User login
Immune-suppressing drugs in IBD linked to higher skin cancer rates
In another sign that immune-suppressing drugs may cause skin cancer, a new Irish study links immunomodulator use in younger patients with inflammatory bowel disease (IBD) to higher rates of nonmelanoma skin cancer (NMSC).
The 19-year study lacks information about medication doses or duration, and it doesn’t confirm a cause-and-effect link. Still, researchers recommend that all patients with IBD be urged to comply with skin cancer prevention guidelines.
As the study notes, previous research has linked immunosuppression – such as that in transplant patients and those with AIDS and lymphoma – to higher rates of NMSC.
Studies have also linked IBD to higher rates of NMSC even before the age of 50, possibly as the result of immune system dysfunction and exposure to immunomodulators, especially thiopurines. The risk of tumor necrosis factor–alpha (TNF-alpha) inhibitors, the study says, is less clear.
To better understand the risk of immunomodulators, researchers led by Julianne Clowry, MBBCh, of St Vincent’s University Hospital in Dublin tracked 2,053 IBD patients at a tertiary adult hospital from 1994 to 2013.
The median age at IBD diagnosis was 31 with a median of 19.6 years of illness, and the patients had both Crohn’s disease (41%) and ulcerative colitis (59%). Fifty-seven percent of patients had taken immunomodulating medication, although the database used didn’t disclose details about dose or duration, and 43% had not.
The study findings appeared Jan. 3 in the Journal of the European Academy of Dermatology and Venereology (doi: 10.1111/jdv.14105).
NMSC was diagnosed in 1.7% of the entire cohort, 1.4% of patients who’d taken immunosuppressants, and 1.9% of those who had not.
Older ages may explain the higher rate in those who didn’t take the medications. The researchers found that the standardized incidence ratio for the patients who took immunomodulators overall was 1.76 [confidence interval, 1.0-2.7], compared with a matched general population cohort, while the ratio was not considered significant among the nonimmunosuppressed [1.07; CI, 0.6-1.6].
The study links use of thiopurines alone and use of both thiopurines and TNF-alpha inhibitors to higher rates of NMSC [odds ratio, 5.26; 95% CI, 2.15-12.93; P less than .001, and OR: 6.45; 95% CI, 2.69-15.95; P less than .001, respectively].
The researchers note that 82% of those who had taken a TNF-alpha inhibitor also took a thiopurine at some point.
The study says the “relatively high” standardized incident ratios are worrisome amid more use of dual immunomodulators and higher IBD rates in kids and younger adults. But the medications are “vital,” the study says, and the researchers suggest “targeted dermatology referrals for IBD patients, particularly those exposed to dual immunomodulatory therapy from an early age.”
The study authors disclose no source of funding and report no relevant disclosures.
In another sign that immune-suppressing drugs may cause skin cancer, a new Irish study links immunomodulator use in younger patients with inflammatory bowel disease (IBD) to higher rates of nonmelanoma skin cancer (NMSC).
The 19-year study lacks information about medication doses or duration, and it doesn’t confirm a cause-and-effect link. Still, researchers recommend that all patients with IBD be urged to comply with skin cancer prevention guidelines.
As the study notes, previous research has linked immunosuppression – such as that in transplant patients and those with AIDS and lymphoma – to higher rates of NMSC.
Studies have also linked IBD to higher rates of NMSC even before the age of 50, possibly as the result of immune system dysfunction and exposure to immunomodulators, especially thiopurines. The risk of tumor necrosis factor–alpha (TNF-alpha) inhibitors, the study says, is less clear.
To better understand the risk of immunomodulators, researchers led by Julianne Clowry, MBBCh, of St Vincent’s University Hospital in Dublin tracked 2,053 IBD patients at a tertiary adult hospital from 1994 to 2013.
The median age at IBD diagnosis was 31 with a median of 19.6 years of illness, and the patients had both Crohn’s disease (41%) and ulcerative colitis (59%). Fifty-seven percent of patients had taken immunomodulating medication, although the database used didn’t disclose details about dose or duration, and 43% had not.
The study findings appeared Jan. 3 in the Journal of the European Academy of Dermatology and Venereology (doi: 10.1111/jdv.14105).
NMSC was diagnosed in 1.7% of the entire cohort, 1.4% of patients who’d taken immunosuppressants, and 1.9% of those who had not.
Older ages may explain the higher rate in those who didn’t take the medications. The researchers found that the standardized incidence ratio for the patients who took immunomodulators overall was 1.76 [confidence interval, 1.0-2.7], compared with a matched general population cohort, while the ratio was not considered significant among the nonimmunosuppressed [1.07; CI, 0.6-1.6].
The study links use of thiopurines alone and use of both thiopurines and TNF-alpha inhibitors to higher rates of NMSC [odds ratio, 5.26; 95% CI, 2.15-12.93; P less than .001, and OR: 6.45; 95% CI, 2.69-15.95; P less than .001, respectively].
The researchers note that 82% of those who had taken a TNF-alpha inhibitor also took a thiopurine at some point.
The study says the “relatively high” standardized incident ratios are worrisome amid more use of dual immunomodulators and higher IBD rates in kids and younger adults. But the medications are “vital,” the study says, and the researchers suggest “targeted dermatology referrals for IBD patients, particularly those exposed to dual immunomodulatory therapy from an early age.”
The study authors disclose no source of funding and report no relevant disclosures.
In another sign that immune-suppressing drugs may cause skin cancer, a new Irish study links immunomodulator use in younger patients with inflammatory bowel disease (IBD) to higher rates of nonmelanoma skin cancer (NMSC).
The 19-year study lacks information about medication doses or duration, and it doesn’t confirm a cause-and-effect link. Still, researchers recommend that all patients with IBD be urged to comply with skin cancer prevention guidelines.
As the study notes, previous research has linked immunosuppression – such as that in transplant patients and those with AIDS and lymphoma – to higher rates of NMSC.
Studies have also linked IBD to higher rates of NMSC even before the age of 50, possibly as the result of immune system dysfunction and exposure to immunomodulators, especially thiopurines. The risk of tumor necrosis factor–alpha (TNF-alpha) inhibitors, the study says, is less clear.
To better understand the risk of immunomodulators, researchers led by Julianne Clowry, MBBCh, of St Vincent’s University Hospital in Dublin tracked 2,053 IBD patients at a tertiary adult hospital from 1994 to 2013.
The median age at IBD diagnosis was 31 with a median of 19.6 years of illness, and the patients had both Crohn’s disease (41%) and ulcerative colitis (59%). Fifty-seven percent of patients had taken immunomodulating medication, although the database used didn’t disclose details about dose or duration, and 43% had not.
The study findings appeared Jan. 3 in the Journal of the European Academy of Dermatology and Venereology (doi: 10.1111/jdv.14105).
NMSC was diagnosed in 1.7% of the entire cohort, 1.4% of patients who’d taken immunosuppressants, and 1.9% of those who had not.
Older ages may explain the higher rate in those who didn’t take the medications. The researchers found that the standardized incidence ratio for the patients who took immunomodulators overall was 1.76 [confidence interval, 1.0-2.7], compared with a matched general population cohort, while the ratio was not considered significant among the nonimmunosuppressed [1.07; CI, 0.6-1.6].
The study links use of thiopurines alone and use of both thiopurines and TNF-alpha inhibitors to higher rates of NMSC [odds ratio, 5.26; 95% CI, 2.15-12.93; P less than .001, and OR: 6.45; 95% CI, 2.69-15.95; P less than .001, respectively].
The researchers note that 82% of those who had taken a TNF-alpha inhibitor also took a thiopurine at some point.
The study says the “relatively high” standardized incident ratios are worrisome amid more use of dual immunomodulators and higher IBD rates in kids and younger adults. But the medications are “vital,” the study says, and the researchers suggest “targeted dermatology referrals for IBD patients, particularly those exposed to dual immunomodulatory therapy from an early age.”
The study authors disclose no source of funding and report no relevant disclosures.
Key clinical point: Younger inflammatory bowel disease (IBD) patients who’ve taken immunomodulating drugs have higher rates of nonmelanoma skin cancer (NMSC).
Major finding: IBD patients who took thiopurines alone and both thiopurines and TNF-alpha inhibitors had higher rates of NMSC [OR, 5.26; 95% CI, 2.15-12.93; P less than .001, and OR, 6.45; 95% CI, 2.69-15.95; P less than .001, respectively], compared with an age-matched general population cohort.
Data source: Retrospective single-center cohort study over 19 years of 2,053 IBD patients with Crohn’s disease (41%) and ulcerative colitis (59%); 57% had taken immunomodulating medications.
Disclosures: The study authors disclose no source of funding and report no relevant disclosures.
SDEF experts tackle atopic dermatitis
Atopic dermatitis (AD) is among the nuts and bolts of any dermatology practice, and as such, gets its time in the spotlight at SDEF’s Annual Hawaii Dermatology Seminar.
This year, SDEF celebrates 41 years of educating dermatologists with the latest in dermatology, featuring presentations from experts on topics ranging from AD treatments and skin cancer chemoprevention to botulinum toxin injections and fillers.
Also last year, Joseph F. Fowler Jr., MD, meeting codirector and clinical professor of dermatology at the University of Louisville (Ky.), shared in a video interview his perspective on addressing parents’ safety concerns about the boxed warning for topical calcineurin inhibitors.
Watch for more coverage and comments from experts at this year’s meeting.
SDEF and this news organization are owned by the same parent company.
Atopic dermatitis (AD) is among the nuts and bolts of any dermatology practice, and as such, gets its time in the spotlight at SDEF’s Annual Hawaii Dermatology Seminar.
This year, SDEF celebrates 41 years of educating dermatologists with the latest in dermatology, featuring presentations from experts on topics ranging from AD treatments and skin cancer chemoprevention to botulinum toxin injections and fillers.
Also last year, Joseph F. Fowler Jr., MD, meeting codirector and clinical professor of dermatology at the University of Louisville (Ky.), shared in a video interview his perspective on addressing parents’ safety concerns about the boxed warning for topical calcineurin inhibitors.
Watch for more coverage and comments from experts at this year’s meeting.
SDEF and this news organization are owned by the same parent company.
Atopic dermatitis (AD) is among the nuts and bolts of any dermatology practice, and as such, gets its time in the spotlight at SDEF’s Annual Hawaii Dermatology Seminar.
This year, SDEF celebrates 41 years of educating dermatologists with the latest in dermatology, featuring presentations from experts on topics ranging from AD treatments and skin cancer chemoprevention to botulinum toxin injections and fillers.
Also last year, Joseph F. Fowler Jr., MD, meeting codirector and clinical professor of dermatology at the University of Louisville (Ky.), shared in a video interview his perspective on addressing parents’ safety concerns about the boxed warning for topical calcineurin inhibitors.
Watch for more coverage and comments from experts at this year’s meeting.
SDEF and this news organization are owned by the same parent company.
An insider’s guide to aesthetic dermatology
When aesthetic dermatology takes the stage at SDEF’s Annual Hawaii Dermatology Seminar, experts will address the latest tips for successful outcomes with filler and toxins, offer guidance on choosing devices, and explain how to make the most of cosmeceuticals in a dermatology practice.
Christopher B. Zachary, MD, meeting codirector and professor and chair of the department of dermatology at the University of California, Irvine, cochairs a pair of aesthetic and procedural dermatology sessions with Michael S. Kaminer, MD, of Yale University, New Haven, Conn., and SkinCare Physicians, Chestnut Hill, Mass.
Last year, Dr. Zachary and a panel of expert aesthetic dermatologists addressed the enduring value of topical retinoids for facial rejuvenation. Read their comments here.
