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Pre-course focuses on perioperative care
Hospitalists packed the room on Monday for a pre-course brimming with information on how to better care for patients undergoing surgery – a category of care that can involve high-stakes and complex decisions before and after a procedure.
Topics covered in the wide-ranging talks included how to assess risk in those with ischemic heart disease, ways to manage anticoagulants in a variety of patients, the basics of anesthesia, and issues particular to patients with neurologic diseases.
“If you keep those things in mind then you will do a good job taking care of patients as long as you use good clinical sense,” said pre-course director Kurt Pfeifer, MD, FHM, professor of internal medicine at the Medical College of Wisconsin, Milwaukee.
Throughout the sessions, presenters posed audience-response questions to keep everyone engaged. In her discussion of perioperative considerations involving neurologic diseases, Rachel Thompson, MD, MPH, SFHM, associate professor of internal medicine at the University of Nebraska Medical Center, Omaha, asked whether it’s true or false that 1 in 10 patients with epilepsy will have a seizure on the day of surgery, even if they maintain their normal medication regimen.
In her talk on using anticoagulants, Barbara Slawski, MD, MS, SFHM, professor of medicine at the Medical College of Wisconsin, said it was important to understand the newest literature when using national guidelines, to consider clotting and bleeding risks when considering bridging anticoagulation therapy, and to make a specific plan for management for each patient.
She emphasized the team approach.
“It’s really important to listen to your surgical colleagues when they’re concerned about bleeding risk,” she said.
Dr. Pfeifer said the hospitalists’ involvement in surgical cases ranges from preoperative assessments, helping handle last-minutes changes in a care plan, managing patients afterward, and postdischarge follow-up.
“When you look at the perioperative continuum, there are a lot of places where we have a role to play – maybe more than anyone else in the equation.”
Hospitalists packed the room on Monday for a pre-course brimming with information on how to better care for patients undergoing surgery – a category of care that can involve high-stakes and complex decisions before and after a procedure.
Topics covered in the wide-ranging talks included how to assess risk in those with ischemic heart disease, ways to manage anticoagulants in a variety of patients, the basics of anesthesia, and issues particular to patients with neurologic diseases.
“If you keep those things in mind then you will do a good job taking care of patients as long as you use good clinical sense,” said pre-course director Kurt Pfeifer, MD, FHM, professor of internal medicine at the Medical College of Wisconsin, Milwaukee.
Throughout the sessions, presenters posed audience-response questions to keep everyone engaged. In her discussion of perioperative considerations involving neurologic diseases, Rachel Thompson, MD, MPH, SFHM, associate professor of internal medicine at the University of Nebraska Medical Center, Omaha, asked whether it’s true or false that 1 in 10 patients with epilepsy will have a seizure on the day of surgery, even if they maintain their normal medication regimen.
In her talk on using anticoagulants, Barbara Slawski, MD, MS, SFHM, professor of medicine at the Medical College of Wisconsin, said it was important to understand the newest literature when using national guidelines, to consider clotting and bleeding risks when considering bridging anticoagulation therapy, and to make a specific plan for management for each patient.
She emphasized the team approach.
“It’s really important to listen to your surgical colleagues when they’re concerned about bleeding risk,” she said.
Dr. Pfeifer said the hospitalists’ involvement in surgical cases ranges from preoperative assessments, helping handle last-minutes changes in a care plan, managing patients afterward, and postdischarge follow-up.
“When you look at the perioperative continuum, there are a lot of places where we have a role to play – maybe more than anyone else in the equation.”
Hospitalists packed the room on Monday for a pre-course brimming with information on how to better care for patients undergoing surgery – a category of care that can involve high-stakes and complex decisions before and after a procedure.
Topics covered in the wide-ranging talks included how to assess risk in those with ischemic heart disease, ways to manage anticoagulants in a variety of patients, the basics of anesthesia, and issues particular to patients with neurologic diseases.
“If you keep those things in mind then you will do a good job taking care of patients as long as you use good clinical sense,” said pre-course director Kurt Pfeifer, MD, FHM, professor of internal medicine at the Medical College of Wisconsin, Milwaukee.
Throughout the sessions, presenters posed audience-response questions to keep everyone engaged. In her discussion of perioperative considerations involving neurologic diseases, Rachel Thompson, MD, MPH, SFHM, associate professor of internal medicine at the University of Nebraska Medical Center, Omaha, asked whether it’s true or false that 1 in 10 patients with epilepsy will have a seizure on the day of surgery, even if they maintain their normal medication regimen.
In her talk on using anticoagulants, Barbara Slawski, MD, MS, SFHM, professor of medicine at the Medical College of Wisconsin, said it was important to understand the newest literature when using national guidelines, to consider clotting and bleeding risks when considering bridging anticoagulation therapy, and to make a specific plan for management for each patient.
She emphasized the team approach.
“It’s really important to listen to your surgical colleagues when they’re concerned about bleeding risk,” she said.
Dr. Pfeifer said the hospitalists’ involvement in surgical cases ranges from preoperative assessments, helping handle last-minutes changes in a care plan, managing patients afterward, and postdischarge follow-up.
“When you look at the perioperative continuum, there are a lot of places where we have a role to play – maybe more than anyone else in the equation.”
Getting paid when patients aren’t in the room
We get paid to see patients. So what happens when patients aren’t in the room?
This is a big, and growing, issue in medicine.
I do hospital call on weekends, and occasionally, I have a long meeting with families. In some cases, this involves a large group in a conference room. These meetings can take quite a bit of time, but since, technically, the patient isn’t present, it requires different charges than if he or she were, even if the whole meeting is about him or her.
Unfortunately, these visits usually aren’t covered by insurance (although this is slowly changing), so families have to pay cash for them, even if they have a direct impact on patient care and take a lot of time.
Telemedicine is the same way. Although it’s getting easier to get visits paid, it’s still not consistent. After all, the patient isn’t physically in the room with you, either. This one, though, at least is starting to take off. But it still has a long way to go.
To date, I haven’t done telemedicine. In a small practice, I can’t afford to lose money on visits, so I don’t plan on starting these until the reimbursement is higher and more consistent. I have to keep the lights on for the patients who depend on me. There are liability issues with it as well since I am unable to examine the patient more than just by sight.
I’m surprised that it’s taking so long for these visits to catch on. If I see someone in my office, I may get paid $80, but if I do it remotely, even for the same amount of time, I get $0. In an era in which people are pushing “patient-centric” care, you’d think telemedicine would be about as patient-centric as you can get. But, apparently, that’s not the case, given the reluctance of many insurers to cover it. And if it’s not being adequately covered, many of us can’t afford to do it.
There needs to be a better realization among payers that patient care doesn’t always involve the patient being physically present, even though we’re still trying to help them.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
We get paid to see patients. So what happens when patients aren’t in the room?
This is a big, and growing, issue in medicine.
I do hospital call on weekends, and occasionally, I have a long meeting with families. In some cases, this involves a large group in a conference room. These meetings can take quite a bit of time, but since, technically, the patient isn’t present, it requires different charges than if he or she were, even if the whole meeting is about him or her.
Unfortunately, these visits usually aren’t covered by insurance (although this is slowly changing), so families have to pay cash for them, even if they have a direct impact on patient care and take a lot of time.
Telemedicine is the same way. Although it’s getting easier to get visits paid, it’s still not consistent. After all, the patient isn’t physically in the room with you, either. This one, though, at least is starting to take off. But it still has a long way to go.
To date, I haven’t done telemedicine. In a small practice, I can’t afford to lose money on visits, so I don’t plan on starting these until the reimbursement is higher and more consistent. I have to keep the lights on for the patients who depend on me. There are liability issues with it as well since I am unable to examine the patient more than just by sight.
I’m surprised that it’s taking so long for these visits to catch on. If I see someone in my office, I may get paid $80, but if I do it remotely, even for the same amount of time, I get $0. In an era in which people are pushing “patient-centric” care, you’d think telemedicine would be about as patient-centric as you can get. But, apparently, that’s not the case, given the reluctance of many insurers to cover it. And if it’s not being adequately covered, many of us can’t afford to do it.
There needs to be a better realization among payers that patient care doesn’t always involve the patient being physically present, even though we’re still trying to help them.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
We get paid to see patients. So what happens when patients aren’t in the room?
This is a big, and growing, issue in medicine.
I do hospital call on weekends, and occasionally, I have a long meeting with families. In some cases, this involves a large group in a conference room. These meetings can take quite a bit of time, but since, technically, the patient isn’t present, it requires different charges than if he or she were, even if the whole meeting is about him or her.
Unfortunately, these visits usually aren’t covered by insurance (although this is slowly changing), so families have to pay cash for them, even if they have a direct impact on patient care and take a lot of time.
Telemedicine is the same way. Although it’s getting easier to get visits paid, it’s still not consistent. After all, the patient isn’t physically in the room with you, either. This one, though, at least is starting to take off. But it still has a long way to go.
To date, I haven’t done telemedicine. In a small practice, I can’t afford to lose money on visits, so I don’t plan on starting these until the reimbursement is higher and more consistent. I have to keep the lights on for the patients who depend on me. There are liability issues with it as well since I am unable to examine the patient more than just by sight.
I’m surprised that it’s taking so long for these visits to catch on. If I see someone in my office, I may get paid $80, but if I do it remotely, even for the same amount of time, I get $0. In an era in which people are pushing “patient-centric” care, you’d think telemedicine would be about as patient-centric as you can get. But, apparently, that’s not the case, given the reluctance of many insurers to cover it. And if it’s not being adequately covered, many of us can’t afford to do it.
There needs to be a better realization among payers that patient care doesn’t always involve the patient being physically present, even though we’re still trying to help them.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Communication expert to explore work-life balance
The hospital medicine field has struggled with the issue of burnout for years. The supply of hospitalists has had trouble keeping up with the demand. Hospitalists, often viewed as agents of change, are also encouraged to take on projects, such as quality improvement initiatives, beyond their clinical duties.
A talk at this year’s meeting will take on the issue of work-life balance, which is often an ideal that hospitalists find difficult to attain.
Dawna Ballard, PhD, will lead the session “Why We Fail at Work-Life Balance,” scheduled for Tuesday, May 2, 3:05–3:45 p.m., as part of the Rapid Fire track.
Dr. Ballard is an associate professor in communication studies at the University of Texas at Austin and is an expert on chronemics, which, as her professional website puts it, is the “study of time as it is bound to human communication.” She does research on why we lead our lives at a certain pace and the effect this pace has on our communication and, ultimately, on the long-term health of organizations.
Recently, she has studied the historical and contemporary problems with the discourse on “work-life balance.” She is also a coauthor of the 2016 book Work Pressures, which explores the ways pressure at work can erode the performance and vitality of people and their organizations.
Dr. Ballard said she has found in her research that the very idea of a “work-life balance” can bring about confusion and frustration.
