In the non-Ashkenazi cohort, the risk reduction was not significant.
Finally, they examined the effect of the mutations on macrophages isolated from four Crohn’s patients who carried the N2081D allele, as well as five patients with the two protective mutations N551K and R1398H and four patients with no mutation. When the macrophages were put in nutrient starvation, those from the N2081D carriers exhibited impaired resting acetylation of alpha-tubulin and poor response to cellular stress. Decreased alpha-tubulin acetylation is associated with poor protein transport through the cytoskeleton. “In contrast, the highest basal acetylation of alpha-tubulin was detected in macrophages of noncarriers and carriers of the protective N551K + R1398H mutations,” the investigators wrote.
“Our study strongly implicates the contribution of LRRK2 in Crohn’s disease risk,” they concluded. “The LRRK2 N2081D risk allele and the N551K/R1398H protective alleles, as well as numerous other variants within the LRRK2 locus, revealed shared genetic effects between Crohn’s and Parkinson’s risk, providing a potential biological basis for clinical co-occurrence. Our findings suggest that LRRK2 may be a useful target for developing drugs to treat Crohn’s disease.”
The research was supported by a variety of grants from the National Institutes of Health, the National Science Foundation, and various other foundations. Five of the authors reported consulting for various pharmaceutical companies or companies selling genetic information products. None of the other authors had relevant disclosures.
SOURCE: Hui K et al. Sci Transl Med. 2018. doi: 10.1126/scitranslmed.aai7795
Crohn’s and Parkinson’s diseases seem to share a common genetic risk pathway, mediated by mutations in a gene that modify disease risk in both directions.
A multidisciplinary collaboration of researchers have discovered that the Crohn’s risk variant N2081D in the leucine-rich repeat kinase 2 (LRRK2) gene lies close to variant G2019S, the major genetic risk factor for both sporadic and familial Parkinson’s. However, protective mutations also occur in the LRRK2 gene, and Ken Y. Hui, MD, of Yale University, New Haven, Conn., and his associates identified two that, when combined, significantly decrease the risk of Crohn’s.
The team first discovered the association in an exome sequencing study of 50 Crohn’s patients of Ashkenazi Jewish descent. This identified more than 4,000 potentially high-yield mutations, which they then examined in a pure Ashkenazi cohort of 1,477 Crohn’s patients and 2,614 healthy controls.
In this phase, the researchers found that N2081D in LRRK2 was associated with a 73% increased odds of Crohn’s. The LRRK2 N551K variant was associated with protection against Crohn’s, reducing odds for the disease by 35% (odds ratio, 0.65), as was R1398H, which conferred a 29% reduction in the likelihood of developing the disease (OR, 0.71). It has been known that these two mutations can combine to provide a protective genetic signature, and the team investigated this compound interaction as well.
After repeated analyses in large, unique case-control cohorts and tissue samples, they determined that the N2081D allele increased the odds of Crohn’s by 70% in the Ashkenazi subjects and by 60% in non-Ashkenazi subjects. The allele was associated with a 10% increased likelihood of Parkinson’s among the Ashkenazi cohort and a 30% increased likelihood among the non-Ashkenazi cohort.
The researchers also examined the two protective alleles, N551K and R1398H, in these further analyses. In the Ashkenazi cohort, N551K decreased the likelihood of Crohn’s by 33%, and it decreased the likelihood of Parkinson’s by 23% in non-Ashkenazi subjects (OR, 0.67 and 0.77, respectively).
In the Ashkenazi cohort, R1398H reduced the odds of Crohn’s by 29% and the odds of Parkinson’s by 16% (OR, 0.71 and 0.84, respectively). In the non-Ashkenazi cohort, the risk reduction was not significant.
Finally, they examined the effect of the mutations on macrophages isolated from four Crohn’s patients who carried the N2081D allele, as well as five patients with the two protective mutations N551K and R1398H and four patients with no mutation. When the macrophages were put in nutrient starvation, those from the N2081D carriers exhibited impaired resting acetylation of alpha-tubulin and poor response to cellular stress. Decreased alpha-tubulin acetylation is associated with poor protein transport through the cytoskeleton. “In contrast, the highest basal acetylation of alpha-tubulin was detected in macrophages of noncarriers and carriers of the protective N551K + R1398H mutations,” the investigators wrote.