Stay tuned for the latest tips and techniques in aesthetic dermatology from the 2017 SDEF Hawaii Dermatology Seminar.
When aesthetic dermatology takes the stage at SDEF’s Annual Hawaii Dermatology Seminar, experts will address the latest tips for successful outcomes with filler and toxins, offer guidance on choosing devices, and explain how to make the most of cosmeceuticals in a dermatology practice.
Christopher B. Zachary, MD, meeting codirector and professor and chair of the department of dermatology at the University of California, Irvine, cochairs a pair of aesthetic and procedural dermatology sessions with Michael S. Kaminer, MD, of Yale University, New Haven, Conn., and SkinCare Physicians, Chestnut Hill, Mass.
Last year, Dr. Zachary and a panel of expert aesthetic dermatologists addressed the enduring value of topical retinoids for facial rejuvenation. Read their comments here.
Stay tuned for the latest tips and techniques in aesthetic dermatology from the 2017 SDEF Hawaii Dermatology Seminar.
When aesthetic dermatology takes the stage at SDEF’s Annual Hawaii Dermatology Seminar, experts will address the latest tips for successful outcomes with filler and toxins, offer guidance on choosing devices, and explain how to make the most of cosmeceuticals in a dermatology practice.
Christopher B. Zachary, MD, meeting codirector and professor and chair of the department of dermatology at the University of California, Irvine, cochairs a pair of aesthetic and procedural dermatology sessions with Michael S. Kaminer, MD, of Yale University, New Haven, Conn., and SkinCare Physicians, Chestnut Hill, Mass.
Last year, Dr. Zachary and a panel of expert aesthetic dermatologists addressed the enduring value of topical retinoids for facial rejuvenation. Read their comments here.
Stay tuned for the latest tips and techniques in aesthetic dermatology from the 2017 SDEF Hawaii Dermatology Seminar.
Guideline: Keep blood pressure below 150 mm Hg in healthy elderly
Treat to lower a persistent systolic blood pressure of 150 mm Hg or more in patients aged 60 years or older who are otherwise healthy, the American College of Physicians and the American Academy of Family Physicians recommended in a new guideline for managing blood pressure in older patients.
The recommendation was “strong,” based on high-quality evidence from the 24 studies reviewed. The groups also made a weak recommendation based on lower-quality evidence to keep systolic blood pressure below 140 mm Hg in patients aged 60 years and older who have a history of stroke, transient ischemic attack, or high cardiovascular risks.
For those patients who are otherwise well, “most patients aged 60 years or older with a SPB [systolic blood pressure] of 150 mm Hg or greater who receive antihypertensive medications will have benefit with acceptable harms and costs from treatment to a BP target of less than 150/90 mm Hg,” according to the guideline’s authors.
“Although some benefit is achieved by aiming for lower BP targets, most benefit occurs with acceptable harms and costs in the pharmacologic treatment of patients who have an SBP of 150 mm Hg or greater,” said the authors, led by Amir Qaseem, MD, PhD, ACP’s vice president of clinical policy (Ann Intern Med. 2017 Jan 17. doi: 10.7326/M16-1754).
Meanwhile, treating hypertension to an SBP of 130-140 mm Hg in older adults with previous transient ischemic attacks or strokes reduces stroke recurrence, according to the guideline. In addition, an SBP of less than 140 mm Hg “is a reasonable goal for some patients with increased cardiovascular risk,” including those with vascular disease, diabetes, chronic kidney disease, or metabolic syndrome.
Trials with lower BP targets had higher rates of hypotension, electrolyte abnormalities, abnormal renal function, cough, and withdrawals because of side effects.
Older “patients might theoretically benefit from more aggressive BP treatment because of higher cardiovascular risks,” the guideline authors noted. “However, they are more likely to be susceptible to serious harm[s] from higher rates of syncope and hypotension, which were seen in some trials. Moreover, the absolute benefits of more aggressive BP treatment in elderly persons, those with multimorbidity, or those who are frail are not well known, given limitations of the trials.”
The advice is based on 21 randomized, controlled trials of hypertension treatment intensity through September 2016, plus three observational studies of harms. Antihypertensive selection varied widely across the studies. The guideline notes the various lifestyle and pharmacy options, but did not recommend any specific treatment.
Nine trials provided high-strength evidence that BP control to less than 150/90 mm Hg reduces mortality (relative risk, 0.90; 95% confidence interval, 0.83-0.98), cardiac events (RR, 0.77; 95% CI, 0.68-0.89), and stroke (RR, 0.74; 95% CI, 0.65-0.84), according to the evidence review (Ann Intern Med. 2017 Jan 17. doi: 10.7326/M16-1754).
Low- to moderate-strength evidence suggested targets at or below 140/85 mm Hg in older people, but there was only a modest decrease in cardiac events (RR, 0.82; 95% CI, 0.64-1.00) and stroke (RR, 0.79; 95% CI, 0.59-0.99), and a statistically insignificant trend toward fewer deaths (RR, 0.86; 95% CI, 0.69-1.06).
Evidence was insufficient for targeting treatment according to diastolic BP.
Patients have to be involved with decisions about BP targets. Ongoing discussions about the risks and benefits of target options need to be a part of routine care, the guideline authors said.
The work was funded by ACP and the U.S. Department of Veterans Affairs. The authors had no disclosures.
To prevent hypertension-related morbidity and mortality, providers should develop an office-based program with the following features:
• High-fidelity BP measurement support, including office BP measurement by well-trained staff, resources to train patients in home monitoring or making ambulatory BP monitoring available, and ongoing quality assurance efforts.
• Routine assessment of global CVD risk in all patients 40 years or older, as well as in younger patients with multiple risk factors or extreme elevations of a single risk factor.
• Provider training in shared decision making for hypertension treatment and CVD risk reduction.
• A registry to track patients who receive hypertension treatment.
• Nonvisit-based follow-up for patients with moderate to severe hypertension who have had treatment initiation or changes.
Such programs, when implemented, have been associated with large improvements in BP control.
Michael Pignone, MD , is the chair of internal medicine at the University of Texas, Austin. Anthony Viera, MD , is the director of the hypertension research program at the University of North Carolina at Chapel Hill. They had no commercial disclosures and made these recommendations in an editorial (Ann Intern Med. 2017 Jan 17. doi: 10.7326/M17-0034 ).
To prevent hypertension-related morbidity and mortality, providers should develop an office-based program with the following features:
• High-fidelity BP measurement support, including office BP measurement by well-trained staff, resources to train patients in home monitoring or making ambulatory BP monitoring available, and ongoing quality assurance efforts.
• Routine assessment of global CVD risk in all patients 40 years or older, as well as in younger patients with multiple risk factors or extreme elevations of a single risk factor.
• Provider training in shared decision making for hypertension treatment and CVD risk reduction.
• A registry to track patients who receive hypertension treatment.
• Nonvisit-based follow-up for patients with moderate to severe hypertension who have had treatment initiation or changes.
Such programs, when implemented, have been associated with large improvements in BP control.
Michael Pignone, MD , is the chair of internal medicine at the University of Texas, Austin. Anthony Viera, MD , is the director of the hypertension research program at the University of North Carolina at Chapel Hill. They had no commercial disclosures and made these recommendations in an editorial (Ann Intern Med. 2017 Jan 17. doi: 10.7326/M17-0034 ).
To prevent hypertension-related morbidity and mortality, providers should develop an office-based program with the following features:
• High-fidelity BP measurement support, including office BP measurement by well-trained staff, resources to train patients in home monitoring or making ambulatory BP monitoring available, and ongoing quality assurance efforts.
• Routine assessment of global CVD risk in all patients 40 years or older, as well as in younger patients with multiple risk factors or extreme elevations of a single risk factor.
• Provider training in shared decision making for hypertension treatment and CVD risk reduction.
• A registry to track patients who receive hypertension treatment.
• Nonvisit-based follow-up for patients with moderate to severe hypertension who have had treatment initiation or changes.
Such programs, when implemented, have been associated with large improvements in BP control.
Michael Pignone, MD , is the chair of internal medicine at the University of Texas, Austin. Anthony Viera, MD , is the director of the hypertension research program at the University of North Carolina at Chapel Hill. They had no commercial disclosures and made these recommendations in an editorial (Ann Intern Med. 2017 Jan 17. doi: 10.7326/M17-0034 ).
Treat to lower a persistent systolic blood pressure of 150 mm Hg or more in patients aged 60 years or older who are otherwise healthy, the American College of Physicians and the American Academy of Family Physicians recommended in a new guideline for managing blood pressure in older patients.
The recommendation was “strong,” based on high-quality evidence from the 24 studies reviewed. The groups also made a weak recommendation based on lower-quality evidence to keep systolic blood pressure below 140 mm Hg in patients aged 60 years and older who have a history of stroke, transient ischemic attack, or high cardiovascular risks.
For those patients who are otherwise well, “most patients aged 60 years or older with a SPB [systolic blood pressure] of 150 mm Hg or greater who receive antihypertensive medications will have benefit with acceptable harms and costs from treatment to a BP target of less than 150/90 mm Hg,” according to the guideline’s authors.
“Although some benefit is achieved by aiming for lower BP targets, most benefit occurs with acceptable harms and costs in the pharmacologic treatment of patients who have an SBP of 150 mm Hg or greater,” said the authors, led by Amir Qaseem, MD, PhD, ACP’s vice president of clinical policy (Ann Intern Med. 2017 Jan 17. doi: 10.7326/M16-1754).
Meanwhile, treating hypertension to an SBP of 130-140 mm Hg in older adults with previous transient ischemic attacks or strokes reduces stroke recurrence, according to the guideline. In addition, an SBP of less than 140 mm Hg “is a reasonable goal for some patients with increased cardiovascular risk,” including those with vascular disease, diabetes, chronic kidney disease, or metabolic syndrome.
Trials with lower BP targets had higher rates of hypotension, electrolyte abnormalities, abnormal renal function, cough, and withdrawals because of side effects.
Older “patients might theoretically benefit from more aggressive BP treatment because of higher cardiovascular risks,” the guideline authors noted. “However, they are more likely to be susceptible to serious harm[s] from higher rates of syncope and hypotension, which were seen in some trials. Moreover, the absolute benefits of more aggressive BP treatment in elderly persons, those with multimorbidity, or those who are frail are not well known, given limitations of the trials.”
The advice is based on 21 randomized, controlled trials of hypertension treatment intensity through September 2016, plus three observational studies of harms. Antihypertensive selection varied widely across the studies. The guideline notes the various lifestyle and pharmacy options, but did not recommend any specific treatment.
Nine trials provided high-strength evidence that BP control to less than 150/90 mm Hg reduces mortality (relative risk, 0.90; 95% confidence interval, 0.83-0.98), cardiac events (RR, 0.77; 95% CI, 0.68-0.89), and stroke (RR, 0.74; 95% CI, 0.65-0.84), according to the evidence review (Ann Intern Med. 2017 Jan 17. doi: 10.7326/M16-1754).
Low- to moderate-strength evidence suggested targets at or below 140/85 mm Hg in older people, but there was only a modest decrease in cardiac events (RR, 0.82; 95% CI, 0.64-1.00) and stroke (RR, 0.79; 95% CI, 0.59-0.99), and a statistically insignificant trend toward fewer deaths (RR, 0.86; 95% CI, 0.69-1.06).
Evidence was insufficient for targeting treatment according to diastolic BP.
Patients have to be involved with decisions about BP targets. Ongoing discussions about the risks and benefits of target options need to be a part of routine care, the guideline authors said.
The work was funded by ACP and the U.S. Department of Veterans Affairs. The authors had no disclosures.
