Patients who were followed for more than 5 years after truncal vagotomy had about a 40% lower risk of being diagnosed with Parkinson’s disease, compared with matched population controls, according to the results of a cohort registry study.

Selective vagotomy did not decrease the risk of Parkinson’s disease (PD), however, reported Bojing Liu of Karolinska Institutet, Stockholm, and her associates. The findings, which reflect those from a prior Danish study, “provide preliminary and indirect support” for the idea that Lewy pathology in PD begins in peripheral nerves and spreads to the central nervous system through “prion-like mechanisms,” they added.

tupungato/Thinkstock

Patients who were followed for more than 5 years after truncal vagotomy had about a 40% lower risk of being diagnosed with Parkinson’s disease, compared with matched population controls, according to the results of a cohort registry study.

Selective vagotomy did not decrease the risk of Parkinson’s disease (PD), however, reported Bojing Liu of Karolinska Institutet, Stockholm, and her associates. The findings, which reflect those from a prior Danish study, “provide preliminary and indirect support” for the idea that Lewy pathology in PD begins in peripheral nerves and spreads to the central nervous system through “prion-like mechanisms,” they added.

tupungato/Thinkstock

Patients who were followed for more than 5 years after truncal vagotomy had about a 40% lower risk of being diagnosed with Parkinson’s disease, compared with matched population controls, according to the results of a cohort registry study.

Selective vagotomy did not decrease the risk of Parkinson’s disease (PD), however, reported Bojing Liu of Karolinska Institutet, Stockholm, and her associates. The findings, which reflect those from a prior Danish study, “provide preliminary and indirect support” for the idea that Lewy pathology in PD begins in peripheral nerves and spreads to the central nervous system through “prion-like mechanisms,” they added.

tupungato/Thinkstock

Look back at the history of SHM’s annual Research, Innovations and Clinical Vignettes poster competition – better known as the RIV – and it may seem inevitable that it’s grown into one of the main highlights of the conference. The RIV has become so popular that the number of submissions has nearly tripled from 634 in 2010 to 1,712 this year.

File photo

The efforts have clearly worked, as RIV is a major driver for annual meeting attendance. The poster competition draws massive crowds that snake their way through the accepted posters.

For those interested in a deeper dive, SHM chooses a dozen or so top abstracts for oral presentations that are, in Dr. Fang’s words, “the creme de la creme of all the research and innovations for the given year.”

The growth of the abstracts competition comes, of course, as the specialty itself has seen its ranks skyrocket. Hospitalists now number an estimated 52,000 nationally, and in addition to providing direct clinical care, have taken ownership of key health care drivers like patient safety, quality improvement, and systems change.

“We do what we do for the good of health care and, ultimately, for the good of our patients,” Dr. Fang said. “Sometimes that’s rounding and taking care of patients in a clinical fashion, and sometimes it’s contributing to the medical literature. It could have been really easy for a specialty to say, ‘Not our problem,’ or ‘No, we’re just rounding.’ ”

HM17 course director Lenny Feldman, MD, FACP, FAAP, SFHM, believes that the commitment of SHM’s founding generation to do research for the past decade has created a group of mentors that push younger hospitalists to do more of the same.

“If we didn’t have the research engine part of hospital medicine, if we didn’t have the folks who are getting into administration and other important leadership areas, we wouldn’t see the maturation of this specialty and we would, in many ways, be stuck at the point at which we started,” Dr. Feldman said. “The only way for us to move forward is to do the research, to be in position to make sure that hospital medicine continues to grow in a direction that is good for our patients, for us, and for the entire system.”

That perspective is what motivates hospitalists to make the RIV bigger each year, said Dr. Fang.

“Having your abstract accepted as a poster or an oral presentation showcases all the work that you’ve put into it,” Dr. Fang said. “There’s a huge amount of pride in showing what you’ve been able to achieve. The driving force is the desire to see what other people are doing, and network to share ideas. That’s the really wonderful part of the RIV competition.”

Look back at the history of SHM’s annual Research, Innovations and Clinical Vignettes poster competition – better known as the RIV – and it may seem inevitable that it’s grown into one of the main highlights of the conference. The RIV has become so popular that the number of submissions has nearly tripled from 634 in 2010 to 1,712 this year.

File photo

The efforts have clearly worked, as RIV is a major driver for annual meeting attendance. The poster competition draws massive crowds that snake their way through the accepted posters.

For those interested in a deeper dive, SHM chooses a dozen or so top abstracts for oral presentations that are, in Dr. Fang’s words, “the creme de la creme of all the research and innovations for the given year.”

The growth of the abstracts competition comes, of course, as the specialty itself has seen its ranks skyrocket. Hospitalists now number an estimated 52,000 nationally, and in addition to providing direct clinical care, have taken ownership of key health care drivers like patient safety, quality improvement, and systems change.

“We do what we do for the good of health care and, ultimately, for the good of our patients,” Dr. Fang said. “Sometimes that’s rounding and taking care of patients in a clinical fashion, and sometimes it’s contributing to the medical literature. It could have been really easy for a specialty to say, ‘Not our problem,’ or ‘No, we’re just rounding.’ ”

HM17 course director Lenny Feldman, MD, FACP, FAAP, SFHM, believes that the commitment of SHM’s founding generation to do research for the past decade has created a group of mentors that push younger hospitalists to do more of the same.

“If we didn’t have the research engine part of hospital medicine, if we didn’t have the folks who are getting into administration and other important leadership areas, we wouldn’t see the maturation of this specialty and we would, in many ways, be stuck at the point at which we started,” Dr. Feldman said. “The only way for us to move forward is to do the research, to be in position to make sure that hospital medicine continues to grow in a direction that is good for our patients, for us, and for the entire system.”

That perspective is what motivates hospitalists to make the RIV bigger each year, said Dr. Fang.

“Having your abstract accepted as a poster or an oral presentation showcases all the work that you’ve put into it,” Dr. Fang said. “There’s a huge amount of pride in showing what you’ve been able to achieve. The driving force is the desire to see what other people are doing, and network to share ideas. That’s the really wonderful part of the RIV competition.”

Look back at the history of SHM’s annual Research, Innovations and Clinical Vignettes poster competition – better known as the RIV – and it may seem inevitable that it’s grown into one of the main highlights of the conference. The RIV has become so popular that the number of submissions has nearly tripled from 634 in 2010 to 1,712 this year.

File photo

The efforts have clearly worked, as RIV is a major driver for annual meeting attendance. The poster competition draws massive crowds that snake their way through the accepted posters.

For those interested in a deeper dive, SHM chooses a dozen or so top abstracts for oral presentations that are, in Dr. Fang’s words, “the creme de la creme of all the research and innovations for the given year.”

The growth of the abstracts competition comes, of course, as the specialty itself has seen its ranks skyrocket. Hospitalists now number an estimated 52,000 nationally, and in addition to providing direct clinical care, have taken ownership of key health care drivers like patient safety, quality improvement, and systems change.

“We do what we do for the good of health care and, ultimately, for the good of our patients,” Dr. Fang said. “Sometimes that’s rounding and taking care of patients in a clinical fashion, and sometimes it’s contributing to the medical literature. It could have been really easy for a specialty to say, ‘Not our problem,’ or ‘No, we’re just rounding.’ ”

HM17 course director Lenny Feldman, MD, FACP, FAAP, SFHM, believes that the commitment of SHM’s founding generation to do research for the past decade has created a group of mentors that push younger hospitalists to do more of the same.