“Just this morning, someone tweeted me that they don’t really like the notion of balance, and they always feel like they’re being punished,” she said recently. “A big part of the problem is our expectations about ourselves around time.”
[[{"fid":"195467","view_mode":"medstat_image_flush_right","attributes":{"height":"220","width":"147","class":"media-element file-medstat-image-flush-right","data-delta":"1"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Dr. Dawna Ballard","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Dr. Dawna Ballard","field_file_image_credit[und][0][value]":""}},"link_text":false}]]Dr. Ballard said she will focus on promoting a better understanding of the relationship between time and work.
“I will identify a few common themes (in everyday talk and popular culture) about the role of time in being effective at work,” she said. “I will then discuss what the research and data suggest is actually true about these relationships between time and work.”
Struggles with balancing personal time and time in the workplace seem to be linked with job satisfaction in hospital medicine, the literature suggests. In survey results published in 2012, 63% of hospitalists reported high job satisfaction, but personal time was one area in which they reported being least satisfied. Satisfaction or dissatisfaction with personal time was also one of the areas that predicted satisfaction or dissatisfaction with their specialty.1
Dr. Ballard said that she hopes to debunk some misconceptions. “The goal of this talk is to identify problems with commonly held assumptions that actually lead to reduced effectiveness at work and increased stress,” she said. “Given the centrality of time to our experience as professional and personal selves, working with a clear (evidence-based) understanding of the sociocultural and historical underpinnings of common assumptions is critical.”
One problem, she said, is that there is “a mythology that this is something that has ever existed or ever could exist, and so it disciplines people and it makes people feel like they’re failing.”
“Work is uneven – especially for doctors, it’s really uneven,” she said. “It can be really intense sometimes and then there can be times where we can pull back. ... Intensity doesn’t have to be bad and not good. It just is descriptive.”
She added, “We love work that can be intense at times.”
Reference
1. Hinami K, Whelan CT, Wolosin RJ, et al. “Worklife and satisfaction of hospitalists: Toward flourishing careers.” J Gen Intern Med. 2012;27(1):28-36.
“Why We Fail at Work-Life Balance”
Tuesday, May 2, 3:05–3:45 p.m.
The hospital medicine field has struggled with the issue of burnout for years. The supply of hospitalists has had trouble keeping up with the demand. Hospitalists, often viewed as agents of change, are also encouraged to take on projects, such as quality improvement initiatives, beyond their clinical duties.
A talk at this year’s meeting will take on the issue of work-life balance, which is often an ideal that hospitalists find difficult to attain.
Dawna Ballard, PhD, will lead the session “Why We Fail at Work-Life Balance,” scheduled for Tuesday, May 2, 3:05–3:45 p.m., as part of the Rapid Fire track.
Dr. Ballard is an associate professor in communication studies at the University of Texas at Austin and is an expert on chronemics, which, as her professional website puts it, is the “study of time as it is bound to human communication.” She does research on why we lead our lives at a certain pace and the effect this pace has on our communication and, ultimately, on the long-term health of organizations.
Recently, she has studied the historical and contemporary problems with the discourse on “work-life balance.” She is also a coauthor of the 2016 book Work Pressures, which explores the ways pressure at work can erode the performance and vitality of people and their organizations.
Dr. Ballard said she has found in her research that the very idea of a “work-life balance” can bring about confusion and frustration.
“Just this morning, someone tweeted me that they don’t really like the notion of balance, and they always feel like they’re being punished,” she said recently. “A big part of the problem is our expectations about ourselves around time.”
[[{"fid":"195467","view_mode":"medstat_image_flush_right","attributes":{"height":"220","width":"147","class":"media-element file-medstat-image-flush-right","data-delta":"1"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Dr. Dawna Ballard","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Dr. Dawna Ballard","field_file_image_credit[und][0][value]":""}},"link_text":false}]]Dr. Ballard said she will focus on promoting a better understanding of the relationship between time and work.
“I will identify a few common themes (in everyday talk and popular culture) about the role of time in being effective at work,” she said. “I will then discuss what the research and data suggest is actually true about these relationships between time and work.”
Struggles with balancing personal time and time in the workplace seem to be linked with job satisfaction in hospital medicine, the literature suggests. In survey results published in 2012, 63% of hospitalists reported high job satisfaction, but personal time was one area in which they reported being least satisfied. Satisfaction or dissatisfaction with personal time was also one of the areas that predicted satisfaction or dissatisfaction with their specialty.1
Dr. Ballard said that she hopes to debunk some misconceptions. “The goal of this talk is to identify problems with commonly held assumptions that actually lead to reduced effectiveness at work and increased stress,” she said. “Given the centrality of time to our experience as professional and personal selves, working with a clear (evidence-based) understanding of the sociocultural and historical underpinnings of common assumptions is critical.”
One problem, she said, is that there is “a mythology that this is something that has ever existed or ever could exist, and so it disciplines people and it makes people feel like they’re failing.”
“Work is uneven – especially for doctors, it’s really uneven,” she said. “It can be really intense sometimes and then there can be times where we can pull back. ... Intensity doesn’t have to be bad and not good. It just is descriptive.”
She added, “We love work that can be intense at times.”
Reference
1. Hinami K, Whelan CT, Wolosin RJ, et al. “Worklife and satisfaction of hospitalists: Toward flourishing careers.” J Gen Intern Med. 2012;27(1):28-36.
“Why We Fail at Work-Life Balance”
Tuesday, May 2, 3:05–3:45 p.m.
The hospital medicine field has struggled with the issue of burnout for years. The supply of hospitalists has had trouble keeping up with the demand. Hospitalists, often viewed as agents of change, are also encouraged to take on projects, such as quality improvement initiatives, beyond their clinical duties.
A talk at this year’s meeting will take on the issue of work-life balance, which is often an ideal that hospitalists find difficult to attain.
Dawna Ballard, PhD, will lead the session “Why We Fail at Work-Life Balance,” scheduled for Tuesday, May 2, 3:05–3:45 p.m., as part of the Rapid Fire track.
Dr. Ballard is an associate professor in communication studies at the University of Texas at Austin and is an expert on chronemics, which, as her professional website puts it, is the “study of time as it is bound to human communication.” She does research on why we lead our lives at a certain pace and the effect this pace has on our communication and, ultimately, on the long-term health of organizations.
Recently, she has studied the historical and contemporary problems with the discourse on “work-life balance.” She is also a coauthor of the 2016 book Work Pressures, which explores the ways pressure at work can erode the performance and vitality of people and their organizations.
Dr. Ballard said she has found in her research that the very idea of a “work-life balance” can bring about confusion and frustration.
“Just this morning, someone tweeted me that they don’t really like the notion of balance, and they always feel like they’re being punished,” she said recently. “A big part of the problem is our expectations about ourselves around time.”
[[{"fid":"195467","view_mode":"medstat_image_flush_right","attributes":{"height":"220","width":"147","class":"media-element file-medstat-image-flush-right","data-delta":"1"},"fields":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Dr. Dawna Ballard","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][format]":"plain_text","field_file_image_credit[und][0][format]":"plain_text"},"type":"media","field_deltas":{"1":{"format":"medstat_image_flush_right","field_file_image_caption[und][0][value]":"Dr. Dawna Ballard","field_file_image_credit[und][0][value]":""}},"link_text":false}]]Dr. Ballard said she will focus on promoting a better understanding of the relationship between time and work.
“I will identify a few common themes (in everyday talk and popular culture) about the role of time in being effective at work,” she said. “I will then discuss what the research and data suggest is actually true about these relationships between time and work.”
Struggles with balancing personal time and time in the workplace seem to be linked with job satisfaction in hospital medicine, the literature suggests. In survey results published in 2012, 63% of hospitalists reported high job satisfaction, but personal time was one area in which they reported being least satisfied. Satisfaction or dissatisfaction with personal time was also one of the areas that predicted satisfaction or dissatisfaction with their specialty.1
Dr. Ballard said that she hopes to debunk some misconceptions. “The goal of this talk is to identify problems with commonly held assumptions that actually lead to reduced effectiveness at work and increased stress,” she said. “Given the centrality of time to our experience as professional and personal selves, working with a clear (evidence-based) understanding of the sociocultural and historical underpinnings of common assumptions is critical.”
One problem, she said, is that there is “a mythology that this is something that has ever existed or ever could exist, and so it disciplines people and it makes people feel like they’re failing.”
“Work is uneven – especially for doctors, it’s really uneven,” she said. “It can be really intense sometimes and then there can be times where we can pull back. ... Intensity doesn’t have to be bad and not good. It just is descriptive.”
She added, “We love work that can be intense at times.”
Reference
1. Hinami K, Whelan CT, Wolosin RJ, et al. “Worklife and satisfaction of hospitalists: Toward flourishing careers.” J Gen Intern Med. 2012;27(1):28-36.
“Why We Fail at Work-Life Balance”
Tuesday, May 2, 3:05–3:45 p.m.
Cosmetic Corner: Dermatologists Weigh in on Products for Sensitive Skin
To improve patient care and outcomes, leading dermatologists offered their recommendations on products for sensitive skin. Consideration must be given to:
- Avène Cicalfate Restorative Skin Cream
Pierre Fabre Dermo-Cosmetique USA
“Sucralfate for speeding up skin repair and the soothing thermal spring waters found in this product make it perfect postprocedure for immediately cooling and calming the skin.”—Jeannette Graf, MD, New York, New York
- Cetaphil RestoraDerm Eczema Calming Body Moisturizer
Galderma Laboratories, LP
“This product is formulated for atopic skin. I personally use it on my face as a moisturizer during the cold New York City winter.”—Anthony M. Rossi, MD, New York, New York
- Vanicream
Pharmaceutical Specialties, Inc
“I recommend Vanicream brand products to patients with sensitive skin or eczema. These products are fragrance free and have minimal ingredients.”— Gary Goldenberg, MD, New York, New York
Cutis invites readers to send us their recommendations. Athlete's foot treatments, cleansing devices, redness-reducing products, and face scrubs will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.
Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.
To improve patient care and outcomes, leading dermatologists offered their recommendations on products for sensitive skin. Consideration must be given to:
- Avène Cicalfate Restorative Skin Cream
Pierre Fabre Dermo-Cosmetique USA
“Sucralfate for speeding up skin repair and the soothing thermal spring waters found in this product make it perfect postprocedure for immediately cooling and calming the skin.”—Jeannette Graf, MD, New York, New York
- Cetaphil RestoraDerm Eczema Calming Body Moisturizer
Galderma Laboratories, LP
“This product is formulated for atopic skin. I personally use it on my face as a moisturizer during the cold New York City winter.”—Anthony M. Rossi, MD, New York, New York
- Vanicream
Pharmaceutical Specialties, Inc
“I recommend Vanicream brand products to patients with sensitive skin or eczema. These products are fragrance free and have minimal ingredients.”— Gary Goldenberg, MD, New York, New York
Cutis invites readers to send us their recommendations. Athlete's foot treatments, cleansing devices, redness-reducing products, and face scrubs will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.
Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.
To improve patient care and outcomes, leading dermatologists offered their recommendations on products for sensitive skin. Consideration must be given to:
- Avène Cicalfate Restorative Skin Cream
Pierre Fabre Dermo-Cosmetique USA
“Sucralfate for speeding up skin repair and the soothing thermal spring waters found in this product make it perfect postprocedure for immediately cooling and calming the skin.”—Jeannette Graf, MD, New York, New York
- Cetaphil RestoraDerm Eczema Calming Body Moisturizer
Galderma Laboratories, LP
“This product is formulated for atopic skin. I personally use it on my face as a moisturizer during the cold New York City winter.”—Anthony M. Rossi, MD, New York, New York
- Vanicream
Pharmaceutical Specialties, Inc
“I recommend Vanicream brand products to patients with sensitive skin or eczema. These products are fragrance free and have minimal ingredients.”— Gary Goldenberg, MD, New York, New York
Cutis invites readers to send us their recommendations. Athlete's foot treatments, cleansing devices, redness-reducing products, and face scrubs will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.
Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.
Bromocriptine shows efficacy, safety for peripartum cardiomyopathy
PARIS – Two regimens of bromocriptine treatment administered with anticoagulation and standard heart failure management were safe, and often effective, for normalizing ejection fraction levels in women diagnosed with peripartum cardiomyopathy in a study with 63 women and designed to be the pivotal trial for this management strategy.
“Bromocriptine therapy applied for 1 week seems sufficient to promote healing from PPCM [peripartum cardiomyopathy] in most patients, although critically ill patients may profit from prolonged [8 week] treatment,” Denise Hilfiker-Kleiner, PhD, said at a meeting of the Heart Failure Association of the ESC.
Women who are suspected of having PPCM but with less compromised ventricular output, with an ejection fraction of 40%-45%, should be closely followed with repeated clinical examinations for 6 months and echocardiography examinations at 3 and 6 months to see if their cardiac output worsens enough to justify initiating a bromocriptine regimen, she advised. “We don’t recommend that every woman with an postpartum ejection fraction of 45% needs to immediately stop lactation [with bromocriptine treatment], but she should be frequently seen by a cardiologist to see whether she recovers or deteriorates further.”
The PPCM (Effect of Bromocriptine on Left Ventricular Function in Women With Peripartum Cardiomyopathy) trial enrolled 63 women with PPCM and severely depressed left ventricular ejection fraction at 12 German centers. Randomization placed 32 women into a group assigned to received 1 week of bromocriptine treatment, with 26 completing the study, and 31 in a group treated with bromocriptine for 8 weeks, with all 31 completing the study. The patients averaged 34 years of age. All patients also received standard heart failure treatment.
The study’s primary endpoint, the change in left ventricular ejection fraction from baseline to 6-month follow-up, was similar in the two treatment groups, with the 1-week regimen leading to an average 21% improvement in ejection fraction and the 8-week regimen averaging a 24% gain in pump function. Among a subgroup of 37 women who entered the study with a left ventricular ejection fraction of less than 30%, slightly more than 60% achieved full heart function by 6-month follow-up with an ejection fraction of 50% or greater, and an additional 35% had partial recovery, with a follow-up ejection fraction of 35%-49%, Dr. Hilfiker-Kleiner reported.
No women in the study developed a thrombotic complication, a potential danger of the bromocriptine intervention. All participants received antithrombotic prophylaxis with either warfarin or subcutaneous heparin. Although the bromocriptine strategy has already been adopted for routine treatment of PPCM in Germany and in many other parts of the world, its uptake in the United States has lagged, largely because of concerns about thrombotic complications, noted Dr. Sliwa, professor of medicine and director of the Hatter Institute for Cardiovascular Research in Africa at the University of Cape Town, South Africa.
Among all 57 women available for a follow-up echocardiography assessment 6 months after the start of treatment, roughly 60% had a left ventricular ejection fraction of 50% or greater, and more than 20% achieved an ejection fraction of 35%-49%. The remaining roughly 18% of women either did not have a 6-month follow-up or failed to reach at least a 35% ejection fraction at 6 months.
PPCM can be a diagnostic challenge, said Dr. Hilfiker-Kleiner, but it is relatively common, with an average worldwide incidence of about 1 case for every 1,000 deliveries. The incidence may be even higher with many cases going undetected, often because the clinical signs of PPCM, including fatigue, difficulty sleeping, edema, and dyspnea, can be dismissed as the results of recent pregnancy or caring for a newborn baby. Certain racial or ethnic groups appear to have an increased incidence of the disease, including African and Hispanic women, likely because of genetic factors, said Dr. Sliwa. Clinical factors that boost risk include pre-eclampsia, smoking, obesity, older age, and multiparity, but not diabetes.
Testing for N-terminal-pro B-type natriuretic peptide levels appears to be a good screen for women who have developed PPCM, with a level of at least 500 pg/mL high enough to warrant further assessment, Dr. Sliwa said. She recommended running an NT-proBNP test on any recent postpartum women with a clinical or demographic risk factor or suggestive clinical presentation, but she also stressed that PPCM can occur in younger, totally healthy, and athletic women who appear to have a normal delivery.
A significant concern about bromocriptine treatment is that it precludes breastfeeding, a reason not to use the drug in women with an ejection fraction of 40% or greater, especially in settings where access to safe baby formula is a challenge.
The PPCM trial enrolled 63 women at 12 German centers.
The trial received no commercial funding. Dr. Hilfiker-Kleiner and Dr. Sliwa had no disclosures.
[email protected]
On Twitter @mitchelzoler
This is a very important trial that was extremely difficult to conduct, and the results are exciting. It represents an effective bedside to bench to bedside sequence of research. The problem of peripartum cardiomyopathy was recognized in clinical practice, understood through basic research that led to a potential treatment, and the treatment is now confirmed through clinical testing. The results provide a reason for hope for the women who develop this disease.
These trial results are important for all mothers, for all women, and for anyone born from a woman.
Mariell Jessup, MD, is a heart failure specialist and chief scientific officer of the Leducq organization in Boston. She had no disclosures. She made these comments as designated discussant for the report by Dr. Hilfiker-Kleiner.
This is a very important trial that was extremely difficult to conduct, and the results are exciting. It represents an effective bedside to bench to bedside sequence of research. The problem of peripartum cardiomyopathy was recognized in clinical practice, understood through basic research that led to a potential treatment, and the treatment is now confirmed through clinical testing. The results provide a reason for hope for the women who develop this disease.
These trial results are important for all mothers, for all women, and for anyone born from a woman.
Mariell Jessup, MD, is a heart failure specialist and chief scientific officer of the Leducq organization in Boston. She had no disclosures. She made these comments as designated discussant for the report by Dr. Hilfiker-Kleiner.
This is a very important trial that was extremely difficult to conduct, and the results are exciting. It represents an effective bedside to bench to bedside sequence of research. The problem of peripartum cardiomyopathy was recognized in clinical practice, understood through basic research that led to a potential treatment, and the treatment is now confirmed through clinical testing. The results provide a reason for hope for the women who develop this disease.
These trial results are important for all mothers, for all women, and for anyone born from a woman.
Mariell Jessup, MD, is a heart failure specialist and chief scientific officer of the Leducq organization in Boston. She had no disclosures. She made these comments as designated discussant for the report by Dr. Hilfiker-Kleiner.
PARIS – Two regimens of bromocriptine treatment administered with anticoagulation and standard heart failure management were safe, and often effective, for normalizing ejection fraction levels in women diagnosed with peripartum cardiomyopathy in a study with 63 women and designed to be the pivotal trial for this management strategy.
“Bromocriptine therapy applied for 1 week seems sufficient to promote healing from PPCM [peripartum cardiomyopathy] in most patients, although critically ill patients may profit from prolonged [8 week] treatment,” Denise Hilfiker-Kleiner, PhD, said at a meeting of the Heart Failure Association of the ESC.
Women who are suspected of having PPCM but with less compromised ventricular output, with an ejection fraction of 40%-45%, should be closely followed with repeated clinical examinations for 6 months and echocardiography examinations at 3 and 6 months to see if their cardiac output worsens enough to justify initiating a bromocriptine regimen, she advised. “We don’t recommend that every woman with an postpartum ejection fraction of 45% needs to immediately stop lactation [with bromocriptine treatment], but she should be frequently seen by a cardiologist to see whether she recovers or deteriorates further.”
The PPCM (Effect of Bromocriptine on Left Ventricular Function in Women With Peripartum Cardiomyopathy) trial enrolled 63 women with PPCM and severely depressed left ventricular ejection fraction at 12 German centers. Randomization placed 32 women into a group assigned to received 1 week of bromocriptine treatment, with 26 completing the study, and 31 in a group treated with bromocriptine for 8 weeks, with all 31 completing the study. The patients averaged 34 years of age. All patients also received standard heart failure treatment.
The study’s primary endpoint, the change in left ventricular ejection fraction from baseline to 6-month follow-up, was similar in the two treatment groups, with the 1-week regimen leading to an average 21% improvement in ejection fraction and the 8-week regimen averaging a 24% gain in pump function. Among a subgroup of 37 women who entered the study with a left ventricular ejection fraction of less than 30%, slightly more than 60% achieved full heart function by 6-month follow-up with an ejection fraction of 50% or greater, and an additional 35% had partial recovery, with a follow-up ejection fraction of 35%-49%, Dr. Hilfiker-Kleiner reported.
No women in the study developed a thrombotic complication, a potential danger of the bromocriptine intervention. All participants received antithrombotic prophylaxis with either warfarin or subcutaneous heparin. Although the bromocriptine strategy has already been adopted for routine treatment of PPCM in Germany and in many other parts of the world, its uptake in the United States has lagged, largely because of concerns about thrombotic complications, noted Dr. Sliwa, professor of medicine and director of the Hatter Institute for Cardiovascular Research in Africa at the University of Cape Town, South Africa.
Among all 57 women available for a follow-up echocardiography assessment 6 months after the start of treatment, roughly 60% had a left ventricular ejection fraction of 50% or greater, and more than 20% achieved an ejection fraction of 35%-49%. The remaining roughly 18% of women either did not have a 6-month follow-up or failed to reach at least a 35% ejection fraction at 6 months.
PPCM can be a diagnostic challenge, said Dr. Hilfiker-Kleiner, but it is relatively common, with an average worldwide incidence of about 1 case for every 1,000 deliveries. The incidence may be even higher with many cases going undetected, often because the clinical signs of PPCM, including fatigue, difficulty sleeping, edema, and dyspnea, can be dismissed as the results of recent pregnancy or caring for a newborn baby. Certain racial or ethnic groups appear to have an increased incidence of the disease, including African and Hispanic women, likely because of genetic factors, said Dr. Sliwa. Clinical factors that boost risk include pre-eclampsia, smoking, obesity, older age, and multiparity, but not diabetes.