Treat to lower a persistent systolic blood pressure of 150 mm Hg or more in patients aged 60 years or older who are otherwise healthy, the American College of Physicians and the American Academy of Family Physicians recommended in a new guideline for managing blood pressure in older patients.
The recommendation was “strong,” based on high-quality evidence from the 24 studies reviewed. The groups also made a weak recommendation based on lower-quality evidence to keep systolic blood pressure below 140 mm Hg in patients aged 60 years and older who have a history of stroke, transient ischemic attack, or high cardiovascular risks.
For those patients who are otherwise well, “most patients aged 60 years or older with a SPB [systolic blood pressure] of 150 mm Hg or greater who receive antihypertensive medications will have benefit with acceptable harms and costs from treatment to a BP target of less than 150/90 mm Hg,” according to the guideline’s authors.
“Although some benefit is achieved by aiming for lower BP targets, most benefit occurs with acceptable harms and costs in the pharmacologic treatment of patients who have an SBP of 150 mm Hg or greater,” said the authors, led by Amir Qaseem, MD, PhD, ACP’s vice president of clinical policy (Ann Intern Med. 2017 Jan 17. doi: 10.7326/M16-1754).
Meanwhile, treating hypertension to an SBP of 130-140 mm Hg in older adults with previous transient ischemic attacks or strokes reduces stroke recurrence, according to the guideline. In addition, an SBP of less than 140 mm Hg “is a reasonable goal for some patients with increased cardiovascular risk,” including those with vascular disease, diabetes, chronic kidney disease, or metabolic syndrome.
Trials with lower BP targets had higher rates of hypotension, electrolyte abnormalities, abnormal renal function, cough, and withdrawals because of side effects.
Older “patients might theoretically benefit from more aggressive BP treatment because of higher cardiovascular risks,” the guideline authors noted. “However, they are more likely to be susceptible to serious harm[s] from higher rates of syncope and hypotension, which were seen in some trials. Moreover, the absolute benefits of more aggressive BP treatment in elderly persons, those with multimorbidity, or those who are frail are not well known, given limitations of the trials.”
The advice is based on 21 randomized, controlled trials of hypertension treatment intensity through September 2016, plus three observational studies of harms. Antihypertensive selection varied widely across the studies. The guideline notes the various lifestyle and pharmacy options, but did not recommend any specific treatment.
Nine trials provided high-strength evidence that BP control to less than 150/90 mm Hg reduces mortality (relative risk, 0.90; 95% confidence interval, 0.83-0.98), cardiac events (RR, 0.77; 95% CI, 0.68-0.89), and stroke (RR, 0.74; 95% CI, 0.65-0.84), according to the evidence review (Ann Intern Med. 2017 Jan 17. doi: 10.7326/M16-1754).
Low- to moderate-strength evidence suggested targets at or below 140/85 mm Hg in older people, but there was only a modest decrease in cardiac events (RR, 0.82; 95% CI, 0.64-1.00) and stroke (RR, 0.79; 95% CI, 0.59-0.99), and a statistically insignificant trend toward fewer deaths (RR, 0.86; 95% CI, 0.69-1.06).
Evidence was insufficient for targeting treatment according to diastolic BP.
Patients have to be involved with decisions about BP targets. Ongoing discussions about the risks and benefits of target options need to be a part of routine care, the guideline authors said.
The work was funded by ACP and the U.S. Department of Veterans Affairs. The authors had no disclosures.
Developing a personal scale for evaluating agitation on inpatient units
Agitation. As a mental health professional, you know it when you see it. While technically, it is the behavior that precedes aggression and violence, every clinical setting has its own flavor, from the voluntary psychiatric unit where I see my most acutely ill patients to the state hospital where I witnessed the type of violence that sent another patient to the emergency department.
Over the past 2 years of residency, I have developed a personal scale for measuring and responding to patient agitation. Through experiences that have provided the lower, upper (and even more upper) bounds to this scale, I have evolved from a nervous first-year intern to become a resident conscious of the need for a cool demeanor and continued engagement with the patient with escalating agitation. 
The 2003 Treatment of Behavioral Emergencies: A Summary of the Expert Consensus Guidelines1 provides an excellent visual scale to measure agitation. It begins with a patient’s refusal to cooperate and ascends stepwise toward motor restlessness, lability and loud speech, intimidation, aggression against property, and hostile verbal behavior, and it ends with directly threatening or assaultive behavior.2 Only when I witnessed signs of clinically significant agitation, hostile countenance, unpredictable anger, pacing, clenched fists, yelling, and threats, did I develop a personal understanding and approach for measuring agitation on the inpatient unit.
The upper bound for my scale initially was defined by my first incident of severe agitation and aggression while on call. I no longer remember if the patient was agitated and psychotic or just angry and agitated. Though schizophrenia and bipolar disorder often are the underlying causes of agitation, personality disorders and substance use complicate or contribute to agitation.3 The nurse called me, saying: “Can you come to the unit right now? Mr. X is agitated and has ripped the soap dispenser off the wall in his bathroom.” It was just after midnight, and already several nursing calls into this situation. Verbal de-escalation had failed with Mr. X, who moved from agitation to aggressive behavior. He already had received two doses of haloperidol and lorazepam since my evening shift began. I looked into his bedroom and saw him wrestling with the sink, which did not come off the wall as easily as the soap dispenser. The thought process of an inexperienced intern went like this: “How much haloperidol is too much haloperidol? Will this night never end?” I called my attending for help, and there was desperation in my voice as I explained: “The medications aren’t working.
These situations usually result in good clinical lessons: Medications take time to work, and in some individuals, the “standard cocktail” might not be the best option. Nonetheless, the lag time can be excruciating. As a more experienced resident, I now consider how certain medications may fail an individual, and there might be a better alternative to haloperidol and lorazepam. I’ve expanded my repertoire of pharmacological methods and opt often for second-generation antipsychotics, such as olanzapine or risperidone, without or without a benzodiazepine, when possible.2
Of course, not all agitation becomes a behavioral health emergency, and an integral part of my training as a resident has been watching an attending run an intervention smoothly. It requires coordination and experience, skills that I’m gaining. In these cases, the agitation is addressed before it escalates, nursing staff and the physicians collaborate to deliver treatment, and the patient responds to verbal redirection and, if offered, accepts oral medications. These types of patients help cement the lower bound for my agitation scale.
Nonetheless, the patients who challenge the positive archetype are the ones who cement lessons for physicians. I remember a man who with his history of serious mental illness had adverse reactions to haloperidol, aripiprazole, olanzapine, and fluphenazine. To address his agitation, the nurses prepared 2 mg of lorazepam and 50 mg of diphenhydramine. As the patient ramped up, I heard a nurse sigh, “Why can’t we add IM thorazine?” I commiserated with the nurse; the psychiatric unit is a dangerous place to work. Psychiatry and emergency department nurses, compared with their counterparts in other units, are the most likely to be assaulted at work.4,5 It is personal for me as well. Studies suggest that 30%-40% of psychiatric residents will be attacked during their 4-year training, and I am in that 70%-90% of residents who has been verbally threatened more than once.6
With time and training, my verbal de-escalation techniques have improved, as I’ve learned to avoid threatening and judgmental body language, avoiding a natural tendency to stand with my arms crossed over my chest or hands on my hips. I now more accurately and incisively inquire about a patient’s mental state. How can I address their frustration? In a nonaccusatory way, I let the patients know that they are behaving in a way that is frightening and that continued behavior may have consequences. Even when faced by the heat of agitation, I try to value the patients’ choice: This event will affect our therapeutic relationship in the longer term.
Whenever possible, I want the patients to choose their medication formulation or at least be able to ask them, “Would you be willing to take … ?” With time, I am earning that cool demeanor psychiatrists are known for. I can model calm behavior and effectively use my knowledge about mentalization to try to de-escalate the situation.
My scale of measuring of agitation and violence had its upper level increased significantly from just a soap dispenser being ripped off the wall. One patient really upped the ante by swiping a public telephone off the wall and then went tearing down the hallway to pull the fire extinguisher out of its supposed “safe” case and hurl it. So on a recent night shift, when I heard yelling through the door of the call room, it was with a sense of understanding rather than trepidation that my co-resident and I approached the patient, already being corralled to his room by nursing staff. He was an enormous man, angry, paranoid, pacing, and shouting about how the other patients wanted to attack him. Despite his size, his menacing posture, and that somewhere in his agitation he had ripped off his scrub shirt, I couldn’t help but think, “Well at least the phone and the fire extinguisher are still attached to the wall.”
References
1 J Psychiatr Pract. 2003 Jan;9(1):16-38. Treatment of behavioral emergencies: A summary of the expert consensus guidelines.
2 J Psychiatr Pract. 2005 Nov;11 Suppl 1:5-108; quiz 110-2. The expert consensus guideline series. Treatment of behavioral emergencies 2005.
3 Clin Pract Epidemiol Ment Health. 2016 Oct 27;12:75-86. State of acute agitation at psychiatric emergencies in Europe: The STAGE study.
4 J Emerg Nurs. 2014 May;40(3):218-28; quiz 295. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors.
5 Work. 2010;35(2):191-200. Physical assault among nursing staff employed in acute care.
6 Psychiatr Serv. 1999 Mar;50(3):381-3. Assaults by patients on psychiatric residents: a survey and training recommendations.
Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.
Agitation. As a mental health professional, you know it when you see it. While technically, it is the behavior that precedes aggression and violence, every clinical setting has its own flavor, from the voluntary psychiatric unit where I see my most acutely ill patients to the state hospital where I witnessed the type of violence that sent another patient to the emergency department.
Over the past 2 years of residency, I have developed a personal scale for measuring and responding to patient agitation. Through experiences that have provided the lower, upper (and even more upper) bounds to this scale, I have evolved from a nervous first-year intern to become a resident conscious of the need for a cool demeanor and continued engagement with the patient with escalating agitation.
The 2003 Treatment of Behavioral Emergencies: A Summary of the Expert Consensus Guidelines1 provides an excellent visual scale to measure agitation. It begins with a patient’s refusal to cooperate and ascends stepwise toward motor restlessness, lability and loud speech, intimidation, aggression against property, and hostile verbal behavior, and it ends with directly threatening or assaultive behavior.2 Only when I witnessed signs of clinically significant agitation, hostile countenance, unpredictable anger, pacing, clenched fists, yelling, and threats, did I develop a personal understanding and approach for measuring agitation on the inpatient unit.
The upper bound for my scale initially was defined by my first incident of severe agitation and aggression while on call. I no longer remember if the patient was agitated and psychotic or just angry and agitated. Though schizophrenia and bipolar disorder often are the underlying causes of agitation, personality disorders and substance use complicate or contribute to agitation.3 The nurse called me, saying: “Can you come to the unit right now? Mr. X is agitated and has ripped the soap dispenser off the wall in his bathroom.” It was just after midnight, and already several nursing calls into this situation. Verbal de-escalation had failed with Mr. X, who moved from agitation to aggressive behavior. He already had received two doses of haloperidol and lorazepam since my evening shift began. I looked into his bedroom and saw him wrestling with the sink, which did not come off the wall as easily as the soap dispenser. The thought process of an inexperienced intern went like this: “How much haloperidol is too much haloperidol? Will this night never end?” I called my attending for help, and there was desperation in my voice as I explained: “The medications aren’t working.