“Our study strongly implicates the contribution of LRRK2 in Crohn’s disease risk,” they concluded. “The LRRK2 N2081D risk allele and the N551K/R1398H protective alleles, as well as numerous other variants within the LRRK2 locus, revealed shared genetic effects between Crohn’s and Parkinson’s risk, providing a potential biological basis for clinical co-occurrence. Our findings suggest that LRRK2 may be a useful target for developing drugs to treat Crohn’s disease.”
The research was supported by a variety of grants from the National Institutes of Health, the National Science Foundation, and various other foundations. Five of the authors reported consulting for various pharmaceutical companies or companies selling genetic information products. None of the other authors had relevant disclosures.
SOURCE: Hui K et al. Sci Transl Med. 2018. doi: 10.1126/scitranslmed.aai7795
Crohn’s and Parkinson’s diseases seem to share a common genetic risk pathway, mediated by mutations in a gene that modify disease risk in both directions.
A multidisciplinary collaboration of researchers have discovered that the Crohn’s risk variant N2081D in the leucine-rich repeat kinase 2 (LRRK2) gene lies close to variant G2019S, the major genetic risk factor for both sporadic and familial Parkinson’s. However, protective mutations also occur in the LRRK2 gene, and Ken Y. Hui, MD, of Yale University, New Haven, Conn., and his associates identified two that, when combined, significantly decrease the risk of Crohn’s.
The team first discovered the association in an exome sequencing study of 50 Crohn’s patients of Ashkenazi Jewish descent. This identified more than 4,000 potentially high-yield mutations, which they then examined in a pure Ashkenazi cohort of 1,477 Crohn’s patients and 2,614 healthy controls.
In this phase, the researchers found that N2081D in LRRK2 was associated with a 73% increased odds of Crohn’s. The LRRK2 N551K variant was associated with protection against Crohn’s, reducing odds for the disease by 35% (odds ratio, 0.65), as was R1398H, which conferred a 29% reduction in the likelihood of developing the disease (OR, 0.71). It has been known that these two mutations can combine to provide a protective genetic signature, and the team investigated this compound interaction as well.
After repeated analyses in large, unique case-control cohorts and tissue samples, they determined that the N2081D allele increased the odds of Crohn’s by 70% in the Ashkenazi subjects and by 60% in non-Ashkenazi subjects. The allele was associated with a 10% increased likelihood of Parkinson’s among the Ashkenazi cohort and a 30% increased likelihood among the non-Ashkenazi cohort.
The researchers also examined the two protective alleles, N551K and R1398H, in these further analyses. In the Ashkenazi cohort, N551K decreased the likelihood of Crohn’s by 33%, and it decreased the likelihood of Parkinson’s by 23% in non-Ashkenazi subjects (OR, 0.67 and 0.77, respectively).
In the Ashkenazi cohort, R1398H reduced the odds of Crohn’s by 29% and the odds of Parkinson’s by 16% (OR, 0.71 and 0.84, respectively). In the non-Ashkenazi cohort, the risk reduction was not significant.
Finally, they examined the effect of the mutations on macrophages isolated from four Crohn’s patients who carried the N2081D allele, as well as five patients with the two protective mutations N551K and R1398H and four patients with no mutation. When the macrophages were put in nutrient starvation, those from the N2081D carriers exhibited impaired resting acetylation of alpha-tubulin and poor response to cellular stress. Decreased alpha-tubulin acetylation is associated with poor protein transport through the cytoskeleton. “In contrast, the highest basal acetylation of alpha-tubulin was detected in macrophages of noncarriers and carriers of the protective N551K + R1398H mutations,” the investigators wrote.
“Our study strongly implicates the contribution of LRRK2 in Crohn’s disease risk,” they concluded. “The LRRK2 N2081D risk allele and the N551K/R1398H protective alleles, as well as numerous other variants within the LRRK2 locus, revealed shared genetic effects between Crohn’s and Parkinson’s risk, providing a potential biological basis for clinical co-occurrence. Our findings suggest that LRRK2 may be a useful target for developing drugs to treat Crohn’s disease.”
