Review the PDF of the fact sheet on transient benign neonatal skin findings with board-relevant, easy-to-review material. This fact sheet lists benign findings that can be seen in neonates and infants.

Practice Questions

1. The parents of a 2-month-old infant present with their child. They are worried because the infant has “acne” that is not going away. Friends told them to try gentle cleansers and they have avoided using lotions or cream on her face. However, the bumps will not go away. On examination she has papules and pustules. Comedones cannot be identified. What are your next steps?

a. adapalene cream 0.1% every night at bedtime
b. benzoyl peroxide cream 4%
c. benzoyl peroxide wash 2.5%
d. erythromycin gel 2%
e. ketoconazole cream 2% twice daily

2. While in the newborn nursery prior to discharge, the attending pediatrician notices a rash on a 2-day-old neonate who is otherwise completely healthy. The pediatrician consults a dermatologist for his/her opinion. The dermatologist sees erythematous macules with central pustules located predominately on the trunk and proximal extremities. A pustule is unroofed with a blade, the contents smeared on a glass slide, and a Giemsa stain is performed. What is the predominant cell type you would expect to see on histological examination?

a. eosinophils
b. Langerhans cells
c. lymphocytes
d. neutrophils
e. no cells are visualized

3. Shortly after delivery, the pediatricians notice that the baby has numerous hyperpigmented macules on the back. No other primary lesions are seen. The neonate is otherwise normal in appearance and nontoxic appearing. A dermatologist is consulted for a recommendation for further workup or potential biopsy. The dermatologist examines the newborn. He is a well-appearing black boy with skin that is otherwise intact. A few pustules on the back are present that have a collarette of scale. The dermatologist reviews the mother’s prenatal history and the review shows that she was screened for syphilis and had a negative screening test with no other history of infectious diseases. What is the most appropriate next step to confirm your suspicions?

a. do a swab of a pustule and send it for viral culture
b. have his blood drawn and check for signs of neonatal herpes simplex virus infection
c. perform a biopsy of a pustule
d. perform a Giemsa stain on a smear of the pustule
e. start treatment with permethrin

4. Which intraoral cysts occur on the alveolar ridge of a neonate?

a. Bohn nodule
b. branchial cleft cyst
c. Epstein pearls
d. median raphe cyst
e. palatal cysts of the newborn

5. Miliaria rubra is associated with inflammation of the sweat glands in what portion of the skin?

a. basement membrane zone
b. dermis
c. dermoepidermal junction
d. intraepidermal
e. subcutis

Answers to practice questions provided on next page

Practice Question Answers

1. The parents of a 2-month-old infant present with their child. They are worried because the infant has “acne” that is not going away. Friends told them to try gentle cleansers and they have avoided using lotions or cream on her face. However, the bumps will not go away. On examination she has papules and pustules. Comedones cannot be identified. What are your next steps?

a. adapalene cream 0.1% every night at bedtime
b. benzoyl peroxide cream 4%
c. benzoyl peroxide wash 2.5%
d. erythromycin gel 2%
e. ketoconazole cream 2% twice daily

2. While in the newborn nursery prior to discharge, the attending pediatrician notices a rash on a 2-day-old neonate who is otherwise completely healthy. The pediatrician consults a dermatologist for his/her opinion. The dermatologist sees erythematous macules with central pustules located predominately on the trunk and proximal extremities. A pustule is unroofed with a blade, the contents smeared on a glass slide, and a Giemsa stain is performed. What is the predominant cell type you would expect to see on histological examination?

a. eosinophils
b. Langerhans cells
c. lymphocytes
d. neutrophils
e. no cells are visualized

3. Shortly after delivery, the pediatricians notice that the baby has numerous hyperpigmented macules on the back. No other primary lesions are seen. The neonate is otherwise normal in appearance and nontoxic appearing. A dermatologist is consulted for a recommendation for further workup or potential biopsy. The dermatologist examines the newborn. He is a well-appearing black boy with skin that is otherwise intact. A few pustules on the back are present that have a collarette of scale. The dermatologist reviews the mother’s prenatal history and the review shows that she was screened for syphilis and had a negative screening test with no other history of infectious diseases. What is the most appropriate next step to confirm your suspicions?

a. do a swab of a pustule and send it for viral culture
b. have his blood drawn and check for signs of neonatal herpes simplex virus infection
c. perform a biopsy of a pustule
d. perform a Giemsa stain on a smear of the pustule
e. start treatment with permethrin

4. Which intraoral cysts occur on the alveolar ridge of a neonate?

a. Bohn nodule
b. branchial cleft cyst
c. Epstein pearls
d. median raphe cyst
e. palatal cysts of the newborn

5. Miliaria rubra is associated with inflammation of the sweat glands in what portion of the skin?

a. basement membrane zone
b. dermis
c. dermoepidermal junction
d. intraepidermal
e. subcutis

Review the PDF of the fact sheet on transient benign neonatal skin findings with board-relevant, easy-to-review material. This fact sheet lists benign findings that can be seen in neonates and infants.