These situations usually result in good clinical lessons: Medications take time to work, and in some individuals, the “standard cocktail” might not be the best option. Nonetheless, the lag time can be excruciating. As a more experienced resident, I now consider how certain medications may fail an individual, and there might be a better alternative to haloperidol and lorazepam. I’ve expanded my repertoire of pharmacological methods and opt often for second-generation antipsychotics, such as olanzapine or risperidone, without or without a benzodiazepine, when possible.2
Of course, not all agitation becomes a behavioral health emergency, and an integral part of my training as a resident has been watching an attending run an intervention smoothly. It requires coordination and experience, skills that I’m gaining. In these cases, the agitation is addressed before it escalates, nursing staff and the physicians collaborate to deliver treatment, and the patient responds to verbal redirection and, if offered, accepts oral medications. These types of patients help cement the lower bound for my agitation scale.
Nonetheless, the patients who challenge the positive archetype are the ones who cement lessons for physicians. I remember a man who with his history of serious mental illness had adverse reactions to haloperidol, aripiprazole, olanzapine, and fluphenazine. To address his agitation, the nurses prepared 2 mg of lorazepam and 50 mg of diphenhydramine. As the patient ramped up, I heard a nurse sigh, “Why can’t we add IM thorazine?” I commiserated with the nurse; the psychiatric unit is a dangerous place to work. Psychiatry and emergency department nurses, compared with their counterparts in other units, are the most likely to be assaulted at work.4,5 It is personal for me as well. Studies suggest that 30%-40% of psychiatric residents will be attacked during their 4-year training, and I am in that 70%-90% of residents who has been verbally threatened more than once.6
With time and training, my verbal de-escalation techniques have improved, as I’ve learned to avoid threatening and judgmental body language, avoiding a natural tendency to stand with my arms crossed over my chest or hands on my hips. I now more accurately and incisively inquire about a patient’s mental state. How can I address their frustration? In a nonaccusatory way, I let the patients know that they are behaving in a way that is frightening and that continued behavior may have consequences. Even when faced by the heat of agitation, I try to value the patients’ choice: This event will affect our therapeutic relationship in the longer term.
Whenever possible, I want the patients to choose their medication formulation or at least be able to ask them, “Would you be willing to take … ?” With time, I am earning that cool demeanor psychiatrists are known for. I can model calm behavior and effectively use my knowledge about mentalization to try to de-escalate the situation.
My scale of measuring of agitation and violence had its upper level increased significantly from just a soap dispenser being ripped off the wall. One patient really upped the ante by swiping a public telephone off the wall and then went tearing down the hallway to pull the fire extinguisher out of its supposed “safe” case and hurl it. So on a recent night shift, when I heard yelling through the door of the call room, it was with a sense of understanding rather than trepidation that my co-resident and I approached the patient, already being corralled to his room by nursing staff. He was an enormous man, angry, paranoid, pacing, and shouting about how the other patients wanted to attack him. Despite his size, his menacing posture, and that somewhere in his agitation he had ripped off his scrub shirt, I couldn’t help but think, “Well at least the phone and the fire extinguisher are still attached to the wall.”
References
1 J Psychiatr Pract. 2003 Jan;9(1):16-38. Treatment of behavioral emergencies: A summary of the expert consensus guidelines.
2 J Psychiatr Pract. 2005 Nov;11 Suppl 1:5-108; quiz 110-2. The expert consensus guideline series. Treatment of behavioral emergencies 2005.
3 Clin Pract Epidemiol Ment Health. 2016 Oct 27;12:75-86. State of acute agitation at psychiatric emergencies in Europe: The STAGE study.
4 J Emerg Nurs. 2014 May;40(3):218-28; quiz 295. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors.
5 Work. 2010;35(2):191-200. Physical assault among nursing staff employed in acute care.
6 Psychiatr Serv. 1999 Mar;50(3):381-3. Assaults by patients on psychiatric residents: a survey and training recommendations.
Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.
Agitation. As a mental health professional, you know it when you see it. While technically, it is the behavior that precedes aggression and violence, every clinical setting has its own flavor, from the voluntary psychiatric unit where I see my most acutely ill patients to the state hospital where I witnessed the type of violence that sent another patient to the emergency department.
Over the past 2 years of residency, I have developed a personal scale for measuring and responding to patient agitation. Through experiences that have provided the lower, upper (and even more upper) bounds to this scale, I have evolved from a nervous first-year intern to become a resident conscious of the need for a cool demeanor and continued engagement with the patient with escalating agitation.
The 2003 Treatment of Behavioral Emergencies: A Summary of the Expert Consensus Guidelines1 provides an excellent visual scale to measure agitation. It begins with a patient’s refusal to cooperate and ascends stepwise toward motor restlessness, lability and loud speech, intimidation, aggression against property, and hostile verbal behavior, and it ends with directly threatening or assaultive behavior.2 Only when I witnessed signs of clinically significant agitation, hostile countenance, unpredictable anger, pacing, clenched fists, yelling, and threats, did I develop a personal understanding and approach for measuring agitation on the inpatient unit.
The upper bound for my scale initially was defined by my first incident of severe agitation and aggression while on call. I no longer remember if the patient was agitated and psychotic or just angry and agitated. Though schizophrenia and bipolar disorder often are the underlying causes of agitation, personality disorders and substance use complicate or contribute to agitation.3 The nurse called me, saying: “Can you come to the unit right now? Mr. X is agitated and has ripped the soap dispenser off the wall in his bathroom.” It was just after midnight, and already several nursing calls into this situation. Verbal de-escalation had failed with Mr. X, who moved from agitation to aggressive behavior. He already had received two doses of haloperidol and lorazepam since my evening shift began. I looked into his bedroom and saw him wrestling with the sink, which did not come off the wall as easily as the soap dispenser. The thought process of an inexperienced intern went like this: “How much haloperidol is too much haloperidol? Will this night never end?” I called my attending for help, and there was desperation in my voice as I explained: “The medications aren’t working.
These situations usually result in good clinical lessons: Medications take time to work, and in some individuals, the “standard cocktail” might not be the best option. Nonetheless, the lag time can be excruciating. As a more experienced resident, I now consider how certain medications may fail an individual, and there might be a better alternative to haloperidol and lorazepam. I’ve expanded my repertoire of pharmacological methods and opt often for second-generation antipsychotics, such as olanzapine or risperidone, without or without a benzodiazepine, when possible.2
Of course, not all agitation becomes a behavioral health emergency, and an integral part of my training as a resident has been watching an attending run an intervention smoothly. It requires coordination and experience, skills that I’m gaining. In these cases, the agitation is addressed before it escalates, nursing staff and the physicians collaborate to deliver treatment, and the patient responds to verbal redirection and, if offered, accepts oral medications. These types of patients help cement the lower bound for my agitation scale.
Nonetheless, the patients who challenge the positive archetype are the ones who cement lessons for physicians. I remember a man who with his history of serious mental illness had adverse reactions to haloperidol, aripiprazole, olanzapine, and fluphenazine. To address his agitation, the nurses prepared 2 mg of lorazepam and 50 mg of diphenhydramine. As the patient ramped up, I heard a nurse sigh, “Why can’t we add IM thorazine?” I commiserated with the nurse; the psychiatric unit is a dangerous place to work. Psychiatry and emergency department nurses, compared with their counterparts in other units, are the most likely to be assaulted at work.4,5 It is personal for me as well. Studies suggest that 30%-40% of psychiatric residents will be attacked during their 4-year training, and I am in that 70%-90% of residents who has been verbally threatened more than once.6
With time and training, my verbal de-escalation techniques have improved, as I’ve learned to avoid threatening and judgmental body language, avoiding a natural tendency to stand with my arms crossed over my chest or hands on my hips. I now more accurately and incisively inquire about a patient’s mental state. How can I address their frustration? In a nonaccusatory way, I let the patients know that they are behaving in a way that is frightening and that continued behavior may have consequences. Even when faced by the heat of agitation, I try to value the patients’ choice: This event will affect our therapeutic relationship in the longer term.
Whenever possible, I want the patients to choose their medication formulation or at least be able to ask them, “Would you be willing to take … ?” With time, I am earning that cool demeanor psychiatrists are known for. I can model calm behavior and effectively use my knowledge about mentalization to try to de-escalate the situation.
My scale of measuring of agitation and violence had its upper level increased significantly from just a soap dispenser being ripped off the wall. One patient really upped the ante by swiping a public telephone off the wall and then went tearing down the hallway to pull the fire extinguisher out of its supposed “safe” case and hurl it. So on a recent night shift, when I heard yelling through the door of the call room, it was with a sense of understanding rather than trepidation that my co-resident and I approached the patient, already being corralled to his room by nursing staff. He was an enormous man, angry, paranoid, pacing, and shouting about how the other patients wanted to attack him. Despite his size, his menacing posture, and that somewhere in his agitation he had ripped off his scrub shirt, I couldn’t help but think, “Well at least the phone and the fire extinguisher are still attached to the wall.”
References
1 J Psychiatr Pract. 2003 Jan;9(1):16-38. Treatment of behavioral emergencies: A summary of the expert consensus guidelines.
2 J Psychiatr Pract. 2005 Nov;11 Suppl 1:5-108; quiz 110-2. The expert consensus guideline series. Treatment of behavioral emergencies 2005.
3 Clin Pract Epidemiol Ment Health. 2016 Oct 27;12:75-86. State of acute agitation at psychiatric emergencies in Europe: The STAGE study.
4 J Emerg Nurs. 2014 May;40(3):218-28; quiz 295. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors.
5 Work. 2010;35(2):191-200. Physical assault among nursing staff employed in acute care.
6 Psychiatr Serv. 1999 Mar;50(3):381-3. Assaults by patients on psychiatric residents: a survey and training recommendations.
Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.
Expert reviews options for refractory pediatric warts
For refractory warts, there are some “last resort” treatments every dermatologist should have on hand, according to pediatric dermatologist Fred E. Ghali, MD.
“It’s good to know about these, although it’s also good to know that sometimes you just have to wait out the warts and let them clear up on their own,” said Dr. Ghali, of the departments of dermatology at University of Texas, Dallas, and Baylor College of Medicine, Houston. Because very few treatment options are approved for warts, Dr. Ghali shared some of his preferred off-label approaches at the meeting provided by Global Academy for Medical Education.
By the time patients make it to his clinic, Dr. Ghali noted that many patients have failed home remedies such as salicylic acid or duct tape. In some cases, however, warts may not respond well to the standard in-office options such as cryotherapy. For refractory cases, he said that one of the following approaches can be considered:
Sectional cryotherapy
For larger, solitary warts, especially ring warts, freezing them in sections can be a good option, according to Dr. Ghali. This can be done best using a cotton-tip applicator rather than the traditional spray gun. In his experience, this minimizes the risk of ring wart formation, which may occur from aggressive cryotherapy focused primarily on the central portion of the wart, sometimes creating a resultant blister much larger than the original wart, with the formation of a ring wart.
Topical immunotherapy
When it comes to refractory cases in younger children, or in cases with multiple warts on the hands and feet, topical immunotherapy is often a preferred treatment. In these cases, Dr. Ghali recommended squaric acid. “The general principle with topical immunotherapy is that you would induce contact allergy with the treatment by applying it to one place on the skin, usually the arm, in the office setting,” he said. If using squaric acid, he recommended starting with 2% to sensitize in the office; then for home use, prescribing a lower concentration of the treatment – usually 0.6% – painted directly onto the lesions to provoke an immune response. This should be done three times a week at first, and then adding one application each week until the warts are being treated daily.
“If there is no response in 2 months, then increase the strength used at home,” Dr. Ghali said.
With this treatment, there is the potential for contact dermatitis, which is usually localized, but can be widespread beyond the areas of application, he cautioned. When this occurs, he recommended decreasing or discontinuing the applications and considering a topical steroid or oral steroid depending upon the severity of the reaction. “I mainly use squaric acid for the hands and feet, and almost always avoid it on the face, neck, and groin,” Dr. Ghali said.