Testing for N-terminal-pro B-type natriuretic peptide levels appears to be a good screen for women who have developed PPCM, with a level of at least 500 pg/mL high enough to warrant further assessment, Dr. Sliwa said. She recommended running an NT-proBNP test on any recent postpartum women with a clinical or demographic risk factor or suggestive clinical presentation, but she also stressed that PPCM can occur in younger, totally healthy, and athletic women who appear to have a normal delivery.
A significant concern about bromocriptine treatment is that it precludes breastfeeding, a reason not to use the drug in women with an ejection fraction of 40% or greater, especially in settings where access to safe baby formula is a challenge.
The PPCM trial enrolled 63 women at 12 German centers.
The trial received no commercial funding. Dr. Hilfiker-Kleiner and Dr. Sliwa had no disclosures.
[email protected]
On Twitter @mitchelzoler
PARIS – Two regimens of bromocriptine treatment administered with anticoagulation and standard heart failure management were safe, and often effective, for normalizing ejection fraction levels in women diagnosed with peripartum cardiomyopathy in a study with 63 women and designed to be the pivotal trial for this management strategy.
“Bromocriptine therapy applied for 1 week seems sufficient to promote healing from PPCM [peripartum cardiomyopathy] in most patients, although critically ill patients may profit from prolonged [8 week] treatment,” Denise Hilfiker-Kleiner, PhD, said at a meeting of the Heart Failure Association of the ESC.
Women who are suspected of having PPCM but with less compromised ventricular output, with an ejection fraction of 40%-45%, should be closely followed with repeated clinical examinations for 6 months and echocardiography examinations at 3 and 6 months to see if their cardiac output worsens enough to justify initiating a bromocriptine regimen, she advised. “We don’t recommend that every woman with an postpartum ejection fraction of 45% needs to immediately stop lactation [with bromocriptine treatment], but she should be frequently seen by a cardiologist to see whether she recovers or deteriorates further.”
The PPCM (Effect of Bromocriptine on Left Ventricular Function in Women With Peripartum Cardiomyopathy) trial enrolled 63 women with PPCM and severely depressed left ventricular ejection fraction at 12 German centers. Randomization placed 32 women into a group assigned to received 1 week of bromocriptine treatment, with 26 completing the study, and 31 in a group treated with bromocriptine for 8 weeks, with all 31 completing the study. The patients averaged 34 years of age. All patients also received standard heart failure treatment.
The study’s primary endpoint, the change in left ventricular ejection fraction from baseline to 6-month follow-up, was similar in the two treatment groups, with the 1-week regimen leading to an average 21% improvement in ejection fraction and the 8-week regimen averaging a 24% gain in pump function. Among a subgroup of 37 women who entered the study with a left ventricular ejection fraction of less than 30%, slightly more than 60% achieved full heart function by 6-month follow-up with an ejection fraction of 50% or greater, and an additional 35% had partial recovery, with a follow-up ejection fraction of 35%-49%, Dr. Hilfiker-Kleiner reported.
No women in the study developed a thrombotic complication, a potential danger of the bromocriptine intervention. All participants received antithrombotic prophylaxis with either warfarin or subcutaneous heparin. Although the bromocriptine strategy has already been adopted for routine treatment of PPCM in Germany and in many other parts of the world, its uptake in the United States has lagged, largely because of concerns about thrombotic complications, noted Dr. Sliwa, professor of medicine and director of the Hatter Institute for Cardiovascular Research in Africa at the University of Cape Town, South Africa.
Among all 57 women available for a follow-up echocardiography assessment 6 months after the start of treatment, roughly 60% had a left ventricular ejection fraction of 50% or greater, and more than 20% achieved an ejection fraction of 35%-49%. The remaining roughly 18% of women either did not have a 6-month follow-up or failed to reach at least a 35% ejection fraction at 6 months.
PPCM can be a diagnostic challenge, said Dr. Hilfiker-Kleiner, but it is relatively common, with an average worldwide incidence of about 1 case for every 1,000 deliveries. The incidence may be even higher with many cases going undetected, often because the clinical signs of PPCM, including fatigue, difficulty sleeping, edema, and dyspnea, can be dismissed as the results of recent pregnancy or caring for a newborn baby. Certain racial or ethnic groups appear to have an increased incidence of the disease, including African and Hispanic women, likely because of genetic factors, said Dr. Sliwa. Clinical factors that boost risk include pre-eclampsia, smoking, obesity, older age, and multiparity, but not diabetes.
Testing for N-terminal-pro B-type natriuretic peptide levels appears to be a good screen for women who have developed PPCM, with a level of at least 500 pg/mL high enough to warrant further assessment, Dr. Sliwa said. She recommended running an NT-proBNP test on any recent postpartum women with a clinical or demographic risk factor or suggestive clinical presentation, but she also stressed that PPCM can occur in younger, totally healthy, and athletic women who appear to have a normal delivery.
A significant concern about bromocriptine treatment is that it precludes breastfeeding, a reason not to use the drug in women with an ejection fraction of 40% or greater, especially in settings where access to safe baby formula is a challenge.
The PPCM trial enrolled 63 women at 12 German centers.
The trial received no commercial funding. Dr. Hilfiker-Kleiner and Dr. Sliwa had no disclosures.
[email protected]
On Twitter @mitchelzoler
AT HEART FAILURE 2017
Key clinical point:
Major finding: At 6-month follow-up, more than 80% of patients had full or partial restoration of their left ventricular function.
Data source: The PPCM trial, which enrolled 63 women at 12 German centers.
Disclosures: The trial received no commercial funding. Dr. Hilfiker-Kleiner and Dr. Sliwa had no disclosures.
Hospitalists get hands-on training at POC ultrasound pre-course
Hospitalists participated in a double-header of hands-on point-of-care ultrasound training here on Monday, looking to gain an edge in expertise in a role that’s becoming more and more common.
Nearly 100 hospitalists and other health care professionals heard talks on the fundamental principles of ultrasound and cardiac, lung and vascular, and abdominal ultrasound. The highlights of the sessions were two 80-minute hands-on segments using the probes.
“This course has grown and grown – this is the largest we’ve ever done,” said pre-course director Nilam Soni, MD, MS, FHM, associate professor of medicine at the University of Texas Health Science Center San Antonio.
A morning and afternoon session were held, each attended by 48 registrants. Because of high demand, the society added 12 spots to each session – and there was still a wait list, said Ricardo Franco-Sadud, MD, the other director of the course and associate professor of medicine at the Medical College of Wisconsin, Milwaukee.
“The idea is to give you the most amount of time with the probe in their hand,” Dr. Franco said.
In one of the hands-on sessions, Adam Merando, MD, a hospitalist and associate program director of the internal medicine residency program at Saint Louis University, slid and rocked the probe on the stomach of a volunteer as the picture came into view.
“Now we’re getting an image,” his bedside instructor, Brandon Boesch, DO, a hospitalist at Highland Hospital in Oakland, Calif., told him. Dr. Merando had found the liver.
He eventually found the main target, the inferior vena cava, and assessed its diameter in relation to the breathing of the “patient.” This information is used to gauge how responsive acute circulatory failure patients are to fluid therapy.
At one point, with another learner, the image shifted.
“You see how it feels like your hand is not moving, but the image is changing?” Dr. Boesch said. “That’s part of the fine motor skill.”
Kirk Spencer, MD, professor of medicine and a cardiologist at the University of Chicago and perennial participant in the course, said it’s a great way for hospitalists who were hesitant about learning ultrasound to get over the hump.
Benji Mathews, MD, assistant professor of medicine at the University of Minnesota, Minneapolis, another bedside instructor, said the enthusiasm about the course is well founded.
“This is one of the few technologies that brings you back to the bedside.”
Hospitalists participated in a double-header of hands-on point-of-care ultrasound training here on Monday, looking to gain an edge in expertise in a role that’s becoming more and more common.
Nearly 100 hospitalists and other health care professionals heard talks on the fundamental principles of ultrasound and cardiac, lung and vascular, and abdominal ultrasound. The highlights of the sessions were two 80-minute hands-on segments using the probes.
“This course has grown and grown – this is the largest we’ve ever done,” said pre-course director Nilam Soni, MD, MS, FHM, associate professor of medicine at the University of Texas Health Science Center San Antonio.
A morning and afternoon session were held, each attended by 48 registrants. Because of high demand, the society added 12 spots to each session – and there was still a wait list, said Ricardo Franco-Sadud, MD, the other director of the course and associate professor of medicine at the Medical College of Wisconsin, Milwaukee.
“The idea is to give you the most amount of time with the probe in their hand,” Dr. Franco said.
In one of the hands-on sessions, Adam Merando, MD, a hospitalist and associate program director of the internal medicine residency program at Saint Louis University, slid and rocked the probe on the stomach of a volunteer as the picture came into view.
“Now we’re getting an image,” his bedside instructor, Brandon Boesch, DO, a hospitalist at Highland Hospital in Oakland, Calif., told him. Dr. Merando had found the liver.
He eventually found the main target, the inferior vena cava, and assessed its diameter in relation to the breathing of the “patient.” This information is used to gauge how responsive acute circulatory failure patients are to fluid therapy.
At one point, with another learner, the image shifted.
“You see how it feels like your hand is not moving, but the image is changing?” Dr. Boesch said. “That’s part of the fine motor skill.”
Kirk Spencer, MD, professor of medicine and a cardiologist at the University of Chicago and perennial participant in the course, said it’s a great way for hospitalists who were hesitant about learning ultrasound to get over the hump.
Benji Mathews, MD, assistant professor of medicine at the University of Minnesota, Minneapolis, another bedside instructor, said the enthusiasm about the course is well founded.
“This is one of the few technologies that brings you back to the bedside.”
Hospitalists participated in a double-header of hands-on point-of-care ultrasound training here on Monday, looking to gain an edge in expertise in a role that’s becoming more and more common.
Nearly 100 hospitalists and other health care professionals heard talks on the fundamental principles of ultrasound and cardiac, lung and vascular, and abdominal ultrasound. The highlights of the sessions were two 80-minute hands-on segments using the probes.
“This course has grown and grown – this is the largest we’ve ever done,” said pre-course director Nilam Soni, MD, MS, FHM, associate professor of medicine at the University of Texas Health Science Center San Antonio.
A morning and afternoon session were held, each attended by 48 registrants. Because of high demand, the society added 12 spots to each session – and there was still a wait list, said Ricardo Franco-Sadud, MD, the other director of the course and associate professor of medicine at the Medical College of Wisconsin, Milwaukee.
“The idea is to give you the most amount of time with the probe in their hand,” Dr. Franco said.
