User login
Zika linked to a spectrum of neuroinflammatory diseases
New evidence in support of a link between Zika virus infection and an increase in the incidence of neurological syndromes in adults has come from a prospective, observational study that demonstrates the presence of the infection in both serum and cerebrospinal fluid of patients with new-onset acute neuroinflammatory disease.
From Dec. 5, 2015, to May 10, 2016, 40 patients who were hospitalized for Guillain-Barré syndrome (GBS), meningoencephalitis, or transverse myelitis were evaluated for Zika virus. Of those, 35 (88%) tested positive for Zika, indicating that there is a correlation between the Zika outbreak and recorded increases in neurological syndromes in adults, according to Ivan Rocha Ferreira da Silva, MD, PhD, of the neurology department of Universidade Federal Fluminense in Niteroi, Brazil, and his coauthors (JAMA Neurol. 2017 Aug 14. doi: 10.1001/jamaneurol.2017.1703). Dr. da Silva is now with the department of neurology at Rush University Medical Center, Chicago.
Overall, it appears that Zika virus is associated with the trend for the rapid increase in hospital admissions for certain neurological syndromes, Dr. da Silva and his coauthors said. In addition, “we believe that our method of matching CSF and blood serologic findings offers a substantial aid to minimize [costs and] cross-reactivity in countries with a high prevalence of other concurrent flavivirosis.”
The study cohort was enrolled at a tertiary care, academic hospital in Rio de Janeiro. The median age was 44, and 15 were women. The study was limited by selection of neurological syndromes that have previously been associated with other flaviviruses, the short study period, and the use of patients from only one hospital.
Dr. da Silva reported no financial disclosures. One author reported receiving grants from Conselho Nacional de Desenvolvimento e Pesquisa and Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro. Other study authors reported no financial disclosures.
The 2015 Zika outbreaks in the Americas were notable for the recognition that Zika virus could be associated with neurological conditions. It was found that the overall risk of congenital neurologic abnormalities in fetuses and liveborn children of mothers enrolled in the Centers for Disease Control and Prevention’s Zika Pregnancy Registry with definite laboratory evidence of Zika virus infection during pregnancy was approximately 17 times higher than the expected baseline rate in uninfected mothers. It wasn’t until later, however, that GBS became the first non–pregnancy-related neurological syndrome to be associate with Zika in adults.
It is critically important to understand both the spectrum and frequency of Zika virus–induced neurologic diseases. The article by Dr. da Silva and colleagues in this issue of JAMA Neurology represents an initial approach to this problem. During the reporting period, they found that 93% of the patients with GBS (27 of 29), 71% of the patients with encephalitis (5 of 7), 67% of the patients with transverse myelitis (2 of 3), and the single patient with chronic inflammatory demyelinating polyneuropathy showed evidence of recent Zika virus infection, indicating a link between neurological syndromes and Zika.
However, it should be noted that, because of factors including referral bias, a study such as this cannot determine exact frequencies of Zika virus infection among patients with the syndromes examined, but it may serve to help confirm that Zika can be associated with such syndromes.
Kenneth L. Tyler, MD, is the Louise Baum Endowed Professor and Chair of the department of neurology at the University of Colorado at Denver, Aurora. Karen L. Roos, MD, is the John and Nancy Professor of Neurology at the University of Indiana, Indianapolis. They published these comments in an editorial accompanying the da Silva et al. article in JAMA Neurology (2017 Aug 14. doi: 10.1001/jamaneurol.2017.1471). Neither author reported any financial disclosures.
The 2015 Zika outbreaks in the Americas were notable for the recognition that Zika virus could be associated with neurological conditions. It was found that the overall risk of congenital neurologic abnormalities in fetuses and liveborn children of mothers enrolled in the Centers for Disease Control and Prevention’s Zika Pregnancy Registry with definite laboratory evidence of Zika virus infection during pregnancy was approximately 17 times higher than the expected baseline rate in uninfected mothers. It wasn’t until later, however, that GBS became the first non–pregnancy-related neurological syndrome to be associate with Zika in adults.
It is critically important to understand both the spectrum and frequency of Zika virus–induced neurologic diseases. The article by Dr. da Silva and colleagues in this issue of JAMA Neurology represents an initial approach to this problem. During the reporting period, they found that 93% of the patients with GBS (27 of 29), 71% of the patients with encephalitis (5 of 7), 67% of the patients with transverse myelitis (2 of 3), and the single patient with chronic inflammatory demyelinating polyneuropathy showed evidence of recent Zika virus infection, indicating a link between neurological syndromes and Zika.
However, it should be noted that, because of factors including referral bias, a study such as this cannot determine exact frequencies of Zika virus infection among patients with the syndromes examined, but it may serve to help confirm that Zika can be associated with such syndromes.
Kenneth L. Tyler, MD, is the Louise Baum Endowed Professor and Chair of the department of neurology at the University of Colorado at Denver, Aurora. Karen L. Roos, MD, is the John and Nancy Professor of Neurology at the University of Indiana, Indianapolis. They published these comments in an editorial accompanying the da Silva et al. article in JAMA Neurology (2017 Aug 14. doi: 10.1001/jamaneurol.2017.1471). Neither author reported any financial disclosures.
The 2015 Zika outbreaks in the Americas were notable for the recognition that Zika virus could be associated with neurological conditions. It was found that the overall risk of congenital neurologic abnormalities in fetuses and liveborn children of mothers enrolled in the Centers for Disease Control and Prevention’s Zika Pregnancy Registry with definite laboratory evidence of Zika virus infection during pregnancy was approximately 17 times higher than the expected baseline rate in uninfected mothers. It wasn’t until later, however, that GBS became the first non–pregnancy-related neurological syndrome to be associate with Zika in adults.
It is critically important to understand both the spectrum and frequency of Zika virus–induced neurologic diseases. The article by Dr. da Silva and colleagues in this issue of JAMA Neurology represents an initial approach to this problem. During the reporting period, they found that 93% of the patients with GBS (27 of 29), 71% of the patients with encephalitis (5 of 7), 67% of the patients with transverse myelitis (2 of 3), and the single patient with chronic inflammatory demyelinating polyneuropathy showed evidence of recent Zika virus infection, indicating a link between neurological syndromes and Zika.
However, it should be noted that, because of factors including referral bias, a study such as this cannot determine exact frequencies of Zika virus infection among patients with the syndromes examined, but it may serve to help confirm that Zika can be associated with such syndromes.
Kenneth L. Tyler, MD, is the Louise Baum Endowed Professor and Chair of the department of neurology at the University of Colorado at Denver, Aurora. Karen L. Roos, MD, is the John and Nancy Professor of Neurology at the University of Indiana, Indianapolis. They published these comments in an editorial accompanying the da Silva et al. article in JAMA Neurology (2017 Aug 14. doi: 10.1001/jamaneurol.2017.1471). Neither author reported any financial disclosures.
New evidence in support of a link between Zika virus infection and an increase in the incidence of neurological syndromes in adults has come from a prospective, observational study that demonstrates the presence of the infection in both serum and cerebrospinal fluid of patients with new-onset acute neuroinflammatory disease.
From Dec. 5, 2015, to May 10, 2016, 40 patients who were hospitalized for Guillain-Barré syndrome (GBS), meningoencephalitis, or transverse myelitis were evaluated for Zika virus. Of those, 35 (88%) tested positive for Zika, indicating that there is a correlation between the Zika outbreak and recorded increases in neurological syndromes in adults, according to Ivan Rocha Ferreira da Silva, MD, PhD, of the neurology department of Universidade Federal Fluminense in Niteroi, Brazil, and his coauthors (JAMA Neurol. 2017 Aug 14. doi: 10.1001/jamaneurol.2017.1703). Dr. da Silva is now with the department of neurology at Rush University Medical Center, Chicago.
Overall, it appears that Zika virus is associated with the trend for the rapid increase in hospital admissions for certain neurological syndromes, Dr. da Silva and his coauthors said. In addition, “we believe that our method of matching CSF and blood serologic findings offers a substantial aid to minimize [costs and] cross-reactivity in countries with a high prevalence of other concurrent flavivirosis.”
The study cohort was enrolled at a tertiary care, academic hospital in Rio de Janeiro. The median age was 44, and 15 were women. The study was limited by selection of neurological syndromes that have previously been associated with other flaviviruses, the short study period, and the use of patients from only one hospital.
Dr. da Silva reported no financial disclosures. One author reported receiving grants from Conselho Nacional de Desenvolvimento e Pesquisa and Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro. Other study authors reported no financial disclosures.
New evidence in support of a link between Zika virus infection and an increase in the incidence of neurological syndromes in adults has come from a prospective, observational study that demonstrates the presence of the infection in both serum and cerebrospinal fluid of patients with new-onset acute neuroinflammatory disease.
From Dec. 5, 2015, to May 10, 2016, 40 patients who were hospitalized for Guillain-Barré syndrome (GBS), meningoencephalitis, or transverse myelitis were evaluated for Zika virus. Of those, 35 (88%) tested positive for Zika, indicating that there is a correlation between the Zika outbreak and recorded increases in neurological syndromes in adults, according to Ivan Rocha Ferreira da Silva, MD, PhD, of the neurology department of Universidade Federal Fluminense in Niteroi, Brazil, and his coauthors (JAMA Neurol. 2017 Aug 14. doi: 10.1001/jamaneurol.2017.1703). Dr. da Silva is now with the department of neurology at Rush University Medical Center, Chicago.
Overall, it appears that Zika virus is associated with the trend for the rapid increase in hospital admissions for certain neurological syndromes, Dr. da Silva and his coauthors said. In addition, “we believe that our method of matching CSF and blood serologic findings offers a substantial aid to minimize [costs and] cross-reactivity in countries with a high prevalence of other concurrent flavivirosis.”
The study cohort was enrolled at a tertiary care, academic hospital in Rio de Janeiro. The median age was 44, and 15 were women. The study was limited by selection of neurological syndromes that have previously been associated with other flaviviruses, the short study period, and the use of patients from only one hospital.
Dr. da Silva reported no financial disclosures. One author reported receiving grants from Conselho Nacional de Desenvolvimento e Pesquisa and Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro. Other study authors reported no financial disclosures.
FROM JAMA NEUROLOGY
Key clinical point: Increases in neurological syndromes in adults are associated with the Zika epidemic.
Major finding: Of 40 patients who were hospitalized for Guillain-Barré syndrome (GBS), meningoencephalitis, or transverse myelitis, 35 tested positive for Zika.
Data source: A prospective, observational cohort study of 40 patients who were admitted to a hospital in Brazil for a number of neurological conditions.
Disclosures: Dr. da Silva reported no financial disclosures. One author reported receiving grants from Conselho Nacional de Desenvolvimento e Pesquisa and Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro. Other study authors reported no financial disclosures.
Miss the MIPS Webinar? View it Online
The SVS Patient Safety Organization and M2S, in conjunction with the SVS, presented a webinar last month on getting started in the Medicare reimbursement program, including the Merit-based Incentive Payment System (MIPS).
For those who couldn't attend, it is posted, along with the presentation slides, on the Vascular Quality Initiative website's home page. View it today to get up to speed on MIPS and MACRA (Medicare Access and CHIP Reauthorization Act of 2015).
The SVS Patient Safety Organization and M2S, in conjunction with the SVS, presented a webinar last month on getting started in the Medicare reimbursement program, including the Merit-based Incentive Payment System (MIPS).
For those who couldn't attend, it is posted, along with the presentation slides, on the Vascular Quality Initiative website's home page. View it today to get up to speed on MIPS and MACRA (Medicare Access and CHIP Reauthorization Act of 2015).
The SVS Patient Safety Organization and M2S, in conjunction with the SVS, presented a webinar last month on getting started in the Medicare reimbursement program, including the Merit-based Incentive Payment System (MIPS).
For those who couldn't attend, it is posted, along with the presentation slides, on the Vascular Quality Initiative website's home page. View it today to get up to speed on MIPS and MACRA (Medicare Access and CHIP Reauthorization Act of 2015).
Birth Control Pills for Acne: Tips From Julie Harper at the Summer AAD
Acne treatment options now extend beyond antibiotics, and hormonal therapy, particularly birth control pills (BCPs), may provide clearance of acne in women who may not respond to other therapies. "Challenge [yourselves] to learn how to safely use BCPs," said Dr. Julie Harper, Clinical Associate Professor of Dermatology at the University of Alabama in Birmingham, in the presentation, "Use of Hormonal Therapy for Acne," at the Summer Meeting of the American Academy of Dermatology. The use of BCPs for acne has a strength-of-recommendation grade of A (consistent, good-quality patient-oriented evidence).
According to Dr. Harper, all combination BCPs should work for acne, except progestin-only BCPs, which will make acne worse. Currently, there are 4 BCPs approved by the US Food and Drug Administration for acne: norgestimate-ethinyl estradiol (Ortho Tri-Cyclen); norethindrone acetate-ethinyl estradiol (Estrostep Fe); drospirenone-ethinyl estradiol (Yaz); and drospirenone-ethinyl estradiol-levomefolate calcium (Beyaz). Birth control pills are known to carry risks for venous thromboembolism (VTE), stroke, hypertension, and myocardial infarction; however, they are generally well tolerated in acne patients. "The risk of venous thromboembolism in women who take BCPs is doubled or tripled compared to women who do not take these pills. This sounds scary until you put it into context," said Dr. Harper. She explains the risks to patients using the following 3-6-9-12 model: A woman's baseline risk of having a VTE if she is not on a BCP is approximately 3 in 10,000 women in one year. When she takes a BCP, her risk doubles to 6 per 10,000 women in one year. If she takes a BCP that contains drospirenone, her risk is 9 per 10,000 women in one year. If she gets pregnant, her risk is 12 per 10,000 women in one year.