In his practice, he finds this treatment is effective about three-quarters of the time, and seems to work particularly well with plantar warts, clearing them up in 2-4 months. The advantages of this approach are that it is not painful, is relatively easy for patients to comply with, and can be combined with other treatments if desired.
Intralesional immunotherapy
When squaric acid or cryotherapy fails, Candida antigen injection is a commonly used technique used to train the immune system to attack the warts, inducing a delayed hypersensitivity reaction. “Injectable immunotherapy is ideal in cases of a solitary [wart] or a limited number of warts,” Dr. Ghali said in an interview. “For most patients, I typically inject 0.1-0.2 cc of Candida antigen per wart. In the case of larger, ring-type warts, especially on the knees and elbows, we may need to use larger volumes, up to 0.2 cc-0.6cc,” he added.
“It’s important to remind patients that temporary, localized swelling may occur after injections; thus, care should be taken when injecting near periungual locations,” Dr. Ghali continued, noting that “it’s probably best practice to avoid subungual injections.”
Immunotherapy has relatively few side effects, and may be effective in about three-quarters of cases, according to Dr. Ghali, although he cautioned that younger children may be anxious about receiving injections and may resist treatment.
Electrodessication and curettage
For challenging warts, such as stubborn palmar or plantar warts, Dr. Ghali suggested using local anesthesia plus electrodessication and curettage.
“Sometimes with these refractory warts, we resort to off-label therapies compounded for home use,” he added. Such therapies may include salicylic acid with 5-fluorouracil, or topical cidofovir 2%-3%. These compounds can be costly depending upon the patient’s insurance coverage.
Dr. Ghali concluded by presenting his top three rules to consider when treating warts, regardless of treatment: There is no cure for warts, no therapy is uniformly effective, and the chosen therapy should take into account the family’s costs, according to their insurance coverage.
Since the landscape of insurance coverage has changed over recent years, the code most often used to treat warts in the office, often applies to the patient’s or family’s deductible. “It’s important to discuss this with the family beforehand, especially since treatment for warts may require several visits,” he said.
Dr. Ghali disclosed several financial relationships with the pharmaceutical industry including Astellas, Galderma, and Valeant, among others.
Global Academy and this news organization are owned by the same parent company.
[email protected]
On Twitter @whitneymcknight
For refractory warts, there are some “last resort” treatments every dermatologist should have on hand, according to pediatric dermatologist Fred E. Ghali, MD.
“It’s good to know about these, although it’s also good to know that sometimes you just have to wait out the warts and let them clear up on their own,” said Dr. Ghali, of the departments of dermatology at University of Texas, Dallas, and Baylor College of Medicine, Houston. Because very few treatment options are approved for warts, Dr. Ghali shared some of his preferred off-label approaches at the meeting provided by Global Academy for Medical Education.
By the time patients make it to his clinic, Dr. Ghali noted that many patients have failed home remedies such as salicylic acid or duct tape. In some cases, however, warts may not respond well to the standard in-office options such as cryotherapy. For refractory cases, he said that one of the following approaches can be considered:
Sectional cryotherapy
For larger, solitary warts, especially ring warts, freezing them in sections can be a good option, according to Dr. Ghali. This can be done best using a cotton-tip applicator rather than the traditional spray gun. In his experience, this minimizes the risk of ring wart formation, which may occur from aggressive cryotherapy focused primarily on the central portion of the wart, sometimes creating a resultant blister much larger than the original wart, with the formation of a ring wart.
Topical immunotherapy
When it comes to refractory cases in younger children, or in cases with multiple warts on the hands and feet, topical immunotherapy is often a preferred treatment. In these cases, Dr. Ghali recommended squaric acid. “The general principle with topical immunotherapy is that you would induce contact allergy with the treatment by applying it to one place on the skin, usually the arm, in the office setting,” he said. If using squaric acid, he recommended starting with 2% to sensitize in the office; then for home use, prescribing a lower concentration of the treatment – usually 0.6% – painted directly onto the lesions to provoke an immune response. This should be done three times a week at first, and then adding one application each week until the warts are being treated daily.
“If there is no response in 2 months, then increase the strength used at home,” Dr. Ghali said.
With this treatment, there is the potential for contact dermatitis, which is usually localized, but can be widespread beyond the areas of application, he cautioned. When this occurs, he recommended decreasing or discontinuing the applications and considering a topical steroid or oral steroid depending upon the severity of the reaction. “I mainly use squaric acid for the hands and feet, and almost always avoid it on the face, neck, and groin,” Dr. Ghali said.
In his practice, he finds this treatment is effective about three-quarters of the time, and seems to work particularly well with plantar warts, clearing them up in 2-4 months. The advantages of this approach are that it is not painful, is relatively easy for patients to comply with, and can be combined with other treatments if desired.
Intralesional immunotherapy
When squaric acid or cryotherapy fails, Candida antigen injection is a commonly used technique used to train the immune system to attack the warts, inducing a delayed hypersensitivity reaction. “Injectable immunotherapy is ideal in cases of a solitary [wart] or a limited number of warts,” Dr. Ghali said in an interview. “For most patients, I typically inject 0.1-0.2 cc of Candida antigen per wart. In the case of larger, ring-type warts, especially on the knees and elbows, we may need to use larger volumes, up to 0.2 cc-0.6cc,” he added.
“It’s important to remind patients that temporary, localized swelling may occur after injections; thus, care should be taken when injecting near periungual locations,” Dr. Ghali continued, noting that “it’s probably best practice to avoid subungual injections.”
Immunotherapy has relatively few side effects, and may be effective in about three-quarters of cases, according to Dr. Ghali, although he cautioned that younger children may be anxious about receiving injections and may resist treatment.
Electrodessication and curettage
For challenging warts, such as stubborn palmar or plantar warts, Dr. Ghali suggested using local anesthesia plus electrodessication and curettage.
“Sometimes with these refractory warts, we resort to off-label therapies compounded for home use,” he added. Such therapies may include salicylic acid with 5-fluorouracil, or topical cidofovir 2%-3%. These compounds can be costly depending upon the patient’s insurance coverage.
Dr. Ghali concluded by presenting his top three rules to consider when treating warts, regardless of treatment: There is no cure for warts, no therapy is uniformly effective, and the chosen therapy should take into account the family’s costs, according to their insurance coverage.
Since the landscape of insurance coverage has changed over recent years, the code most often used to treat warts in the office, often applies to the patient’s or family’s deductible. “It’s important to discuss this with the family beforehand, especially since treatment for warts may require several visits,” he said.
Dr. Ghali disclosed several financial relationships with the pharmaceutical industry including Astellas, Galderma, and Valeant, among others.
Global Academy and this news organization are owned by the same parent company.
[email protected]
On Twitter @whitneymcknight
For refractory warts, there are some “last resort” treatments every dermatologist should have on hand, according to pediatric dermatologist Fred E. Ghali, MD.
“It’s good to know about these, although it’s also good to know that sometimes you just have to wait out the warts and let them clear up on their own,” said Dr. Ghali, of the departments of dermatology at University of Texas, Dallas, and Baylor College of Medicine, Houston. Because very few treatment options are approved for warts, Dr. Ghali shared some of his preferred off-label approaches at the meeting provided by Global Academy for Medical Education.
By the time patients make it to his clinic, Dr. Ghali noted that many patients have failed home remedies such as salicylic acid or duct tape. In some cases, however, warts may not respond well to the standard in-office options such as cryotherapy. For refractory cases, he said that one of the following approaches can be considered:
Sectional cryotherapy
For larger, solitary warts, especially ring warts, freezing them in sections can be a good option, according to Dr. Ghali. This can be done best using a cotton-tip applicator rather than the traditional spray gun. In his experience, this minimizes the risk of ring wart formation, which may occur from aggressive cryotherapy focused primarily on the central portion of the wart, sometimes creating a resultant blister much larger than the original wart, with the formation of a ring wart.
Topical immunotherapy
When it comes to refractory cases in younger children, or in cases with multiple warts on the hands and feet, topical immunotherapy is often a preferred treatment. In these cases, Dr. Ghali recommended squaric acid. “The general principle with topical immunotherapy is that you would induce contact allergy with the treatment by applying it to one place on the skin, usually the arm, in the office setting,” he said. If using squaric acid, he recommended starting with 2% to sensitize in the office; then for home use, prescribing a lower concentration of the treatment – usually 0.6% – painted directly onto the lesions to provoke an immune response. This should be done three times a week at first, and then adding one application each week until the warts are being treated daily.
“If there is no response in 2 months, then increase the strength used at home,” Dr. Ghali said.
With this treatment, there is the potential for contact dermatitis, which is usually localized, but can be widespread beyond the areas of application, he cautioned. When this occurs, he recommended decreasing or discontinuing the applications and considering a topical steroid or oral steroid depending upon the severity of the reaction. “I mainly use squaric acid for the hands and feet, and almost always avoid it on the face, neck, and groin,” Dr. Ghali said.
In his practice, he finds this treatment is effective about three-quarters of the time, and seems to work particularly well with plantar warts, clearing them up in 2-4 months. The advantages of this approach are that it is not painful, is relatively easy for patients to comply with, and can be combined with other treatments if desired.
Intralesional immunotherapy
When squaric acid or cryotherapy fails, Candida antigen injection is a commonly used technique used to train the immune system to attack the warts, inducing a delayed hypersensitivity reaction. “Injectable immunotherapy is ideal in cases of a solitary [wart] or a limited number of warts,” Dr. Ghali said in an interview. “For most patients, I typically inject 0.1-0.2 cc of Candida antigen per wart. In the case of larger, ring-type warts, especially on the knees and elbows, we may need to use larger volumes, up to 0.2 cc-0.6cc,” he added.
“It’s important to remind patients that temporary, localized swelling may occur after injections; thus, care should be taken when injecting near periungual locations,” Dr. Ghali continued, noting that “it’s probably best practice to avoid subungual injections.”
Immunotherapy has relatively few side effects, and may be effective in about three-quarters of cases, according to Dr. Ghali, although he cautioned that younger children may be anxious about receiving injections and may resist treatment.
Electrodessication and curettage
For challenging warts, such as stubborn palmar or plantar warts, Dr. Ghali suggested using local anesthesia plus electrodessication and curettage.
“Sometimes with these refractory warts, we resort to off-label therapies compounded for home use,” he added. Such therapies may include salicylic acid with 5-fluorouracil, or topical cidofovir 2%-3%. These compounds can be costly depending upon the patient’s insurance coverage.
Dr. Ghali concluded by presenting his top three rules to consider when treating warts, regardless of treatment: There is no cure for warts, no therapy is uniformly effective, and the chosen therapy should take into account the family’s costs, according to their insurance coverage.
Since the landscape of insurance coverage has changed over recent years, the code most often used to treat warts in the office, often applies to the patient’s or family’s deductible. “It’s important to discuss this with the family beforehand, especially since treatment for warts may require several visits,” he said.
Dr. Ghali disclosed several financial relationships with the pharmaceutical industry including Astellas, Galderma, and Valeant, among others.
Global Academy and this news organization are owned by the same parent company.
[email protected]
On Twitter @whitneymcknight
EXPERT ANALYSIS FROM THE CARIBBEAN DERMATOLOGY SYMPOSIUM
Interval cholecystectomy may be a risky business
HOLLYWOOD, FLA – Interval cholecystectomy remains a challenging procedure, with longer operative times and ICU stays, greater blood loss, more biliary and bowel injuries, and even hints of increased mortality, compared with immediate cholecystectomy, according to the findings from a retrospective study of 404 patients.