Practice Questions

1. The parents of a 2-month-old infant present with their child. They are worried because the infant has “acne” that is not going away. Friends told them to try gentle cleansers and they have avoided using lotions or cream on her face. However, the bumps will not go away. On examination she has papules and pustules. Comedones cannot be identified. What are your next steps?

a. adapalene cream 0.1% every night at bedtime
b. benzoyl peroxide cream 4%
c. benzoyl peroxide wash 2.5%
d. erythromycin gel 2%
e. ketoconazole cream 2% twice daily

2. While in the newborn nursery prior to discharge, the attending pediatrician notices a rash on a 2-day-old neonate who is otherwise completely healthy. The pediatrician consults a dermatologist for his/her opinion. The dermatologist sees erythematous macules with central pustules located predominately on the trunk and proximal extremities. A pustule is unroofed with a blade, the contents smeared on a glass slide, and a Giemsa stain is performed. What is the predominant cell type you would expect to see on histological examination?

a. eosinophils
b. Langerhans cells
c. lymphocytes
d. neutrophils
e. no cells are visualized

3. Shortly after delivery, the pediatricians notice that the baby has numerous hyperpigmented macules on the back. No other primary lesions are seen. The neonate is otherwise normal in appearance and nontoxic appearing. A dermatologist is consulted for a recommendation for further workup or potential biopsy. The dermatologist examines the newborn. He is a well-appearing black boy with skin that is otherwise intact. A few pustules on the back are present that have a collarette of scale. The dermatologist reviews the mother’s prenatal history and the review shows that she was screened for syphilis and had a negative screening test with no other history of infectious diseases. What is the most appropriate next step to confirm your suspicions?

a. do a swab of a pustule and send it for viral culture
b. have his blood drawn and check for signs of neonatal herpes simplex virus infection
c. perform a biopsy of a pustule
d. perform a Giemsa stain on a smear of the pustule
e. start treatment with permethrin

4. Which intraoral cysts occur on the alveolar ridge of a neonate?

a. Bohn nodule
b. branchial cleft cyst
c. Epstein pearls
d. median raphe cyst
e. palatal cysts of the newborn

5. Miliaria rubra is associated with inflammation of the sweat glands in what portion of the skin?

a. basement membrane zone
b. dermis
c. dermoepidermal junction
d. intraepidermal
e. subcutis

Answers to practice questions provided on next page

Practice Question Answers

1. The parents of a 2-month-old infant present with their child. They are worried because the infant has “acne” that is not going away. Friends told them to try gentle cleansers and they have avoided using lotions or cream on her face. However, the bumps will not go away. On examination she has papules and pustules. Comedones cannot be identified. What are your next steps?

a. adapalene cream 0.1% every night at bedtime
b. benzoyl peroxide cream 4%
c. benzoyl peroxide wash 2.5%
d. erythromycin gel 2%
e. ketoconazole cream 2% twice daily

2. While in the newborn nursery prior to discharge, the attending pediatrician notices a rash on a 2-day-old neonate who is otherwise completely healthy. The pediatrician consults a dermatologist for his/her opinion. The dermatologist sees erythematous macules with central pustules located predominately on the trunk and proximal extremities. A pustule is unroofed with a blade, the contents smeared on a glass slide, and a Giemsa stain is performed. What is the predominant cell type you would expect to see on histological examination?

a. eosinophils
b. Langerhans cells
c. lymphocytes
d. neutrophils
e. no cells are visualized

3. Shortly after delivery, the pediatricians notice that the baby has numerous hyperpigmented macules on the back. No other primary lesions are seen. The neonate is otherwise normal in appearance and nontoxic appearing. A dermatologist is consulted for a recommendation for further workup or potential biopsy. The dermatologist examines the newborn. He is a well-appearing black boy with skin that is otherwise intact. A few pustules on the back are present that have a collarette of scale. The dermatologist reviews the mother’s prenatal history and the review shows that she was screened for syphilis and had a negative screening test with no other history of infectious diseases. What is the most appropriate next step to confirm your suspicions?