In one of the hands-on sessions, Adam Merando, MD, a hospitalist and associate program director of the internal medicine residency program at Saint Louis University, slid and rocked the probe on the stomach of a volunteer as the picture came into view.
“Now we’re getting an image,” his bedside instructor, Brandon Boesch, DO, a hospitalist at Highland Hospital in Oakland, Calif., told him. Dr. Merando had found the liver.
He eventually found the main target, the inferior vena cava, and assessed its diameter in relation to the breathing of the “patient.” This information is used to gauge how responsive acute circulatory failure patients are to fluid therapy.
At one point, with another learner, the image shifted.
“You see how it feels like your hand is not moving, but the image is changing?” Dr. Boesch said. “That’s part of the fine motor skill.”
Kirk Spencer, MD, professor of medicine and a cardiologist at the University of Chicago and perennial participant in the course, said it’s a great way for hospitalists who were hesitant about learning ultrasound to get over the hump.
Benji Mathews, MD, assistant professor of medicine at the University of Minnesota, Minneapolis, another bedside instructor, said the enthusiasm about the course is well founded.
“This is one of the few technologies that brings you back to the bedside.”
What’s Eating You? Cheyletiella Mites
Identifying Characteristics and Disease Transmission
Cheyletiella are nonburrowing mites characterized by hooklike anterior palps (Figure 1) that have a worldwide distribution. Human dermatitis is the result of contact with an affected animal and may present as papular or bullous lesions. Cheyletiella blakei affects cats, Cheyletiella parasitovorax is found on rabbits, and Cheyletiella yasguri is found on dogs. The mites live in the outer layer of the epidermis of the host animal and feed on surface debris and tissue fluids.1 They complete an entire 35-day life cycle on a single animal host. The larval, nymph, and adult male mites die within 48 hours of separation from a host. The female mite and possibly the eggs can live up to 10 days off the host, which makes environmental decontamination a critical part of pest control.2 In animals, the mite often produces a subtle dermatitis sometimes called walking dandruff (Figure 2).3 Affected animals also can be asymptomatic, and up to 50% of rabbits in commercial colonies may harbor Cheyletiella or other mites.4
The typical human patient with Cheyletiella-associated dermatitis is a female 40 years or younger who presents with grouped pruritic papules.5 Although papules usually are grouped on exposed areas, they also may be widespread.6,7 Bullous eruptions caused by Cheyletiella mites may mimic those found in immunobullous diseases (Figure 3).8 Children may experience widespread dermatitis after taking a nap where a dog has slept.9 Pet owners, farmers, and veterinarians frequently present with zoonotic mite-induced dermatitis.10 Arthralgia and peripheral eosinophilia caused by Cheyletiella infestation also has been reported.11
Management of Affected Pets
In a case of human infestation resulting from an affected pet, the implicated pet should be evaluated by a qualified veterinarian. Various diagnostic techniques for animals have been used, including adhesive tape preparations.12 A rapid knockdown insecticidal spray marketed for use on animals has been used to facilitate collection of mites, but some pets may be susceptible to toxicity from insecticides. The scaly area should be carefully brushed with a toothbrush or fine-tooth comb, and all scales, crust, and hair collected should be placed in a resealable plastic storage bag. When alcohol is added to the bag, most contents will sink, but the mites tend to float. Vacuum cleaners fitted with in-line filters also have been used to collect mites. The filter samples can be treated with hot potassium hydroxide, then floated in a concentrated sugar solution to collect the ectoparasites.13 Often, a straightforward approach using a #10 blade to provide a skin scraping from the animal in question is effective.14
Various treatment modalities may be employed by the veterinarian, including dips or shampoos, as well as fipronil.15,16 A single application of fipronil 10% has been shown to be highly effective in the elimination of mites after a single application in cats.17 Oral ivermectin and topical amitraz also have been used.18,19 A veterinarian should treat the animals, as some are more susceptible to toxicity from topical or systemic agents.
Treatment in Humans
Cheyletiella infestations in humans usually are self-limited and resolve within a few weeks after treatment of the source animal. Symptomatic treatment with antipruritic medications and topical steroids may be of use while awaiting resolution. Identification and treatment of the vector is key to eliminating the infestation and preventing recurrence.
- Angarano DW, Parish LC. Comparative dermatology: parasitic disorders. Clin Dermatol. 1994;12:543-550.
- Kunkle GA, Miller WH Jr. Cheyletiella infestation in humans. Arch Dermatol. 1980;116:1345.
- Rivers JK, Martin J, Pukay B. Walking dandruff and Cheyletiella dermatitis. J Am Acad Dermatol. 1986;15:1130-1133.
- Flatt RE, Wiemers J. A survey of fur mites in domestic rabbits. Lab Animal Sci. 1976;26:758-761.
- Lee BW. Cheyletiella dermatitis: a report of fourteen cases. Cutis. 1991;47:111-114.
- Cohen SR. Cheyletiella dermatitis. A mite infestation of rabbit, cat, dog and man. Arch Dermatol. 1980;116:435-437.
- Bradrup F, Andersen KE, Kristensen S. Infection in man and dog with the mite, Cheyletiella yasguri Smiley [in German]. Hautarzt. 1979;30:497-500.
- Cvancara JL, Elston DM. Bullous eruption in a patient with systemic lupus erythematosus: mite dermatitis caused by Cheyletiella blakei. J Am Acad Dermatol. 1997;37:265-267.
- Shelley ED, Shelley WB, Pula JF, et al. The diagnostic challenge of nonburrowing mite bites. Cheyletiella yasguri. JAMA. 1984;251:2690-2691.
- Beck W. Farm animals as disease vectors of parasitic epizoonoses and zoophilic dermatophytes and their importance in dermatology [in German]. Hautartz. 1999;50:621-628.
- Dobrosavljevic DD, Popovic ND, Radovanovic SS. Systemic manifestations of Cheyletiella infestation in man. Int J Dermatol. 2007;46:397-399.
- Ottenschot TR, Gil D. Cheyletiellosis in long-haired cats. Tijdschr Diergeneeskd. 1978;103:1104-1108.
- Klayman E, Schillhorn van Veen TW. Diagnosis of ectoparasitism. Mod Vet Pract. 1981;62:767-771.
- Milley C, Dryden M, Rosenkrantz W, et al. Comparison of parasitic mite retrieval methods in a population of community cats [published online Jun 3, 2016]. J Feline Med Surg. pii:1098612X16650717.
- McKeever PJ, Allen SK. Dermatitis associated with Cheyletiella infestation in cats. J Am Vet Med Assoc. 1979;174:718-720.
- Chadwick AJ. Use of a 0.25 per cent fipronil pump spray formulation to treat canine cheyletiellosis. J Small Anim Pract. 1997;38:261-262.
- Scarampella F, Pollmeier M, Visser M, et al. Efficacy of fipronil in the treatment of feline cheyletiellosis. Vet Parasitol. 2005;129:333-339.
- Folz SD, Kakuk TJ, Henke CL, et al. Clinical evaluation of amitraz for treatment of canine scabies. Mod Vet Pract. 1984;65:597-600.
- Dourmishev AL, Dourmishev LA, Schwartz RA. Ivermectin: pharmacology and application in dermatology. Int J Dermatol. 2005;44:981-988.
Identifying Characteristics and Disease Transmission
Cheyletiella are nonburrowing mites characterized by hooklike anterior palps (Figure 1) that have a worldwide distribution. Human dermatitis is the result of contact with an affected animal and may present as papular or bullous lesions. Cheyletiella blakei affects cats, Cheyletiella parasitovorax is found on rabbits, and Cheyletiella yasguri is found on dogs. The mites live in the outer layer of the epidermis of the host animal and feed on surface debris and tissue fluids.1 They complete an entire 35-day life cycle on a single animal host. The larval, nymph, and adult male mites die within 48 hours of separation from a host. The female mite and possibly the eggs can live up to 10 days off the host, which makes environmental decontamination a critical part of pest control.2 In animals, the mite often produces a subtle dermatitis sometimes called walking dandruff (Figure 2).3 Affected animals also can be asymptomatic, and up to 50% of rabbits in commercial colonies may harbor Cheyletiella or other mites.4
The typical human patient with Cheyletiella-associated dermatitis is a female 40 years or younger who presents with grouped pruritic papules.5 Although papules usually are grouped on exposed areas, they also may be widespread.6,7 Bullous eruptions caused by Cheyletiella mites may mimic those found in immunobullous diseases (Figure 3).8 Children may experience widespread dermatitis after taking a nap where a dog has slept.9 Pet owners, farmers, and veterinarians frequently present with zoonotic mite-induced dermatitis.10 Arthralgia and peripheral eosinophilia caused by Cheyletiella infestation also has been reported.11
Management of Affected Pets
In a case of human infestation resulting from an affected pet, the implicated pet should be evaluated by a qualified veterinarian. Various diagnostic techniques for animals have been used, including adhesive tape preparations.12 A rapid knockdown insecticidal spray marketed for use on animals has been used to facilitate collection of mites, but some pets may be susceptible to toxicity from insecticides. The scaly area should be carefully brushed with a toothbrush or fine-tooth comb, and all scales, crust, and hair collected should be placed in a resealable plastic storage bag. When alcohol is added to the bag, most contents will sink, but the mites tend to float. Vacuum cleaners fitted with in-line filters also have been used to collect mites. The filter samples can be treated with hot potassium hydroxide, then floated in a concentrated sugar solution to collect the ectoparasites.13 Often, a straightforward approach using a #10 blade to provide a skin scraping from the animal in question is effective.14
Various treatment modalities may be employed by the veterinarian, including dips or shampoos, as well as fipronil.15,16 A single application of fipronil 10% has been shown to be highly effective in the elimination of mites after a single application in cats.17 Oral ivermectin and topical amitraz also have been used.18,19 A veterinarian should treat the animals, as some are more susceptible to toxicity from topical or systemic agents.
Treatment in Humans
Cheyletiella infestations in humans usually are self-limited and resolve within a few weeks after treatment of the source animal. Symptomatic treatment with antipruritic medications and topical steroids may be of use while awaiting resolution. Identification and treatment of the vector is key to eliminating the infestation and preventing recurrence.