“If we didn’t have the research engine part of hospital medicine, if we didn’t have the folks who are getting into administration and other important leadership areas, we wouldn’t see the maturation of this specialty and we would, in many ways, be stuck at the point at which we started,” Dr. Feldman said. “The only way for us to move forward is to do the research, to be in position to make sure that hospital medicine continues to grow in a direction that is good for our patients, for us, and for the entire system.”

That perspective is what motivates hospitalists to make the RIV bigger each year, said Dr. Fang.

“Having your abstract accepted as a poster or an oral presentation showcases all the work that you’ve put into it,” Dr. Fang said. “There’s a huge amount of pride in showing what you’ve been able to achieve. The driving force is the desire to see what other people are doing, and network to share ideas. That’s the really wonderful part of the RIV competition.”

AT ENDO 2017

ORLANDO – The neurokinin 3 receptor (NK3R) antagonist fezolinetant successfully and safely reduced hot flashes in postmenopausal women in a phase II clinical trial.

After 12 weeks of treatment with the oral small molecule, women had a 93% reduction in moderate to severe hot flashes, compared with a 23% reduction for those taking placebo (P less than .0001). The effects of fezolinetant were seen earlier as well, with an 88% reduction in hot flashes at 4 weeks into the trial, compared with a 12% reduction for the placebo group (P less than .001).

Kari Oakes/Frontline Medical News

[email protected]

On Twitter @karioakes

AT ENDO 2017

ORLANDO – The neurokinin 3 receptor (NK3R) antagonist fezolinetant successfully and safely reduced hot flashes in postmenopausal women in a phase II clinical trial.

After 12 weeks of treatment with the oral small molecule, women had a 93% reduction in moderate to severe hot flashes, compared with a 23% reduction for those taking placebo (P less than .0001). The effects of fezolinetant were seen earlier as well, with an 88% reduction in hot flashes at 4 weeks into the trial, compared with a 12% reduction for the placebo group (P less than .001).

Kari Oakes/Frontline Medical News

[email protected]

On Twitter @karioakes

AT ENDO 2017

ORLANDO – The neurokinin 3 receptor (NK3R) antagonist fezolinetant successfully and safely reduced hot flashes in postmenopausal women in a phase II clinical trial.

After 12 weeks of treatment with the oral small molecule, women had a 93% reduction in moderate to severe hot flashes, compared with a 23% reduction for those taking placebo (P less than .0001). The effects of fezolinetant were seen earlier as well, with an 88% reduction in hot flashes at 4 weeks into the trial, compared with a 12% reduction for the placebo group (P less than .001).

Kari Oakes/Frontline Medical News

[email protected]

On Twitter @karioakes

A) Didelphys uterus INCORRECT

A didelphys uterus occurs as a result of complete nonfusion of the Müllerian duct, resulting in duplicated uterine horns, duplicated cervices, and occasionally the proximal vagina, which is often associated with a transverse or longitudinal vaginal septum.^1,2 Fusion anomalies (didelphys and bicornuate) can be differentiated from resorption anomalies (septate and arcuate) on ultrasonography (US) by a deep fundal cleft (>1 cm).¹ 3D US is highly accurate in identifying Müllerian duct anomalies (MDAs), it correlates well with magnetic resonance imaging (MRI), and it is more cost effective and accessible.³ For the didelphys uterus, 3D US obtained coronal to the uterine fundus often demonstrates widely divergent uterine horns separated by a deep serosal fundal cleft (>1 cm) and noncommunicating endometrial cavities with 2 cervices.¹ Identifying a duplicated vaginal canal can help differentiate a didelphys uterus from a bicornuate bicollis uterus.¹

B) Unicornuate uterus INCORRECT

A unicornuate uterus results from arrested development of one Müllerian duct and normal development of the other. There are 4 different subtypes: no rudimentary horn, rudimentary horn without endometrial cavity, rudimentary horn with communicating endometrial cavity, and rudimentary horn with noncommunicating uterine cavity.¹ Renal anomalies, especially renal agenesis when present, are usually ipsilateral to the rudimentary horn.¹ On US, unicornuate uterus appears as a lobular oblong (banana-shaped) structure away from the midline. The rudimentary horn is often difficult to identify and, when seen, the presence or absence of endometrium is an important finding.¹

C) Partial septate uterus CORRECT

A septate uterus is a result of a resorption anomaly. The septum may be partial (subseptate) or complete secondary to failure of resorption of the uterovaginal septum. A complete septum extends to the external cervical os and occasionally to the vagina.¹ US demonstrates interruption of the myometrium by a hypoechoic fibrous septum and/or a muscular septum which is isoechoic to the myometrium and arises midline from the fundus.¹ 3D US often clearly delineates the septum and improves visualization of the external fundal contour.² The external fundal contour in septate uterus is convex (little or no serosal fundal cleft) and the apex is greater than 5 mm above the interostial line compared with a bicornuate or didelphys uterus, where the apex is less than 5 mm from the interostial line.^1,2 Additionally, the intercornual distance is less than 4 cm.⁴ A septate uterus with duplicated cervix can appear similar to a bicornuate bicollis uterus and can be correctly diagnosed by evaluating the external fundal contour.¹

D) Arcuate uterus INCORRECT

The arcuate uterus also represents a resorption anomaly as a sequela of near-complete resorption of the uterovaginal septum.¹ On 3D US, the fundal indentation in an arcuate uterus is well delineated and appears broad based with an obtuse angle at the most central point, which can help differentiate it from a septate uterus that has an acute angle.^2,3 Both an arcuate and a septate uterus have a normal external (serosal) fundal contour.^2,3 With an arcuate uterus, the length of the vertical measurement from the tubal ostia line, which is drawn horizontally between the tubal ostia to the fundal midline component of the endometrial cavity, is 1 cm or less. With a septate uterus, this vertical distance is greater than 1 cm.

A) Didelphys uterus INCORRECT

A didelphys uterus occurs as a result of complete nonfusion of the Müllerian duct, resulting in duplicated uterine horns, duplicated cervices, and occasionally the proximal vagina, which is often associated with a transverse or longitudinal vaginal septum.^1,2 Fusion anomalies (didelphys and bicornuate) can be differentiated from resorption anomalies (septate and arcuate) on ultrasonography (US) by a deep fundal cleft (>1 cm).¹ 3D US is highly accurate in identifying Müllerian duct anomalies (MDAs), it correlates well with magnetic resonance imaging (MRI), and it is more cost effective and accessible.³ For the didelphys uterus, 3D US obtained coronal to the uterine fundus often demonstrates widely divergent uterine horns separated by a deep serosal fundal cleft (>1 cm) and noncommunicating endometrial cavities with 2 cervices.¹ Identifying a duplicated vaginal canal can help differentiate a didelphys uterus from a bicornuate bicollis uterus.¹

B) Unicornuate uterus INCORRECT

A unicornuate uterus results from arrested development of one Müllerian duct and normal development of the other. There are 4 different subtypes: no rudimentary horn, rudimentary horn without endometrial cavity, rudimentary horn with communicating endometrial cavity, and rudimentary horn with noncommunicating uterine cavity.¹ Renal anomalies, especially renal agenesis when present, are usually ipsilateral to the rudimentary horn.¹ On US, unicornuate uterus appears as a lobular oblong (banana-shaped) structure away from the midline. The rudimentary horn is often difficult to identify and, when seen, the presence or absence of endometrium is an important finding.¹