a. do a swab of a pustule and send it for viral culture
b. have his blood drawn and check for signs of neonatal herpes simplex virus infection
c. perform a biopsy of a pustule
d. perform a Giemsa stain on a smear of the pustule
e. start treatment with permethrin

4. Which intraoral cysts occur on the alveolar ridge of a neonate?

a. Bohn nodule
b. branchial cleft cyst
c. Epstein pearls
d. median raphe cyst
e. palatal cysts of the newborn

5. Miliaria rubra is associated with inflammation of the sweat glands in what portion of the skin?

a. basement membrane zone
b. dermis
c. dermoepidermal junction
d. intraepidermal
e. subcutis

Review the PDF of the fact sheet on transient benign neonatal skin findings with board-relevant, easy-to-review material. This fact sheet lists benign findings that can be seen in neonates and infants.

Practice Questions

1. The parents of a 2-month-old infant present with their child. They are worried because the infant has “acne” that is not going away. Friends told them to try gentle cleansers and they have avoided using lotions or cream on her face. However, the bumps will not go away. On examination she has papules and pustules. Comedones cannot be identified. What are your next steps?

a. adapalene cream 0.1% every night at bedtime
b. benzoyl peroxide cream 4%
c. benzoyl peroxide wash 2.5%
d. erythromycin gel 2%
e. ketoconazole cream 2% twice daily

2. While in the newborn nursery prior to discharge, the attending pediatrician notices a rash on a 2-day-old neonate who is otherwise completely healthy. The pediatrician consults a dermatologist for his/her opinion. The dermatologist sees erythematous macules with central pustules located predominately on the trunk and proximal extremities. A pustule is unroofed with a blade, the contents smeared on a glass slide, and a Giemsa stain is performed. What is the predominant cell type you would expect to see on histological examination?

a. eosinophils
b. Langerhans cells
c. lymphocytes
d. neutrophils
e. no cells are visualized

3. Shortly after delivery, the pediatricians notice that the baby has numerous hyperpigmented macules on the back. No other primary lesions are seen. The neonate is otherwise normal in appearance and nontoxic appearing. A dermatologist is consulted for a recommendation for further workup or potential biopsy. The dermatologist examines the newborn. He is a well-appearing black boy with skin that is otherwise intact. A few pustules on the back are present that have a collarette of scale. The dermatologist reviews the mother’s prenatal history and the review shows that she was screened for syphilis and had a negative screening test with no other history of infectious diseases. What is the most appropriate next step to confirm your suspicions?

a. do a swab of a pustule and send it for viral culture
b. have his blood drawn and check for signs of neonatal herpes simplex virus infection
c. perform a biopsy of a pustule
d. perform a Giemsa stain on a smear of the pustule
e. start treatment with permethrin

4. Which intraoral cysts occur on the alveolar ridge of a neonate?

a. Bohn nodule
b. branchial cleft cyst
c. Epstein pearls
d. median raphe cyst
e. palatal cysts of the newborn

5. Miliaria rubra is associated with inflammation of the sweat glands in what portion of the skin?

a. basement membrane zone
b. dermis
c. dermoepidermal junction
d. intraepidermal
e. subcutis

Answers to practice questions provided on next page

Practice Question Answers

1. The parents of a 2-month-old infant present with their child. They are worried because the infant has “acne” that is not going away. Friends told them to try gentle cleansers and they have avoided using lotions or cream on her face. However, the bumps will not go away. On examination she has papules and pustules. Comedones cannot be identified. What are your next steps?

a. adapalene cream 0.1% every night at bedtime
b. benzoyl peroxide cream 4%
c. benzoyl peroxide wash 2.5%
d. erythromycin gel 2%
e. ketoconazole cream 2% twice daily

2. While in the newborn nursery prior to discharge, the attending pediatrician notices a rash on a 2-day-old neonate who is otherwise completely healthy. The pediatrician consults a dermatologist for his/her opinion. The dermatologist sees erythematous macules with central pustules located predominately on the trunk and proximal extremities. A pustule is unroofed with a blade, the contents smeared on a glass slide, and a Giemsa stain is performed. What is the predominant cell type you would expect to see on histological examination?

a. eosinophils
b. Langerhans cells
c. lymphocytes
d. neutrophils
e. no cells are visualized