Identifying Characteristics and Disease Transmission
Cheyletiella are nonburrowing mites characterized by hooklike anterior palps (Figure 1) that have a worldwide distribution. Human dermatitis is the result of contact with an affected animal and may present as papular or bullous lesions. Cheyletiella blakei affects cats, Cheyletiella parasitovorax is found on rabbits, and Cheyletiella yasguri is found on dogs. The mites live in the outer layer of the epidermis of the host animal and feed on surface debris and tissue fluids.1 They complete an entire 35-day life cycle on a single animal host. The larval, nymph, and adult male mites die within 48 hours of separation from a host. The female mite and possibly the eggs can live up to 10 days off the host, which makes environmental decontamination a critical part of pest control.2 In animals, the mite often produces a subtle dermatitis sometimes called walking dandruff (Figure 2).3 Affected animals also can be asymptomatic, and up to 50% of rabbits in commercial colonies may harbor Cheyletiella or other mites.4
The typical human patient with Cheyletiella-associated dermatitis is a female 40 years or younger who presents with grouped pruritic papules.5 Although papules usually are grouped on exposed areas, they also may be widespread.6,7 Bullous eruptions caused by Cheyletiella mites may mimic those found in immunobullous diseases (Figure 3).8 Children may experience widespread dermatitis after taking a nap where a dog has slept.9 Pet owners, farmers, and veterinarians frequently present with zoonotic mite-induced dermatitis.10 Arthralgia and peripheral eosinophilia caused by Cheyletiella infestation also has been reported.11
Management of Affected Pets
In a case of human infestation resulting from an affected pet, the implicated pet should be evaluated by a qualified veterinarian. Various diagnostic techniques for animals have been used, including adhesive tape preparations.12 A rapid knockdown insecticidal spray marketed for use on animals has been used to facilitate collection of mites, but some pets may be susceptible to toxicity from insecticides. The scaly area should be carefully brushed with a toothbrush or fine-tooth comb, and all scales, crust, and hair collected should be placed in a resealable plastic storage bag. When alcohol is added to the bag, most contents will sink, but the mites tend to float. Vacuum cleaners fitted with in-line filters also have been used to collect mites. The filter samples can be treated with hot potassium hydroxide, then floated in a concentrated sugar solution to collect the ectoparasites.13 Often, a straightforward approach using a #10 blade to provide a skin scraping from the animal in question is effective.14
Various treatment modalities may be employed by the veterinarian, including dips or shampoos, as well as fipronil.15,16 A single application of fipronil 10% has been shown to be highly effective in the elimination of mites after a single application in cats.17 Oral ivermectin and topical amitraz also have been used.18,19 A veterinarian should treat the animals, as some are more susceptible to toxicity from topical or systemic agents.
Treatment in Humans
Cheyletiella infestations in humans usually are self-limited and resolve within a few weeks after treatment of the source animal. Symptomatic treatment with antipruritic medications and topical steroids may be of use while awaiting resolution. Identification and treatment of the vector is key to eliminating the infestation and preventing recurrence.
- Angarano DW, Parish LC. Comparative dermatology: parasitic disorders. Clin Dermatol. 1994;12:543-550.
- Kunkle GA, Miller WH Jr. Cheyletiella infestation in humans. Arch Dermatol. 1980;116:1345.
- Rivers JK, Martin J, Pukay B. Walking dandruff and Cheyletiella dermatitis. J Am Acad Dermatol. 1986;15:1130-1133.
- Flatt RE, Wiemers J. A survey of fur mites in domestic rabbits. Lab Animal Sci. 1976;26:758-761.
- Lee BW. Cheyletiella dermatitis: a report of fourteen cases. Cutis. 1991;47:111-114.
- Cohen SR. Cheyletiella dermatitis. A mite infestation of rabbit, cat, dog and man. Arch Dermatol. 1980;116:435-437.
- Bradrup F, Andersen KE, Kristensen S. Infection in man and dog with the mite, Cheyletiella yasguri Smiley [in German]. Hautarzt. 1979;30:497-500.
- Cvancara JL, Elston DM. Bullous eruption in a patient with systemic lupus erythematosus: mite dermatitis caused by Cheyletiella blakei. J Am Acad Dermatol. 1997;37:265-267.
- Shelley ED, Shelley WB, Pula JF, et al. The diagnostic challenge of nonburrowing mite bites. Cheyletiella yasguri. JAMA. 1984;251:2690-2691.
- Beck W. Farm animals as disease vectors of parasitic epizoonoses and zoophilic dermatophytes and their importance in dermatology [in German]. Hautartz. 1999;50:621-628.
- Dobrosavljevic DD, Popovic ND, Radovanovic SS. Systemic manifestations of Cheyletiella infestation in man. Int J Dermatol. 2007;46:397-399.
- Ottenschot TR, Gil D. Cheyletiellosis in long-haired cats. Tijdschr Diergeneeskd. 1978;103:1104-1108.
- Klayman E, Schillhorn van Veen TW. Diagnosis of ectoparasitism. Mod Vet Pract. 1981;62:767-771.
- Milley C, Dryden M, Rosenkrantz W, et al. Comparison of parasitic mite retrieval methods in a population of community cats [published online Jun 3, 2016]. J Feline Med Surg. pii:1098612X16650717.
- McKeever PJ, Allen SK. Dermatitis associated with Cheyletiella infestation in cats. J Am Vet Med Assoc. 1979;174:718-720.
- Chadwick AJ. Use of a 0.25 per cent fipronil pump spray formulation to treat canine cheyletiellosis. J Small Anim Pract. 1997;38:261-262.
- Scarampella F, Pollmeier M, Visser M, et al. Efficacy of fipronil in the treatment of feline cheyletiellosis. Vet Parasitol. 2005;129:333-339.
- Folz SD, Kakuk TJ, Henke CL, et al. Clinical evaluation of amitraz for treatment of canine scabies. Mod Vet Pract. 1984;65:597-600.
- Dourmishev AL, Dourmishev LA, Schwartz RA. Ivermectin: pharmacology and application in dermatology. Int J Dermatol. 2005;44:981-988.
- Angarano DW, Parish LC. Comparative dermatology: parasitic disorders. Clin Dermatol. 1994;12:543-550.
- Kunkle GA, Miller WH Jr. Cheyletiella infestation in humans. Arch Dermatol. 1980;116:1345.
- Rivers JK, Martin J, Pukay B. Walking dandruff and Cheyletiella dermatitis. J Am Acad Dermatol. 1986;15:1130-1133.
- Flatt RE, Wiemers J. A survey of fur mites in domestic rabbits. Lab Animal Sci. 1976;26:758-761.
- Lee BW. Cheyletiella dermatitis: a report of fourteen cases. Cutis. 1991;47:111-114.
- Cohen SR. Cheyletiella dermatitis. A mite infestation of rabbit, cat, dog and man. Arch Dermatol. 1980;116:435-437.
- Bradrup F, Andersen KE, Kristensen S. Infection in man and dog with the mite, Cheyletiella yasguri Smiley [in German]. Hautarzt. 1979;30:497-500.
- Cvancara JL, Elston DM. Bullous eruption in a patient with systemic lupus erythematosus: mite dermatitis caused by Cheyletiella blakei. J Am Acad Dermatol. 1997;37:265-267.
- Shelley ED, Shelley WB, Pula JF, et al. The diagnostic challenge of nonburrowing mite bites. Cheyletiella yasguri. JAMA. 1984;251:2690-2691.
- Beck W. Farm animals as disease vectors of parasitic epizoonoses and zoophilic dermatophytes and their importance in dermatology [in German]. Hautartz. 1999;50:621-628.
- Dobrosavljevic DD, Popovic ND, Radovanovic SS. Systemic manifestations of Cheyletiella infestation in man. Int J Dermatol. 2007;46:397-399.
- Ottenschot TR, Gil D. Cheyletiellosis in long-haired cats. Tijdschr Diergeneeskd. 1978;103:1104-1108.
- Klayman E, Schillhorn van Veen TW. Diagnosis of ectoparasitism. Mod Vet Pract. 1981;62:767-771.
- Milley C, Dryden M, Rosenkrantz W, et al. Comparison of parasitic mite retrieval methods in a population of community cats [published online Jun 3, 2016]. J Feline Med Surg. pii:1098612X16650717.
- McKeever PJ, Allen SK. Dermatitis associated with Cheyletiella infestation in cats. J Am Vet Med Assoc. 1979;174:718-720.
- Chadwick AJ. Use of a 0.25 per cent fipronil pump spray formulation to treat canine cheyletiellosis. J Small Anim Pract. 1997;38:261-262.
- Scarampella F, Pollmeier M, Visser M, et al. Efficacy of fipronil in the treatment of feline cheyletiellosis. Vet Parasitol. 2005;129:333-339.
- Folz SD, Kakuk TJ, Henke CL, et al. Clinical evaluation of amitraz for treatment of canine scabies. Mod Vet Pract. 1984;65:597-600.
- Dourmishev AL, Dourmishev LA, Schwartz RA. Ivermectin: pharmacology and application in dermatology. Int J Dermatol. 2005;44:981-988.
Practice Points
- Cheyletiella mites can cause a range of cutaneous and systemic symptoms in affected individuals.
- Diagnosis can be difficult and requires a high level of suspicion, with inquiries directed at animal exposures.
- Identification of the animal vector and treatment by a knowledgeable veterinarian is necessary to prevent recurrence in humans.
Living With Psoriasis: How the Disease Impacts the Daily Activities of Patients
Psoriasis impacts the ability to perform activities, causes embarrassment and social discrimination, and leads to a severe emotional impact in both adult and pediatric patients, according to a public meeting hosted by the US Food and Drug Administration (FDA) to hear patient perspectives. A common source of distress in daily life among psoriasis patients was the lack of understanding of the disease in the general population with wrongful concerns that psoriasis is infectious or contagious.
Approximately 70 psoriasis patients or patient representatives attended the meeting in person and others attended through a live webcast. The impact of psoriasis on daily life was underscored throughout the meeting. Daily activities impacted by psoriasis included physical limitations such as an inability to participate in sports among children due to cracking of the hands and feet, or the impracticability of managing a household or going to work among adults. The inconsistency and unpredictability of the condition led patients to be viewed as unreliable. One participant explained, “If you join a team you can play this week but you can’t play next week.”
Patients and their loved ones often experienced embarrassment and social discrimination. A caregiver stated, “Specifically to a child, psoriasis means something different. It means hiding. It means feeling ashamed and it means being ashamed, and it means thinking twice before being yourself. No child should have to think twice before learning to express themselves.” Social isolation and bullying also were prominent in children, mostly because an uniformed parent or classmate did not understand the disease process.
These effects on the daily life of psoriasis patients often led to a severe emotional impact and social isolation. At a young age, psoriasis can have a devastating social and emotional toll. One caregiver shared that his/her child admitted to having thoughts of suicide. The FDA asked how many participants missed days from work and school because of the emotional toll of their psoriasis symptoms and the majority of participants raised their hands. Several participants also indicated that they had sought treatment for depression and anxiety. Many adult patients also noted that they reconsidered having children because of the destructive effects psoriasis has had on multiple generations of family members.
Dermatologists may use these patient insights to monitor the psychological impact of psoriasis on patients and refer them to a psychiatrist or psychologist when needed.
The psoriasis public meeting in March 2016 was the FDA’s 18th patient-focused drug development meeting. The FDA sought this information to have a greater understanding of the burden of psoriasis on patients and the treatments currently used to treat psoriasis and its symptoms. This information will help guide the FDA as they consider future drug approvals.