C) Partial septate uterus CORRECT

A septate uterus is a result of a resorption anomaly. The septum may be partial (subseptate) or complete secondary to failure of resorption of the uterovaginal septum. A complete septum extends to the external cervical os and occasionally to the vagina.¹ US demonstrates interruption of the myometrium by a hypoechoic fibrous septum and/or a muscular septum which is isoechoic to the myometrium and arises midline from the fundus.¹ 3D US often clearly delineates the septum and improves visualization of the external fundal contour.² The external fundal contour in septate uterus is convex (little or no serosal fundal cleft) and the apex is greater than 5 mm above the interostial line compared with a bicornuate or didelphys uterus, where the apex is less than 5 mm from the interostial line.^1,2 Additionally, the intercornual distance is less than 4 cm.⁴ A septate uterus with duplicated cervix can appear similar to a bicornuate bicollis uterus and can be correctly diagnosed by evaluating the external fundal contour.¹

D) Arcuate uterus INCORRECT

The arcuate uterus also represents a resorption anomaly as a sequela of near-complete resorption of the uterovaginal septum.¹ On 3D US, the fundal indentation in an arcuate uterus is well delineated and appears broad based with an obtuse angle at the most central point, which can help differentiate it from a septate uterus that has an acute angle.^2,3 Both an arcuate and a septate uterus have a normal external (serosal) fundal contour.^2,3 With an arcuate uterus, the length of the vertical measurement from the tubal ostia line, which is drawn horizontally between the tubal ostia to the fundal midline component of the endometrial cavity, is 1 cm or less. With a septate uterus, this vertical distance is greater than 1 cm.

A) Didelphys uterus INCORRECT

A didelphys uterus occurs as a result of complete nonfusion of the Müllerian duct, resulting in duplicated uterine horns, duplicated cervices, and occasionally the proximal vagina, which is often associated with a transverse or longitudinal vaginal septum.^1,2 Fusion anomalies (didelphys and bicornuate) can be differentiated from resorption anomalies (septate and arcuate) on ultrasonography (US) by a deep fundal cleft (>1 cm).¹ 3D US is highly accurate in identifying Müllerian duct anomalies (MDAs), it correlates well with magnetic resonance imaging (MRI), and it is more cost effective and accessible.³ For the didelphys uterus, 3D US obtained coronal to the uterine fundus often demonstrates widely divergent uterine horns separated by a deep serosal fundal cleft (>1 cm) and noncommunicating endometrial cavities with 2 cervices.¹ Identifying a duplicated vaginal canal can help differentiate a didelphys uterus from a bicornuate bicollis uterus.¹

B) Unicornuate uterus INCORRECT

A unicornuate uterus results from arrested development of one Müllerian duct and normal development of the other. There are 4 different subtypes: no rudimentary horn, rudimentary horn without endometrial cavity, rudimentary horn with communicating endometrial cavity, and rudimentary horn with noncommunicating uterine cavity.¹ Renal anomalies, especially renal agenesis when present, are usually ipsilateral to the rudimentary horn.¹ On US, unicornuate uterus appears as a lobular oblong (banana-shaped) structure away from the midline. The rudimentary horn is often difficult to identify and, when seen, the presence or absence of endometrium is an important finding.¹

C) Partial septate uterus CORRECT

A septate uterus is a result of a resorption anomaly. The septum may be partial (subseptate) or complete secondary to failure of resorption of the uterovaginal septum. A complete septum extends to the external cervical os and occasionally to the vagina.¹ US demonstrates interruption of the myometrium by a hypoechoic fibrous septum and/or a muscular septum which is isoechoic to the myometrium and arises midline from the fundus.¹ 3D US often clearly delineates the septum and improves visualization of the external fundal contour.² The external fundal contour in septate uterus is convex (little or no serosal fundal cleft) and the apex is greater than 5 mm above the interostial line compared with a bicornuate or didelphys uterus, where the apex is less than 5 mm from the interostial line.^1,2 Additionally, the intercornual distance is less than 4 cm.⁴ A septate uterus with duplicated cervix can appear similar to a bicornuate bicollis uterus and can be correctly diagnosed by evaluating the external fundal contour.¹

D) Arcuate uterus INCORRECT

The arcuate uterus also represents a resorption anomaly as a sequela of near-complete resorption of the uterovaginal septum.¹ On 3D US, the fundal indentation in an arcuate uterus is well delineated and appears broad based with an obtuse angle at the most central point, which can help differentiate it from a septate uterus that has an acute angle.^2,3 Both an arcuate and a septate uterus have a normal external (serosal) fundal contour.^2,3 With an arcuate uterus, the length of the vertical measurement from the tubal ostia line, which is drawn horizontally between the tubal ostia to the fundal midline component of the endometrial cavity, is 1 cm or less. With a septate uterus, this vertical distance is greater than 1 cm.

Republicans are targeting two key consumer protections in their latest attempt to gain enough votes to pass the American Health Care Act, phase 1 of their Affordable Care Act repeal and replace plan.

On the chopping block are the essential health care benefits package and so-called community rating provisions – which prevent insurers from charging significantly more for older patients and those with preexisting conditions.

franckreporter/Thinkstock

• Reduce average premiums.
• Increase enrollment.
• Stabilize the health insurance market.
• Stabilize premiums for individuals with preexisting conditions.
• Increase consumer choice.

For a state to change community rating provisions, its waiver also would need to create a mechanism, such as high-risk pools, to help those patients. Funding for these pools is provided for in the AHCA, but has been criticized as being inadequate on a national level.

Mr. Cannon of the Cato Institute predicted that such waivers ultimately would lead to more adverse selections for people needing comprehensive coverage and could force more people to lose coverage than to gain access to affordable, high-quality plans.

“If you waive essential health benefits in a community-rated market, you get even more adverse selection against comprehensive plans that sick people want, so those plans disappear,” Mr. Cannon said. “They either disappear because the insurers stop offering them or they disappear because insurers try to make the coverage worse, because Obamacare penalizes them if they don’t make coverage worse.”

He said these waivers provide little incentive for health insurers to stay in the individual markets and they could, as they are already, flee the individual markets.

The AHCA is phase 1 of the GOP repeal and replace plan. Congressional Republicans want to use the budget reconciliation process for the AHCA, so that they need only a simple majority to change revenue-generating provisions of the ACA. Phase 2 is a comprehensive review of all federal health care regulations and phase 3 is slated to be new legislation to replace the ACA with a new health care reform plan, which will require a two-thirds majority in the Senate to pass.

[email protected]

Republicans are targeting two key consumer protections in their latest attempt to gain enough votes to pass the American Health Care Act, phase 1 of their Affordable Care Act repeal and replace plan.

On the chopping block are the essential health care benefits package and so-called community rating provisions – which prevent insurers from charging significantly more for older patients and those with preexisting conditions.

franckreporter/Thinkstock

• Reduce average premiums.
• Increase enrollment.
• Stabilize the health insurance market.
• Stabilize premiums for individuals with preexisting conditions.
• Increase consumer choice.

For a state to change community rating provisions, its waiver also would need to create a mechanism, such as high-risk pools, to help those patients. Funding for these pools is provided for in the AHCA, but has been criticized as being inadequate on a national level.

Mr. Cannon of the Cato Institute predicted that such waivers ultimately would lead to more adverse selections for people needing comprehensive coverage and could force more people to lose coverage than to gain access to affordable, high-quality plans.

“If you waive essential health benefits in a community-rated market, you get even more adverse selection against comprehensive plans that sick people want, so those plans disappear,” Mr. Cannon said. “They either disappear because the insurers stop offering them or they disappear because insurers try to make the coverage worse, because Obamacare penalizes them if they don’t make coverage worse.”