3. Shortly after delivery, the pediatricians notice that the baby has numerous hyperpigmented macules on the back. No other primary lesions are seen. The neonate is otherwise normal in appearance and nontoxic appearing. A dermatologist is consulted for a recommendation for further workup or potential biopsy. The dermatologist examines the newborn. He is a well-appearing black boy with skin that is otherwise intact. A few pustules on the back are present that have a collarette of scale. The dermatologist reviews the mother’s prenatal history and the review shows that she was screened for syphilis and had a negative screening test with no other history of infectious diseases. What is the most appropriate next step to confirm your suspicions?

a. do a swab of a pustule and send it for viral culture
b. have his blood drawn and check for signs of neonatal herpes simplex virus infection
c. perform a biopsy of a pustule
d. perform a Giemsa stain on a smear of the pustule
e. start treatment with permethrin

4. Which intraoral cysts occur on the alveolar ridge of a neonate?

a. Bohn nodule
b. branchial cleft cyst
c. Epstein pearls
d. median raphe cyst
e. palatal cysts of the newborn

5. Miliaria rubra is associated with inflammation of the sweat glands in what portion of the skin?

a. basement membrane zone
b. dermis
c. dermoepidermal junction
d. intraepidermal
e. subcutis

The New Year brings new leadership in the United States, with President-elect Donald Trump taking office later this month. With a Republican-controlled Congress, party leaders have the opportunity to shape the nation’s policies around conservative ideals. This includes health care.

Since the Affordable Care Act (ACA) was passed in 2010, Republicans have vowed to repeal and replace it. This could be their opportunity.

However, “there is no clear coalescence around specific policy reforms that would replace the Affordable Care Act,” says Christine Eibner, PhD, a senior economist at Rand and a professor at the Pardee Rand Graduate School.

As a candidate, Trump did little to advance policy ideas around health care. Meanwhile, House Speaker Paul Ryan (R-Wis.) and others have, over the years, proposed reforms with which Trump may or may not agree.

Where we stand January 2017

Whether the Republicans can or will repeal the ACA in its entirety and improve it remains unknown. But, the experts say, the landmark law has left its mark on the American health care system.

“Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years,” says Ron Greeno, MD, FCCP, MHM, senior advisor for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect. “There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty.”

In an analysis for the Commonwealth Fund, Dr. Eibner investigated the economic implications of aspects of Trump’s plans as a candidate. Using a computer model that incorporates economic theory and data to simulate the effects of health policy changes, Dr. Eibner found that Trump’s plans (full repeal alone or repeal with tax deductions for health care premiums, Medicaid block grants, or selling health insurance across state lines) would increase the number of uninsured people by 16 million to 25 million, disproportionately impact low-income and sicker patients, expose individual market enrollees to higher out-of-pocket costs, and increase the federal deficit by $0.5 billion to $41 billion.¹ The Congressional Budget Office (CBO) estimates full repeal could increase the federal deficit by $137 billion to $353 billion by 2025.² Rep. Ryan’s plan, A Better Way, proposes providing people more control over their health care, giving tax credits instead of subsidies for premiums, capping the employer-sponsored health insurance tax exclusion, and expanding use of health savings accounts.³ However, Rep. Ryan’s plan “doesn’t reduce the cost of health care. It puts more onus on individuals, and their costs go up,” Ms. Hoffman says. “The weight of that will be more on people who have preexisting conditions.”

Key provisions: A delicate balance

Many people equate the ACA with the individual mandate, which requires nearly all Americans to purchase health insurance or pay a fine. The federal government provides subsidies to enrollees between 138% and 400% of the federal poverty level so their out-of-pocket costs never exceed a defined threshold even if premiums go up. These could be on the chopping block.

“The last bill Congress passed to repeal the Affordable Care Act, which Obama vetoed, repealed the individual mandate and subsidies for people to buy insurance,” Ms. Hoffman says. “If they do repeal it, private insurance through the exchanges will crumble.”

Mr. Trump’s tax deductions to offset premium costs are based on income, making them more generous for higher-income earners than low-income ones, Hoffman adds.

And … Medicare

The other entitlement program facing abrupt change is Medicare, typically considered the third rail of American politics.

“This is the hot political moment,” Ms. Hoffman says. “This is the point where the Republicans think they can tick off their wish list. For many Republicans, this kind of entitlement program is the opposite of what they believe in.”