The research was supported by a variety of grants from the National Institutes of Health, the National Science Foundation, and various other foundations. Five of the authors reported consulting for various pharmaceutical companies or companies selling genetic information products. None of the other authors had relevant disclosures.
SOURCE: Hui K et al. Sci Transl Med. 2018. doi: 10.1126/scitranslmed.aai7795
FROM SCIENCE TRANSLATIONAL MEDICINE
Key clinical point:
Major finding: Variant N2081D in LRRK2 was associated with a 73% increased risk of Crohn’s.
Study details: The study comprised data from 30,269 patients and controls.
Disclosures: The research was supported by a variety of grants from the National Institutes of Health, the National Science Foundation, and various other foundations. Five of the authors reported consulting for various pharmaceutical companies or companies selling genetic information products. None of the other authors had relevant disclosures.
Source: Hui K et al. Sci Transl Med. 2018. doi: 10.1126/scitranslmed.aai7795
Debunking Acne Myths: Do Patients Need to Worry About Acne After Adolescence?
Myth: Acne only occurs in teenagers
Acne typically is associated with teenagers and puberty, and many adult patients may not be aware that acne can persist beyond adolescence or even develop for the first time in adulthood. As the prevalence of adults with acne increases, it is important to educate this population about factors associated with postadolescent acne development and let them know that effective treatments are available.
There are 2 types of adult acne: persistent acne, which refers to adolescent acne that continues beyond 25 years of age, and late-onset acne, which develops for the first time after 25 years of age. Adult acne generally is mild to moderate in severity and may be refractory to treatment. Unlike adolescent acne, which is more prominent in adolescent boys and manifests as the more severe forms of the disease, adult acne primarily affects women and is more inflammatory in nature, making these patients more susceptible to scarring. In one study, acne prevalence among 1055 adult participants (age range, 20–60 years) was estimated at 61.5%; however, only 36.8% were aware of their condition and only 25% sought treatment. The most commonly affected area was the malar region, which differs from acne seen in teenagers. In addition to the cheeks, adult acne generally is more prominent on the lower chin, jawline, and neck, and lesions more commonly present as closed comedones.
Fluctuating hormone levels are a common cause of adult acne, particularly in women during menses or pregnancy, menopause, or perimenopause; women also may experience breakouts after starting or discontinuing birth control pills. Acne flare-ups in adults also have been linked to chronic stress, family history, hair and skin care products, medication side effects, undiagnosed medical conditions, steroid use, increased calorie intake, whole and fat-reduced milk consumption, and tobacco smoking. Adult acne also has been found to be associated with other dermatologic conditions including hirsutism, alopecia, and seborrhea.
Early diagnosis and treatment of adult acne is crucial to ensure good cosmetic outcomes and minimize disease burden. When treating adult acne, particularly in women, dermatologists should consider a variety of factors that set this condition apart from adolescent acne, including the predisposition of older skin to irritation, possible slow response to treatment, a high likelihood of good adherence to treatment, and the psychosocial impact of acne in the adult population. In adult women, it also is important to consider whether patients are of childbearing age when selecting a treatment. Patients also should be encouraged to read the labels on their personal care products to ensure they are noncomedogenic and will not clog pores.
Adult acne. American Academy of Dermatology website. https://www.aad.org/public/diseases/acne-and-rosacea/adult-acne. Accessed January 9, 2018.
Dréno B, Layton A, Zouboulis CC, et al. Adult female acne: a new paradigm [published online January 10, 2013]. J Eur Acad Dermatol Venereol. 2013;27:1063-1070.
Khunger N, Kumar C. A clinic-epidemiological study of adult acne: is it different from adolescent acne? Indian J Dermatol Venereol Leprol. 2012;78:335-341.
Semedo D, Ladeiro F, Ruivo M, et al. Adult acne: prevalence and portrayal in primary healthcare patients, in the Great Porto Area, Portugal [published online September 30, 2016]. Acta Med Port. 2016;29:507-513.