The staged procedure, completed after antibiotic therapy and percutaneous cholecystostomy, has been increasing in frequency over the past 10 years, but has not been rigorously studied, James Ackerman, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
“Looking at Medicare data over the past decade, we see a 50% increase in this procedure, which is marked by some striking regional variation,” from 5% of acute cholecystitis cases in the Northeast to less than 1% in some other regions. “This shows that as a group, we really don’t know what to do with this procedure.”
The revised Tokyo Guidelines for the management of acute cholangitis and cholecystitis aren’t hugely helpful either, noted Dr. Ackerman of the University of Pittsburgh Medical Center. While the guidelines are fairly straightforward for patients with grade 1 and grade 3 disease, “there’s a lot of gray area in grade 2.”
Treatment for these patients should include biliary drainage with antibiotics, but, he said, the recommendations for surgery, and whether it should be elective, immediate, or delayed, can be confusing for this group.
Dr. Ackerman’s retrospective analysis comprised 177 patients with acute cholecystitis who underwent an interval cholecystectomy (IC) after percutaneous cholecystostomy, and 227 controls who underwent an immediate cholecystectomy. The analysis spanned 2008-2013 and used data from seven hospitals in one health care system.
Patients who had the IC were older (70 vs. 55 years), had a worse American Society of Anesthesiologists class (3 vs. 2.5), and a worse Tokyo Grade (2 vs. 1).
Most of the IC procedures (119) were laparoscopic. There were 43 conversions to open and 15 were planned open surgeries. Among the immediate cholecystectomies, most (192) were laparoscopic. There were 28 conversions to open and six planned open surgeries.
The conversion rate was significantly higher among the IC group (28% vs.13%). The most common reasons for conversion were hostile abdomen (48% vs. 16%) and hostile right upper quadrant (34% vs. 58%).
Operating time was significantly longer in the IC group (121 vs. 90 minutes). Estimated blood loss was also significantly higher (30 vs. 15 cc). Total hospital stay was significantly longer (7 vs. 5 days), as was ICU stay (1 vs. 0.1 day).
There were no biliary tract injuries in the cholecystectomy group, while 5.7% of IC patients sustained such an injury. Bowel injuries, most often serosal, were also more common in the IC group (6% vs. 0.4%). The IC group had more surgical site infections as well (12% vs. 0.44%).
There was no significant difference in 30-day mortality, but at 1 year, IC patients were significantly more likely to have died (15% vs. 0.44%).
The ongoing CHOCOLATE trial (Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy) may help clarify the issue further, Dr. Ackerman said. The study being conducted in the Netherlands is randomizing high-risk cholecystitis patients to either laparoscopic cholecystectomy or percutaneous drainage.
Dr. Ackerman had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
HOLLYWOOD, FLA – Interval cholecystectomy remains a challenging procedure, with longer operative times and ICU stays, greater blood loss, more biliary and bowel injuries, and even hints of increased mortality, compared with immediate cholecystectomy, according to the findings from a retrospective study of 404 patients.
The staged procedure, completed after antibiotic therapy and percutaneous cholecystostomy, has been increasing in frequency over the past 10 years, but has not been rigorously studied, James Ackerman, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
“Looking at Medicare data over the past decade, we see a 50% increase in this procedure, which is marked by some striking regional variation,” from 5% of acute cholecystitis cases in the Northeast to less than 1% in some other regions. “This shows that as a group, we really don’t know what to do with this procedure.”
The revised Tokyo Guidelines for the management of acute cholangitis and cholecystitis aren’t hugely helpful either, noted Dr. Ackerman of the University of Pittsburgh Medical Center. While the guidelines are fairly straightforward for patients with grade 1 and grade 3 disease, “there’s a lot of gray area in grade 2.”
Treatment for these patients should include biliary drainage with antibiotics, but, he said, the recommendations for surgery, and whether it should be elective, immediate, or delayed, can be confusing for this group.
Dr. Ackerman’s retrospective analysis comprised 177 patients with acute cholecystitis who underwent an interval cholecystectomy (IC) after percutaneous cholecystostomy, and 227 controls who underwent an immediate cholecystectomy. The analysis spanned 2008-2013 and used data from seven hospitals in one health care system.
Patients who had the IC were older (70 vs. 55 years), had a worse American Society of Anesthesiologists class (3 vs. 2.5), and a worse Tokyo Grade (2 vs. 1).
Most of the IC procedures (119) were laparoscopic. There were 43 conversions to open and 15 were planned open surgeries. Among the immediate cholecystectomies, most (192) were laparoscopic. There were 28 conversions to open and six planned open surgeries.
The conversion rate was significantly higher among the IC group (28% vs.13%). The most common reasons for conversion were hostile abdomen (48% vs. 16%) and hostile right upper quadrant (34% vs. 58%).
Operating time was significantly longer in the IC group (121 vs. 90 minutes). Estimated blood loss was also significantly higher (30 vs. 15 cc). Total hospital stay was significantly longer (7 vs. 5 days), as was ICU stay (1 vs. 0.1 day).
There were no biliary tract injuries in the cholecystectomy group, while 5.7% of IC patients sustained such an injury. Bowel injuries, most often serosal, were also more common in the IC group (6% vs. 0.4%). The IC group had more surgical site infections as well (12% vs. 0.44%).
There was no significant difference in 30-day mortality, but at 1 year, IC patients were significantly more likely to have died (15% vs. 0.44%).
The ongoing CHOCOLATE trial (Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy) may help clarify the issue further, Dr. Ackerman said. The study being conducted in the Netherlands is randomizing high-risk cholecystitis patients to either laparoscopic cholecystectomy or percutaneous drainage.
Dr. Ackerman had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
HOLLYWOOD, FLA – Interval cholecystectomy remains a challenging procedure, with longer operative times and ICU stays, greater blood loss, more biliary and bowel injuries, and even hints of increased mortality, compared with immediate cholecystectomy, according to the findings from a retrospective study of 404 patients.
The staged procedure, completed after antibiotic therapy and percutaneous cholecystostomy, has been increasing in frequency over the past 10 years, but has not been rigorously studied, James Ackerman, MD, said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.
“Looking at Medicare data over the past decade, we see a 50% increase in this procedure, which is marked by some striking regional variation,” from 5% of acute cholecystitis cases in the Northeast to less than 1% in some other regions. “This shows that as a group, we really don’t know what to do with this procedure.”
The revised Tokyo Guidelines for the management of acute cholangitis and cholecystitis aren’t hugely helpful either, noted Dr. Ackerman of the University of Pittsburgh Medical Center. While the guidelines are fairly straightforward for patients with grade 1 and grade 3 disease, “there’s a lot of gray area in grade 2.”
Treatment for these patients should include biliary drainage with antibiotics, but, he said, the recommendations for surgery, and whether it should be elective, immediate, or delayed, can be confusing for this group.
Dr. Ackerman’s retrospective analysis comprised 177 patients with acute cholecystitis who underwent an interval cholecystectomy (IC) after percutaneous cholecystostomy, and 227 controls who underwent an immediate cholecystectomy. The analysis spanned 2008-2013 and used data from seven hospitals in one health care system.
Patients who had the IC were older (70 vs. 55 years), had a worse American Society of Anesthesiologists class (3 vs. 2.5), and a worse Tokyo Grade (2 vs. 1).
Most of the IC procedures (119) were laparoscopic. There were 43 conversions to open and 15 were planned open surgeries. Among the immediate cholecystectomies, most (192) were laparoscopic. There were 28 conversions to open and six planned open surgeries.
The conversion rate was significantly higher among the IC group (28% vs.13%). The most common reasons for conversion were hostile abdomen (48% vs. 16%) and hostile right upper quadrant (34% vs. 58%).
Operating time was significantly longer in the IC group (121 vs. 90 minutes). Estimated blood loss was also significantly higher (30 vs. 15 cc). Total hospital stay was significantly longer (7 vs. 5 days), as was ICU stay (1 vs. 0.1 day).
There were no biliary tract injuries in the cholecystectomy group, while 5.7% of IC patients sustained such an injury. Bowel injuries, most often serosal, were also more common in the IC group (6% vs. 0.4%). The IC group had more surgical site infections as well (12% vs. 0.44%).
There was no significant difference in 30-day mortality, but at 1 year, IC patients were significantly more likely to have died (15% vs. 0.44%).
The ongoing CHOCOLATE trial (Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy) may help clarify the issue further, Dr. Ackerman said. The study being conducted in the Netherlands is randomizing high-risk cholecystitis patients to either laparoscopic cholecystectomy or percutaneous drainage.
Dr. Ackerman had no financial disclosures.
[email protected]
On Twitter @Alz_Gal
AT THE EAST ANNUAL SCIENTIFIC ASSEMBLY
Key clinical point:
Major finding: Interval cholecystectomy was associated with greater blood loss, more conversions to open surgery, bowel and biliary injuries, and even higher 1-year mortality (15% vs. 0.44%).
Data source: A retrospective review comparing 177 patients with interval surgery to 227 who had immediate surgery.
Disclosures: Dr. Ackerman had no financial disclosures.
One GOP plan says states that like their Obamacare can keep it
Some states could keep their federally funded insurance exchange with consumer protections intact under a proposal unveiled Monday by two Republican U.S. senators.
Sen. Bill Cassidy (R-La.) and Sen. Susan Collins (R-Maine) said their proposed legislation would allow states that embraced the Affordable Care Act to keep operating under many of the current federal rules.
Another option is for states to pursue a less-regulated alternative to Obamacare under the Patient Freedom Act. Or they could reject federal dollars completely in favor of a new state solution for health coverage.
“We give states the option,” Sen. Cassidy said at press conference Jan. 23.
Some health law supporters say the Cassidy-Collins proposal, one of several in the GOP-controlled Congress, could represent a lifeline for states such as California that have invested heavily in expanding coverage under the ACA.
But many Democrats at the state and national level criticized the plan as potentially harmful to millions of Americans who rely on the health law because it does not promise sufficient funding and consumer protections.
“It provides a somewhat illusory option to stay in the ACA without the guarantee of federal assistance necessary to allow states to maintain the level of coverage they are currently providing,” California Insurance Commissioner Dave Jones, an elected Democrat, said in an interview.
California fully implemented the health law by expanding Medicaid coverage to millions of low-income people and creating its own insurance exchange, which ultimately covered 1.3 million enrollees. Supporters have held the state up as proof that the health law can work as intended – and as a counterpoint to Republican contentions that Obamacare is collapsing nationally.
Sen. Cassidy said his legislation promotes the Republican doctrine of states’ rights while avoiding the one-size-fits-all approach from Washington.
Sen. Collins echoed that sentiment, saying she favors letting states that had success with the health law maintain the status quo. She described it as “reimplementation of the ACA” in those states.
“If a state chooses to remain covered by the ACA, exchange policies will continue to be eligible for cost-sharing subsidies and advance premium tax credits,” she said in a Senate floor speech Jan. 23. “The insurance market will still be subject to ACA requirements, and the individual mandate and employer mandate will also remain in place in that state.”
Sen. Cassidy and Sen. Collins acknowledged that details of their bill haven’t been worked out, nor is it clear how it will mesh with other proposals. Competing plans in Congress don’t envision these state options, and it’s unclear what approach President Donald Trump and his nascent administration will take in crafting a replacement plan.
Still, some industry experts and analysts say the Cassidy-Collins proposal is intriguing.
“The advantage to a state like California is we could protect what we have accomplished already,” said Howard Kahn, former chief executive of L.A. Care Health Plan, an insurer on the Covered California exchange. The large managed care plan serves patients in Medi-Cal, the state’s Medicaid program.
“Cassidy’s proposal could work for California better than other alternatives in the short term. The question is whether they maintain federal funding for the longer term,” Mr. Kahn said. “My feeling is you do have to engage with the rational Republicans who are trying to find something that doesn’t tear it all apart.”