Though Mr. Trump has said before he would not alter Medicare, he remained quiet on this point in the aftermath of the election. Repealing the ACA would affect Medicare by potentially reopening the Part D prescription drug doughnut hole and eliminating some of the savings provisions in the law. In fact, the CBO estimates Medicare’s direct spending would increase $802 billion between 2016 and 2025.¹ Rep. Ryan has talked about privatizing Medicare by offering seniors who rely on it vouchers to apply toward private insurance.

“At the highest level, it’s moving Medicare from a defined benefit to a defined contribution program,” Ms. Hoffman says. “It shifts financial risk from the federal government onto beneficiaries. If Medicare spending continues to grow faster than the rest of the economy, Medicare beneficiaries will pay more and more.”

Seniors may also find themselves rationing or skimping on care.

Despite Rep. Ryan’s statements to the contrary, Medicare is not broken because of the ACA, Ms. Hoffman says. Its solvency has been prolonged, and though the reasons are not clear, Medicare spending has slowed since the passage of the ACA.⁶

MACRA launch

Another key factor in the health care policy landscape is MACRA, the Medicare Access and CHIP Reauthorization Act, which fundamentally shifts the way the government administrates and reimburses physicians for health care. MACRA begins in 2017. Dr. Greeno is concerned that changes to the ACA will impact the testing of payment models CMS is testing.

“There are hundreds of hospitals and thousands of physicians already invested in different models, so I don’t expect anybody has any desire to pull the rug from under physicians who are testing alternative payment models [APMs],” he says. “MACRA was passed on a strong bipartisan vote, and it created an APM track. Obviously, Congress intended APM models to continue to expand.”

Dr. Greeno says hospitalists are helping “shape these models,” working with the CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to ensure physicians participate in APMs and feel engaged rather than being a worker in a model someone else controls.”

On the campaign trail, Mr. Trump spoke of importing pharmaceuticals from overseas in an effort to control high prices. This policy is no longer part of his online plan. He also proposes allowing the sale of health insurance across state lines.

“It would be giving enrollees in states with stricter regulations the opportunity to circumvent to a looser state, which undermines the state with the stricter regulations,” Dr. Eibner says. “That would really create winners and losers. People who are healthy can buy a policy in a state with looser regulations, and their costs would likely fall. But someone sicker and older, it would be harder.”

Ms. Hoffman defines such a plan as a “race to the bottom.” Without well-established networks of physicians and hospitals, startup costs in new states are prohibitive, and many insurers may not wish to compete across state lines, she adds.

Repeal of the ACA could also limit some of the health benefits it required of plans on the individual market. For example, policymakers might be allowed to strip the contraceptive coverage regulation, which provides for free birth control.

“The reality is a lot of things changing in health care now were changing before the Affordable Care Act passed – PQRS, value-based purchasing, hospital-acquired infections,” Dr. Greeno says. “MACRA will continue the journey away from fee-for-service toward outcome-based models.”

At such a pivotal time, he strongly encourages hospitalists to join SHM if they are not already members and to get involved in SHM’s Grassroots Network.

“For a society of our age – young – and size, we’ve been tremendously impactful in helping with delivery system reform,” Dr. Greeno says. “I think it’s because we’re supporting change, not trying to stop it. We just want it to be intelligent change.”

He also is “convinced” hospitalists will be “critical to the redesign of the health care system. Since we are going to be taking care of the majority of hospitalized adult patients in hospitals, hospitalists want to have our say.” 

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Eibner C. Donald Trump’s health care reform proposals: Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund website. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal. Accessed Nov. 17, 2016.

2. Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Available at: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016.

3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed Nov. 17, 2016.

4. Pollitz K. High-risk pools for uninsurable individuals. Kaiser Family Foundation website. Available at: http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/. Accessed Nov. 17, 2016.

5. How accessible is individual health insurance for consumers in less-than-ideal health? Kaiser Family Foundation website. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-is-individual-health-insurance-for-consumer-in-less-than-perfect-health-report.pdf. Accessed Nov. 17, 2016.

6. The Affordable Care Act and Medicare. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/publications/fund-reports/2015/jun/medicare-affordable-care-act Accessed Nov. 17, 2016.

The New Year brings new leadership in the United States, with President-elect Donald Trump taking office later this month. With a Republican-controlled Congress, party leaders have the opportunity to shape the nation’s policies around conservative ideals. This includes health care.

Since the Affordable Care Act (ACA) was passed in 2010, Republicans have vowed to repeal and replace it. This could be their opportunity.

However, “there is no clear coalescence around specific policy reforms that would replace the Affordable Care Act,” says Christine Eibner, PhD, a senior economist at Rand and a professor at the Pardee Rand Graduate School.