Myth: Acne only occurs in teenagers
Acne typically is associated with teenagers and puberty, and many adult patients may not be aware that acne can persist beyond adolescence or even develop for the first time in adulthood. As the prevalence of adults with acne increases, it is important to educate this population about factors associated with postadolescent acne development and let them know that effective treatments are available.
There are 2 types of adult acne: persistent acne, which refers to adolescent acne that continues beyond 25 years of age, and late-onset acne, which develops for the first time after 25 years of age. Adult acne generally is mild to moderate in severity and may be refractory to treatment. Unlike adolescent acne, which is more prominent in adolescent boys and manifests as the more severe forms of the disease, adult acne primarily affects women and is more inflammatory in nature, making these patients more susceptible to scarring. In one study, acne prevalence among 1055 adult participants (age range, 20–60 years) was estimated at 61.5%; however, only 36.8% were aware of their condition and only 25% sought treatment. The most commonly affected area was the malar region, which differs from acne seen in teenagers. In addition to the cheeks, adult acne generally is more prominent on the lower chin, jawline, and neck, and lesions more commonly present as closed comedones.
Fluctuating hormone levels are a common cause of adult acne, particularly in women during menses or pregnancy, menopause, or perimenopause; women also may experience breakouts after starting or discontinuing birth control pills. Acne flare-ups in adults also have been linked to chronic stress, family history, hair and skin care products, medication side effects, undiagnosed medical conditions, steroid use, increased calorie intake, whole and fat-reduced milk consumption, and tobacco smoking. Adult acne also has been found to be associated with other dermatologic conditions including hirsutism, alopecia, and seborrhea.
Early diagnosis and treatment of adult acne is crucial to ensure good cosmetic outcomes and minimize disease burden. When treating adult acne, particularly in women, dermatologists should consider a variety of factors that set this condition apart from adolescent acne, including the predisposition of older skin to irritation, possible slow response to treatment, a high likelihood of good adherence to treatment, and the psychosocial impact of acne in the adult population. In adult women, it also is important to consider whether patients are of childbearing age when selecting a treatment. Patients also should be encouraged to read the labels on their personal care products to ensure they are noncomedogenic and will not clog pores.
Myth: Acne only occurs in teenagers
Acne typically is associated with teenagers and puberty, and many adult patients may not be aware that acne can persist beyond adolescence or even develop for the first time in adulthood. As the prevalence of adults with acne increases, it is important to educate this population about factors associated with postadolescent acne development and let them know that effective treatments are available.
There are 2 types of adult acne: persistent acne, which refers to adolescent acne that continues beyond 25 years of age, and late-onset acne, which develops for the first time after 25 years of age. Adult acne generally is mild to moderate in severity and may be refractory to treatment. Unlike adolescent acne, which is more prominent in adolescent boys and manifests as the more severe forms of the disease, adult acne primarily affects women and is more inflammatory in nature, making these patients more susceptible to scarring. In one study, acne prevalence among 1055 adult participants (age range, 20–60 years) was estimated at 61.5%; however, only 36.8% were aware of their condition and only 25% sought treatment. The most commonly affected area was the malar region, which differs from acne seen in teenagers. In addition to the cheeks, adult acne generally is more prominent on the lower chin, jawline, and neck, and lesions more commonly present as closed comedones.
Fluctuating hormone levels are a common cause of adult acne, particularly in women during menses or pregnancy, menopause, or perimenopause; women also may experience breakouts after starting or discontinuing birth control pills. Acne flare-ups in adults also have been linked to chronic stress, family history, hair and skin care products, medication side effects, undiagnosed medical conditions, steroid use, increased calorie intake, whole and fat-reduced milk consumption, and tobacco smoking. Adult acne also has been found to be associated with other dermatologic conditions including hirsutism, alopecia, and seborrhea.
Early diagnosis and treatment of adult acne is crucial to ensure good cosmetic outcomes and minimize disease burden. When treating adult acne, particularly in women, dermatologists should consider a variety of factors that set this condition apart from adolescent acne, including the predisposition of older skin to irritation, possible slow response to treatment, a high likelihood of good adherence to treatment, and the psychosocial impact of acne in the adult population. In adult women, it also is important to consider whether patients are of childbearing age when selecting a treatment. Patients also should be encouraged to read the labels on their personal care products to ensure they are noncomedogenic and will not clog pores.