Dermatologists may be apprehensive to prescribe BCPs, but Dr. Harper provided several important tips on managing patient expectations and monitoring patients. Dr. Harper emphasized that BCPs should be used patiently for acne. "It frequently takes at least 3 cycles of BCPs to see a meaningful change in acne reduction," she advised. She recommended obtaining a thorough medical history and blood pressure measurement prior to prescribing BCPs. However, a Papanicolaou test and bimanual pelvic examination are no longer deemed mandatory prior to initiating a BCP, according to the World Health Organization and the American Congress of Obstetricians and Gynecologists. "While these exams may help to detect cervical cancer and other pelvic diseases, BCPs help to prevent unwanted pregnancies and the risks that accompany those pregnancies," said Dr. Harper. "Remember that BCPs reduce the risk of ovarian, uterine and colorectal cancer and also lessen ovarian cysts and pelvic inflammatory disease." Dermatologists also should inform patients that rifampin and griseofulvin, both anti-infectives, will interact with BCPs, lessening their effectiveness.
A March 2017 study published in Cutis (2017;99:195-201) of US dermatologists' knowledge, comfort, and prescribing practices (N=116) revealed that most dermatologists (95.4%) believe BCPs effectively treat acne; however, only 54% reported prescribing them. The American Academy of Dermatology's guidelines of care for the management of acne vulgaris published in February 2016 (J Am Acad Dermatol. 2016;74:945-973) stated that "estrogen-containing combined oral contraceptives are effective and recommended in the treatment of inflammatory acne in females."
Overall, Dr. Harper's take-home message was that dermatologists should not be afraid to prescribe BCPs, even in teenaged girls (following the onset of menarche). "Birth control pills can be used in younger patients but it is not my first line of treatment," said Dr. Harper. "It is recommended that BCPs not be prescribed for acne until 2 years after the young woman has achieved menarche. When considering whether or not to use a BCP in the early teenage years, keep in mind that these are not short-term treatments. If a BCP does help acne, it will likely need to be maintained for many years." When discussing this treatment in front of parents/guardians, consider referring to it as hormonal therapy and use the term birth control pills only initially.
Acne treatment options now extend beyond antibiotics, and hormonal therapy, particularly birth control pills (BCPs), may provide clearance of acne in women who may not respond to other therapies. "Challenge [yourselves] to learn how to safely use BCPs," said Dr. Julie Harper, Clinical Associate Professor of Dermatology at the University of Alabama in Birmingham, in the presentation, "Use of Hormonal Therapy for Acne," at the Summer Meeting of the American Academy of Dermatology. The use of BCPs for acne has a strength-of-recommendation grade of A (consistent, good-quality patient-oriented evidence).
According to Dr. Harper, all combination BCPs should work for acne, except progestin-only BCPs, which will make acne worse. Currently, there are 4 BCPs approved by the US Food and Drug Administration for acne: norgestimate-ethinyl estradiol (Ortho Tri-Cyclen); norethindrone acetate-ethinyl estradiol (Estrostep Fe); drospirenone-ethinyl estradiol (Yaz); and drospirenone-ethinyl estradiol-levomefolate calcium (Beyaz). Birth control pills are known to carry risks for venous thromboembolism (VTE), stroke, hypertension, and myocardial infarction; however, they are generally well tolerated in acne patients. "The risk of venous thromboembolism in women who take BCPs is doubled or tripled compared to women who do not take these pills. This sounds scary until you put it into context," said Dr. Harper. She explains the risks to patients using the following 3-6-9-12 model: A woman's baseline risk of having a VTE if she is not on a BCP is approximately 3 in 10,000 women in one year. When she takes a BCP, her risk doubles to 6 per 10,000 women in one year. If she takes a BCP that contains drospirenone, her risk is 9 per 10,000 women in one year. If she gets pregnant, her risk is 12 per 10,000 women in one year.
Dermatologists may be apprehensive to prescribe BCPs, but Dr. Harper provided several important tips on managing patient expectations and monitoring patients. Dr. Harper emphasized that BCPs should be used patiently for acne. "It frequently takes at least 3 cycles of BCPs to see a meaningful change in acne reduction," she advised. She recommended obtaining a thorough medical history and blood pressure measurement prior to prescribing BCPs. However, a Papanicolaou test and bimanual pelvic examination are no longer deemed mandatory prior to initiating a BCP, according to the World Health Organization and the American Congress of Obstetricians and Gynecologists. "While these exams may help to detect cervical cancer and other pelvic diseases, BCPs help to prevent unwanted pregnancies and the risks that accompany those pregnancies," said Dr. Harper. "Remember that BCPs reduce the risk of ovarian, uterine and colorectal cancer and also lessen ovarian cysts and pelvic inflammatory disease." Dermatologists also should inform patients that rifampin and griseofulvin, both anti-infectives, will interact with BCPs, lessening their effectiveness.
A March 2017 study published in Cutis (2017;99:195-201) of US dermatologists' knowledge, comfort, and prescribing practices (N=116) revealed that most dermatologists (95.4%) believe BCPs effectively treat acne; however, only 54% reported prescribing them. The American Academy of Dermatology's guidelines of care for the management of acne vulgaris published in February 2016 (J Am Acad Dermatol. 2016;74:945-973) stated that "estrogen-containing combined oral contraceptives are effective and recommended in the treatment of inflammatory acne in females."
Overall, Dr. Harper's take-home message was that dermatologists should not be afraid to prescribe BCPs, even in teenaged girls (following the onset of menarche). "Birth control pills can be used in younger patients but it is not my first line of treatment," said Dr. Harper. "It is recommended that BCPs not be prescribed for acne until 2 years after the young woman has achieved menarche. When considering whether or not to use a BCP in the early teenage years, keep in mind that these are not short-term treatments. If a BCP does help acne, it will likely need to be maintained for many years." When discussing this treatment in front of parents/guardians, consider referring to it as hormonal therapy and use the term birth control pills only initially.
Acne treatment options now extend beyond antibiotics, and hormonal therapy, particularly birth control pills (BCPs), may provide clearance of acne in women who may not respond to other therapies. "Challenge [yourselves] to learn how to safely use BCPs," said Dr. Julie Harper, Clinical Associate Professor of Dermatology at the University of Alabama in Birmingham, in the presentation, "Use of Hormonal Therapy for Acne," at the Summer Meeting of the American Academy of Dermatology. The use of BCPs for acne has a strength-of-recommendation grade of A (consistent, good-quality patient-oriented evidence).
According to Dr. Harper, all combination BCPs should work for acne, except progestin-only BCPs, which will make acne worse. Currently, there are 4 BCPs approved by the US Food and Drug Administration for acne: norgestimate-ethinyl estradiol (Ortho Tri-Cyclen); norethindrone acetate-ethinyl estradiol (Estrostep Fe); drospirenone-ethinyl estradiol (Yaz); and drospirenone-ethinyl estradiol-levomefolate calcium (Beyaz). Birth control pills are known to carry risks for venous thromboembolism (VTE), stroke, hypertension, and myocardial infarction; however, they are generally well tolerated in acne patients. "The risk of venous thromboembolism in women who take BCPs is doubled or tripled compared to women who do not take these pills. This sounds scary until you put it into context," said Dr. Harper. She explains the risks to patients using the following 3-6-9-12 model: A woman's baseline risk of having a VTE if she is not on a BCP is approximately 3 in 10,000 women in one year. When she takes a BCP, her risk doubles to 6 per 10,000 women in one year. If she takes a BCP that contains drospirenone, her risk is 9 per 10,000 women in one year. If she gets pregnant, her risk is 12 per 10,000 women in one year.
Dermatologists may be apprehensive to prescribe BCPs, but Dr. Harper provided several important tips on managing patient expectations and monitoring patients. Dr. Harper emphasized that BCPs should be used patiently for acne. "It frequently takes at least 3 cycles of BCPs to see a meaningful change in acne reduction," she advised. She recommended obtaining a thorough medical history and blood pressure measurement prior to prescribing BCPs. However, a Papanicolaou test and bimanual pelvic examination are no longer deemed mandatory prior to initiating a BCP, according to the World Health Organization and the American Congress of Obstetricians and Gynecologists. "While these exams may help to detect cervical cancer and other pelvic diseases, BCPs help to prevent unwanted pregnancies and the risks that accompany those pregnancies," said Dr. Harper. "Remember that BCPs reduce the risk of ovarian, uterine and colorectal cancer and also lessen ovarian cysts and pelvic inflammatory disease." Dermatologists also should inform patients that rifampin and griseofulvin, both anti-infectives, will interact with BCPs, lessening their effectiveness.
A March 2017 study published in Cutis (2017;99:195-201) of US dermatologists' knowledge, comfort, and prescribing practices (N=116) revealed that most dermatologists (95.4%) believe BCPs effectively treat acne; however, only 54% reported prescribing them. The American Academy of Dermatology's guidelines of care for the management of acne vulgaris published in February 2016 (J Am Acad Dermatol. 2016;74:945-973) stated that "estrogen-containing combined oral contraceptives are effective and recommended in the treatment of inflammatory acne in females."
Overall, Dr. Harper's take-home message was that dermatologists should not be afraid to prescribe BCPs, even in teenaged girls (following the onset of menarche). "Birth control pills can be used in younger patients but it is not my first line of treatment," said Dr. Harper. "It is recommended that BCPs not be prescribed for acne until 2 years after the young woman has achieved menarche. When considering whether or not to use a BCP in the early teenage years, keep in mind that these are not short-term treatments. If a BCP does help acne, it will likely need to be maintained for many years." When discussing this treatment in front of parents/guardians, consider referring to it as hormonal therapy and use the term birth control pills only initially.
‘Motivational pharmacotherapy’ engages Latino patients with depression
MIAMI – Approaching treatment as a partnership between clinician and patient can help improve adherence in underserved members of racial/ethnic groups with depression, according to an expert.
“There is plenty of evidence that clinicians are less likely to engage minorities in a participatory way,” Roberto Lewis-Fernández, MD, said during a plenary session at a meeting of the American Society of Clinical Psychopharmacology, formerly the New Clinical Drug Evaluation Unit meeting. “They tend to ask fewer questions [of patients]. They tend to engage [patients] less in clinical decision making.”
This can lead to nonadherence or even discontinuation of therapy, said Dr. Lewis-Fernández, director of the New York State (NYS) Center of Excellence for Cultural Competence, as well as the Anxiety Disorders Clinic and the Hispanic Treatment Program at NYS Psychiatric Institute.
One solution for bridging what Dr. Lewis-Fernández calls the “power differential” between therapist and patient, and improving adherence rates, is to use “motivational pharmacotherapy,” a derivative of motivational interviewing, created by Dr. Lewis-Fernández and his colleagues. With motivational pharmacotherapy, patients are viewed as the experts in their challenges when meeting the needs of their treatment plan. The clinician is the expert partner in the technical aspects of care.
In a 12-week, open-trial pilot study for this intervention in 50 first-generation Latino patients diagnosed with major depressive disorder, Dr. Lewis-Fernández and his colleagues found that 20% of patients discontinued treatment, with a mean therapy duration of 74.2 out of 84 days (Psychiatry. 2013 Fall;76[3]:210-22).This was in comparison to reports in the literature of discontinuation rates among Latino patients ranging from 32% to 53%, and to rates between 36% and 46% in previous studies conducted at Dr. Lewis-Fernández’s own clinic, using similar medications and methods.
They also found that responder and remitter rates were 82% and 68%. The average length of the first clinical visit was 36.7 minutes, and 24.3 minutes for subsequent visits, which Dr. Lewis-Fernández said was compatible with community clinics.
Motivational pharmacotherapy relies on the psychotherapy components of motivational interviewing that address the need for behavioral change and for helping patients reduce their ambivalence about taking antidepressants. Those components are combined with manualized pharmacotherapy, said Dr. Lewis-Fernández, professor of clinical psychiatry at Columbia University, New York.
The language and tone of this kind of intervention must be empathetic and nonconfrontational, he said. “You can’t say to people who are ambivalent, ‘No, you’re wrong. Take your medication.’ Instead, [focus on] the discrepancy between the current situation and the desired state. Then medication can serve as the solution.”
This allows the patient to “roll with their resistance,” he said, rather than meet it head on. In turn, this approach emphasizes the patient’s capacity to advocate for himself or herself.
“You can’t do the treatment without the patient,” Dr. Lewis-Fernández said. “It’s essentially psychoeducation.”
Among some of the tips for conducting this intervention cited by Dr. Lewis-Fernández:
- Ask questions to elicit the patients’ cultural understanding about their illness and what troubles them most about their condition.
- Ask patients’ permission to show them the supportive data for the intervention.
- Ask them about their thoughts and feelings in response to learning the data.
- Use their understanding of the pros and cons of the medication to “negotiate” their engagement.
In previous studies, Dr. Lewis-Fernández said, he and his colleagues analyzed the reasons for nonadherence, which he said often were tied to the “chaos of their lives.” However, he said, there were improvements after the patients engaged in this psychoeducation-enriched intervention.
Not blaming minority patients for poor adherence is important, he said, since their ambivalence takes place in the context of having less access to quality care. Among the many obstacles these patients face in getting the care they need, insufficient clinician training in how to engage them should not have to be one of them, Dr. Lewis-Fernández said. “We should be doing something about this as a profession.”
Dr. Lewis-Fernández said he had no relevant disclosures. The study on motivational pharmacotherapy was sponsored by Pfizer and the National Institute of Mental Health.
On Twitter @whitneymcknight
MIAMI – Approaching treatment as a partnership between clinician and patient can help improve adherence in underserved members of racial/ethnic groups with depression, according to an expert.
“There is plenty of evidence that clinicians are less likely to engage minorities in a participatory way,” Roberto Lewis-Fernández, MD, said during a plenary session at a meeting of the American Society of Clinical Psychopharmacology, formerly the New Clinical Drug Evaluation Unit meeting. “They tend to ask fewer questions [of patients]. They tend to engage [patients] less in clinical decision making.”
This can lead to nonadherence or even discontinuation of therapy, said Dr. Lewis-Fernández, director of the New York State (NYS) Center of Excellence for Cultural Competence, as well as the Anxiety Disorders Clinic and the Hispanic Treatment Program at NYS Psychiatric Institute.