Psoriasis impacts the ability to perform activities, causes embarrassment and social discrimination, and leads to a severe emotional impact in both adult and pediatric patients, according to a public meeting hosted by the US Food and Drug Administration (FDA) to hear patient perspectives. A common source of distress in daily life among psoriasis patients was the lack of understanding of the disease in the general population with wrongful concerns that psoriasis is infectious or contagious.
Approximately 70 psoriasis patients or patient representatives attended the meeting in person and others attended through a live webcast. The impact of psoriasis on daily life was underscored throughout the meeting. Daily activities impacted by psoriasis included physical limitations such as an inability to participate in sports among children due to cracking of the hands and feet, or the impracticability of managing a household or going to work among adults. The inconsistency and unpredictability of the condition led patients to be viewed as unreliable. One participant explained, “If you join a team you can play this week but you can’t play next week.”
Patients and their loved ones often experienced embarrassment and social discrimination. A caregiver stated, “Specifically to a child, psoriasis means something different. It means hiding. It means feeling ashamed and it means being ashamed, and it means thinking twice before being yourself. No child should have to think twice before learning to express themselves.” Social isolation and bullying also were prominent in children, mostly because an uniformed parent or classmate did not understand the disease process.
These effects on the daily life of psoriasis patients often led to a severe emotional impact and social isolation. At a young age, psoriasis can have a devastating social and emotional toll. One caregiver shared that his/her child admitted to having thoughts of suicide. The FDA asked how many participants missed days from work and school because of the emotional toll of their psoriasis symptoms and the majority of participants raised their hands. Several participants also indicated that they had sought treatment for depression and anxiety. Many adult patients also noted that they reconsidered having children because of the destructive effects psoriasis has had on multiple generations of family members.
Dermatologists may use these patient insights to monitor the psychological impact of psoriasis on patients and refer them to a psychiatrist or psychologist when needed.
The psoriasis public meeting in March 2016 was the FDA’s 18th patient-focused drug development meeting. The FDA sought this information to have a greater understanding of the burden of psoriasis on patients and the treatments currently used to treat psoriasis and its symptoms. This information will help guide the FDA as they consider future drug approvals.
Psoriasis impacts the ability to perform activities, causes embarrassment and social discrimination, and leads to a severe emotional impact in both adult and pediatric patients, according to a public meeting hosted by the US Food and Drug Administration (FDA) to hear patient perspectives. A common source of distress in daily life among psoriasis patients was the lack of understanding of the disease in the general population with wrongful concerns that psoriasis is infectious or contagious.
Approximately 70 psoriasis patients or patient representatives attended the meeting in person and others attended through a live webcast. The impact of psoriasis on daily life was underscored throughout the meeting. Daily activities impacted by psoriasis included physical limitations such as an inability to participate in sports among children due to cracking of the hands and feet, or the impracticability of managing a household or going to work among adults. The inconsistency and unpredictability of the condition led patients to be viewed as unreliable. One participant explained, “If you join a team you can play this week but you can’t play next week.”
Patients and their loved ones often experienced embarrassment and social discrimination. A caregiver stated, “Specifically to a child, psoriasis means something different. It means hiding. It means feeling ashamed and it means being ashamed, and it means thinking twice before being yourself. No child should have to think twice before learning to express themselves.” Social isolation and bullying also were prominent in children, mostly because an uniformed parent or classmate did not understand the disease process.
These effects on the daily life of psoriasis patients often led to a severe emotional impact and social isolation. At a young age, psoriasis can have a devastating social and emotional toll. One caregiver shared that his/her child admitted to having thoughts of suicide. The FDA asked how many participants missed days from work and school because of the emotional toll of their psoriasis symptoms and the majority of participants raised their hands. Several participants also indicated that they had sought treatment for depression and anxiety. Many adult patients also noted that they reconsidered having children because of the destructive effects psoriasis has had on multiple generations of family members.
Dermatologists may use these patient insights to monitor the psychological impact of psoriasis on patients and refer them to a psychiatrist or psychologist when needed.
The psoriasis public meeting in March 2016 was the FDA’s 18th patient-focused drug development meeting. The FDA sought this information to have a greater understanding of the burden of psoriasis on patients and the treatments currently used to treat psoriasis and its symptoms. This information will help guide the FDA as they consider future drug approvals.
Filling the gap: Hospitalists & palliative care
Most Americans diagnosed with serious illness will be hospitalized in their last months. During these hospitalizations, hospitalists direct their care.
For seriously ill patients, consultation with palliative care specialists has been shown to promote patient- and family-centered care, ensuring that care is consistent with patients’ goals, values, and preferences. Yet, many hospitalized patients lack access to palliative care consultation, and specialists have identified key domains of primary palliative care that can be delivered by nonspecialists.
To fill this gap, SHM’s Center for Quality Improvement partnered with The Hastings Center, a world-renowned bioethics research institution, to develop a resource room focused on hospitalists’ role in providing high-quality communication about prognosis and goals of care. The resource room presents a Prognosis and Goals of Care Communication Pathway, which highlights key processes and maps them onto the daily workflows of hospitalist physicians.
The care pathway is grounded in palliative care communication research and the consensus guidance of The Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life. It was informed by a national stakeholder meeting of hospitalists, other hospital clinicians, patient and family advocates, bioethicists, social scientists, and other experts, who identified professional values of hospital medicine aligned with communication as part of good care for seriously ill patients.
A collaborative interdisciplinary work group convened by SHM and including hospitalists, palliative medicine physicians, a bioethicist, and a palliative nursing specialist constructed the care pathway in terms of key processes occurring at admission, during hospitalization, and in discharge planning to support primary palliative care integration into normal workflow. The resource room also includes skills-building tools and resources for individual hospitals, teams, and institutions.
The work group will present a workshop on the care pathway at Hospital Medicine 2017: “Demystifying Difficult Decisions: Strategies and Skills to Equip Hospitalists for High-Quality Goals of Care Conversations with Seriously Ill Patients and Their Families.” For more information on the resource room, visit www.hospitalmedicine.org/EOL.
Dr. Anderson is associate professor in residence in the division of hospital medicine at the University of California, San Francisco. She also serves as attending physician in the Palliative Care Program and codirector of the School of Nursing Interprofessional Palliative Care Training Program at UCSF.
Most Americans diagnosed with serious illness will be hospitalized in their last months. During these hospitalizations, hospitalists direct their care.
For seriously ill patients, consultation with palliative care specialists has been shown to promote patient- and family-centered care, ensuring that care is consistent with patients’ goals, values, and preferences. Yet, many hospitalized patients lack access to palliative care consultation, and specialists have identified key domains of primary palliative care that can be delivered by nonspecialists.
To fill this gap, SHM’s Center for Quality Improvement partnered with The Hastings Center, a world-renowned bioethics research institution, to develop a resource room focused on hospitalists’ role in providing high-quality communication about prognosis and goals of care. The resource room presents a Prognosis and Goals of Care Communication Pathway, which highlights key processes and maps them onto the daily workflows of hospitalist physicians.
The care pathway is grounded in palliative care communication research and the consensus guidance of The Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life. It was informed by a national stakeholder meeting of hospitalists, other hospital clinicians, patient and family advocates, bioethicists, social scientists, and other experts, who identified professional values of hospital medicine aligned with communication as part of good care for seriously ill patients.
A collaborative interdisciplinary work group convened by SHM and including hospitalists, palliative medicine physicians, a bioethicist, and a palliative nursing specialist constructed the care pathway in terms of key processes occurring at admission, during hospitalization, and in discharge planning to support primary palliative care integration into normal workflow. The resource room also includes skills-building tools and resources for individual hospitals, teams, and institutions.
The work group will present a workshop on the care pathway at Hospital Medicine 2017: “Demystifying Difficult Decisions: Strategies and Skills to Equip Hospitalists for High-Quality Goals of Care Conversations with Seriously Ill Patients and Their Families.” For more information on the resource room, visit www.hospitalmedicine.org/EOL.
Dr. Anderson is associate professor in residence in the division of hospital medicine at the University of California, San Francisco. She also serves as attending physician in the Palliative Care Program and codirector of the School of Nursing Interprofessional Palliative Care Training Program at UCSF.
Most Americans diagnosed with serious illness will be hospitalized in their last months. During these hospitalizations, hospitalists direct their care.
For seriously ill patients, consultation with palliative care specialists has been shown to promote patient- and family-centered care, ensuring that care is consistent with patients’ goals, values, and preferences. Yet, many hospitalized patients lack access to palliative care consultation, and specialists have identified key domains of primary palliative care that can be delivered by nonspecialists.
To fill this gap, SHM’s Center for Quality Improvement partnered with The Hastings Center, a world-renowned bioethics research institution, to develop a resource room focused on hospitalists’ role in providing high-quality communication about prognosis and goals of care. The resource room presents a Prognosis and Goals of Care Communication Pathway, which highlights key processes and maps them onto the daily workflows of hospitalist physicians.
The care pathway is grounded in palliative care communication research and the consensus guidance of The Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life. It was informed by a national stakeholder meeting of hospitalists, other hospital clinicians, patient and family advocates, bioethicists, social scientists, and other experts, who identified professional values of hospital medicine aligned with communication as part of good care for seriously ill patients.
A collaborative interdisciplinary work group convened by SHM and including hospitalists, palliative medicine physicians, a bioethicist, and a palliative nursing specialist constructed the care pathway in terms of key processes occurring at admission, during hospitalization, and in discharge planning to support primary palliative care integration into normal workflow. The resource room also includes skills-building tools and resources for individual hospitals, teams, and institutions.
The work group will present a workshop on the care pathway at Hospital Medicine 2017: “Demystifying Difficult Decisions: Strategies and Skills to Equip Hospitalists for High-Quality Goals of Care Conversations with Seriously Ill Patients and Their Families.” For more information on the resource room, visit www.hospitalmedicine.org/EOL.
Dr. Anderson is associate professor in residence in the division of hospital medicine at the University of California, San Francisco. She also serves as attending physician in the Palliative Care Program and codirector of the School of Nursing Interprofessional Palliative Care Training Program at UCSF.
Some data support botulinum toxin for psoriasis and rosacea
ORLANDO – Botulinum toxin may have a place in treating psoriasis and rosacea.
There is not a huge body of literature supporting the use of neuromodulators for these conditions, but a smattering of case reports have shown positive results and some clinicians are exploring their off label use, Erin Gilbert, MD, said at the annual meeting of the American Academy of Dermatology.
Her own interest was originally piqued when she began working with Nicole Ward, PhD, director of the morphology core of the Skin Diseases Research Center in the department of dermatology at Case Western Reserve University, Cleveland, who developed a transgenic mouse model of psoriasis. Dr. Ward discovered that transecting the thoracic-level cutaneous nerves at their entry site into back skin resulted in rapid and significant changes in the psoriatic phenotype (J Invest Dermatol. 2011 Jul;131[7]:1530–8). These included decreases of up to 40% in various immune cell populations and a 30% improvement in acanthosis relative to sham surgery sites on the same animals.