He said these waivers provide little incentive for health insurers to stay in the individual markets and they could, as they are already, flee the individual markets.

The AHCA is phase 1 of the GOP repeal and replace plan. Congressional Republicans want to use the budget reconciliation process for the AHCA, so that they need only a simple majority to change revenue-generating provisions of the ACA. Phase 2 is a comprehensive review of all federal health care regulations and phase 3 is slated to be new legislation to replace the ACA with a new health care reform plan, which will require a two-thirds majority in the Senate to pass.

[email protected]

Republicans are targeting two key consumer protections in their latest attempt to gain enough votes to pass the American Health Care Act, phase 1 of their Affordable Care Act repeal and replace plan.

On the chopping block are the essential health care benefits package and so-called community rating provisions – which prevent insurers from charging significantly more for older patients and those with preexisting conditions.

franckreporter/Thinkstock

• Reduce average premiums.
• Increase enrollment.
• Stabilize the health insurance market.
• Stabilize premiums for individuals with preexisting conditions.
• Increase consumer choice.

For a state to change community rating provisions, its waiver also would need to create a mechanism, such as high-risk pools, to help those patients. Funding for these pools is provided for in the AHCA, but has been criticized as being inadequate on a national level.

Mr. Cannon of the Cato Institute predicted that such waivers ultimately would lead to more adverse selections for people needing comprehensive coverage and could force more people to lose coverage than to gain access to affordable, high-quality plans.

“If you waive essential health benefits in a community-rated market, you get even more adverse selection against comprehensive plans that sick people want, so those plans disappear,” Mr. Cannon said. “They either disappear because the insurers stop offering them or they disappear because insurers try to make the coverage worse, because Obamacare penalizes them if they don’t make coverage worse.”

He said these waivers provide little incentive for health insurers to stay in the individual markets and they could, as they are already, flee the individual markets.

The AHCA is phase 1 of the GOP repeal and replace plan. Congressional Republicans want to use the budget reconciliation process for the AHCA, so that they need only a simple majority to change revenue-generating provisions of the ACA. Phase 2 is a comprehensive review of all federal health care regulations and phase 3 is slated to be new legislation to replace the ACA with a new health care reform plan, which will require a two-thirds majority in the Senate to pass.

[email protected]

BOSTON – Adjunctive treatment with cannabidiol significantly reduced convulsive seizure frequency in Dravet syndrome patients in a randomized, double-blind, placebo-controlled trial.

Over a 14-week treatment period, including 2 weeks of titration and 12 weeks of maintenance, convulsive seizure frequency in 61 treated children and adolescents decreased from a median of 12.4 to 5.9 per month (median reduction of 39%), compared with a decrease from a median of 14.9 to 14.1 per month (median reduction of 13%) in 59 patients who received placebo, J. Helen Cross, MD, reported at the annual meeting of the American Academy of Neurology.

The proportion of patients with at least a 50% reduction in convulsive seizures was 42.6% with cannabidiol vs. 27.1% with placebo (odds ratio, 2.0), but this difference did not reach statistical significance, said Dr. Cross of the University College London Great Ormond Street Institute of Child Health and the Great Ormond Street Hospital for Children NHS Trust, London.

In a video interview, Dr. Cross discussed the findings and the importance of improving seizure control in patients with Dravet syndrome, a rare infantile-onset developmental and epileptic encephalopathy with very poor prognosis for long-term seizure control and neurodevelopmental outcomes.

Participants in the study (GWPCARE1) had a mean age of 10 years, but nearly a third were younger than 6 years. All had Dravet syndrome and drug-resistant seizures; the median number of antiepilepsy drugs previously tried was four, and the median number being used was three. Those randomized to the treatment group received cannabidiol oral solution up to 20 mg/kg per day.

Adverse events were common, occurring in 93.4% and 74.6% of treatment group and placebo group patients, respectively. But adverse events reported in the treatment group were mild or moderate in 84% of patients, and treatment was generally well tolerated.

“These are very complex patients with a high seizure burden... and therefore, to have another medication that looks as if it can be of benefit is really very exciting for this population,” Dr. Cross said, noting that cannabidiol was also shown in other studies presented at the AAN meeting (GWPCARE3 and GWPCARE4) to reduce seizure frequency in patients with Lennox-Gastaut syndrome.

GW Research sponsored the study. Dr. Cross is a member of the advisory boards for Eisai, GW Pharmaceuticals, Shire, and Zogenix.

[email protected]

BOSTON – Adjunctive treatment with cannabidiol significantly reduced convulsive seizure frequency in Dravet syndrome patients in a randomized, double-blind, placebo-controlled trial.

Over a 14-week treatment period, including 2 weeks of titration and 12 weeks of maintenance, convulsive seizure frequency in 61 treated children and adolescents decreased from a median of 12.4 to 5.9 per month (median reduction of 39%), compared with a decrease from a median of 14.9 to 14.1 per month (median reduction of 13%) in 59 patients who received placebo, J. Helen Cross, MD, reported at the annual meeting of the American Academy of Neurology.

The proportion of patients with at least a 50% reduction in convulsive seizures was 42.6% with cannabidiol vs. 27.1% with placebo (odds ratio, 2.0), but this difference did not reach statistical significance, said Dr. Cross of the University College London Great Ormond Street Institute of Child Health and the Great Ormond Street Hospital for Children NHS Trust, London.

In a video interview, Dr. Cross discussed the findings and the importance of improving seizure control in patients with Dravet syndrome, a rare infantile-onset developmental and epileptic encephalopathy with very poor prognosis for long-term seizure control and neurodevelopmental outcomes.

Participants in the study (GWPCARE1) had a mean age of 10 years, but nearly a third were younger than 6 years. All had Dravet syndrome and drug-resistant seizures; the median number of antiepilepsy drugs previously tried was four, and the median number being used was three. Those randomized to the treatment group received cannabidiol oral solution up to 20 mg/kg per day.

Adverse events were common, occurring in 93.4% and 74.6% of treatment group and placebo group patients, respectively. But adverse events reported in the treatment group were mild or moderate in 84% of patients, and treatment was generally well tolerated.

“These are very complex patients with a high seizure burden... and therefore, to have another medication that looks as if it can be of benefit is really very exciting for this population,” Dr. Cross said, noting that cannabidiol was also shown in other studies presented at the AAN meeting (GWPCARE3 and GWPCARE4) to reduce seizure frequency in patients with Lennox-Gastaut syndrome.

GW Research sponsored the study. Dr. Cross is a member of the advisory boards for Eisai, GW Pharmaceuticals, Shire, and Zogenix.

[email protected]

BOSTON – Adjunctive treatment with cannabidiol significantly reduced convulsive seizure frequency in Dravet syndrome patients in a randomized, double-blind, placebo-controlled trial.

Over a 14-week treatment period, including 2 weeks of titration and 12 weeks of maintenance, convulsive seizure frequency in 61 treated children and adolescents decreased from a median of 12.4 to 5.9 per month (median reduction of 39%), compared with a decrease from a median of 14.9 to 14.1 per month (median reduction of 13%) in 59 patients who received placebo, J. Helen Cross, MD, reported at the annual meeting of the American Academy of Neurology.

The proportion of patients with at least a 50% reduction in convulsive seizures was 42.6% with cannabidiol vs. 27.1% with placebo (odds ratio, 2.0), but this difference did not reach statistical significance, said Dr. Cross of the University College London Great Ormond Street Institute of Child Health and the Great Ormond Street Hospital for Children NHS Trust, London.