Adult acne. American Academy of Dermatology website. https://www.aad.org/public/diseases/acne-and-rosacea/adult-acne. Accessed January 9, 2018.
Dréno B, Layton A, Zouboulis CC, et al. Adult female acne: a new paradigm [published online January 10, 2013]. J Eur Acad Dermatol Venereol. 2013;27:1063-1070.
Khunger N, Kumar C. A clinic-epidemiological study of adult acne: is it different from adolescent acne? Indian J Dermatol Venereol Leprol. 2012;78:335-341.
Semedo D, Ladeiro F, Ruivo M, et al. Adult acne: prevalence and portrayal in primary healthcare patients, in the Great Porto Area, Portugal [published online September 30, 2016]. Acta Med Port. 2016;29:507-513.
Adult acne. American Academy of Dermatology website. https://www.aad.org/public/diseases/acne-and-rosacea/adult-acne. Accessed January 9, 2018.
Dréno B, Layton A, Zouboulis CC, et al. Adult female acne: a new paradigm [published online January 10, 2013]. J Eur Acad Dermatol Venereol. 2013;27:1063-1070.
Khunger N, Kumar C. A clinic-epidemiological study of adult acne: is it different from adolescent acne? Indian J Dermatol Venereol Leprol. 2012;78:335-341.
Semedo D, Ladeiro F, Ruivo M, et al. Adult acne: prevalence and portrayal in primary healthcare patients, in the Great Porto Area, Portugal [published online September 30, 2016]. Acta Med Port. 2016;29:507-513.
CMV colitis mortality rates similar in both immunocompetent and immunocompromised patients
Cytomegalovirus (CMV) colitis has mortality rates similar in immunocompetent patients to that in immunocompromised patients, according to Puo-Hsien Le, MD, and associates.
In a retrospective study, the investigators analyzed data from 42 immunocompetent patients and 27 patients who were immunocompromised because of HIV infection, solid organ or bone marrow transplantation, immunosuppressive drug use, chemotherapeutic agent use within 6 months, or other reasons. In-hospital mortality was 26.2% in immunocompetent patients and 25.9% in immunocompromised patients.
While diarrhea and melena were the first presenting symptom in a similar number of patients, immunocompetent patients were more likely to present with melena while immunocompromised patients were more likely to present with diarrhea. The number of days until diagnosis was the only independent predictor of in-hospital mortality according to the analysis, with patients who were diagnosed within 9 days of admittance having a significantly higher survival rate.
“Contrary to data published up to this point, we found that CMV colitis was not rare and that it could be fatal in immunocompetent hosts, especially those patients with advanced age, specific comorbidities associated with immune dysfunction, critical illness, or IBD. ... Being alert to the different presentations can greatly help make an accurate early diagnosis and materially improve survival for CMV colitis patients,” the investigators concluded.
Find the full study in Therapeutics and Clinical Risk Management (doi: 10.2147/TCRM.S151180).
Cytomegalovirus (CMV) colitis has mortality rates similar in immunocompetent patients to that in immunocompromised patients, according to Puo-Hsien Le, MD, and associates.
In a retrospective study, the investigators analyzed data from 42 immunocompetent patients and 27 patients who were immunocompromised because of HIV infection, solid organ or bone marrow transplantation, immunosuppressive drug use, chemotherapeutic agent use within 6 months, or other reasons. In-hospital mortality was 26.2% in immunocompetent patients and 25.9% in immunocompromised patients.
While diarrhea and melena were the first presenting symptom in a similar number of patients, immunocompetent patients were more likely to present with melena while immunocompromised patients were more likely to present with diarrhea. The number of days until diagnosis was the only independent predictor of in-hospital mortality according to the analysis, with patients who were diagnosed within 9 days of admittance having a significantly higher survival rate.