Federal funding is a key issue for states. In a summary of the bill posted by Sen. Collins, it said states choosing to retain Obamacare or pick the Republican alternative could receive “funding equal to 95% of federal premium tax credits and cost-sharing subsidies, as well as the federal match for Medicaid expansion.”
Dylan H. Roby, of the department of health services administration at the University of Maryland School of Public Health, College Park, said “California would still have to absorb a 5% cut, at least, in the premium tax credits and cost-sharing subsidies.”
Republicans will need 60 votes in the U.S. Senate to pass a full replacement for the ACA. Sen. Cassidy said his compromise approach is designed to win over some Democrats and reach that 60-vote majority.
In her speech on the Senate floor, Sen. Collins said children could still stay on their parents’ health plans until they are 26 years old. There would be no discrimination against preexisting conditions and no caps on annual or lifetime coverage, she said.
Other key features of the legislation include a provision allowing states to automatically enroll eligible people in health plans unless they opt out. The plan also promotes health savings accounts and price transparency requiring hospitals and other providers to disclose costs so consumers can shop around for the best price.
This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
Some states could keep their federally funded insurance exchange with consumer protections intact under a proposal unveiled Monday by two Republican U.S. senators.
Sen. Bill Cassidy (R-La.) and Sen. Susan Collins (R-Maine) said their proposed legislation would allow states that embraced the Affordable Care Act to keep operating under many of the current federal rules.
Another option is for states to pursue a less-regulated alternative to Obamacare under the Patient Freedom Act. Or they could reject federal dollars completely in favor of a new state solution for health coverage.
“We give states the option,” Sen. Cassidy said at press conference Jan. 23.
Some health law supporters say the Cassidy-Collins proposal, one of several in the GOP-controlled Congress, could represent a lifeline for states such as California that have invested heavily in expanding coverage under the ACA.
But many Democrats at the state and national level criticized the plan as potentially harmful to millions of Americans who rely on the health law because it does not promise sufficient funding and consumer protections.
“It provides a somewhat illusory option to stay in the ACA without the guarantee of federal assistance necessary to allow states to maintain the level of coverage they are currently providing,” California Insurance Commissioner Dave Jones, an elected Democrat, said in an interview.
California fully implemented the health law by expanding Medicaid coverage to millions of low-income people and creating its own insurance exchange, which ultimately covered 1.3 million enrollees. Supporters have held the state up as proof that the health law can work as intended – and as a counterpoint to Republican contentions that Obamacare is collapsing nationally.
Sen. Cassidy said his legislation promotes the Republican doctrine of states’ rights while avoiding the one-size-fits-all approach from Washington.
Sen. Collins echoed that sentiment, saying she favors letting states that had success with the health law maintain the status quo. She described it as “reimplementation of the ACA” in those states.
“If a state chooses to remain covered by the ACA, exchange policies will continue to be eligible for cost-sharing subsidies and advance premium tax credits,” she said in a Senate floor speech Jan. 23. “The insurance market will still be subject to ACA requirements, and the individual mandate and employer mandate will also remain in place in that state.”
Sen. Cassidy and Sen. Collins acknowledged that details of their bill haven’t been worked out, nor is it clear how it will mesh with other proposals. Competing plans in Congress don’t envision these state options, and it’s unclear what approach President Donald Trump and his nascent administration will take in crafting a replacement plan.
Still, some industry experts and analysts say the Cassidy-Collins proposal is intriguing.
“The advantage to a state like California is we could protect what we have accomplished already,” said Howard Kahn, former chief executive of L.A. Care Health Plan, an insurer on the Covered California exchange. The large managed care plan serves patients in Medi-Cal, the state’s Medicaid program.
“Cassidy’s proposal could work for California better than other alternatives in the short term. The question is whether they maintain federal funding for the longer term,” Mr. Kahn said. “My feeling is you do have to engage with the rational Republicans who are trying to find something that doesn’t tear it all apart.”
Federal funding is a key issue for states. In a summary of the bill posted by Sen. Collins, it said states choosing to retain Obamacare or pick the Republican alternative could receive “funding equal to 95% of federal premium tax credits and cost-sharing subsidies, as well as the federal match for Medicaid expansion.”
Dylan H. Roby, of the department of health services administration at the University of Maryland School of Public Health, College Park, said “California would still have to absorb a 5% cut, at least, in the premium tax credits and cost-sharing subsidies.”
Republicans will need 60 votes in the U.S. Senate to pass a full replacement for the ACA. Sen. Cassidy said his compromise approach is designed to win over some Democrats and reach that 60-vote majority.
In her speech on the Senate floor, Sen. Collins said children could still stay on their parents’ health plans until they are 26 years old. There would be no discrimination against preexisting conditions and no caps on annual or lifetime coverage, she said.
Other key features of the legislation include a provision allowing states to automatically enroll eligible people in health plans unless they opt out. The plan also promotes health savings accounts and price transparency requiring hospitals and other providers to disclose costs so consumers can shop around for the best price.
This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
Some states could keep their federally funded insurance exchange with consumer protections intact under a proposal unveiled Monday by two Republican U.S. senators.
Sen. Bill Cassidy (R-La.) and Sen. Susan Collins (R-Maine) said their proposed legislation would allow states that embraced the Affordable Care Act to keep operating under many of the current federal rules.
Another option is for states to pursue a less-regulated alternative to Obamacare under the Patient Freedom Act. Or they could reject federal dollars completely in favor of a new state solution for health coverage.
“We give states the option,” Sen. Cassidy said at press conference Jan. 23.
Some health law supporters say the Cassidy-Collins proposal, one of several in the GOP-controlled Congress, could represent a lifeline for states such as California that have invested heavily in expanding coverage under the ACA.
But many Democrats at the state and national level criticized the plan as potentially harmful to millions of Americans who rely on the health law because it does not promise sufficient funding and consumer protections.
“It provides a somewhat illusory option to stay in the ACA without the guarantee of federal assistance necessary to allow states to maintain the level of coverage they are currently providing,” California Insurance Commissioner Dave Jones, an elected Democrat, said in an interview.
California fully implemented the health law by expanding Medicaid coverage to millions of low-income people and creating its own insurance exchange, which ultimately covered 1.3 million enrollees. Supporters have held the state up as proof that the health law can work as intended – and as a counterpoint to Republican contentions that Obamacare is collapsing nationally.
Sen. Cassidy said his legislation promotes the Republican doctrine of states’ rights while avoiding the one-size-fits-all approach from Washington.
Sen. Collins echoed that sentiment, saying she favors letting states that had success with the health law maintain the status quo. She described it as “reimplementation of the ACA” in those states.
“If a state chooses to remain covered by the ACA, exchange policies will continue to be eligible for cost-sharing subsidies and advance premium tax credits,” she said in a Senate floor speech Jan. 23. “The insurance market will still be subject to ACA requirements, and the individual mandate and employer mandate will also remain in place in that state.”
Sen. Cassidy and Sen. Collins acknowledged that details of their bill haven’t been worked out, nor is it clear how it will mesh with other proposals. Competing plans in Congress don’t envision these state options, and it’s unclear what approach President Donald Trump and his nascent administration will take in crafting a replacement plan.
Still, some industry experts and analysts say the Cassidy-Collins proposal is intriguing.
“The advantage to a state like California is we could protect what we have accomplished already,” said Howard Kahn, former chief executive of L.A. Care Health Plan, an insurer on the Covered California exchange. The large managed care plan serves patients in Medi-Cal, the state’s Medicaid program.
“Cassidy’s proposal could work for California better than other alternatives in the short term. The question is whether they maintain federal funding for the longer term,” Mr. Kahn said. “My feeling is you do have to engage with the rational Republicans who are trying to find something that doesn’t tear it all apart.”
Federal funding is a key issue for states. In a summary of the bill posted by Sen. Collins, it said states choosing to retain Obamacare or pick the Republican alternative could receive “funding equal to 95% of federal premium tax credits and cost-sharing subsidies, as well as the federal match for Medicaid expansion.”
Dylan H. Roby, of the department of health services administration at the University of Maryland School of Public Health, College Park, said “California would still have to absorb a 5% cut, at least, in the premium tax credits and cost-sharing subsidies.”
Republicans will need 60 votes in the U.S. Senate to pass a full replacement for the ACA. Sen. Cassidy said his compromise approach is designed to win over some Democrats and reach that 60-vote majority.
In her speech on the Senate floor, Sen. Collins said children could still stay on their parents’ health plans until they are 26 years old. There would be no discrimination against preexisting conditions and no caps on annual or lifetime coverage, she said.
Other key features of the legislation include a provision allowing states to automatically enroll eligible people in health plans unless they opt out. The plan also promotes health savings accounts and price transparency requiring hospitals and other providers to disclose costs so consumers can shop around for the best price.
This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
ECT tied to better responses in late-onset depression in older patients
Older patients with late-onset treatment-resistant depression and psychotic symptoms appear to get better results from electroconvulsive therapy than those with early-onset depression and fewer psychotic symptoms, a longitudinal study of 110 patients suggests.
“Our results indicate that [electroconvulsive therapy] is very effective even in pharmacotherapy-resistant [late-life depression] with vascular burden,” wrote Annemiek Dols, MD, PhD, Filip Bouckaert, MD, and associates.
The investigators recruited severely depressed patients who were receiving electroconvulsive therapy (ECT) from psychiatric hospitals in Amsterdam and Leuven, Belgium, as part of the Mood Disorders in Elderly Treated with Electroconvulsive Therapy (MODECT) study between January 2011 and December 2013.
They defined early-onset depression as a first depressive episode experienced by patients before age 55 years. Late-onset depression was defined as a first depressive episode that occurred at age 55 and older, reported Dr. Dols of the department of old age psychiatry at GGZ inGeest in Amsterdam and Dr. Bouckaert of the department of radiology and nuclear medicine at VU University Medical Center, also in Amsterdam.
The average age of the 110 patients was 73 years, and 72 were women. Patients with diagnoses of bipolar and schizoaffective disorder were excluded, as were patients with a history of neurologic illnesses such as Parkinson’s disease, stroke, or dementia.
Dr. Dols, Dr. Bouckaert, and associates measured the patients’ cognition using several instruments, including the 30-point Mini-Mental State Examination (MMSE) before, during, and after 1 week of a course of ECT. A response was defined as an improvement of 50% or more in Montgomery-Åsberg Depression Rating Scale (MADRS) scores from baseline during an ECT course. Remission was defined as a MADRS score below 10 points after ECT (Am J Geriatr Psychiatry. 2017 Feb;25[2]:178-89).
Mean MMSE scores climbed from 24.5 before ECT to 27.25 for the early-onset depression patients, compared with 24.04 to 25.39 for the late-onset depression patients. Overall, the investigators reported, patients with late-onset depression had a response rate of 86.9%, compared with a response rate of 67.3% for those with early-onset depression after receiving a similar number of ECT sessions.
However, the higher response rates in late-onset depression could not be explained by “clinical or structural brain characteristics,” the investigators noted. “The number of responders with [late-onset depression] was probably too low (n = 8) to find statistically significant associations.”
To read more about the study, click here.
[email protected]
On Twitter @ginalhenderson
Older patients with late-onset treatment-resistant depression and psychotic symptoms appear to get better results from electroconvulsive therapy than those with early-onset depression and fewer psychotic symptoms, a longitudinal study of 110 patients suggests.
“Our results indicate that [electroconvulsive therapy] is very effective even in pharmacotherapy-resistant [late-life depression] with vascular burden,” wrote Annemiek Dols, MD, PhD, Filip Bouckaert, MD, and associates.