In a video interview, Dr. Cross discussed the findings and the importance of improving seizure control in patients with Dravet syndrome, a rare infantile-onset developmental and epileptic encephalopathy with very poor prognosis for long-term seizure control and neurodevelopmental outcomes.

Participants in the study (GWPCARE1) had a mean age of 10 years, but nearly a third were younger than 6 years. All had Dravet syndrome and drug-resistant seizures; the median number of antiepilepsy drugs previously tried was four, and the median number being used was three. Those randomized to the treatment group received cannabidiol oral solution up to 20 mg/kg per day.

Adverse events were common, occurring in 93.4% and 74.6% of treatment group and placebo group patients, respectively. But adverse events reported in the treatment group were mild or moderate in 84% of patients, and treatment was generally well tolerated.

“These are very complex patients with a high seizure burden... and therefore, to have another medication that looks as if it can be of benefit is really very exciting for this population,” Dr. Cross said, noting that cannabidiol was also shown in other studies presented at the AAN meeting (GWPCARE3 and GWPCARE4) to reduce seizure frequency in patients with Lennox-Gastaut syndrome.

GW Research sponsored the study. Dr. Cross is a member of the advisory boards for Eisai, GW Pharmaceuticals, Shire, and Zogenix.

[email protected]

BOSTON – Children with multiple sclerosis (MS) and related conditions are as much as 10 times more likely than the general population to need to be hospitalized for various psychiatric conditions, a study showed.

“The true prevalence of morbidity is almost certainly higher than suggested by our data,” said study lead author Julia Pakpoor, BM BCh, who presented data from her research at the annual meeting of the American Academy of Neurology.

While several studies have examined links between MS and mental illness in adults, there’s been little research into the topic in children. The number of children with the disease is far from tiny, however. According to the National MS Society, an estimated 8,000-10,000 children have the condition in the United States.

SIphotography/Thinkstock

[email protected]

BOSTON – Children with multiple sclerosis (MS) and related conditions are as much as 10 times more likely than the general population to need to be hospitalized for various psychiatric conditions, a study showed.

“The true prevalence of morbidity is almost certainly higher than suggested by our data,” said study lead author Julia Pakpoor, BM BCh, who presented data from her research at the annual meeting of the American Academy of Neurology.

While several studies have examined links between MS and mental illness in adults, there’s been little research into the topic in children. The number of children with the disease is far from tiny, however. According to the National MS Society, an estimated 8,000-10,000 children have the condition in the United States.

SIphotography/Thinkstock

[email protected]

BOSTON – Children with multiple sclerosis (MS) and related conditions are as much as 10 times more likely than the general population to need to be hospitalized for various psychiatric conditions, a study showed.

“The true prevalence of morbidity is almost certainly higher than suggested by our data,” said study lead author Julia Pakpoor, BM BCh, who presented data from her research at the annual meeting of the American Academy of Neurology.

While several studies have examined links between MS and mental illness in adults, there’s been little research into the topic in children. The number of children with the disease is far from tiny, however. According to the National MS Society, an estimated 8,000-10,000 children have the condition in the United States.

SIphotography/Thinkstock

[email protected]

SAN DIEGO – Laser hair removal isn’t typically in an office cleaner’s job description. So it’s no wonder that Virginia legislators were spooked when they heard from a constituent who was treated by a spa worker who turned out to be a janitor.

Earlier this year, legislators in the Old Dominion passed a bill limiting laser hair removal procedures to a “properly trained” medical doctor, physician assistant, or nurse practitioner – or a “properly trained” person who is supervised by one of these professionals. Therefore, it’s still possible for a “properly trained” person without a degree of any kind to operate a laser in Virginia.

To the north in New Jersey, the rules are much stricter: Only physicians can perform laser procedures. But in New York, it appears that anyone can fire up a laser and go to work on unwanted hair. And in Florida, nonphysicians can perform laser procedures only if they’re physician assistants or nurse practitioners. But they’re only allowed to remove hair with lasers at a clinic that just performs laser hair removal.

Such is the chaotic state of laser law in the United States, a new study finds. The rules, which vary widely from state to state, are often vague and confusing. And, as Virginia’s new law shows, they’re still evolving. (The study is current as of March 2016.)

1. Who can operate a laser?

At other clinics across the country, nonphysician employees — such as nurse practitioners and registered nurses – often operate lasers. Whether they can legally actually do so isn’t always obvious.

New Jersey is the only state that requires laser operators to be physicians. At the other extreme, 11 states, including Massachusetts, Colorado, Florida, Missouri, New York, and Pennsylvania, have “no” limits on who can perform laser procedures. (At Massachusetts General Hospital, physicians perform all laser procedures.)

So does that mean anyone can perform a laser procedure? It’s not clear. “The laws are a lot more vague than they should be,” Dr. DiGiorgio said in an interview.

Eighteen states allow people to perform laser procedures as part of the “practice of medicine,” although legislation can be vague on what that means. Those states include Illinois, Michigan, Minnesota, North Carolina, and Texas.

Another 19 states, including California, Ohio, Washington, Wisconsin, and now Virginia, have specific limits on who can perform laser procedures. In California, for example, physician assistants and registered nurses – but not licensed vocational nurses – are allowed to use lasers to remove hair, spider veins, and tattoos. Unlicensed medical assistants, cosmetologists, electrologists, and estheticians are not allowed to perform the procedures

2. Can someone delegate laser procedures to someone else?

In nine states, including Iowa and New Hampshire, there’s no oversight of delegation or nonphysicians can delegate procedures to someone else.

In another nine states, certain procedures can be delegated with no physician oversight, such as laser hair removal in Alaska and ablative procedures (to advanced practice registered nurses only) in Utah.

3. Is supervision required of nonphysicians?

Physicians don’t need to supervise certain laser procedures in 11 states, including Hawaii, Oregon, and Vermont, where they can be performed by a nonphysician with no supervision or under supervision by a non-physician.

In 17 states, supervision isn’t always required or it’s under the discretion of the supervising physician. These states include California, Michigan, Pennsylvania, and Wisconsin.

In 11 states, including Illinois and Massachusetts, only certain procedures require on-site supervision. Six states, including Connecticut and Maryland, require on-site physician supervision for all laser procedures, but Dr. DiGiorgio said the requirements can be vague about what “on site” actually means.

Idaho requires the physician to be on site or immediately available, and South Carolina allows registered nurses to perform laser hair and leg vein removal if a physician is on site and can respond within 5 minutes.

“We don’t know what the ideal regulation is,” Dr. DiGiorgio said. But she believes laser regulations are crucial to safety, especially as fields such as plastic surgery, ophthalmology, and gynecology embrace cosmetic laser procedures.

Information about state-by-state laser operator laws is available on the American Med Spa Association website.

Dr. DiGiorgio reported no relevant disclosures.

SAN DIEGO – Laser hair removal isn’t typically in an office cleaner’s job description. So it’s no wonder that Virginia legislators were spooked when they heard from a constituent who was treated by a spa worker who turned out to be a janitor.

Earlier this year, legislators in the Old Dominion passed a bill limiting laser hair removal procedures to a “properly trained” medical doctor, physician assistant, or nurse practitioner – or a “properly trained” person who is supervised by one of these professionals. Therefore, it’s still possible for a “properly trained” person without a degree of any kind to operate a laser in Virginia.