“Contrary to data published up to this point, we found that CMV colitis was not rare and that it could be fatal in immunocompetent hosts, especially those patients with advanced age, specific comorbidities associated with immune dysfunction, critical illness, or IBD. ... Being alert to the different presentations can greatly help make an accurate early diagnosis and materially improve survival for CMV colitis patients,” the investigators concluded.
Find the full study in Therapeutics and Clinical Risk Management (doi: 10.2147/TCRM.S151180).
Cytomegalovirus (CMV) colitis has mortality rates similar in immunocompetent patients to that in immunocompromised patients, according to Puo-Hsien Le, MD, and associates.
In a retrospective study, the investigators analyzed data from 42 immunocompetent patients and 27 patients who were immunocompromised because of HIV infection, solid organ or bone marrow transplantation, immunosuppressive drug use, chemotherapeutic agent use within 6 months, or other reasons. In-hospital mortality was 26.2% in immunocompetent patients and 25.9% in immunocompromised patients.
While diarrhea and melena were the first presenting symptom in a similar number of patients, immunocompetent patients were more likely to present with melena while immunocompromised patients were more likely to present with diarrhea. The number of days until diagnosis was the only independent predictor of in-hospital mortality according to the analysis, with patients who were diagnosed within 9 days of admittance having a significantly higher survival rate.
“Contrary to data published up to this point, we found that CMV colitis was not rare and that it could be fatal in immunocompetent hosts, especially those patients with advanced age, specific comorbidities associated with immune dysfunction, critical illness, or IBD. ... Being alert to the different presentations can greatly help make an accurate early diagnosis and materially improve survival for CMV colitis patients,” the investigators concluded.
Find the full study in Therapeutics and Clinical Risk Management (doi: 10.2147/TCRM.S151180).
FROM THERAPEUTICS AND CLINICAL RISK MANAGEMENT
Optimal rate of flow for high-flow nasal cannula in young children
Clinical question
Is there an optimal rate of flow for high-flow nasal cannula in respiratory distress?
Background
High-flow nasal cannula (HFNC) has been increasingly used to treat children with moderate to severe bronchiolitis, both in intensive care unit (ICU) settings and on inpatient wards. Studies have shown it may allow children with bronchiolitis to avoid ICU admission and intubation. In preterm infants it has been shown to decrease work of breathing. No prior studies, however, have examined optimizing the rate of flow for individual patients, and considerable heterogeneity exists in choosing initial HFNC flow rates.
Reliably measuring effort of breathing has proved challenging. Placing a manometer in the esophagus allows measurement of the pressure-rate product (PRP), a previously validated measure of effort of breathing computed by multiplying the difference between maximum and minimum esophageal pressures by the respiratory rate.1 An increasing PRP indicates increasing effort of breathing. The authors chose systems from Fisher & Paykel and Vapotherm for their testing.
Study design
Single-center prospective observational trial.
Setting
24-bed pediatric intensive care unit in a 347-bed urban free-standing children’s hospital.
Synopsis
A single center recruited patients aged 37 weeks corrected gestational age to 3 years who were admitted to the ICU with respiratory distress. Fifty-four patients met inclusion criteria and 21 were enrolled and completed the study. Prior data suggested a sample size of 20 would be sufficient to identify a clinically significant effect size. Median age was 6 months.
Thirteen patients had bronchiolitis, three had pneumonia, and five had other respiratory illnesses. Each patient received HFNC delivered by both systems in sequence with flow rates of 0.5, 1, 1.5, and 2 L/kg per minute to a maximum of 30 L/min. Following the trials, patients remained on HFNC as per usual care with twice-daily PRP measurements until weaned off HFNC.
A dose-dependent relationship existed between flow and change in PRP, with the greatest reduction in PRP at 2 L/kg per minute flow (P less than .001) and a slightly smaller but similar reduction in PRP at 1.5 L/kg per minute. When stratifying the subjects by weight, this effect was not statistically significant for patients heavier than 8 kg (P = .38), with all significant changes being in patients less than 8 kg (P less than .001) with a median drop in PRP of 25%. Further examining these younger and lighter patients, the greatest reduction in PRP was in the lightest patients (less than 5 kg).