One solution for bridging what Dr. Lewis-Fernández calls the “power differential” between therapist and patient, and improving adherence rates, is to use “motivational pharmacotherapy,” a derivative of motivational interviewing, created by Dr. Lewis-Fernández and his colleagues. With motivational pharmacotherapy, patients are viewed as the experts in their challenges when meeting the needs of their treatment plan. The clinician is the expert partner in the technical aspects of care.
In a 12-week, open-trial pilot study for this intervention in 50 first-generation Latino patients diagnosed with major depressive disorder, Dr. Lewis-Fernández and his colleagues found that 20% of patients discontinued treatment, with a mean therapy duration of 74.2 out of 84 days (Psychiatry. 2013 Fall;76[3]:210-22).This was in comparison to reports in the literature of discontinuation rates among Latino patients ranging from 32% to 53%, and to rates between 36% and 46% in previous studies conducted at Dr. Lewis-Fernández’s own clinic, using similar medications and methods.
They also found that responder and remitter rates were 82% and 68%. The average length of the first clinical visit was 36.7 minutes, and 24.3 minutes for subsequent visits, which Dr. Lewis-Fernández said was compatible with community clinics.
Motivational pharmacotherapy relies on the psychotherapy components of motivational interviewing that address the need for behavioral change and for helping patients reduce their ambivalence about taking antidepressants. Those components are combined with manualized pharmacotherapy, said Dr. Lewis-Fernández, professor of clinical psychiatry at Columbia University, New York.
The language and tone of this kind of intervention must be empathetic and nonconfrontational, he said. “You can’t say to people who are ambivalent, ‘No, you’re wrong. Take your medication.’ Instead, [focus on] the discrepancy between the current situation and the desired state. Then medication can serve as the solution.”
This allows the patient to “roll with their resistance,” he said, rather than meet it head on. In turn, this approach emphasizes the patient’s capacity to advocate for himself or herself.
“You can’t do the treatment without the patient,” Dr. Lewis-Fernández said. “It’s essentially psychoeducation.”
Among some of the tips for conducting this intervention cited by Dr. Lewis-Fernández:
- Ask questions to elicit the patients’ cultural understanding about their illness and what troubles them most about their condition.
- Ask patients’ permission to show them the supportive data for the intervention.
- Ask them about their thoughts and feelings in response to learning the data.
- Use their understanding of the pros and cons of the medication to “negotiate” their engagement.
In previous studies, Dr. Lewis-Fernández said, he and his colleagues analyzed the reasons for nonadherence, which he said often were tied to the “chaos of their lives.” However, he said, there were improvements after the patients engaged in this psychoeducation-enriched intervention.
Not blaming minority patients for poor adherence is important, he said, since their ambivalence takes place in the context of having less access to quality care. Among the many obstacles these patients face in getting the care they need, insufficient clinician training in how to engage them should not have to be one of them, Dr. Lewis-Fernández said. “We should be doing something about this as a profession.”
Dr. Lewis-Fernández said he had no relevant disclosures. The study on motivational pharmacotherapy was sponsored by Pfizer and the National Institute of Mental Health.
On Twitter @whitneymcknight
MIAMI – Approaching treatment as a partnership between clinician and patient can help improve adherence in underserved members of racial/ethnic groups with depression, according to an expert.
“There is plenty of evidence that clinicians are less likely to engage minorities in a participatory way,” Roberto Lewis-Fernández, MD, said during a plenary session at a meeting of the American Society of Clinical Psychopharmacology, formerly the New Clinical Drug Evaluation Unit meeting. “They tend to ask fewer questions [of patients]. They tend to engage [patients] less in clinical decision making.”
This can lead to nonadherence or even discontinuation of therapy, said Dr. Lewis-Fernández, director of the New York State (NYS) Center of Excellence for Cultural Competence, as well as the Anxiety Disorders Clinic and the Hispanic Treatment Program at NYS Psychiatric Institute.
One solution for bridging what Dr. Lewis-Fernández calls the “power differential” between therapist and patient, and improving adherence rates, is to use “motivational pharmacotherapy,” a derivative of motivational interviewing, created by Dr. Lewis-Fernández and his colleagues. With motivational pharmacotherapy, patients are viewed as the experts in their challenges when meeting the needs of their treatment plan. The clinician is the expert partner in the technical aspects of care.
In a 12-week, open-trial pilot study for this intervention in 50 first-generation Latino patients diagnosed with major depressive disorder, Dr. Lewis-Fernández and his colleagues found that 20% of patients discontinued treatment, with a mean therapy duration of 74.2 out of 84 days (Psychiatry. 2013 Fall;76[3]:210-22).This was in comparison to reports in the literature of discontinuation rates among Latino patients ranging from 32% to 53%, and to rates between 36% and 46% in previous studies conducted at Dr. Lewis-Fernández’s own clinic, using similar medications and methods.
They also found that responder and remitter rates were 82% and 68%. The average length of the first clinical visit was 36.7 minutes, and 24.3 minutes for subsequent visits, which Dr. Lewis-Fernández said was compatible with community clinics.
Motivational pharmacotherapy relies on the psychotherapy components of motivational interviewing that address the need for behavioral change and for helping patients reduce their ambivalence about taking antidepressants. Those components are combined with manualized pharmacotherapy, said Dr. Lewis-Fernández, professor of clinical psychiatry at Columbia University, New York.
The language and tone of this kind of intervention must be empathetic and nonconfrontational, he said. “You can’t say to people who are ambivalent, ‘No, you’re wrong. Take your medication.’ Instead, [focus on] the discrepancy between the current situation and the desired state. Then medication can serve as the solution.”
This allows the patient to “roll with their resistance,” he said, rather than meet it head on. In turn, this approach emphasizes the patient’s capacity to advocate for himself or herself.
“You can’t do the treatment without the patient,” Dr. Lewis-Fernández said. “It’s essentially psychoeducation.”
Among some of the tips for conducting this intervention cited by Dr. Lewis-Fernández:
- Ask questions to elicit the patients’ cultural understanding about their illness and what troubles them most about their condition.
- Ask patients’ permission to show them the supportive data for the intervention.
- Ask them about their thoughts and feelings in response to learning the data.
- Use their understanding of the pros and cons of the medication to “negotiate” their engagement.
In previous studies, Dr. Lewis-Fernández said, he and his colleagues analyzed the reasons for nonadherence, which he said often were tied to the “chaos of their lives.” However, he said, there were improvements after the patients engaged in this psychoeducation-enriched intervention.
Not blaming minority patients for poor adherence is important, he said, since their ambivalence takes place in the context of having less access to quality care. Among the many obstacles these patients face in getting the care they need, insufficient clinician training in how to engage them should not have to be one of them, Dr. Lewis-Fernández said. “We should be doing something about this as a profession.”
Dr. Lewis-Fernández said he had no relevant disclosures. The study on motivational pharmacotherapy was sponsored by Pfizer and the National Institute of Mental Health.
On Twitter @whitneymcknight
EXPERT ANALYSIS FROM THE ASCP ANNUAL MEETING
ACA lawsuits progress through the courts
While Republican efforts to repeal and/or replace the Affordable Care Act are likely to resurface after the congressional summer recess, lawsuits challenging the health law continue to wind their way through the courts.
Judges recently ruled in three ACA cases regarding the contraceptive mandate, risk corridors program, and cost-sharing reduction payments.
Real Alternatives Inc. v. HHS
Secular groups are not entitled to a religious exemption to the ACA’s contraceptive mandate and must offer plans to employees that cover birth control, the United States Court of Appeals for the Third Circuit ruled in an Aug. 4 opinion.
But a majority of appeal judges disagreed, concluding that Real Alternatives is not similar to a religious denomination or one of its nontheistic counterparts, “not in structure, not in aim, not in purpose, and not in function.”
“We do not doubt that Real Alternative’s stance on contraceptives is grounded in sincerely-held moral values, but religion is not generally confined to one question or one moral teaching, it has a broader scope,” Judge Marjorie O. Rendell wrote in the majority opinion. “Real Alternatives is functionally similar not to a church, but to the countless nonreligious nonprofit organizations that take morally informed positions on some discrete set of issues ... While commitment to an anti-abortion platform may be important to the people who hold them, that commitment is not a religion in any legally or theologically accepted sense; and organizations do not become quasi-churches for equal-protection purposes merely by espousing a commitment of that sort.”
Molina Healthcare v. HHS
The federal Heath & Human Services department may have to dish out millions to marketplace insurers after a recent decision by the U.S. Court of Federal Claims. In an Aug. 4 opinion, a federal claims judge ruled the federal government owes Long Beach, Calif.–based insurer Molina Healthcare $52 million in risk corridor payments under the ACA.
The decision stems from a lawsuit by Molina and dozens of other insurers against HHS over the ACA’s risk corridor program. The program requires HHS to collect funds from excessively profitable insurers that offer qualified health plans (QHP) under the exchanges, while paying out funds to QHP insurers with excessive losses. Collections from profitable insurers under the program fell short in 2014 and again in 2015, resulting in HHS paying about 12 cents on the dollar in payments to insurers.
Insurers allege they’ve been shortchanged and that the government must reimburse them full payments for 2014 and 2015. Under the Obama administration, the Department of Justice requested to dismiss the cases, arguing that riders attached to appropriations bills in 2015 and 2016 barred it from making full risk corridor payments.
In his decision, Judge Thomas Wheeler said the ACA mandates that HHS pay insurers what they are owed under the risk corridor program, regardless of the riders.
“The undisputed facts show the government entered into an implied-in-fact contract with Molina and subsequently breached the contract when it failed to make full risk corridor payments,” Judge Wheeler wrote. “Importantly, Molina prevails on its argument of breach of an implied-in-fact contract regardless of the government’s appropriation law defenses – later appropriation restrictions cannot erase a previously created contractual obligation ...The government is liable for its breach of a statutory and contractual obligation to make full annual payments to insurers who participated in the risk corridor program.”
Judge Wheeler ruled similarly in February when he concluded the federal government owes Portland, Ore.–based Moda Health $214 million in risk corridor payments.
The issue is far from over. More than 25 lawsuits have been filed in the Court of Federal Claims by insurers seeking risk corridor money. Several of the cases have moved onto federal appeals courts, while other cases have been dismissed. Analysts say the issue is likely to reach the U.S. Supreme Court. It’s unclear where the Trump administration would get the funds to reimburse insurers if the payback rulings stand. About $19.3 billion in risk corridor payments are at stake for 2014 and 2015 and an estimated $3 billion is in play for 2016, the final risk corridor year.
House v. Price
A U.S. appeals court has allowed 16 states to intervene in a lawsuit over whether subsidy payments made to insurers under the ACA are legal. The decision comes as President Trump recently threatened to cut off the cost sharing reduction (CSR) payments to marketplace insurers, calling them a “bailout.”
On Aug. 1, the U.S. Court of Appeals for the District of Columbia Circuit granted a motion by 18 attorneys general to enter the lawsuit. The attorneys general represent California, New York, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, New Mexico, North Carolina, Pennsylvania, Vermont, Virginia, Washington, and the District of Columbia.
Under the ACA, the federal government provides CSR payments to insurers to offset the costs for providing discount plans to patients who earn up to 200% of the federal poverty level. Plans on the individual exchanges are required to cover a package of essential benefits with pricing limitations to ensure that out-of-pocket costs are low enough for low-income patients.
Republican members of the House of Representatives sued the HHS over the CSR payments under the Obama administration, claiming the funding was illegal because it was never appropriated by Congress. A court ruled in favor of the House in 2016, but an appeal filed by the Obama administration allowed the CSR payments to continue. President Trump has not indicated whether he plans to drop the appeal or carry on the case. But if he fails to continue the suit, the move would immediately end the CSR payments.
On July 29, President Trump tweeted, “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!”
The state attorneys general are ready to defend the ACA and the cost sharing reduction payments, California Attorney General Xavier Becerra said in a statement.
“If Donald Trump won’t defend these vital subsidies for American families, then we will,” Mr. Becerra said in the statement. “This ruling gives my fellow attorneys general and me the ability to stand up for the millions of families who otherwise would lack access to affordable health care. It’s time Americans knew we were working for them, not against them.”
[email protected]
On Twitter @legal_med
While Republican efforts to repeal and/or replace the Affordable Care Act are likely to resurface after the congressional summer recess, lawsuits challenging the health law continue to wind their way through the courts.
Judges recently ruled in three ACA cases regarding the contraceptive mandate, risk corridors program, and cost-sharing reduction payments.
Real Alternatives Inc. v. HHS
Secular groups are not entitled to a religious exemption to the ACA’s contraceptive mandate and must offer plans to employees that cover birth control, the United States Court of Appeals for the Third Circuit ruled in an Aug. 4 opinion.
But a majority of appeal judges disagreed, concluding that Real Alternatives is not similar to a religious denomination or one of its nontheistic counterparts, “not in structure, not in aim, not in purpose, and not in function.”
“We do not doubt that Real Alternative’s stance on contraceptives is grounded in sincerely-held moral values, but religion is not generally confined to one question or one moral teaching, it has a broader scope,” Judge Marjorie O. Rendell wrote in the majority opinion. “Real Alternatives is functionally similar not to a church, but to the countless nonreligious nonprofit organizations that take morally informed positions on some discrete set of issues ... While commitment to an anti-abortion platform may be important to the people who hold them, that commitment is not a religion in any legally or theologically accepted sense; and organizations do not become quasi-churches for equal-protection purposes merely by espousing a commitment of that sort.”
Molina Healthcare v. HHS
The federal Heath & Human Services department may have to dish out millions to marketplace insurers after a recent decision by the U.S. Court of Federal Claims. In an Aug. 4 opinion, a federal claims judge ruled the federal government owes Long Beach, Calif.–based insurer Molina Healthcare $52 million in risk corridor payments under the ACA.