To the north in New Jersey, the rules are much stricter: Only physicians can perform laser procedures. But in New York, it appears that anyone can fire up a laser and go to work on unwanted hair. And in Florida, nonphysicians can perform laser procedures only if they’re physician assistants or nurse practitioners. But they’re only allowed to remove hair with lasers at a clinic that just performs laser hair removal.

Such is the chaotic state of laser law in the United States, a new study finds. The rules, which vary widely from state to state, are often vague and confusing. And, as Virginia’s new law shows, they’re still evolving. (The study is current as of March 2016.)

1. Who can operate a laser?

At other clinics across the country, nonphysician employees — such as nurse practitioners and registered nurses – often operate lasers. Whether they can legally actually do so isn’t always obvious.

New Jersey is the only state that requires laser operators to be physicians. At the other extreme, 11 states, including Massachusetts, Colorado, Florida, Missouri, New York, and Pennsylvania, have “no” limits on who can perform laser procedures. (At Massachusetts General Hospital, physicians perform all laser procedures.)

So does that mean anyone can perform a laser procedure? It’s not clear. “The laws are a lot more vague than they should be,” Dr. DiGiorgio said in an interview.

Eighteen states allow people to perform laser procedures as part of the “practice of medicine,” although legislation can be vague on what that means. Those states include Illinois, Michigan, Minnesota, North Carolina, and Texas.

Another 19 states, including California, Ohio, Washington, Wisconsin, and now Virginia, have specific limits on who can perform laser procedures. In California, for example, physician assistants and registered nurses – but not licensed vocational nurses – are allowed to use lasers to remove hair, spider veins, and tattoos. Unlicensed medical assistants, cosmetologists, electrologists, and estheticians are not allowed to perform the procedures

2. Can someone delegate laser procedures to someone else?

In nine states, including Iowa and New Hampshire, there’s no oversight of delegation or nonphysicians can delegate procedures to someone else.

In another nine states, certain procedures can be delegated with no physician oversight, such as laser hair removal in Alaska and ablative procedures (to advanced practice registered nurses only) in Utah.

3. Is supervision required of nonphysicians?

Physicians don’t need to supervise certain laser procedures in 11 states, including Hawaii, Oregon, and Vermont, where they can be performed by a nonphysician with no supervision or under supervision by a non-physician.

In 17 states, supervision isn’t always required or it’s under the discretion of the supervising physician. These states include California, Michigan, Pennsylvania, and Wisconsin.

In 11 states, including Illinois and Massachusetts, only certain procedures require on-site supervision. Six states, including Connecticut and Maryland, require on-site physician supervision for all laser procedures, but Dr. DiGiorgio said the requirements can be vague about what “on site” actually means.

Idaho requires the physician to be on site or immediately available, and South Carolina allows registered nurses to perform laser hair and leg vein removal if a physician is on site and can respond within 5 minutes.

“We don’t know what the ideal regulation is,” Dr. DiGiorgio said. But she believes laser regulations are crucial to safety, especially as fields such as plastic surgery, ophthalmology, and gynecology embrace cosmetic laser procedures.

Information about state-by-state laser operator laws is available on the American Med Spa Association website.

Dr. DiGiorgio reported no relevant disclosures.

SAN DIEGO – Laser hair removal isn’t typically in an office cleaner’s job description. So it’s no wonder that Virginia legislators were spooked when they heard from a constituent who was treated by a spa worker who turned out to be a janitor.

Earlier this year, legislators in the Old Dominion passed a bill limiting laser hair removal procedures to a “properly trained” medical doctor, physician assistant, or nurse practitioner – or a “properly trained” person who is supervised by one of these professionals. Therefore, it’s still possible for a “properly trained” person without a degree of any kind to operate a laser in Virginia.

To the north in New Jersey, the rules are much stricter: Only physicians can perform laser procedures. But in New York, it appears that anyone can fire up a laser and go to work on unwanted hair. And in Florida, nonphysicians can perform laser procedures only if they’re physician assistants or nurse practitioners. But they’re only allowed to remove hair with lasers at a clinic that just performs laser hair removal.

Such is the chaotic state of laser law in the United States, a new study finds. The rules, which vary widely from state to state, are often vague and confusing. And, as Virginia’s new law shows, they’re still evolving. (The study is current as of March 2016.)

1. Who can operate a laser?

At other clinics across the country, nonphysician employees — such as nurse practitioners and registered nurses – often operate lasers. Whether they can legally actually do so isn’t always obvious.

New Jersey is the only state that requires laser operators to be physicians. At the other extreme, 11 states, including Massachusetts, Colorado, Florida, Missouri, New York, and Pennsylvania, have “no” limits on who can perform laser procedures. (At Massachusetts General Hospital, physicians perform all laser procedures.)

So does that mean anyone can perform a laser procedure? It’s not clear. “The laws are a lot more vague than they should be,” Dr. DiGiorgio said in an interview.

Eighteen states allow people to perform laser procedures as part of the “practice of medicine,” although legislation can be vague on what that means. Those states include Illinois, Michigan, Minnesota, North Carolina, and Texas.

Another 19 states, including California, Ohio, Washington, Wisconsin, and now Virginia, have specific limits on who can perform laser procedures. In California, for example, physician assistants and registered nurses – but not licensed vocational nurses – are allowed to use lasers to remove hair, spider veins, and tattoos. Unlicensed medical assistants, cosmetologists, electrologists, and estheticians are not allowed to perform the procedures

2. Can someone delegate laser procedures to someone else?

In nine states, including Iowa and New Hampshire, there’s no oversight of delegation or nonphysicians can delegate procedures to someone else.

In another nine states, certain procedures can be delegated with no physician oversight, such as laser hair removal in Alaska and ablative procedures (to advanced practice registered nurses only) in Utah.

3. Is supervision required of nonphysicians?

Physicians don’t need to supervise certain laser procedures in 11 states, including Hawaii, Oregon, and Vermont, where they can be performed by a nonphysician with no supervision or under supervision by a non-physician.

In 17 states, supervision isn’t always required or it’s under the discretion of the supervising physician. These states include California, Michigan, Pennsylvania, and Wisconsin.

In 11 states, including Illinois and Massachusetts, only certain procedures require on-site supervision. Six states, including Connecticut and Maryland, require on-site physician supervision for all laser procedures, but Dr. DiGiorgio said the requirements can be vague about what “on site” actually means.

Idaho requires the physician to be on site or immediately available, and South Carolina allows registered nurses to perform laser hair and leg vein removal if a physician is on site and can respond within 5 minutes.

“We don’t know what the ideal regulation is,” Dr. DiGiorgio said. But she believes laser regulations are crucial to safety, especially as fields such as plastic surgery, ophthalmology, and gynecology embrace cosmetic laser procedures.

Information about state-by-state laser operator laws is available on the American Med Spa Association website.

Dr. DiGiorgio reported no relevant disclosures.

How many times do you come out of the exam room after seeing a patient in follow-up and heave a sigh because the parents did not give their child the medicine as you prescribed it?

Without adherence to the medication plan, a lot of suboptimal outcomes can and do occur. A urinary tract infection may come back partially treated, requiring a more extensive work-up. A strep infection may spread to family members. Inflammatory bowel disease may require bowel resection. Asthma may simmer with long-term inflammation and pulmonary compromise as well as concurrent activity limitations. Often children with asthma are given less than 50% of prescribed controller medicines. In one pediatric study, medication adherence was not even asked about in 66% of cases. In adults, 20%-30% of prescriptions are never filled.