Given the similarity in drop in PRP at 1.5 L/kg per minute and 2 L/kg per minute, the authors suggest this flow rate yields a plateau effect and minimal further improvement would be seen with increasing flow rates. A rate of 2 L/kg per minute was chosen as a maximum a priori as it was judged the highest level of HFNC patients could tolerate without worsening agitation or air leak. There was no difference seen between the two HFNC systems in the study. The authors did not report the fraction of inspired oxygen settings used, the size of HFNC cannulas, or how PRP changed over several days as HFNC was weaned.
Bottom line
The optimal HFNC rate to decrease effort of breathing for children less than 3 years old is between 1.5 and 2 L/kg/min with the greatest improvement expected in children under 5 kg.
Citation
Weiler T et al. The Relationship between High Flow Nasal Cannula Flow Rate and Effort of Breathing in Children. The Journal of Pediatrics. October 2017. doi: 10.1016/j.jpeds.2017.06.006.
Reference
1. Argent AC, Newth CJL, Klein M. The mechanics of breathing in children with acute severe croup. Intensive Care Med. 2008;34(2):324-32. doi: 10.1007/s00134-007-0910-x.
Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Jefferson Medical College in Philadelphia.
Clinical question
Is there an optimal rate of flow for high-flow nasal cannula in respiratory distress?
Background
High-flow nasal cannula (HFNC) has been increasingly used to treat children with moderate to severe bronchiolitis, both in intensive care unit (ICU) settings and on inpatient wards. Studies have shown it may allow children with bronchiolitis to avoid ICU admission and intubation. In preterm infants it has been shown to decrease work of breathing. No prior studies, however, have examined optimizing the rate of flow for individual patients, and considerable heterogeneity exists in choosing initial HFNC flow rates.
Reliably measuring effort of breathing has proved challenging. Placing a manometer in the esophagus allows measurement of the pressure-rate product (PRP), a previously validated measure of effort of breathing computed by multiplying the difference between maximum and minimum esophageal pressures by the respiratory rate.1 An increasing PRP indicates increasing effort of breathing. The authors chose systems from Fisher & Paykel and Vapotherm for their testing.
Study design
Single-center prospective observational trial.
Setting
24-bed pediatric intensive care unit in a 347-bed urban free-standing children’s hospital.
Synopsis
A single center recruited patients aged 37 weeks corrected gestational age to 3 years who were admitted to the ICU with respiratory distress. Fifty-four patients met inclusion criteria and 21 were enrolled and completed the study. Prior data suggested a sample size of 20 would be sufficient to identify a clinically significant effect size. Median age was 6 months.
Thirteen patients had bronchiolitis, three had pneumonia, and five had other respiratory illnesses. Each patient received HFNC delivered by both systems in sequence with flow rates of 0.5, 1, 1.5, and 2 L/kg per minute to a maximum of 30 L/min. Following the trials, patients remained on HFNC as per usual care with twice-daily PRP measurements until weaned off HFNC.
A dose-dependent relationship existed between flow and change in PRP, with the greatest reduction in PRP at 2 L/kg per minute flow (P less than .001) and a slightly smaller but similar reduction in PRP at 1.5 L/kg per minute. When stratifying the subjects by weight, this effect was not statistically significant for patients heavier than 8 kg (P = .38), with all significant changes being in patients less than 8 kg (P less than .001) with a median drop in PRP of 25%. Further examining these younger and lighter patients, the greatest reduction in PRP was in the lightest patients (less than 5 kg).
Given the similarity in drop in PRP at 1.5 L/kg per minute and 2 L/kg per minute, the authors suggest this flow rate yields a plateau effect and minimal further improvement would be seen with increasing flow rates. A rate of 2 L/kg per minute was chosen as a maximum a priori as it was judged the highest level of HFNC patients could tolerate without worsening agitation or air leak. There was no difference seen between the two HFNC systems in the study. The authors did not report the fraction of inspired oxygen settings used, the size of HFNC cannulas, or how PRP changed over several days as HFNC was weaned.