The decision stems from a lawsuit by Molina and dozens of other insurers against HHS over the ACA’s risk corridor program. The program requires HHS to collect funds from excessively profitable insurers that offer qualified health plans (QHP) under the exchanges, while paying out funds to QHP insurers with excessive losses. Collections from profitable insurers under the program fell short in 2014 and again in 2015, resulting in HHS paying about 12 cents on the dollar in payments to insurers.
Insurers allege they’ve been shortchanged and that the government must reimburse them full payments for 2014 and 2015. Under the Obama administration, the Department of Justice requested to dismiss the cases, arguing that riders attached to appropriations bills in 2015 and 2016 barred it from making full risk corridor payments.
In his decision, Judge Thomas Wheeler said the ACA mandates that HHS pay insurers what they are owed under the risk corridor program, regardless of the riders.
“The undisputed facts show the government entered into an implied-in-fact contract with Molina and subsequently breached the contract when it failed to make full risk corridor payments,” Judge Wheeler wrote. “Importantly, Molina prevails on its argument of breach of an implied-in-fact contract regardless of the government’s appropriation law defenses – later appropriation restrictions cannot erase a previously created contractual obligation ...The government is liable for its breach of a statutory and contractual obligation to make full annual payments to insurers who participated in the risk corridor program.”
Judge Wheeler ruled similarly in February when he concluded the federal government owes Portland, Ore.–based Moda Health $214 million in risk corridor payments.
The issue is far from over. More than 25 lawsuits have been filed in the Court of Federal Claims by insurers seeking risk corridor money. Several of the cases have moved onto federal appeals courts, while other cases have been dismissed. Analysts say the issue is likely to reach the U.S. Supreme Court. It’s unclear where the Trump administration would get the funds to reimburse insurers if the payback rulings stand. About $19.3 billion in risk corridor payments are at stake for 2014 and 2015 and an estimated $3 billion is in play for 2016, the final risk corridor year.
House v. Price
A U.S. appeals court has allowed 16 states to intervene in a lawsuit over whether subsidy payments made to insurers under the ACA are legal. The decision comes as President Trump recently threatened to cut off the cost sharing reduction (CSR) payments to marketplace insurers, calling them a “bailout.”
On Aug. 1, the U.S. Court of Appeals for the District of Columbia Circuit granted a motion by 18 attorneys general to enter the lawsuit. The attorneys general represent California, New York, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, New Mexico, North Carolina, Pennsylvania, Vermont, Virginia, Washington, and the District of Columbia.
Under the ACA, the federal government provides CSR payments to insurers to offset the costs for providing discount plans to patients who earn up to 200% of the federal poverty level. Plans on the individual exchanges are required to cover a package of essential benefits with pricing limitations to ensure that out-of-pocket costs are low enough for low-income patients.
Republican members of the House of Representatives sued the HHS over the CSR payments under the Obama administration, claiming the funding was illegal because it was never appropriated by Congress. A court ruled in favor of the House in 2016, but an appeal filed by the Obama administration allowed the CSR payments to continue. President Trump has not indicated whether he plans to drop the appeal or carry on the case. But if he fails to continue the suit, the move would immediately end the CSR payments.
On July 29, President Trump tweeted, “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!”
The state attorneys general are ready to defend the ACA and the cost sharing reduction payments, California Attorney General Xavier Becerra said in a statement.
“If Donald Trump won’t defend these vital subsidies for American families, then we will,” Mr. Becerra said in the statement. “This ruling gives my fellow attorneys general and me the ability to stand up for the millions of families who otherwise would lack access to affordable health care. It’s time Americans knew we were working for them, not against them.”
[email protected]
On Twitter @legal_med
While Republican efforts to repeal and/or replace the Affordable Care Act are likely to resurface after the congressional summer recess, lawsuits challenging the health law continue to wind their way through the courts.
Judges recently ruled in three ACA cases regarding the contraceptive mandate, risk corridors program, and cost-sharing reduction payments.
Real Alternatives Inc. v. HHS
Secular groups are not entitled to a religious exemption to the ACA’s contraceptive mandate and must offer plans to employees that cover birth control, the United States Court of Appeals for the Third Circuit ruled in an Aug. 4 opinion.
But a majority of appeal judges disagreed, concluding that Real Alternatives is not similar to a religious denomination or one of its nontheistic counterparts, “not in structure, not in aim, not in purpose, and not in function.”
“We do not doubt that Real Alternative’s stance on contraceptives is grounded in sincerely-held moral values, but religion is not generally confined to one question or one moral teaching, it has a broader scope,” Judge Marjorie O. Rendell wrote in the majority opinion. “Real Alternatives is functionally similar not to a church, but to the countless nonreligious nonprofit organizations that take morally informed positions on some discrete set of issues ... While commitment to an anti-abortion platform may be important to the people who hold them, that commitment is not a religion in any legally or theologically accepted sense; and organizations do not become quasi-churches for equal-protection purposes merely by espousing a commitment of that sort.”
Molina Healthcare v. HHS
The federal Heath & Human Services department may have to dish out millions to marketplace insurers after a recent decision by the U.S. Court of Federal Claims. In an Aug. 4 opinion, a federal claims judge ruled the federal government owes Long Beach, Calif.–based insurer Molina Healthcare $52 million in risk corridor payments under the ACA.
The decision stems from a lawsuit by Molina and dozens of other insurers against HHS over the ACA’s risk corridor program. The program requires HHS to collect funds from excessively profitable insurers that offer qualified health plans (QHP) under the exchanges, while paying out funds to QHP insurers with excessive losses. Collections from profitable insurers under the program fell short in 2014 and again in 2015, resulting in HHS paying about 12 cents on the dollar in payments to insurers.
Insurers allege they’ve been shortchanged and that the government must reimburse them full payments for 2014 and 2015. Under the Obama administration, the Department of Justice requested to dismiss the cases, arguing that riders attached to appropriations bills in 2015 and 2016 barred it from making full risk corridor payments.
In his decision, Judge Thomas Wheeler said the ACA mandates that HHS pay insurers what they are owed under the risk corridor program, regardless of the riders.
“The undisputed facts show the government entered into an implied-in-fact contract with Molina and subsequently breached the contract when it failed to make full risk corridor payments,” Judge Wheeler wrote. “Importantly, Molina prevails on its argument of breach of an implied-in-fact contract regardless of the government’s appropriation law defenses – later appropriation restrictions cannot erase a previously created contractual obligation ...The government is liable for its breach of a statutory and contractual obligation to make full annual payments to insurers who participated in the risk corridor program.”
Judge Wheeler ruled similarly in February when he concluded the federal government owes Portland, Ore.–based Moda Health $214 million in risk corridor payments.
The issue is far from over. More than 25 lawsuits have been filed in the Court of Federal Claims by insurers seeking risk corridor money. Several of the cases have moved onto federal appeals courts, while other cases have been dismissed. Analysts say the issue is likely to reach the U.S. Supreme Court. It’s unclear where the Trump administration would get the funds to reimburse insurers if the payback rulings stand. About $19.3 billion in risk corridor payments are at stake for 2014 and 2015 and an estimated $3 billion is in play for 2016, the final risk corridor year.
House v. Price
A U.S. appeals court has allowed 16 states to intervene in a lawsuit over whether subsidy payments made to insurers under the ACA are legal. The decision comes as President Trump recently threatened to cut off the cost sharing reduction (CSR) payments to marketplace insurers, calling them a “bailout.”
On Aug. 1, the U.S. Court of Appeals for the District of Columbia Circuit granted a motion by 18 attorneys general to enter the lawsuit. The attorneys general represent California, New York, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maryland, Massachusetts, Minnesota, New Mexico, North Carolina, Pennsylvania, Vermont, Virginia, Washington, and the District of Columbia.
Under the ACA, the federal government provides CSR payments to insurers to offset the costs for providing discount plans to patients who earn up to 200% of the federal poverty level. Plans on the individual exchanges are required to cover a package of essential benefits with pricing limitations to ensure that out-of-pocket costs are low enough for low-income patients.
Republican members of the House of Representatives sued the HHS over the CSR payments under the Obama administration, claiming the funding was illegal because it was never appropriated by Congress. A court ruled in favor of the House in 2016, but an appeal filed by the Obama administration allowed the CSR payments to continue. President Trump has not indicated whether he plans to drop the appeal or carry on the case. But if he fails to continue the suit, the move would immediately end the CSR payments.
On July 29, President Trump tweeted, “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!”
The state attorneys general are ready to defend the ACA and the cost sharing reduction payments, California Attorney General Xavier Becerra said in a statement.
“If Donald Trump won’t defend these vital subsidies for American families, then we will,” Mr. Becerra said in the statement. “This ruling gives my fellow attorneys general and me the ability to stand up for the millions of families who otherwise would lack access to affordable health care. It’s time Americans knew we were working for them, not against them.”
[email protected]
On Twitter @legal_med
Practitioner Cognitive Reframing: Working More Effectively in Addictions
I am a behavioral health-licensed clinical social worker, an approved motivational enhancement therapy provider, and the point of contact for substance use disorders at the Berks CBOC of the Lebanon VAMC in Wyomissing, Pennsylvania. Recently, an exasperated primary care provider at the Berks CBOC approached me about working with patients with substance use disorders and asked “How do you work with this challenging population?”
The question was cause for some introspection. When I started working in addictions, I had to modify my approach to work effectively with this population. I experienced a paradigm shift in which I no longer assigned myself credit or blame for a veteran’s continued sobriety or relapse: Each patient is responsible for his or her progress in the recovery journey. When a patient has a relapse, I remind myself that statistically relapse is a probability for the majority of those in recovery; even multiple relapses are common. Therefore, another way of viewing relapse is that the relapse itself may bring the veteran a step closer to permanent abstinence.
Cognitive Reframing
Consider a toddler learning to walk. Parents and caregivers of the child expect the child to fall quite a few times before he or she has mastered walking. The parents and caregivers don’t get angry, take the situation personally, or feel manipulated by the child’s “failure.” Instead, the parents offer the child emotional support and encouragement.
Arguably, the practitioner should take a similar stance—emotionally supportive and encouraging—in combination with dialogue guided by motivational interviewing to support change and help the veteran get back on track. Although not inevitable, relapse is a normal part of recovery.
Practitioners should avoid either scolding or praising patients. Scolding doesn’t help in the recovery journey, and if the veteran learns that the practitioner reacts by scolding after learning of the relapse, then it is less likely that he or she will be open about future missteps. In fact, the veteran may not return at all. The goal is to have the patient come back when relapse occurs to help him or her progress to recovery.
Too much praise can cause similar problems. A veteran accustomed to praise when he or she is doing well, may be too embarrassed or ashamed to return to ask for help after a relapse. Instead the practitioner should use affirmations, which are widely discussed in motivational interviewing (MI) literature.
“I want to be clean and sober” or “I want to stop drinking” are vague statements that should raise a red flag for experienced practitioners. Is this patient just telling me what he or she thinks I want to hear to respond? That may be the case but also may be an assumption. Instead these assertions could be regarded as global treatment goals, and the task of the practitioner is to help the veteran develop objectives and interventions in relation to this goal. These broad statements can be a starting point in MI. These words can sound just as foreign to a patient who isn’t sure whether becoming clean and sober is a possibility. The veteran may not have the confidence to reach the goal of being clean and sober, and these statements may seem awkward and out of sync with his or her facial expression and body language.
Showing disbelief in a veteran also can have negative consequences. The veteran might feel that “even my therapist/health care provider doesn’t believe I can become clean and sober.” Instead, I remind myself that we all must manipulate our environment for survival. I find it more valuable to think of the veteran as being resourceful rather than manipulative.
This point may seem self-evident, but it took me a while to catch on: Most of the change in the recovery journey transpires outside the practitioner’s office. I had to embrace this truism and be prepared when the veteran returned for the next session. The task, then, is to determine at this moment where the veteran is in his or her recovery journey instead of continuing the conversation from the previous session. The previous session may be irrelevant. Thinking this way was an adjustment for me. One of my favorite therapy approaches was to consciously continue a conversation from the previous session to demonstrate that I remembered what the patient had said, thereby showing that I care.
In addition, get to know the patient underneath, behind, and before the substance use disorder. Knowing and liking the veteran helps me avoid burnout, bringing me back to my values and the reason I became a therapist. I make efforts in my thinking process to convert “alcoholic” or “drug abuser” into a more helpful “client addicted to alcohol” or “client with a substance use disorder.” The veteran should not be labeled.
Motivational Interviewing
Oftentimes what propels veterans forward in their recovery is the cognitive dissonance created between who they were and how they acted before substance addiction and how they act now. Conversation steered in this direction, fueled by MI, can enhance a veteran’s motivation to change and ready the veteran to change behaviors. Listen to the veteran’s account of loved ones and remember the names of these important family members and friends. Weave into the conversation the names of these loved ones when the veteran makes statements about becoming a better son/father/grandfather or daughter/mother/grandmother. These references make the goal concrete . A loved one can even be a pet; and for some, the desire to be a more competent and reliable pet owner can be a strong motivation. Give the veteran an opportunity to describe his or her strengths and bask in a self-description. In recovery, it is critical to identify strengths that can be built on to sustain recovery.
Veterans who are confronting a substance use disorder may approach the practitioner with a “fix it for me” attitude as a mental inventory is being taken of all of the negative consequences (eg, homelessness, legal issues, or unemployment). Getting the veteran to take ownership of the problem and the solution is key.
I don’t promise to fix things, instead I engage the veteran in problem-solving. I offer to team up with the veteran in this process, and I promise my best efforts but not outcomes. I avoid giving advice and work to empower the veteran to make sound decisions. Veterans who make their own decisions feel as though they have more control over their lives.
Working with the substance use disorder population is challenging but rewarding when a practitioner can embrace some of the paradigms described in this article. Practitioners may need to do some cognitive reframing within their own thinking, as I described in this article, to become more effective in the field and to help avoid burnout.
I am a behavioral health-licensed clinical social worker, an approved motivational enhancement therapy provider, and the point of contact for substance use disorders at the Berks CBOC of the Lebanon VAMC in Wyomissing, Pennsylvania. Recently, an exasperated primary care provider at the Berks CBOC approached me about working with patients with substance use disorders and asked “How do you work with this challenging population?”