As physicians, we are carefully schooled in making complex diagnoses, sorting out and prioritizing the laboratory work-up, and memorizing the latest and most effective treatment regimens. What is rarely taught, however, is how to conduct the conversation needed to optimize subsequent adherence to the medication plan.

Problem-solving counseling is an evidence-based method to improve medication adherence. This is a semistructured form of cognitive-behavioral intervention designed to engage the responsible person (parent or child) in shared decision making about whether and how to take medication, and which one to take. After all, for good or for bad, it is really their choice!

1. Problem definition. This step involves developing a clear and specific definition of the problem. Educating families about a medical condition has to start with asking what they already know. This often includes sagas of bad outcomes in relatives. Ask: Who do you know with asthma? How was it for them? The family needs to know symptoms, simple pathophysiology (such as inflammation you can’t see or feel), course, and prognosis. They also need to know where their child’s condition falls on the continuum. And they need to understand the essential prevention aspect of controllers in what appears to be an asymptomatic child. Failure to communicate this is a common reason for nonadherence in asthma.

2. Generation of alternatives. This involves brainstorming to identify multiple and creative solutions. This step will reveal past experiences as well as things the family learned on the Internet that may be true and relevant, or true but irrelevant, or false. Ask: What have you heard about treatments for asthma? What do you think would be best for your child? Generic handouts with a sampling of medicines, advantages and disadvantages, side effects, and costs of the main choices have been shown to be helpful guides that enhance adherence through empowering the family in their choice and reassuring family members that you have been thorough. It can be a balancing act to describe possible side effects without scaring the family into shutting down and being unable to make any choice at all. However, failure to discuss common effects they may notice – such as a racing heart from rescue medications – but that you think of as trivial, may also lead to nonadherence. A way to communicate about perceived side effects and manage them has to be part of an effective plan. Planning a phone or email check-in can make a big difference.

3. Decision making. This step involves evaluating all the solutions to identify the most effective and feasible option. Once the family understands the problem and the alternatives, it is crucial for you, as the physician, to not only ask their preference but be ready to suggest what you think would be best. While not wanting to be patronized, families want your opinion. I like to have family members close their eyes and visualize carrying out the selected routine. This is a good hypnotic technique for future remembering, but you also may discover important facts by this simple exercise, such as that the child gets up alone for school, making morning dosing unreliable. Shared decision making is not a way to abdicate your expert opinion, just to incorporate family preferences and factors.

4. Solution implementation. This step involves carrying out the plan. There is no substitute for a real life trial! There may be surprising issues: Autistic children may be afraid of a nebulizer machine. Sensitive children may refuse the flavor of some inhalers.

5. Solution verification. Evaluate the effectiveness of the solution and modify the plan as necessary. Follow-up contact is crucial, especially at the start of a new chronic medication plan. When families know that the plan can be changed if things do not go well or they change their minds, they will be less fearful of giving it a try and more honest about barriers they perceive or encounter rather than simply showing up at the next visit with the child’s condition out of control.

Although using problem-solving counseling may sound complicated, it is intended to be focused and brief, and has been shown to be feasibly done in the clinic by primary care providers, without lengthening the visit. CHADIS even has teleprompter text specific to parent-reported barriers to help you.

Even when family members understand and agrees to a medication plan during the visit, there are a variety of reasons they may not adhere to it. They may forget to give the medicine, be unable to afford it once prescribed, experience unpleasant side effects, encounter resistance from the child, or get unanticipated push back from family members. All of these issues can be addressed if you know that they happen. You just have to ask! Recommending smartphone reminders or reminder apps (such as Medisafe), using GoodRx to find cheaper sources, suggesting candy as a chaser, recommending behavior strategies for feisty kids, and providing written materials (or a phone call) for reluctant relatives are strategies you can prepare in advance to have in your quiver and are well worth your time.

If it weren’t enough to address adherence to optimize outcomes, asthma management and control will likely be a Clinical Quality Measure, determining how we will be paid starting this year. Now you have a tool to do it!
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.

How many times do you come out of the exam room after seeing a patient in follow-up and heave a sigh because the parents did not give their child the medicine as you prescribed it?

Without adherence to the medication plan, a lot of suboptimal outcomes can and do occur. A urinary tract infection may come back partially treated, requiring a more extensive work-up. A strep infection may spread to family members. Inflammatory bowel disease may require bowel resection. Asthma may simmer with long-term inflammation and pulmonary compromise as well as concurrent activity limitations. Often children with asthma are given less than 50% of prescribed controller medicines. In one pediatric study, medication adherence was not even asked about in 66% of cases. In adults, 20%-30% of prescriptions are never filled.

As physicians, we are carefully schooled in making complex diagnoses, sorting out and prioritizing the laboratory work-up, and memorizing the latest and most effective treatment regimens. What is rarely taught, however, is how to conduct the conversation needed to optimize subsequent adherence to the medication plan.

Problem-solving counseling is an evidence-based method to improve medication adherence. This is a semistructured form of cognitive-behavioral intervention designed to engage the responsible person (parent or child) in shared decision making about whether and how to take medication, and which one to take. After all, for good or for bad, it is really their choice!

1. Problem definition. This step involves developing a clear and specific definition of the problem. Educating families about a medical condition has to start with asking what they already know. This often includes sagas of bad outcomes in relatives. Ask: Who do you know with asthma? How was it for them? The family needs to know symptoms, simple pathophysiology (such as inflammation you can’t see or feel), course, and prognosis. They also need to know where their child’s condition falls on the continuum. And they need to understand the essential prevention aspect of controllers in what appears to be an asymptomatic child. Failure to communicate this is a common reason for nonadherence in asthma.

2. Generation of alternatives. This involves brainstorming to identify multiple and creative solutions. This step will reveal past experiences as well as things the family learned on the Internet that may be true and relevant, or true but irrelevant, or false. Ask: What have you heard about treatments for asthma? What do you think would be best for your child? Generic handouts with a sampling of medicines, advantages and disadvantages, side effects, and costs of the main choices have been shown to be helpful guides that enhance adherence through empowering the family in their choice and reassuring family members that you have been thorough. It can be a balancing act to describe possible side effects without scaring the family into shutting down and being unable to make any choice at all. However, failure to discuss common effects they may notice – such as a racing heart from rescue medications – but that you think of as trivial, may also lead to nonadherence. A way to communicate about perceived side effects and manage them has to be part of an effective plan. Planning a phone or email check-in can make a big difference.

3. Decision making. This step involves evaluating all the solutions to identify the most effective and feasible option. Once the family understands the problem and the alternatives, it is crucial for you, as the physician, to not only ask their preference but be ready to suggest what you think would be best. While not wanting to be patronized, families want your opinion. I like to have family members close their eyes and visualize carrying out the selected routine. This is a good hypnotic technique for future remembering, but you also may discover important facts by this simple exercise, such as that the child gets up alone for school, making morning dosing unreliable. Shared decision making is not a way to abdicate your expert opinion, just to incorporate family preferences and factors.

4. Solution implementation. This step involves carrying out the plan. There is no substitute for a real life trial! There may be surprising issues: Autistic children may be afraid of a nebulizer machine. Sensitive children may refuse the flavor of some inhalers.

5. Solution verification. Evaluate the effectiveness of the solution and modify the plan as necessary. Follow-up contact is crucial, especially at the start of a new chronic medication plan. When families know that the plan can be changed if things do not go well or they change their minds, they will be less fearful of giving it a try and more honest about barriers they perceive or encounter rather than simply showing up at the next visit with the child’s condition out of control.