Bottom line
The optimal HFNC rate to decrease effort of breathing for children less than 3 years old is between 1.5 and 2 L/kg/min with the greatest improvement expected in children under 5 kg.
Citation
Weiler T et al. The Relationship between High Flow Nasal Cannula Flow Rate and Effort of Breathing in Children. The Journal of Pediatrics. October 2017. doi: 10.1016/j.jpeds.2017.06.006.
Reference
1. Argent AC, Newth CJL, Klein M. The mechanics of breathing in children with acute severe croup. Intensive Care Med. 2008;34(2):324-32. doi: 10.1007/s00134-007-0910-x.
Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Jefferson Medical College in Philadelphia.
Clinical question
Is there an optimal rate of flow for high-flow nasal cannula in respiratory distress?
Background
High-flow nasal cannula (HFNC) has been increasingly used to treat children with moderate to severe bronchiolitis, both in intensive care unit (ICU) settings and on inpatient wards. Studies have shown it may allow children with bronchiolitis to avoid ICU admission and intubation. In preterm infants it has been shown to decrease work of breathing. No prior studies, however, have examined optimizing the rate of flow for individual patients, and considerable heterogeneity exists in choosing initial HFNC flow rates.
Reliably measuring effort of breathing has proved challenging. Placing a manometer in the esophagus allows measurement of the pressure-rate product (PRP), a previously validated measure of effort of breathing computed by multiplying the difference between maximum and minimum esophageal pressures by the respiratory rate.1 An increasing PRP indicates increasing effort of breathing. The authors chose systems from Fisher & Paykel and Vapotherm for their testing.
Study design
Single-center prospective observational trial.
Setting
24-bed pediatric intensive care unit in a 347-bed urban free-standing children’s hospital.
Synopsis
A single center recruited patients aged 37 weeks corrected gestational age to 3 years who were admitted to the ICU with respiratory distress. Fifty-four patients met inclusion criteria and 21 were enrolled and completed the study. Prior data suggested a sample size of 20 would be sufficient to identify a clinically significant effect size. Median age was 6 months.
Thirteen patients had bronchiolitis, three had pneumonia, and five had other respiratory illnesses. Each patient received HFNC delivered by both systems in sequence with flow rates of 0.5, 1, 1.5, and 2 L/kg per minute to a maximum of 30 L/min. Following the trials, patients remained on HFNC as per usual care with twice-daily PRP measurements until weaned off HFNC.
A dose-dependent relationship existed between flow and change in PRP, with the greatest reduction in PRP at 2 L/kg per minute flow (P less than .001) and a slightly smaller but similar reduction in PRP at 1.5 L/kg per minute. When stratifying the subjects by weight, this effect was not statistically significant for patients heavier than 8 kg (P = .38), with all significant changes being in patients less than 8 kg (P less than .001) with a median drop in PRP of 25%. Further examining these younger and lighter patients, the greatest reduction in PRP was in the lightest patients (less than 5 kg).
Given the similarity in drop in PRP at 1.5 L/kg per minute and 2 L/kg per minute, the authors suggest this flow rate yields a plateau effect and minimal further improvement would be seen with increasing flow rates. A rate of 2 L/kg per minute was chosen as a maximum a priori as it was judged the highest level of HFNC patients could tolerate without worsening agitation or air leak. There was no difference seen between the two HFNC systems in the study. The authors did not report the fraction of inspired oxygen settings used, the size of HFNC cannulas, or how PRP changed over several days as HFNC was weaned.
Bottom line
The optimal HFNC rate to decrease effort of breathing for children less than 3 years old is between 1.5 and 2 L/kg/min with the greatest improvement expected in children under 5 kg.
Citation
Weiler T et al. The Relationship between High Flow Nasal Cannula Flow Rate and Effort of Breathing in Children. The Journal of Pediatrics. October 2017. doi: 10.1016/j.jpeds.2017.06.006.
Reference
1. Argent AC, Newth CJL, Klein M. The mechanics of breathing in children with acute severe croup. Intensive Care Med. 2008;34(2):324-32. doi: 10.1007/s00134-007-0910-x.
Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and clinical assistant professor of pediatrics at Jefferson Medical College in Philadelphia.