The question was cause for some introspection. When I started working in addictions, I had to modify my approach to work effectively with this population. I experienced a paradigm shift in which I no longer assigned myself credit or blame for a veteran’s continued sobriety or relapse: Each patient is responsible for his or her progress in the recovery journey. When a patient has a relapse, I remind myself that statistically relapse is a probability for the majority of those in recovery; even multiple relapses are common. Therefore, another way of viewing relapse is that the relapse itself may bring the veteran a step closer to permanent abstinence.
Cognitive Reframing
Consider a toddler learning to walk. Parents and caregivers of the child expect the child to fall quite a few times before he or she has mastered walking. The parents and caregivers don’t get angry, take the situation personally, or feel manipulated by the child’s “failure.” Instead, the parents offer the child emotional support and encouragement.
Arguably, the practitioner should take a similar stance—emotionally supportive and encouraging—in combination with dialogue guided by motivational interviewing to support change and help the veteran get back on track. Although not inevitable, relapse is a normal part of recovery.
Practitioners should avoid either scolding or praising patients. Scolding doesn’t help in the recovery journey, and if the veteran learns that the practitioner reacts by scolding after learning of the relapse, then it is less likely that he or she will be open about future missteps. In fact, the veteran may not return at all. The goal is to have the patient come back when relapse occurs to help him or her progress to recovery.
Too much praise can cause similar problems. A veteran accustomed to praise when he or she is doing well, may be too embarrassed or ashamed to return to ask for help after a relapse. Instead the practitioner should use affirmations, which are widely discussed in motivational interviewing (MI) literature.
“I want to be clean and sober” or “I want to stop drinking” are vague statements that should raise a red flag for experienced practitioners. Is this patient just telling me what he or she thinks I want to hear to respond? That may be the case but also may be an assumption. Instead these assertions could be regarded as global treatment goals, and the task of the practitioner is to help the veteran develop objectives and interventions in relation to this goal. These broad statements can be a starting point in MI. These words can sound just as foreign to a patient who isn’t sure whether becoming clean and sober is a possibility. The veteran may not have the confidence to reach the goal of being clean and sober, and these statements may seem awkward and out of sync with his or her facial expression and body language.
Showing disbelief in a veteran also can have negative consequences. The veteran might feel that “even my therapist/health care provider doesn’t believe I can become clean and sober.” Instead, I remind myself that we all must manipulate our environment for survival. I find it more valuable to think of the veteran as being resourceful rather than manipulative.
This point may seem self-evident, but it took me a while to catch on: Most of the change in the recovery journey transpires outside the practitioner’s office. I had to embrace this truism and be prepared when the veteran returned for the next session. The task, then, is to determine at this moment where the veteran is in his or her recovery journey instead of continuing the conversation from the previous session. The previous session may be irrelevant. Thinking this way was an adjustment for me. One of my favorite therapy approaches was to consciously continue a conversation from the previous session to demonstrate that I remembered what the patient had said, thereby showing that I care.
In addition, get to know the patient underneath, behind, and before the substance use disorder. Knowing and liking the veteran helps me avoid burnout, bringing me back to my values and the reason I became a therapist. I make efforts in my thinking process to convert “alcoholic” or “drug abuser” into a more helpful “client addicted to alcohol” or “client with a substance use disorder.” The veteran should not be labeled.
Motivational Interviewing
Oftentimes what propels veterans forward in their recovery is the cognitive dissonance created between who they were and how they acted before substance addiction and how they act now. Conversation steered in this direction, fueled by MI, can enhance a veteran’s motivation to change and ready the veteran to change behaviors. Listen to the veteran’s account of loved ones and remember the names of these important family members and friends. Weave into the conversation the names of these loved ones when the veteran makes statements about becoming a better son/father/grandfather or daughter/mother/grandmother. These references make the goal concrete . A loved one can even be a pet; and for some, the desire to be a more competent and reliable pet owner can be a strong motivation. Give the veteran an opportunity to describe his or her strengths and bask in a self-description. In recovery, it is critical to identify strengths that can be built on to sustain recovery.
Veterans who are confronting a substance use disorder may approach the practitioner with a “fix it for me” attitude as a mental inventory is being taken of all of the negative consequences (eg, homelessness, legal issues, or unemployment). Getting the veteran to take ownership of the problem and the solution is key.
I don’t promise to fix things, instead I engage the veteran in problem-solving. I offer to team up with the veteran in this process, and I promise my best efforts but not outcomes. I avoid giving advice and work to empower the veteran to make sound decisions. Veterans who make their own decisions feel as though they have more control over their lives.
Working with the substance use disorder population is challenging but rewarding when a practitioner can embrace some of the paradigms described in this article. Practitioners may need to do some cognitive reframing within their own thinking, as I described in this article, to become more effective in the field and to help avoid burnout.
I am a behavioral health-licensed clinical social worker, an approved motivational enhancement therapy provider, and the point of contact for substance use disorders at the Berks CBOC of the Lebanon VAMC in Wyomissing, Pennsylvania. Recently, an exasperated primary care provider at the Berks CBOC approached me about working with patients with substance use disorders and asked “How do you work with this challenging population?”
The question was cause for some introspection. When I started working in addictions, I had to modify my approach to work effectively with this population. I experienced a paradigm shift in which I no longer assigned myself credit or blame for a veteran’s continued sobriety or relapse: Each patient is responsible for his or her progress in the recovery journey. When a patient has a relapse, I remind myself that statistically relapse is a probability for the majority of those in recovery; even multiple relapses are common. Therefore, another way of viewing relapse is that the relapse itself may bring the veteran a step closer to permanent abstinence.
Cognitive Reframing
Consider a toddler learning to walk. Parents and caregivers of the child expect the child to fall quite a few times before he or she has mastered walking. The parents and caregivers don’t get angry, take the situation personally, or feel manipulated by the child’s “failure.” Instead, the parents offer the child emotional support and encouragement.
Arguably, the practitioner should take a similar stance—emotionally supportive and encouraging—in combination with dialogue guided by motivational interviewing to support change and help the veteran get back on track. Although not inevitable, relapse is a normal part of recovery.
Practitioners should avoid either scolding or praising patients. Scolding doesn’t help in the recovery journey, and if the veteran learns that the practitioner reacts by scolding after learning of the relapse, then it is less likely that he or she will be open about future missteps. In fact, the veteran may not return at all. The goal is to have the patient come back when relapse occurs to help him or her progress to recovery.
Too much praise can cause similar problems. A veteran accustomed to praise when he or she is doing well, may be too embarrassed or ashamed to return to ask for help after a relapse. Instead the practitioner should use affirmations, which are widely discussed in motivational interviewing (MI) literature.
“I want to be clean and sober” or “I want to stop drinking” are vague statements that should raise a red flag for experienced practitioners. Is this patient just telling me what he or she thinks I want to hear to respond? That may be the case but also may be an assumption. Instead these assertions could be regarded as global treatment goals, and the task of the practitioner is to help the veteran develop objectives and interventions in relation to this goal. These broad statements can be a starting point in MI. These words can sound just as foreign to a patient who isn’t sure whether becoming clean and sober is a possibility. The veteran may not have the confidence to reach the goal of being clean and sober, and these statements may seem awkward and out of sync with his or her facial expression and body language.
Showing disbelief in a veteran also can have negative consequences. The veteran might feel that “even my therapist/health care provider doesn’t believe I can become clean and sober.” Instead, I remind myself that we all must manipulate our environment for survival. I find it more valuable to think of the veteran as being resourceful rather than manipulative.
This point may seem self-evident, but it took me a while to catch on: Most of the change in the recovery journey transpires outside the practitioner’s office. I had to embrace this truism and be prepared when the veteran returned for the next session. The task, then, is to determine at this moment where the veteran is in his or her recovery journey instead of continuing the conversation from the previous session. The previous session may be irrelevant. Thinking this way was an adjustment for me. One of my favorite therapy approaches was to consciously continue a conversation from the previous session to demonstrate that I remembered what the patient had said, thereby showing that I care.
In addition, get to know the patient underneath, behind, and before the substance use disorder. Knowing and liking the veteran helps me avoid burnout, bringing me back to my values and the reason I became a therapist. I make efforts in my thinking process to convert “alcoholic” or “drug abuser” into a more helpful “client addicted to alcohol” or “client with a substance use disorder.” The veteran should not be labeled.
Motivational Interviewing
Oftentimes what propels veterans forward in their recovery is the cognitive dissonance created between who they were and how they acted before substance addiction and how they act now. Conversation steered in this direction, fueled by MI, can enhance a veteran’s motivation to change and ready the veteran to change behaviors. Listen to the veteran’s account of loved ones and remember the names of these important family members and friends. Weave into the conversation the names of these loved ones when the veteran makes statements about becoming a better son/father/grandfather or daughter/mother/grandmother. These references make the goal concrete . A loved one can even be a pet; and for some, the desire to be a more competent and reliable pet owner can be a strong motivation. Give the veteran an opportunity to describe his or her strengths and bask in a self-description. In recovery, it is critical to identify strengths that can be built on to sustain recovery.
Veterans who are confronting a substance use disorder may approach the practitioner with a “fix it for me” attitude as a mental inventory is being taken of all of the negative consequences (eg, homelessness, legal issues, or unemployment). Getting the veteran to take ownership of the problem and the solution is key.
I don’t promise to fix things, instead I engage the veteran in problem-solving. I offer to team up with the veteran in this process, and I promise my best efforts but not outcomes. I avoid giving advice and work to empower the veteran to make sound decisions. Veterans who make their own decisions feel as though they have more control over their lives.
Working with the substance use disorder population is challenging but rewarding when a practitioner can embrace some of the paradigms described in this article. Practitioners may need to do some cognitive reframing within their own thinking, as I described in this article, to become more effective in the field and to help avoid burnout.
Preop atrial fib in CABG patients spells trouble
COLORADO SPRINGS – Preoperative atrial fibrillation is present in more than 10% of patients undergoing isolated coronary artery bypass graft (CABG) surgery, and if not subjected to concomitant surgical ablation it’s associated with increased perioperative and long-term major morbidity and mortality, S. Chris Malaisrie, MD, reported at the annual meeting of the Western Thoracic Surgical Association.
The increased early and late risks posed by preoperative atrial fibrillation (AF) that go unaddressed remain significant even after adjusting for the numerous comorbid conditions more prevalent in CABG patients with preoperative AF than in those without the arrhythmia, added Dr. Malaisrie, a cardiac surgeon at Northwestern University in Chicago.
The unadjusted operative mortality rate was 1.8% in the no-AF group and 4.0% in patients with preoperative AF. Unadjusted in-hospital rates of permanent stroke, prolonged ventilation, reoperation, and new renal failure were also significantly higher in the preoperative AF group.
Not surprisingly, the preoperative AF group was older. They also had significantly higher baseline rates of numerous comorbid conditions, including diabetes, peripheral vascular disease, renal failure, and prior stroke, as well as a lower mean left ventricular ejection fraction. However, after adjustment for the many comorbidities in multivariate regression analysis, the risks of all in-hospital adverse outcomes remained significantly higher in the preoperative AF group. For example, their adjusted risk of operative mortality was 1.5-fold greater than in the no-AF patients.
In the long-term follow-up analysis, the unadjusted risk of mortality in the first 5 years after CABG was 2.5-fold greater in the preoperative AF group. Their 5-year risk of stroke or systemic embolization was 1.5-fold greater, too. Upon adjustment for potentially confounding comorbid conditions, preoperative AF was associated with a 1.5-fold increased 5-year risk of mortality and a 1.2-fold increase in stroke or systemic embolism.
In an effort to identify a particularly high-risk group of CABG patients with preoperative AF, Dr. Malaisrie and his coinvestigators stratified the group’s long-term stroke and mortality risks by their CHA2DS2-VASc score at the time of surgery. The results were revealing: the unadjusted 5-year risk of stroke or systemic embolization was 7.9% in those with a CHA2DS2-VASc score of 1-3, 12.2% with a score of 4-6, and 15.4% with a score of 7-9. The 5-year survival rate was 74.8% with a score of 1-3, 56.5% with a score of 4-6, and 41.2% with a score of 7-9.
“That’s really a striking finding,” Dr. Malaisrie observed. “When you consider a patient who’s, say, 72-75 years old, who is undergoing isolated CABG with preoperative atrial fibrillation and who has a high CHA2DS2-VASc score of 7-9, 5-year survival is only 41%, with a 15% risk of stroke or systemic embolization.”
Discussant William T. Caine, MD, found the study results unsettling.
“I was surprised to see that in this day and age, fully two-thirds of the patients who had preoperative atrial fibrillation had no attempt at any ablation procedure to treat their atrial fibrillation,” declared Dr. Caine of Intermountain Medical Center in Salt Lake City.
In reply, Dr. Malaisrie noted that other, smaller studies have also found that only about 30% of CABG patients with preoperative AF undergo surgical AF ablation through a maze procedure or some other method.
“Probably most of us in this room would go ahead and perform surgical ablation, but the STS database represents all isolated CABG procedures done throughout the United States,” Dr. Malaisrie said. “I think this dataset should help convince the other 70% of surgeons out there that there is a high cost for preoperative AF – in particular, in patients with very high CHA2DS2-VASc scores. If you can identify a group of patients at increased risk for stroke and mortality, you’d certainly want to bend their survival curve.”
The maze procedure has been convincingly shown to be very safe, with no associated increased risk of perioperative morbidity and mortality. The downside is cost. But while it’s true that adding surgical ablation to an isolated CABG procedure boosts OR time and procedural costs, a successful ablation is likely to pay dividends through reduced downstream rates of major morbidity and mortality.
“I look forward to the second part of our analysis, where we’ll look at the comparative data for the patients who did in fact have surgical ablation. That dataset is pending from the Duke Clinical Research Institute,” according to Dr. Malaisrie.