This gave rise to a new thought, Dr. Gilbert said. Could chemical denervation produce similar improvements?
Using the same mouse model, she and Dr. Ward evaluated the effect of injecting botulinum neurotoxin A (BoNT-A) 9 units/kg diluted in 1 ml saline at one site, and saline control at another site (J Invest Dermatol. 2012 Jul;132[7]:1927–30). The mice were euthanized at 2 and 6 weeks after treatment. The results were similar to those of the surgical denervation: At 6 weeks, a 25% reduction in acanthosis was observed relative to the control site, with decreases in immune cells and inflammatory markers.
BoNT-A inhibits the release of neurotransmitters by cleaving the SPAP25 protein, an inhibitor of acetylcholine, at the neuromuscular junction. This is the root of the toxin’s ability to relax muscle spasm and decrease hyperhidrosis. The investigators also suggested that BoNT-A inhibits nerve-derived release of calcitonin gene-related peptide and substance P – important peptides in pain and itch sensation.
Dr. Gilbert and Dr. Ward also published a case report in which abobotulinumtoxinA was used off label to treat a recalcitrant psoriatic plaque in a 75-year-old woman (J Drugs Dermatol. 2014;13[11]:1407-8).
“This patient had psoriatic plaques concentrated on her trunk, arms, buttocks, and legs. She had been using strong topical corticosteroids for quite a long time with incomplete relief. I asked her to withdraw from all steroids for 3 months and then treated one lesion.”
The treated plaque was on the patient’s buttock. Dr. Gilbert injected a total of 30 units of abobotulinumtoxinA intradermally at eight points, about 1 cm apart. Within 3 weeks, there was complete remission of that plaque, sustained for 7 months. During this time, new lesions formed on other areas of her body. At 8 months, the treated plaque returned in the same place.
“Some of my patients had been completely recalcitrant to other therapies, and, following off label injection with neuromodulators, they have had life-changing results. In my experience, the key to consistently successful treatment is using adequate doses of toxin.”
This practice is supported by case reports in 2012 and 2015 (J Drugs Dermatol. 2012;11[12]:e76-e79; Dermatology 2015;230:299-301). Some investigators seem to think that, along with the anti-inflammatory and neurotransmitter effects, the toxin alters vascular tone.
Dr. Gilbert acknowledged that these treatments are expensive and cannot, in the case of psoriasis, be used in disseminated disease. However, she said that, for many patients, the relief is so profound and the benefit so long-lasting, that the expense is worth it. An argument in favor of this approach is that, where effective, BoNT-A could be used as a steroid-sparing agent and one that might reduce the need for systemic therapies.
“I will tell you that, sometimes, we get only partial relief and still need adjunctive therapies. Ultimately, neuromodulators may be especially useful for psoriatic plaques that are of cosmetic concern, such as those in the scalp or on the face. Limitations to their use include cost, the need for further studies, and safety concerns, such as muscle weakness.”
Dr. Gilbert had no relevant financial disclosures.
[email protected]
On Twitter @alz_gal
ORLANDO – Botulinum toxin may have a place in treating psoriasis and rosacea.
There is not a huge body of literature supporting the use of neuromodulators for these conditions, but a smattering of case reports have shown positive results and some clinicians are exploring their off label use, Erin Gilbert, MD, said at the annual meeting of the American Academy of Dermatology.
Her own interest was originally piqued when she began working with Nicole Ward, PhD, director of the morphology core of the Skin Diseases Research Center in the department of dermatology at Case Western Reserve University, Cleveland, who developed a transgenic mouse model of psoriasis. Dr. Ward discovered that transecting the thoracic-level cutaneous nerves at their entry site into back skin resulted in rapid and significant changes in the psoriatic phenotype (J Invest Dermatol. 2011 Jul;131[7]:1530–8). These included decreases of up to 40% in various immune cell populations and a 30% improvement in acanthosis relative to sham surgery sites on the same animals.
This gave rise to a new thought, Dr. Gilbert said. Could chemical denervation produce similar improvements?
Using the same mouse model, she and Dr. Ward evaluated the effect of injecting botulinum neurotoxin A (BoNT-A) 9 units/kg diluted in 1 ml saline at one site, and saline control at another site (J Invest Dermatol. 2012 Jul;132[7]:1927–30). The mice were euthanized at 2 and 6 weeks after treatment. The results were similar to those of the surgical denervation: At 6 weeks, a 25% reduction in acanthosis was observed relative to the control site, with decreases in immune cells and inflammatory markers.
BoNT-A inhibits the release of neurotransmitters by cleaving the SPAP25 protein, an inhibitor of acetylcholine, at the neuromuscular junction. This is the root of the toxin’s ability to relax muscle spasm and decrease hyperhidrosis. The investigators also suggested that BoNT-A inhibits nerve-derived release of calcitonin gene-related peptide and substance P – important peptides in pain and itch sensation.
Dr. Gilbert and Dr. Ward also published a case report in which abobotulinumtoxinA was used off label to treat a recalcitrant psoriatic plaque in a 75-year-old woman (J Drugs Dermatol. 2014;13[11]:1407-8).
“This patient had psoriatic plaques concentrated on her trunk, arms, buttocks, and legs. She had been using strong topical corticosteroids for quite a long time with incomplete relief. I asked her to withdraw from all steroids for 3 months and then treated one lesion.”
The treated plaque was on the patient’s buttock. Dr. Gilbert injected a total of 30 units of abobotulinumtoxinA intradermally at eight points, about 1 cm apart. Within 3 weeks, there was complete remission of that plaque, sustained for 7 months. During this time, new lesions formed on other areas of her body. At 8 months, the treated plaque returned in the same place.
“Some of my patients had been completely recalcitrant to other therapies, and, following off label injection with neuromodulators, they have had life-changing results. In my experience, the key to consistently successful treatment is using adequate doses of toxin.”
This practice is supported by case reports in 2012 and 2015 (J Drugs Dermatol. 2012;11[12]:e76-e79; Dermatology 2015;230:299-301). Some investigators seem to think that, along with the anti-inflammatory and neurotransmitter effects, the toxin alters vascular tone.
Dr. Gilbert acknowledged that these treatments are expensive and cannot, in the case of psoriasis, be used in disseminated disease. However, she said that, for many patients, the relief is so profound and the benefit so long-lasting, that the expense is worth it. An argument in favor of this approach is that, where effective, BoNT-A could be used as a steroid-sparing agent and one that might reduce the need for systemic therapies.
“I will tell you that, sometimes, we get only partial relief and still need adjunctive therapies. Ultimately, neuromodulators may be especially useful for psoriatic plaques that are of cosmetic concern, such as those in the scalp or on the face. Limitations to their use include cost, the need for further studies, and safety concerns, such as muscle weakness.”
Dr. Gilbert had no relevant financial disclosures.
[email protected]
On Twitter @alz_gal
ORLANDO – Botulinum toxin may have a place in treating psoriasis and rosacea.
There is not a huge body of literature supporting the use of neuromodulators for these conditions, but a smattering of case reports have shown positive results and some clinicians are exploring their off label use, Erin Gilbert, MD, said at the annual meeting of the American Academy of Dermatology.
Her own interest was originally piqued when she began working with Nicole Ward, PhD, director of the morphology core of the Skin Diseases Research Center in the department of dermatology at Case Western Reserve University, Cleveland, who developed a transgenic mouse model of psoriasis. Dr. Ward discovered that transecting the thoracic-level cutaneous nerves at their entry site into back skin resulted in rapid and significant changes in the psoriatic phenotype (J Invest Dermatol. 2011 Jul;131[7]:1530–8). These included decreases of up to 40% in various immune cell populations and a 30% improvement in acanthosis relative to sham surgery sites on the same animals.
This gave rise to a new thought, Dr. Gilbert said. Could chemical denervation produce similar improvements?
Using the same mouse model, she and Dr. Ward evaluated the effect of injecting botulinum neurotoxin A (BoNT-A) 9 units/kg diluted in 1 ml saline at one site, and saline control at another site (J Invest Dermatol. 2012 Jul;132[7]:1927–30). The mice were euthanized at 2 and 6 weeks after treatment. The results were similar to those of the surgical denervation: At 6 weeks, a 25% reduction in acanthosis was observed relative to the control site, with decreases in immune cells and inflammatory markers.
BoNT-A inhibits the release of neurotransmitters by cleaving the SPAP25 protein, an inhibitor of acetylcholine, at the neuromuscular junction. This is the root of the toxin’s ability to relax muscle spasm and decrease hyperhidrosis. The investigators also suggested that BoNT-A inhibits nerve-derived release of calcitonin gene-related peptide and substance P – important peptides in pain and itch sensation.
Dr. Gilbert and Dr. Ward also published a case report in which abobotulinumtoxinA was used off label to treat a recalcitrant psoriatic plaque in a 75-year-old woman (J Drugs Dermatol. 2014;13[11]:1407-8).
“This patient had psoriatic plaques concentrated on her trunk, arms, buttocks, and legs. She had been using strong topical corticosteroids for quite a long time with incomplete relief. I asked her to withdraw from all steroids for 3 months and then treated one lesion.”
The treated plaque was on the patient’s buttock. Dr. Gilbert injected a total of 30 units of abobotulinumtoxinA intradermally at eight points, about 1 cm apart. Within 3 weeks, there was complete remission of that plaque, sustained for 7 months. During this time, new lesions formed on other areas of her body. At 8 months, the treated plaque returned in the same place.
“Some of my patients had been completely recalcitrant to other therapies, and, following off label injection with neuromodulators, they have had life-changing results. In my experience, the key to consistently successful treatment is using adequate doses of toxin.”
This practice is supported by case reports in 2012 and 2015 (J Drugs Dermatol. 2012;11[12]:e76-e79; Dermatology 2015;230:299-301). Some investigators seem to think that, along with the anti-inflammatory and neurotransmitter effects, the toxin alters vascular tone.
Dr. Gilbert acknowledged that these treatments are expensive and cannot, in the case of psoriasis, be used in disseminated disease. However, she said that, for many patients, the relief is so profound and the benefit so long-lasting, that the expense is worth it. An argument in favor of this approach is that, where effective, BoNT-A could be used as a steroid-sparing agent and one that might reduce the need for systemic therapies.
“I will tell you that, sometimes, we get only partial relief and still need adjunctive therapies. Ultimately, neuromodulators may be especially useful for psoriatic plaques that are of cosmetic concern, such as those in the scalp or on the face. Limitations to their use include cost, the need for further studies, and safety concerns, such as muscle weakness.”
Dr. Gilbert had no relevant financial disclosures.
[email protected]
On Twitter @alz_gal
EXPERT ANALYSIS FROM AAD 17