Although using problem-solving counseling may sound complicated, it is intended to be focused and brief, and has been shown to be feasibly done in the clinic by primary care providers, without lengthening the visit. CHADIS even has teleprompter text specific to parent-reported barriers to help you.

Even when family members understand and agrees to a medication plan during the visit, there are a variety of reasons they may not adhere to it. They may forget to give the medicine, be unable to afford it once prescribed, experience unpleasant side effects, encounter resistance from the child, or get unanticipated push back from family members. All of these issues can be addressed if you know that they happen. You just have to ask! Recommending smartphone reminders or reminder apps (such as Medisafe), using GoodRx to find cheaper sources, suggesting candy as a chaser, recommending behavior strategies for feisty kids, and providing written materials (or a phone call) for reluctant relatives are strategies you can prepare in advance to have in your quiver and are well worth your time.

If it weren’t enough to address adherence to optimize outcomes, asthma management and control will likely be a Clinical Quality Measure, determining how we will be paid starting this year. Now you have a tool to do it!
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.

How many times do you come out of the exam room after seeing a patient in follow-up and heave a sigh because the parents did not give their child the medicine as you prescribed it?

Without adherence to the medication plan, a lot of suboptimal outcomes can and do occur. A urinary tract infection may come back partially treated, requiring a more extensive work-up. A strep infection may spread to family members. Inflammatory bowel disease may require bowel resection. Asthma may simmer with long-term inflammation and pulmonary compromise as well as concurrent activity limitations. Often children with asthma are given less than 50% of prescribed controller medicines. In one pediatric study, medication adherence was not even asked about in 66% of cases. In adults, 20%-30% of prescriptions are never filled.

As physicians, we are carefully schooled in making complex diagnoses, sorting out and prioritizing the laboratory work-up, and memorizing the latest and most effective treatment regimens. What is rarely taught, however, is how to conduct the conversation needed to optimize subsequent adherence to the medication plan.

Problem-solving counseling is an evidence-based method to improve medication adherence. This is a semistructured form of cognitive-behavioral intervention designed to engage the responsible person (parent or child) in shared decision making about whether and how to take medication, and which one to take. After all, for good or for bad, it is really their choice!

1. Problem definition. This step involves developing a clear and specific definition of the problem. Educating families about a medical condition has to start with asking what they already know. This often includes sagas of bad outcomes in relatives. Ask: Who do you know with asthma? How was it for them? The family needs to know symptoms, simple pathophysiology (such as inflammation you can’t see or feel), course, and prognosis. They also need to know where their child’s condition falls on the continuum. And they need to understand the essential prevention aspect of controllers in what appears to be an asymptomatic child. Failure to communicate this is a common reason for nonadherence in asthma.

2. Generation of alternatives. This involves brainstorming to identify multiple and creative solutions. This step will reveal past experiences as well as things the family learned on the Internet that may be true and relevant, or true but irrelevant, or false. Ask: What have you heard about treatments for asthma? What do you think would be best for your child? Generic handouts with a sampling of medicines, advantages and disadvantages, side effects, and costs of the main choices have been shown to be helpful guides that enhance adherence through empowering the family in their choice and reassuring family members that you have been thorough. It can be a balancing act to describe possible side effects without scaring the family into shutting down and being unable to make any choice at all. However, failure to discuss common effects they may notice – such as a racing heart from rescue medications – but that you think of as trivial, may also lead to nonadherence. A way to communicate about perceived side effects and manage them has to be part of an effective plan. Planning a phone or email check-in can make a big difference.

3. Decision making. This step involves evaluating all the solutions to identify the most effective and feasible option. Once the family understands the problem and the alternatives, it is crucial for you, as the physician, to not only ask their preference but be ready to suggest what you think would be best. While not wanting to be patronized, families want your opinion. I like to have family members close their eyes and visualize carrying out the selected routine. This is a good hypnotic technique for future remembering, but you also may discover important facts by this simple exercise, such as that the child gets up alone for school, making morning dosing unreliable. Shared decision making is not a way to abdicate your expert opinion, just to incorporate family preferences and factors.

4. Solution implementation. This step involves carrying out the plan. There is no substitute for a real life trial! There may be surprising issues: Autistic children may be afraid of a nebulizer machine. Sensitive children may refuse the flavor of some inhalers.

5. Solution verification. Evaluate the effectiveness of the solution and modify the plan as necessary. Follow-up contact is crucial, especially at the start of a new chronic medication plan. When families know that the plan can be changed if things do not go well or they change their minds, they will be less fearful of giving it a try and more honest about barriers they perceive or encounter rather than simply showing up at the next visit with the child’s condition out of control.

Although using problem-solving counseling may sound complicated, it is intended to be focused and brief, and has been shown to be feasibly done in the clinic by primary care providers, without lengthening the visit. CHADIS even has teleprompter text specific to parent-reported barriers to help you.

Even when family members understand and agrees to a medication plan during the visit, there are a variety of reasons they may not adhere to it. They may forget to give the medicine, be unable to afford it once prescribed, experience unpleasant side effects, encounter resistance from the child, or get unanticipated push back from family members. All of these issues can be addressed if you know that they happen. You just have to ask! Recommending smartphone reminders or reminder apps (such as Medisafe), using GoodRx to find cheaper sources, suggesting candy as a chaser, recommending behavior strategies for feisty kids, and providing written materials (or a phone call) for reluctant relatives are strategies you can prepare in advance to have in your quiver and are well worth your time.

If it weren’t enough to address adherence to optimize outcomes, asthma management and control will likely be a Clinical Quality Measure, determining how we will be paid starting this year. Now you have a tool to do it!
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.

Traveler’s diarrhea (TD) is the most common illness in people traveling from resource-advantaged countries to resource-limited regions of the globe. Approximately 50% of these types of travelers will contract diarrhea.

I knew of a group of infectious disease experts traveling to India together – presumably well-versed in how to avoid such things – and one-half of the group developed it.

I have many patients sending me electronic messages asking me for their standard 3-day ciprofloxacin prescriptions, “just in case.” I am guilty of having provided this, along with warnings that we could make matters worse by giving them Clostridium difficile colitis. Antibiotics may also increase the risk for post-TD irritable bowel syndrome, which can occur in up to 15% of patients.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Traveler’s diarrhea (TD) is the most common illness in people traveling from resource-advantaged countries to resource-limited regions of the globe. Approximately 50% of these types of travelers will contract diarrhea.

I knew of a group of infectious disease experts traveling to India together – presumably well-versed in how to avoid such things – and one-half of the group developed it.

I have many patients sending me electronic messages asking me for their standard 3-day ciprofloxacin prescriptions, “just in case.” I am guilty of having provided this, along with warnings that we could make matters worse by giving them Clostridium difficile colitis. Antibiotics may also increase the risk for post-TD irritable bowel syndrome, which can occur in up to 15% of patients.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.

Traveler’s diarrhea (TD) is the most common illness in people traveling from resource-advantaged countries to resource-limited regions of the globe. Approximately 50% of these types of travelers will contract diarrhea.

I knew of a group of infectious disease experts traveling to India together – presumably well-versed in how to avoid such things – and one-half of the group developed it.

I have many patients sending me electronic messages asking me for their standard 3-day ciprofloxacin prescriptions, “just in case.” I am guilty of having provided this, along with warnings that we could make matters worse by giving them Clostridium difficile colitis. Antibiotics may also increase the risk for post-TD irritable bowel syndrome, which can occur in up to 15% of patients.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.