He cited as study limitations the inability to complete linkage to the Medicare database in about 37% of CABG patients in the STS database, or more than 200,000 people. Also, the Medicare database is an administrative dataset reliant upon medical record coding. The mortality data are probably quite accurate, but the stroke and systemic embolization rates cited in this analysis likely underestimate the true rates.
He reported serving as a consultant to Edwards Lifesciences, Abbott Vascular, and Baxter, and serving on speakers’ bureaus for Bolton and Abiomed. However, the STS analysis was funded exclusively by philanthropy.
COLORADO SPRINGS – Preoperative atrial fibrillation is present in more than 10% of patients undergoing isolated coronary artery bypass graft (CABG) surgery, and if not subjected to concomitant surgical ablation it’s associated with increased perioperative and long-term major morbidity and mortality, S. Chris Malaisrie, MD, reported at the annual meeting of the Western Thoracic Surgical Association.
The increased early and late risks posed by preoperative atrial fibrillation (AF) that go unaddressed remain significant even after adjusting for the numerous comorbid conditions more prevalent in CABG patients with preoperative AF than in those without the arrhythmia, added Dr. Malaisrie, a cardiac surgeon at Northwestern University in Chicago.
The unadjusted operative mortality rate was 1.8% in the no-AF group and 4.0% in patients with preoperative AF. Unadjusted in-hospital rates of permanent stroke, prolonged ventilation, reoperation, and new renal failure were also significantly higher in the preoperative AF group.
Not surprisingly, the preoperative AF group was older. They also had significantly higher baseline rates of numerous comorbid conditions, including diabetes, peripheral vascular disease, renal failure, and prior stroke, as well as a lower mean left ventricular ejection fraction. However, after adjustment for the many comorbidities in multivariate regression analysis, the risks of all in-hospital adverse outcomes remained significantly higher in the preoperative AF group. For example, their adjusted risk of operative mortality was 1.5-fold greater than in the no-AF patients.
In the long-term follow-up analysis, the unadjusted risk of mortality in the first 5 years after CABG was 2.5-fold greater in the preoperative AF group. Their 5-year risk of stroke or systemic embolization was 1.5-fold greater, too. Upon adjustment for potentially confounding comorbid conditions, preoperative AF was associated with a 1.5-fold increased 5-year risk of mortality and a 1.2-fold increase in stroke or systemic embolism.
In an effort to identify a particularly high-risk group of CABG patients with preoperative AF, Dr. Malaisrie and his coinvestigators stratified the group’s long-term stroke and mortality risks by their CHA2DS2-VASc score at the time of surgery. The results were revealing: the unadjusted 5-year risk of stroke or systemic embolization was 7.9% in those with a CHA2DS2-VASc score of 1-3, 12.2% with a score of 4-6, and 15.4% with a score of 7-9. The 5-year survival rate was 74.8% with a score of 1-3, 56.5% with a score of 4-6, and 41.2% with a score of 7-9.
“That’s really a striking finding,” Dr. Malaisrie observed. “When you consider a patient who’s, say, 72-75 years old, who is undergoing isolated CABG with preoperative atrial fibrillation and who has a high CHA2DS2-VASc score of 7-9, 5-year survival is only 41%, with a 15% risk of stroke or systemic embolization.”
Discussant William T. Caine, MD, found the study results unsettling.
“I was surprised to see that in this day and age, fully two-thirds of the patients who had preoperative atrial fibrillation had no attempt at any ablation procedure to treat their atrial fibrillation,” declared Dr. Caine of Intermountain Medical Center in Salt Lake City.
In reply, Dr. Malaisrie noted that other, smaller studies have also found that only about 30% of CABG patients with preoperative AF undergo surgical AF ablation through a maze procedure or some other method.
“Probably most of us in this room would go ahead and perform surgical ablation, but the STS database represents all isolated CABG procedures done throughout the United States,” Dr. Malaisrie said. “I think this dataset should help convince the other 70% of surgeons out there that there is a high cost for preoperative AF – in particular, in patients with very high CHA2DS2-VASc scores. If you can identify a group of patients at increased risk for stroke and mortality, you’d certainly want to bend their survival curve.”
The maze procedure has been convincingly shown to be very safe, with no associated increased risk of perioperative morbidity and mortality. The downside is cost. But while it’s true that adding surgical ablation to an isolated CABG procedure boosts OR time and procedural costs, a successful ablation is likely to pay dividends through reduced downstream rates of major morbidity and mortality.
“I look forward to the second part of our analysis, where we’ll look at the comparative data for the patients who did in fact have surgical ablation. That dataset is pending from the Duke Clinical Research Institute,” according to Dr. Malaisrie.
He cited as study limitations the inability to complete linkage to the Medicare database in about 37% of CABG patients in the STS database, or more than 200,000 people. Also, the Medicare database is an administrative dataset reliant upon medical record coding. The mortality data are probably quite accurate, but the stroke and systemic embolization rates cited in this analysis likely underestimate the true rates.
He reported serving as a consultant to Edwards Lifesciences, Abbott Vascular, and Baxter, and serving on speakers’ bureaus for Bolton and Abiomed. However, the STS analysis was funded exclusively by philanthropy.
COLORADO SPRINGS – Preoperative atrial fibrillation is present in more than 10% of patients undergoing isolated coronary artery bypass graft (CABG) surgery, and if not subjected to concomitant surgical ablation it’s associated with increased perioperative and long-term major morbidity and mortality, S. Chris Malaisrie, MD, reported at the annual meeting of the Western Thoracic Surgical Association.
The increased early and late risks posed by preoperative atrial fibrillation (AF) that go unaddressed remain significant even after adjusting for the numerous comorbid conditions more prevalent in CABG patients with preoperative AF than in those without the arrhythmia, added Dr. Malaisrie, a cardiac surgeon at Northwestern University in Chicago.
The unadjusted operative mortality rate was 1.8% in the no-AF group and 4.0% in patients with preoperative AF. Unadjusted in-hospital rates of permanent stroke, prolonged ventilation, reoperation, and new renal failure were also significantly higher in the preoperative AF group.
Not surprisingly, the preoperative AF group was older. They also had significantly higher baseline rates of numerous comorbid conditions, including diabetes, peripheral vascular disease, renal failure, and prior stroke, as well as a lower mean left ventricular ejection fraction. However, after adjustment for the many comorbidities in multivariate regression analysis, the risks of all in-hospital adverse outcomes remained significantly higher in the preoperative AF group. For example, their adjusted risk of operative mortality was 1.5-fold greater than in the no-AF patients.
In the long-term follow-up analysis, the unadjusted risk of mortality in the first 5 years after CABG was 2.5-fold greater in the preoperative AF group. Their 5-year risk of stroke or systemic embolization was 1.5-fold greater, too. Upon adjustment for potentially confounding comorbid conditions, preoperative AF was associated with a 1.5-fold increased 5-year risk of mortality and a 1.2-fold increase in stroke or systemic embolism.
In an effort to identify a particularly high-risk group of CABG patients with preoperative AF, Dr. Malaisrie and his coinvestigators stratified the group’s long-term stroke and mortality risks by their CHA2DS2-VASc score at the time of surgery. The results were revealing: the unadjusted 5-year risk of stroke or systemic embolization was 7.9% in those with a CHA2DS2-VASc score of 1-3, 12.2% with a score of 4-6, and 15.4% with a score of 7-9. The 5-year survival rate was 74.8% with a score of 1-3, 56.5% with a score of 4-6, and 41.2% with a score of 7-9.
“That’s really a striking finding,” Dr. Malaisrie observed. “When you consider a patient who’s, say, 72-75 years old, who is undergoing isolated CABG with preoperative atrial fibrillation and who has a high CHA2DS2-VASc score of 7-9, 5-year survival is only 41%, with a 15% risk of stroke or systemic embolization.”
Discussant William T. Caine, MD, found the study results unsettling.
“I was surprised to see that in this day and age, fully two-thirds of the patients who had preoperative atrial fibrillation had no attempt at any ablation procedure to treat their atrial fibrillation,” declared Dr. Caine of Intermountain Medical Center in Salt Lake City.
In reply, Dr. Malaisrie noted that other, smaller studies have also found that only about 30% of CABG patients with preoperative AF undergo surgical AF ablation through a maze procedure or some other method.
“Probably most of us in this room would go ahead and perform surgical ablation, but the STS database represents all isolated CABG procedures done throughout the United States,” Dr. Malaisrie said. “I think this dataset should help convince the other 70% of surgeons out there that there is a high cost for preoperative AF – in particular, in patients with very high CHA2DS2-VASc scores. If you can identify a group of patients at increased risk for stroke and mortality, you’d certainly want to bend their survival curve.”
The maze procedure has been convincingly shown to be very safe, with no associated increased risk of perioperative morbidity and mortality. The downside is cost. But while it’s true that adding surgical ablation to an isolated CABG procedure boosts OR time and procedural costs, a successful ablation is likely to pay dividends through reduced downstream rates of major morbidity and mortality.
“I look forward to the second part of our analysis, where we’ll look at the comparative data for the patients who did in fact have surgical ablation. That dataset is pending from the Duke Clinical Research Institute,” according to Dr. Malaisrie.
He cited as study limitations the inability to complete linkage to the Medicare database in about 37% of CABG patients in the STS database, or more than 200,000 people. Also, the Medicare database is an administrative dataset reliant upon medical record coding. The mortality data are probably quite accurate, but the stroke and systemic embolization rates cited in this analysis likely underestimate the true rates.
He reported serving as a consultant to Edwards Lifesciences, Abbott Vascular, and Baxter, and serving on speakers’ bureaus for Bolton and Abiomed. However, the STS analysis was funded exclusively by philanthropy.
AT THE WTSA ANNUAL MEETING
Key clinical point:
Major finding: Preoperative AF in patients undergoing isolated CABG was tied to an adjusted 45% greater 5-year mortality and 25% increase in stroke and systemic embolization risk, compared with CABG patients without the preoperative arrhythmia.
Data source: This retrospective study compared perioperative and long-term morbidity and mortality in nearly 350,000 patients in the Society of Thoracic Surgeons database who underwent isolated CABG, including more than 24,000 who had preoperative atrial fibrillation that wasn’t addressed surgically.
Disclosures: The study presenter reported serving as a consultant to Edwards Lifesciences, Abbott Vascular, and Baxter, and serving on speakers’ bureaus for Bolton and Abiomed. However, the STS analysis was funded exclusively by philanthropy.
VSTs can treat 5 different viral infections after HSCT
New research suggests virus-specific T cells (VSTs) can protect patients from severe viral infections that sometimes occur after hematopoietic stem cell transplant (HSCT).
The VSTs proved effective against 5 different viruses—Epstein-Barr virus (EBV), adenovirus (AdV), cytomegalovirus (CMV), BK virus (BKV), and human herpesvirus 6 (HHV-6).
Ifigeneia Tzannou, MD, of Baylor College of Medicine in Houston, Texas, and her colleagues reported these findings in the Journal of Clinical Oncology.
“In this study, we continued our previous work . . . in which we showed that patients who had developed an Epstein-Barr virus infection after a transplant . . . could be helped by receiving immune cells specialized in eliminating that particular virus,” Dr Tzannou said. “Then, we and others successfully targeted other viruses—namely, adenoviruses and cytomegalovirus.”
“The novel contribution of this study is that we have targeted additional viruses, the BK virus and the HHV-6 virus, which had not been targeted this way before,” added study author Bilal Omer, MD, of Baylor College of Medicine.
“This is important because the BK virus does not have an effective treatment, and the complications are significant, including severe pain and bleeding. These patients are in the hospital for weeks, months sometimes, and, now, we have a treatment option.”
The researchers tested their VSTs in a phase 2 trial of 38 HSCT recipients with at least 1 of the aforementioned viruses.
“[To prepare the VSTs,] we take blood from healthy donors who have already been exposed to these viruses and who we have confirmed have immune cells that can fight the infections,” Dr Tzannou said.
“We isolate the cells and let them multiply in culture. The final product is a mixture of cells that, together, can target all 5 viruses. We prepared 59 sets of virus-specific cells from different donors following this procedure.”
“Our strategy is to prepare a number of sets of virus-specific cells ahead of time and store them in a freezer, ready to use when a patient needs them,” Dr Omer noted. “To match patient and donor, we use elaborate matching algorithms.”
Patients
The trial included 38 patients who had undergone HSCT to treat acute myeloid leukemia/myelodysplastic syndromes (n=20), acute lymphoblastic leukemia (n=9), lymphoma/myeloma (n=3), or nonmalignant disorders (n=6).
These 38 patients had a total of 45 infections—CMV (n=17), EBV (n=2), AdV (n=7), BKV (n=16), and HHV-6 (n=3).
Response
The researchers monitored virus levels and other clinical responses in the 37 evaluable patients.
Six weeks after the first VST infusion, the overall response rate was 91.9%.
Seventeen patients received VSTs for persistent CMV. Sixteen of these patients (94.1%) responded, 6 with complete responses (CRs) and 10 with partial responses (PRs).
Two patients received VSTs for EBV, and both achieved a virologic CR.
Seven patients received VSTs for persistent AdV. The response rate was 71.4%. Four patients achieved a CR, 1 had a PR, and 2 patients did not respond.
Three patients received VSTs to treat HHV-6 reactivations. The response rate was 67%. Two patients had a PR, and 1 was not evaluable.
Sixteen patients received VSTs for BKV-associated hemorrhagic cystitis (n= 14) or BKV-associated nephritis (n=2).
All 16 patients responded. One had a clinical and virologic CR. Six had a clinical CR but a virologic PR. Seven had a virologic and clinical PR. And 2 patients had only a virologic PR.
A total of 15 patients received a second VST infusion—1 due to lack of response, 7 who had a PR, and 7 due to recurrence. Ten of these patients responded to the second infusion—1 with a CR and 9 with a PR.
Four patients received a third infusion of VSTs. Two achieved a CR, 1 had a PR, and 1 did not respond.
Toxicity
One patient developed an isolated fever within 24 hours of VST infusion, but the researchers did not observe any other immediate toxicities.