The investigators recruited severely depressed patients who were receiving electroconvulsive therapy (ECT) from psychiatric hospitals in Amsterdam and Leuven, Belgium, as part of the Mood Disorders in Elderly Treated with Electroconvulsive Therapy (MODECT) study between January 2011 and December 2013.
They defined early-onset depression as a first depressive episode experienced by patients before age 55 years. Late-onset depression was defined as a first depressive episode that occurred at age 55 and older, reported Dr. Dols of the department of old age psychiatry at GGZ inGeest in Amsterdam and Dr. Bouckaert of the department of radiology and nuclear medicine at VU University Medical Center, also in Amsterdam.
The average age of the 110 patients was 73 years, and 72 were women. Patients with diagnoses of bipolar and schizoaffective disorder were excluded, as were patients with a history of neurologic illnesses such as Parkinson’s disease, stroke, or dementia.
Dr. Dols, Dr. Bouckaert, and associates measured the patients’ cognition using several instruments, including the 30-point Mini-Mental State Examination (MMSE) before, during, and after 1 week of a course of ECT. A response was defined as an improvement of 50% or more in Montgomery-Åsberg Depression Rating Scale (MADRS) scores from baseline during an ECT course. Remission was defined as a MADRS score below 10 points after ECT (Am J Geriatr Psychiatry. 2017 Feb;25[2]:178-89).
Mean MMSE scores climbed from 24.5 before ECT to 27.25 for the early-onset depression patients, compared with 24.04 to 25.39 for the late-onset depression patients. Overall, the investigators reported, patients with late-onset depression had a response rate of 86.9%, compared with a response rate of 67.3% for those with early-onset depression after receiving a similar number of ECT sessions.
However, the higher response rates in late-onset depression could not be explained by “clinical or structural brain characteristics,” the investigators noted. “The number of responders with [late-onset depression] was probably too low (n = 8) to find statistically significant associations.”
To read more about the study, click here.
[email protected]
On Twitter @ginalhenderson
Older patients with late-onset treatment-resistant depression and psychotic symptoms appear to get better results from electroconvulsive therapy than those with early-onset depression and fewer psychotic symptoms, a longitudinal study of 110 patients suggests.
“Our results indicate that [electroconvulsive therapy] is very effective even in pharmacotherapy-resistant [late-life depression] with vascular burden,” wrote Annemiek Dols, MD, PhD, Filip Bouckaert, MD, and associates.
The investigators recruited severely depressed patients who were receiving electroconvulsive therapy (ECT) from psychiatric hospitals in Amsterdam and Leuven, Belgium, as part of the Mood Disorders in Elderly Treated with Electroconvulsive Therapy (MODECT) study between January 2011 and December 2013.
They defined early-onset depression as a first depressive episode experienced by patients before age 55 years. Late-onset depression was defined as a first depressive episode that occurred at age 55 and older, reported Dr. Dols of the department of old age psychiatry at GGZ inGeest in Amsterdam and Dr. Bouckaert of the department of radiology and nuclear medicine at VU University Medical Center, also in Amsterdam.
The average age of the 110 patients was 73 years, and 72 were women. Patients with diagnoses of bipolar and schizoaffective disorder were excluded, as were patients with a history of neurologic illnesses such as Parkinson’s disease, stroke, or dementia.
Dr. Dols, Dr. Bouckaert, and associates measured the patients’ cognition using several instruments, including the 30-point Mini-Mental State Examination (MMSE) before, during, and after 1 week of a course of ECT. A response was defined as an improvement of 50% or more in Montgomery-Åsberg Depression Rating Scale (MADRS) scores from baseline during an ECT course. Remission was defined as a MADRS score below 10 points after ECT (Am J Geriatr Psychiatry. 2017 Feb;25[2]:178-89).
Mean MMSE scores climbed from 24.5 before ECT to 27.25 for the early-onset depression patients, compared with 24.04 to 25.39 for the late-onset depression patients. Overall, the investigators reported, patients with late-onset depression had a response rate of 86.9%, compared with a response rate of 67.3% for those with early-onset depression after receiving a similar number of ECT sessions.
However, the higher response rates in late-onset depression could not be explained by “clinical or structural brain characteristics,” the investigators noted. “The number of responders with [late-onset depression] was probably too low (n = 8) to find statistically significant associations.”
To read more about the study, click here.
[email protected]
On Twitter @ginalhenderson
FROM THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY
Strokes, migraines linked in women with possible CAD
NEW ORLEANS – Women who underwent a clinically indicated coronary angiogram and also reported having migraine headaches had a twofold increased rate of strokes, compared with similar women without a history of migraine, in a prospective, observational study of 888 women followed for a median of 6.5 years.
This finding “underscores that more attention should be placed on evaluating women with a history of migraine headache for cardiovascular disease,” Cecil A. Rambarat, MD, said at the American Heart Association scientific sessions.
Aspirin aside, what’s important for these women is to “modify their risk factors and look at their family history,” reported Dr Rambarat of the University of Florida in Gainesville.
The study used data collected on women enrolled in the Women’s Ischemic Syndrome Evaluation (WISE) study during 1996-1999. WISE entered women at four U.S. centers scheduled for a clinically indicated coronary angiogram as part of their routine care for chest pain symptoms or suspected myocardial ischemia.
Among the 936 women enrolled in WISE, 917 completed a baseline questionnaire about their migraine history that showed 224 women had a migraine history and 693 women did not report having migraine headaches. The average age of women with a migraine history was 54 years, compared with 59 years in those without migraines.
All 917 women were followed for a median of 6.5 years for the incidence of nonfatal myocardial infarction, stroke, or heart failure. A subgroup of 888 of these women were also followed for a median of 9.5 years for mortality, including the incidence of cardiovascular death.
After the investigators adjusted for age, race, body mass index, history of diabetes or hypertension, dyslipidemia, smoking, and other variables, women with migraine were 83% more likely to have a cardiovascular event (cardiovascular death or nonfatal event) during follow-up, compared with women with no migraine history, a statistically significant difference.
Women with migraine were also 2.33-fold more likely to have a nonfatal stroke during follow-up, also a statistically significant difference. The increased stroke rate seems to have largely driven the significant difference in all cardiovascular events.
The mechanisms that might link migraine headaches with stroke are not clear, but Dr. Rambarat suggested several possibilities. Women with migraine may have dysfunction of their vascular endothelium, increased inflammatory markers, increased release of prothrombotic factors, a patent foramen ovale, or certain genetic risk factors that predispose them to migraine and to stroke or other cardiovascular disease, he said.
A report of these findings was recently published online (Am J Med. 2016 Dec 28. doi: 10.1016/j.amjmed.2016.12.028).
Dr. Rambarat had no relevant financial disclosures.
[email protected]
On Twitter @mitchelzoler
NEW ORLEANS – Women who underwent a clinically indicated coronary angiogram and also reported having migraine headaches had a twofold increased rate of strokes, compared with similar women without a history of migraine, in a prospective, observational study of 888 women followed for a median of 6.5 years.
This finding “underscores that more attention should be placed on evaluating women with a history of migraine headache for cardiovascular disease,” Cecil A. Rambarat, MD, said at the American Heart Association scientific sessions.
Aspirin aside, what’s important for these women is to “modify their risk factors and look at their family history,” reported Dr Rambarat of the University of Florida in Gainesville.
The study used data collected on women enrolled in the Women’s Ischemic Syndrome Evaluation (WISE) study during 1996-1999. WISE entered women at four U.S. centers scheduled for a clinically indicated coronary angiogram as part of their routine care for chest pain symptoms or suspected myocardial ischemia.
Among the 936 women enrolled in WISE, 917 completed a baseline questionnaire about their migraine history that showed 224 women had a migraine history and 693 women did not report having migraine headaches. The average age of women with a migraine history was 54 years, compared with 59 years in those without migraines.
All 917 women were followed for a median of 6.5 years for the incidence of nonfatal myocardial infarction, stroke, or heart failure. A subgroup of 888 of these women were also followed for a median of 9.5 years for mortality, including the incidence of cardiovascular death.
After the investigators adjusted for age, race, body mass index, history of diabetes or hypertension, dyslipidemia, smoking, and other variables, women with migraine were 83% more likely to have a cardiovascular event (cardiovascular death or nonfatal event) during follow-up, compared with women with no migraine history, a statistically significant difference.
Women with migraine were also 2.33-fold more likely to have a nonfatal stroke during follow-up, also a statistically significant difference. The increased stroke rate seems to have largely driven the significant difference in all cardiovascular events.
The mechanisms that might link migraine headaches with stroke are not clear, but Dr. Rambarat suggested several possibilities. Women with migraine may have dysfunction of their vascular endothelium, increased inflammatory markers, increased release of prothrombotic factors, a patent foramen ovale, or certain genetic risk factors that predispose them to migraine and to stroke or other cardiovascular disease, he said.
A report of these findings was recently published online (Am J Med. 2016 Dec 28. doi: 10.1016/j.amjmed.2016.12.028).
Dr. Rambarat had no relevant financial disclosures.
[email protected]
On Twitter @mitchelzoler
NEW ORLEANS – Women who underwent a clinically indicated coronary angiogram and also reported having migraine headaches had a twofold increased rate of strokes, compared with similar women without a history of migraine, in a prospective, observational study of 888 women followed for a median of 6.5 years.
This finding “underscores that more attention should be placed on evaluating women with a history of migraine headache for cardiovascular disease,” Cecil A. Rambarat, MD, said at the American Heart Association scientific sessions.
Aspirin aside, what’s important for these women is to “modify their risk factors and look at their family history,” reported Dr Rambarat of the University of Florida in Gainesville.
The study used data collected on women enrolled in the Women’s Ischemic Syndrome Evaluation (WISE) study during 1996-1999. WISE entered women at four U.S. centers scheduled for a clinically indicated coronary angiogram as part of their routine care for chest pain symptoms or suspected myocardial ischemia.
Among the 936 women enrolled in WISE, 917 completed a baseline questionnaire about their migraine history that showed 224 women had a migraine history and 693 women did not report having migraine headaches. The average age of women with a migraine history was 54 years, compared with 59 years in those without migraines.
All 917 women were followed for a median of 6.5 years for the incidence of nonfatal myocardial infarction, stroke, or heart failure. A subgroup of 888 of these women were also followed for a median of 9.5 years for mortality, including the incidence of cardiovascular death.
After the investigators adjusted for age, race, body mass index, history of diabetes or hypertension, dyslipidemia, smoking, and other variables, women with migraine were 83% more likely to have a cardiovascular event (cardiovascular death or nonfatal event) during follow-up, compared with women with no migraine history, a statistically significant difference.
Women with migraine were also 2.33-fold more likely to have a nonfatal stroke during follow-up, also a statistically significant difference. The increased stroke rate seems to have largely driven the significant difference in all cardiovascular events.
The mechanisms that might link migraine headaches with stroke are not clear, but Dr. Rambarat suggested several possibilities. Women with migraine may have dysfunction of their vascular endothelium, increased inflammatory markers, increased release of prothrombotic factors, a patent foramen ovale, or certain genetic risk factors that predispose them to migraine and to stroke or other cardiovascular disease, he said.
A report of these findings was recently published online (Am J Med. 2016 Dec 28. doi: 10.1016/j.amjmed.2016.12.028).
Dr. Rambarat had no relevant financial disclosures.
[email protected]
On Twitter @mitchelzoler
AT THE AHA SCIENTIFIC SESSIONS
Key clinical point:
Major finding: The stroke rate during 6.5 years of follow-up was more than twofold greater in women with a migraine headache history.
Data source: WISE, a study of 936 U.S. women enrolled during 1996-1999 and followed prospectively.
Disclosures: Dr. Rambarat had no relevant financial disclosures.