One of the patients with BKV-associated hemorrhagic cystitis experienced transient hydronephrosis and a decrease in renal function associated with a concomitant bacterial urinary tract infection.
Nineteen patients had prior grade 2 to 4 graft-versus-host disease (GVHD)—15 with grade 2 and 4 with grade 3. All GVHD was quiescent at the time of VST infusion.
One patient developed recurrent grade 3 gastrointestinal GVHD after VST infusion and rapid corticosteroid taper. Five patients developed recurrent (n=3) or de novo (n=2) grade 1 to 2 skin GVHD, which resolved with topical treatment (n=4) and reinitiation of corticosteroid treatment (n=1).
Two patients had a flare of upper-gastrointestinal GVHD, which resolved after a brief corticosteroid course.
“We didn’t have any significant toxicities,” Dr Tzannou said. “Taken together, the results of this trial suggest that it is reasonable to consider this treatment as an early option for these patients. We hope that the results of a future multicenter, phase 3 clinical trial will help raise awareness in both physicians and patients that this treatment, which is safe and effective, is available.” 
New research suggests virus-specific T cells (VSTs) can protect patients from severe viral infections that sometimes occur after hematopoietic stem cell transplant (HSCT).
The VSTs proved effective against 5 different viruses—Epstein-Barr virus (EBV), adenovirus (AdV), cytomegalovirus (CMV), BK virus (BKV), and human herpesvirus 6 (HHV-6).
Ifigeneia Tzannou, MD, of Baylor College of Medicine in Houston, Texas, and her colleagues reported these findings in the Journal of Clinical Oncology.
“In this study, we continued our previous work . . . in which we showed that patients who had developed an Epstein-Barr virus infection after a transplant . . . could be helped by receiving immune cells specialized in eliminating that particular virus,” Dr Tzannou said. “Then, we and others successfully targeted other viruses—namely, adenoviruses and cytomegalovirus.”
“The novel contribution of this study is that we have targeted additional viruses, the BK virus and the HHV-6 virus, which had not been targeted this way before,” added study author Bilal Omer, MD, of Baylor College of Medicine.
“This is important because the BK virus does not have an effective treatment, and the complications are significant, including severe pain and bleeding. These patients are in the hospital for weeks, months sometimes, and, now, we have a treatment option.”
The researchers tested their VSTs in a phase 2 trial of 38 HSCT recipients with at least 1 of the aforementioned viruses.
“[To prepare the VSTs,] we take blood from healthy donors who have already been exposed to these viruses and who we have confirmed have immune cells that can fight the infections,” Dr Tzannou said.
“We isolate the cells and let them multiply in culture. The final product is a mixture of cells that, together, can target all 5 viruses. We prepared 59 sets of virus-specific cells from different donors following this procedure.”
“Our strategy is to prepare a number of sets of virus-specific cells ahead of time and store them in a freezer, ready to use when a patient needs them,” Dr Omer noted. “To match patient and donor, we use elaborate matching algorithms.”
Patients
The trial included 38 patients who had undergone HSCT to treat acute myeloid leukemia/myelodysplastic syndromes (n=20), acute lymphoblastic leukemia (n=9), lymphoma/myeloma (n=3), or nonmalignant disorders (n=6).
These 38 patients had a total of 45 infections—CMV (n=17), EBV (n=2), AdV (n=7), BKV (n=16), and HHV-6 (n=3).
Response
The researchers monitored virus levels and other clinical responses in the 37 evaluable patients.
Six weeks after the first VST infusion, the overall response rate was 91.9%.
Seventeen patients received VSTs for persistent CMV. Sixteen of these patients (94.1%) responded, 6 with complete responses (CRs) and 10 with partial responses (PRs).
Two patients received VSTs for EBV, and both achieved a virologic CR.
Seven patients received VSTs for persistent AdV. The response rate was 71.4%. Four patients achieved a CR, 1 had a PR, and 2 patients did not respond.
Three patients received VSTs to treat HHV-6 reactivations. The response rate was 67%. Two patients had a PR, and 1 was not evaluable.
Sixteen patients received VSTs for BKV-associated hemorrhagic cystitis (n= 14) or BKV-associated nephritis (n=2).
All 16 patients responded. One had a clinical and virologic CR. Six had a clinical CR but a virologic PR. Seven had a virologic and clinical PR. And 2 patients had only a virologic PR.
A total of 15 patients received a second VST infusion—1 due to lack of response, 7 who had a PR, and 7 due to recurrence. Ten of these patients responded to the second infusion—1 with a CR and 9 with a PR.
Four patients received a third infusion of VSTs. Two achieved a CR, 1 had a PR, and 1 did not respond.
Toxicity
One patient developed an isolated fever within 24 hours of VST infusion, but the researchers did not observe any other immediate toxicities.
One of the patients with BKV-associated hemorrhagic cystitis experienced transient hydronephrosis and a decrease in renal function associated with a concomitant bacterial urinary tract infection.
Nineteen patients had prior grade 2 to 4 graft-versus-host disease (GVHD)—15 with grade 2 and 4 with grade 3. All GVHD was quiescent at the time of VST infusion.
One patient developed recurrent grade 3 gastrointestinal GVHD after VST infusion and rapid corticosteroid taper. Five patients developed recurrent (n=3) or de novo (n=2) grade 1 to 2 skin GVHD, which resolved with topical treatment (n=4) and reinitiation of corticosteroid treatment (n=1).
Two patients had a flare of upper-gastrointestinal GVHD, which resolved after a brief corticosteroid course.
“We didn’t have any significant toxicities,” Dr Tzannou said. “Taken together, the results of this trial suggest that it is reasonable to consider this treatment as an early option for these patients. We hope that the results of a future multicenter, phase 3 clinical trial will help raise awareness in both physicians and patients that this treatment, which is safe and effective, is available.”
New research suggests virus-specific T cells (VSTs) can protect patients from severe viral infections that sometimes occur after hematopoietic stem cell transplant (HSCT).
The VSTs proved effective against 5 different viruses—Epstein-Barr virus (EBV), adenovirus (AdV), cytomegalovirus (CMV), BK virus (BKV), and human herpesvirus 6 (HHV-6).
Ifigeneia Tzannou, MD, of Baylor College of Medicine in Houston, Texas, and her colleagues reported these findings in the Journal of Clinical Oncology.
“In this study, we continued our previous work . . . in which we showed that patients who had developed an Epstein-Barr virus infection after a transplant . . . could be helped by receiving immune cells specialized in eliminating that particular virus,” Dr Tzannou said. “Then, we and others successfully targeted other viruses—namely, adenoviruses and cytomegalovirus.”
“The novel contribution of this study is that we have targeted additional viruses, the BK virus and the HHV-6 virus, which had not been targeted this way before,” added study author Bilal Omer, MD, of Baylor College of Medicine.
“This is important because the BK virus does not have an effective treatment, and the complications are significant, including severe pain and bleeding. These patients are in the hospital for weeks, months sometimes, and, now, we have a treatment option.”
The researchers tested their VSTs in a phase 2 trial of 38 HSCT recipients with at least 1 of the aforementioned viruses.
“[To prepare the VSTs,] we take blood from healthy donors who have already been exposed to these viruses and who we have confirmed have immune cells that can fight the infections,” Dr Tzannou said.
“We isolate the cells and let them multiply in culture. The final product is a mixture of cells that, together, can target all 5 viruses. We prepared 59 sets of virus-specific cells from different donors following this procedure.”
“Our strategy is to prepare a number of sets of virus-specific cells ahead of time and store them in a freezer, ready to use when a patient needs them,” Dr Omer noted. “To match patient and donor, we use elaborate matching algorithms.”
Patients
The trial included 38 patients who had undergone HSCT to treat acute myeloid leukemia/myelodysplastic syndromes (n=20), acute lymphoblastic leukemia (n=9), lymphoma/myeloma (n=3), or nonmalignant disorders (n=6).
These 38 patients had a total of 45 infections—CMV (n=17), EBV (n=2), AdV (n=7), BKV (n=16), and HHV-6 (n=3).
Response
The researchers monitored virus levels and other clinical responses in the 37 evaluable patients.
Six weeks after the first VST infusion, the overall response rate was 91.9%.
Seventeen patients received VSTs for persistent CMV. Sixteen of these patients (94.1%) responded, 6 with complete responses (CRs) and 10 with partial responses (PRs).
Two patients received VSTs for EBV, and both achieved a virologic CR.
Seven patients received VSTs for persistent AdV. The response rate was 71.4%. Four patients achieved a CR, 1 had a PR, and 2 patients did not respond.
Three patients received VSTs to treat HHV-6 reactivations. The response rate was 67%. Two patients had a PR, and 1 was not evaluable.
Sixteen patients received VSTs for BKV-associated hemorrhagic cystitis (n= 14) or BKV-associated nephritis (n=2).
All 16 patients responded. One had a clinical and virologic CR. Six had a clinical CR but a virologic PR. Seven had a virologic and clinical PR. And 2 patients had only a virologic PR.
A total of 15 patients received a second VST infusion—1 due to lack of response, 7 who had a PR, and 7 due to recurrence. Ten of these patients responded to the second infusion—1 with a CR and 9 with a PR.
Four patients received a third infusion of VSTs. Two achieved a CR, 1 had a PR, and 1 did not respond.
Toxicity
One patient developed an isolated fever within 24 hours of VST infusion, but the researchers did not observe any other immediate toxicities.
One of the patients with BKV-associated hemorrhagic cystitis experienced transient hydronephrosis and a decrease in renal function associated with a concomitant bacterial urinary tract infection.
Nineteen patients had prior grade 2 to 4 graft-versus-host disease (GVHD)—15 with grade 2 and 4 with grade 3. All GVHD was quiescent at the time of VST infusion.
One patient developed recurrent grade 3 gastrointestinal GVHD after VST infusion and rapid corticosteroid taper. Five patients developed recurrent (n=3) or de novo (n=2) grade 1 to 2 skin GVHD, which resolved with topical treatment (n=4) and reinitiation of corticosteroid treatment (n=1).
Two patients had a flare of upper-gastrointestinal GVHD, which resolved after a brief corticosteroid course.
“We didn’t have any significant toxicities,” Dr Tzannou said. “Taken together, the results of this trial suggest that it is reasonable to consider this treatment as an early option for these patients. We hope that the results of a future multicenter, phase 3 clinical trial will help raise awareness in both physicians and patients that this treatment, which is safe and effective, is available.”
Young & Crusty
1. A 4-year-old boy presents with erythematous, oozing, excoriated plaques on the cheeks and chin (sparing the nose), trunk, and extensor surfaces of the arms and legs. His parents report that the “rash,” which flares on occasion, has been apparent since the boy was 6 months old, and he does anything he can to scratch the itch.
Diagnosis: Diagnosis of atopic dermatitis (AD) is made by age 5 in 85% to 90% of children who develop the disease, and by age 1 in 60% to 65%. AD persists into adulthood in up to one-third of patients. Although the cause is unknown, AD may be triggered by viral infections, food allergens, or weather, and in turn may trigger an inflammatory progression known as atopic march. Other factors affecting AD development include genetics and hygiene.
For more information:
“A Practical Overview of Pediatric Atopic Dermatitis, Part 2: Triggers and Grading.” Cutis. 2016;97(5):326-329.
“A Practical Overview of Pediatric Atopic Dermatitis, Part 3: Differential Diagnosis, Comorbidities, and Measurement of Disease Burden.” Cutis. 2016;97(6):408-412.
2. A child presents with a history of flaccid bullae and encased fluid progressing from clear yellow to turbid and darkish yellow. The pustules have ruptured, resulting in thin, light brown to golden yellow crusts and a collarette of scale at the periphery of the erosion. Itching is mild.
Diagnosis: Bullous impetigo most commonly affects neonates, hence the occasionally used (and inadvisably employed) name pemphigus neonatorum. Bullous impetigo appears to be less contagious than the nonbullous form and is usually sporadic in presentation. Typical areas of occurrence include the trunk and extremities, as well as intertriginous zones (eg, the diaper area, neck folds, and axillae).
For more information, see “Impetigo Update: New Challenges in the Era of Methicillin Resistance.” Cutis. 2010;85(2):65-70.
3. A 16-year-old Hispanic girl seeks consultation for a perioral rash that first appeared two weeks ago, shortly after she used an OTC depilatory agent. The rash has worsened despite application of topical neomycin ointment. The patient reports pruritus and occasional burning. Examination reveals erythema, hyperpigmentation, and excoriation of the skin around the corners of the mouth.
Diagnosis: An allergic contact dermatitis to both the depilatory agent and neomycin was suspected. The patient was advised to discontinue use of both products, and a medium-potency topical steroid was prescribed. She returned for follow-up in 10 days, at which time the condition had improved by about 75%. Therapy was changed to 1% hydrocortisone cream. The patient was instructed to return for patch testing if the dermatitis recurred.
Reprinted with permission from Emergency Medicine. 2010;42(8):19-20. http://www.mdedge.com/emed-journal/article/71585/dermatology/lesion-scrotum
4. The rash on this 5-month-old baby’s hands manifested several weeks ago. It spread to his arms and trunk and is now essentially everywhere except his face. Despite a number of treatment attempts, including oral antibiotics and OTC topical steroid creams, the problem persists.
Diagnosis: The diagnosis of scabies should be confirmed, whenever possible, with microscopic scabetic findings. In addition, treating the whole family and identifying the source of the infestation are crucial. Diagnosis of scabies is difficult in infants, as any part of an infant’s thin, soft, relatively hairless skin is fair game (whereas, in adults, scabies rarely affects skin above the neck). And although infants with scabies undoubtedly itch—probably just as much as adults—they are inept excoriators and even worse historians. In contrast, adults with scabies will scratch and complain continuously while in the exam room.
For more information, see “Baby Has Rash; Parents Feel Itchy.” Clinician Reviews. 2014;24(9):W3.
1. A 4-year-old boy presents with erythematous, oozing, excoriated plaques on the cheeks and chin (sparing the nose), trunk, and extensor surfaces of the arms and legs. His parents report that the “rash,” which flares on occasion, has been apparent since the boy was 6 months old, and he does anything he can to scratch the itch.
Diagnosis: Diagnosis of atopic dermatitis (AD) is made by age 5 in 85% to 90% of children who develop the disease, and by age 1 in 60% to 65%. AD persists into adulthood in up to one-third of patients. Although the cause is unknown, AD may be triggered by viral infections, food allergens, or weather, and in turn may trigger an inflammatory progression known as atopic march. Other factors affecting AD development include genetics and hygiene.
For more information:
“A Practical Overview of Pediatric Atopic Dermatitis, Part 2: Triggers and Grading.” Cutis. 2016;97(5):326-329.
“A Practical Overview of Pediatric Atopic Dermatitis, Part 3: Differential Diagnosis, Comorbidities, and Measurement of Disease Burden.” Cutis. 2016;97(6):408-412.
2. A child presents with a history of flaccid bullae and encased fluid progressing from clear yellow to turbid and darkish yellow. The pustules have ruptured, resulting in thin, light brown to golden yellow crusts and a collarette of scale at the periphery of the erosion. Itching is mild.
Diagnosis: Bullous impetigo most commonly affects neonates, hence the occasionally used (and inadvisably employed) name pemphigus neonatorum. Bullous impetigo appears to be less contagious than the nonbullous form and is usually sporadic in presentation. Typical areas of occurrence include the trunk and extremities, as well as intertriginous zones (eg, the diaper area, neck folds, and axillae).
For more information, see “Impetigo Update: New Challenges in the Era of Methicillin Resistance.” Cutis. 2010;85(2):65-70.
3. A 16-year-old Hispanic girl seeks consultation for a perioral rash that first appeared two weeks ago, shortly after she used an OTC depilatory agent. The rash has worsened despite application of topical neomycin ointment. The patient reports pruritus and occasional burning. Examination reveals erythema, hyperpigmentation, and excoriation of the skin around the corners of the mouth.
Diagnosis: An allergic contact dermatitis to both the depilatory agent and neomycin was suspected. The patient was advised to discontinue use of both products, and a medium-potency topical steroid was prescribed. She returned for follow-up in 10 days, at which time the condition had improved by about 75%. Therapy was changed to 1% hydrocortisone cream. The patient was instructed to return for patch testing if the dermatitis recurred.
Reprinted with permission from Emergency Medicine. 2010;42(8):19-20. http://www.mdedge.com/emed-journal/article/71585/dermatology/lesion-scrotum
4. The rash on this 5-month-old baby’s hands manifested several weeks ago. It spread to his arms and trunk and is now essentially everywhere except his face. Despite a number of treatment attempts, including oral antibiotics and OTC topical steroid creams, the problem persists.
Diagnosis: The diagnosis of scabies should be confirmed, whenever possible, with microscopic scabetic findings. In addition, treating the whole family and identifying the source of the infestation are crucial. Diagnosis of scabies is difficult in infants, as any part of an infant’s thin, soft, relatively hairless skin is fair game (whereas, in adults, scabies rarely affects skin above the neck). And although infants with scabies undoubtedly itch—probably just as much as adults—they are inept excoriators and even worse historians. In contrast, adults with scabies will scratch and complain continuously while in the exam room.
For more information, see “Baby Has Rash; Parents Feel Itchy.” Clinician Reviews. 2014;24(9):W3.
1. A 4-year-old boy presents with erythematous, oozing, excoriated plaques on the cheeks and chin (sparing the nose), trunk, and extensor surfaces of the arms and legs. His parents report that the “rash,” which flares on occasion, has been apparent since the boy was 6 months old, and he does anything he can to scratch the itch.
Diagnosis: Diagnosis of atopic dermatitis (AD) is made by age 5 in 85% to 90% of children who develop the disease, and by age 1 in 60% to 65%. AD persists into adulthood in up to one-third of patients. Although the cause is unknown, AD may be triggered by viral infections, food allergens, or weather, and in turn may trigger an inflammatory progression known as atopic march. Other factors affecting AD development include genetics and hygiene.
For more information:
“A Practical Overview of Pediatric Atopic Dermatitis, Part 2: Triggers and Grading.” Cutis. 2016;97(5):326-329.
“A Practical Overview of Pediatric Atopic Dermatitis, Part 3: Differential Diagnosis, Comorbidities, and Measurement of Disease Burden.” Cutis. 2016;97(6):408-412.
2. A child presents with a history of flaccid bullae and encased fluid progressing from clear yellow to turbid and darkish yellow. The pustules have ruptured, resulting in thin, light brown to golden yellow crusts and a collarette of scale at the periphery of the erosion. Itching is mild.
Diagnosis: Bullous impetigo most commonly affects neonates, hence the occasionally used (and inadvisably employed) name pemphigus neonatorum. Bullous impetigo appears to be less contagious than the nonbullous form and is usually sporadic in presentation. Typical areas of occurrence include the trunk and extremities, as well as intertriginous zones (eg, the diaper area, neck folds, and axillae).
For more information, see “Impetigo Update: New Challenges in the Era of Methicillin Resistance.” Cutis. 2010;85(2):65-70.
3. A 16-year-old Hispanic girl seeks consultation for a perioral rash that first appeared two weeks ago, shortly after she used an OTC depilatory agent. The rash has worsened despite application of topical neomycin ointment. The patient reports pruritus and occasional burning. Examination reveals erythema, hyperpigmentation, and excoriation of the skin around the corners of the mouth.
Diagnosis: An allergic contact dermatitis to both the depilatory agent and neomycin was suspected. The patient was advised to discontinue use of both products, and a medium-potency topical steroid was prescribed. She returned for follow-up in 10 days, at which time the condition had improved by about 75%. Therapy was changed to 1% hydrocortisone cream. The patient was instructed to return for patch testing if the dermatitis recurred.
Reprinted with permission from Emergency Medicine. 2010;42(8):19-20. http://www.mdedge.com/emed-journal/article/71585/dermatology/lesion-scrotum
4. The rash on this 5-month-old baby’s hands manifested several weeks ago. It spread to his arms and trunk and is now essentially everywhere except his face. Despite a number of treatment attempts, including oral antibiotics and OTC topical steroid creams, the problem persists.
Diagnosis: The diagnosis of scabies should be confirmed, whenever possible, with microscopic scabetic findings. In addition, treating the whole family and identifying the source of the infestation are crucial. Diagnosis of scabies is difficult in infants, as any part of an infant’s thin, soft, relatively hairless skin is fair game (whereas, in adults, scabies rarely affects skin above the neck). And although infants with scabies undoubtedly itch—probably just as much as adults—they are inept excoriators and even worse historians. In contrast, adults with scabies will scratch and complain continuously while in the exam room.
For more information, see “Baby Has Rash; Parents Feel Itchy.” Clinician Reviews. 2014;24(9):W3.
From the Editors: Your call is important to us
There they were – dropping like a stone toward the lunar surface some 48 years ago. Buzz Aldrin looked at his onboard computer and it reported Error 1202, and alarms started going off in the Lunar Module. Fortunately for Neil Armstrong and Buzz Aldrin, they had a healthy relationship with their computer systems and IT support. Mission control was only 1.5 seconds away and had a huge team of experts that told them they could ignore the error message. The rest is, of course, history. Human beings, not computer software, landed the Eagle. They used their own judgment and experience and data provided by the computer to make their landing decisions.
At 25,000 feet Mission Control answers. Buzz describes the error code. Mission Control reports that his computer is made by Grumman and that Mission Control uses Lockheed-based software. He is advised to call the Grumman help line. At 15,000 feet Grumman responds. They report that Buzz’s password expired about the time the lunar descent burn occurred. He needs to put in a new password and confirm it. He will receive a confirmation email within the next 24 hours. Neil is getting increasingly restive despite his famously bland emotional responses in crises.
At 10,000 feet Buzz gets a new password confirmation, but Error 1202 remains on the display. The moon is enormous in the windshield. Grumman support responds that the error is likely because Buzz put in the wrong weight for the Lunar Module. Buzz begins again feeding in the data to the onboard computer. Grumman suggests that had Buzz simply created the right template, this problem would not have occurred. Buzz, through gritted teeth, asks how he was supposed to create a template for a problem that no one seemed to expect.
They are down to 150 feet now. Neil tells Buzz what he thinks of the computer systems and is told by Mission Control his microphone is hot and that such comments are not appropriate. At Mission Control, a notation is made on their system that Neil will need to discuss this pilot error with the astronaut office upon his return. Neil simply turns off the onboard computer and lands the Lunar Module with seconds of fuel left as he avoids a large boulder field and finds just the right spot. Tranquility Base reports in to Mission Control. Mankind has landed on the Moon.
The alternative history is what surgeons are experiencing every day because of the unhealthy relationship existing between American health care today and our institutional computer systems. Like Neil and Buzz, these surgeons are heroes who avoid boulder fields despite so many obstacles unrelated to their missions. No wonder burnout (a missile term) is so prevalent. We’ve gone from inconvenient to intolerable. Our health care computer systems must be interoperable to have any meaningful use. Our formats need to be understandable. Surgeons need computers to help them make judgments based on easily accessible data in real time. Surgeons need to “fly” the missions and computer systems need to be our servants, not our masters.
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.
There they were – dropping like a stone toward the lunar surface some 48 years ago. Buzz Aldrin looked at his onboard computer and it reported Error 1202, and alarms started going off in the Lunar Module. Fortunately for Neil Armstrong and Buzz Aldrin, they had a healthy relationship with their computer systems and IT support. Mission control was only 1.5 seconds away and had a huge team of experts that told them they could ignore the error message. The rest is, of course, history. Human beings, not computer software, landed the Eagle. They used their own judgment and experience and data provided by the computer to make their landing decisions.
At 25,000 feet Mission Control answers. Buzz describes the error code. Mission Control reports that his computer is made by Grumman and that Mission Control uses Lockheed-based software. He is advised to call the Grumman help line. At 15,000 feet Grumman responds. They report that Buzz’s password expired about the time the lunar descent burn occurred. He needs to put in a new password and confirm it. He will receive a confirmation email within the next 24 hours. Neil is getting increasingly restive despite his famously bland emotional responses in crises.
At 10,000 feet Buzz gets a new password confirmation, but Error 1202 remains on the display. The moon is enormous in the windshield. Grumman support responds that the error is likely because Buzz put in the wrong weight for the Lunar Module. Buzz begins again feeding in the data to the onboard computer. Grumman suggests that had Buzz simply created the right template, this problem would not have occurred. Buzz, through gritted teeth, asks how he was supposed to create a template for a problem that no one seemed to expect.
They are down to 150 feet now. Neil tells Buzz what he thinks of the computer systems and is told by Mission Control his microphone is hot and that such comments are not appropriate. At Mission Control, a notation is made on their system that Neil will need to discuss this pilot error with the astronaut office upon his return. Neil simply turns off the onboard computer and lands the Lunar Module with seconds of fuel left as he avoids a large boulder field and finds just the right spot. Tranquility Base reports in to Mission Control. Mankind has landed on the Moon.
The alternative history is what surgeons are experiencing every day because of the unhealthy relationship existing between American health care today and our institutional computer systems. Like Neil and Buzz, these surgeons are heroes who avoid boulder fields despite so many obstacles unrelated to their missions. No wonder burnout (a missile term) is so prevalent. We’ve gone from inconvenient to intolerable. Our health care computer systems must be interoperable to have any meaningful use. Our formats need to be understandable. Surgeons need computers to help them make judgments based on easily accessible data in real time. Surgeons need to “fly” the missions and computer systems need to be our servants, not our masters.
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.
There they were – dropping like a stone toward the lunar surface some 48 years ago. Buzz Aldrin looked at his onboard computer and it reported Error 1202, and alarms started going off in the Lunar Module. Fortunately for Neil Armstrong and Buzz Aldrin, they had a healthy relationship with their computer systems and IT support. Mission control was only 1.5 seconds away and had a huge team of experts that told them they could ignore the error message. The rest is, of course, history. Human beings, not computer software, landed the Eagle. They used their own judgment and experience and data provided by the computer to make their landing decisions.
At 25,000 feet Mission Control answers. Buzz describes the error code. Mission Control reports that his computer is made by Grumman and that Mission Control uses Lockheed-based software. He is advised to call the Grumman help line. At 15,000 feet Grumman responds. They report that Buzz’s password expired about the time the lunar descent burn occurred. He needs to put in a new password and confirm it. He will receive a confirmation email within the next 24 hours. Neil is getting increasingly restive despite his famously bland emotional responses in crises.
At 10,000 feet Buzz gets a new password confirmation, but Error 1202 remains on the display. The moon is enormous in the windshield. Grumman support responds that the error is likely because Buzz put in the wrong weight for the Lunar Module. Buzz begins again feeding in the data to the onboard computer. Grumman suggests that had Buzz simply created the right template, this problem would not have occurred. Buzz, through gritted teeth, asks how he was supposed to create a template for a problem that no one seemed to expect.
They are down to 150 feet now. Neil tells Buzz what he thinks of the computer systems and is told by Mission Control his microphone is hot and that such comments are not appropriate. At Mission Control, a notation is made on their system that Neil will need to discuss this pilot error with the astronaut office upon his return. Neil simply turns off the onboard computer and lands the Lunar Module with seconds of fuel left as he avoids a large boulder field and finds just the right spot. Tranquility Base reports in to Mission Control. Mankind has landed on the Moon.
The alternative history is what surgeons are experiencing every day because of the unhealthy relationship existing between American health care today and our institutional computer systems. Like Neil and Buzz, these surgeons are heroes who avoid boulder fields despite so many obstacles unrelated to their missions. No wonder burnout (a missile term) is so prevalent. We’ve gone from inconvenient to intolerable. Our health care computer systems must be interoperable to have any meaningful use. Our formats need to be understandable. Surgeons need computers to help them make judgments based on easily accessible data in real time. Surgeons need to “fly” the missions and computer systems need to be our servants, not our masters.
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.