As a candidate, Trump did little to advance policy ideas around health care. Meanwhile, House Speaker Paul Ryan (R-Wis.) and others have, over the years, proposed reforms with which Trump may or may not agree.

Where we stand January 2017

Whether the Republicans can or will repeal the ACA in its entirety and improve it remains unknown. But, the experts say, the landmark law has left its mark on the American health care system.

“Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years,” says Ron Greeno, MD, FCCP, MHM, senior advisor for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect. “There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty.”

In an analysis for the Commonwealth Fund, Dr. Eibner investigated the economic implications of aspects of Trump’s plans as a candidate. Using a computer model that incorporates economic theory and data to simulate the effects of health policy changes, Dr. Eibner found that Trump’s plans (full repeal alone or repeal with tax deductions for health care premiums, Medicaid block grants, or selling health insurance across state lines) would increase the number of uninsured people by 16 million to 25 million, disproportionately impact low-income and sicker patients, expose individual market enrollees to higher out-of-pocket costs, and increase the federal deficit by $0.5 billion to $41 billion.¹ The Congressional Budget Office (CBO) estimates full repeal could increase the federal deficit by $137 billion to $353 billion by 2025.² Rep. Ryan’s plan, A Better Way, proposes providing people more control over their health care, giving tax credits instead of subsidies for premiums, capping the employer-sponsored health insurance tax exclusion, and expanding use of health savings accounts.³ However, Rep. Ryan’s plan “doesn’t reduce the cost of health care. It puts more onus on individuals, and their costs go up,” Ms. Hoffman says. “The weight of that will be more on people who have preexisting conditions.”

Key provisions: A delicate balance

Many people equate the ACA with the individual mandate, which requires nearly all Americans to purchase health insurance or pay a fine. The federal government provides subsidies to enrollees between 138% and 400% of the federal poverty level so their out-of-pocket costs never exceed a defined threshold even if premiums go up. These could be on the chopping block.

“The last bill Congress passed to repeal the Affordable Care Act, which Obama vetoed, repealed the individual mandate and subsidies for people to buy insurance,” Ms. Hoffman says. “If they do repeal it, private insurance through the exchanges will crumble.”

Mr. Trump’s tax deductions to offset premium costs are based on income, making them more generous for higher-income earners than low-income ones, Hoffman adds.

And … Medicare

The other entitlement program facing abrupt change is Medicare, typically considered the third rail of American politics.

“This is the hot political moment,” Ms. Hoffman says. “This is the point where the Republicans think they can tick off their wish list. For many Republicans, this kind of entitlement program is the opposite of what they believe in.”

Though Mr. Trump has said before he would not alter Medicare, he remained quiet on this point in the aftermath of the election. Repealing the ACA would affect Medicare by potentially reopening the Part D prescription drug doughnut hole and eliminating some of the savings provisions in the law. In fact, the CBO estimates Medicare’s direct spending would increase $802 billion between 2016 and 2025.¹ Rep. Ryan has talked about privatizing Medicare by offering seniors who rely on it vouchers to apply toward private insurance.

“At the highest level, it’s moving Medicare from a defined benefit to a defined contribution program,” Ms. Hoffman says. “It shifts financial risk from the federal government onto beneficiaries. If Medicare spending continues to grow faster than the rest of the economy, Medicare beneficiaries will pay more and more.”

Seniors may also find themselves rationing or skimping on care.

Despite Rep. Ryan’s statements to the contrary, Medicare is not broken because of the ACA, Ms. Hoffman says. Its solvency has been prolonged, and though the reasons are not clear, Medicare spending has slowed since the passage of the ACA.⁶

MACRA launch

Another key factor in the health care policy landscape is MACRA, the Medicare Access and CHIP Reauthorization Act, which fundamentally shifts the way the government administrates and reimburses physicians for health care. MACRA begins in 2017. Dr. Greeno is concerned that changes to the ACA will impact the testing of payment models CMS is testing.

“There are hundreds of hospitals and thousands of physicians already invested in different models, so I don’t expect anybody has any desire to pull the rug from under physicians who are testing alternative payment models [APMs],” he says. “MACRA was passed on a strong bipartisan vote, and it created an APM track. Obviously, Congress intended APM models to continue to expand.”

Dr. Greeno says hospitalists are helping “shape these models,” working with the CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to ensure physicians participate in APMs and feel engaged rather than being a worker in a model someone else controls.”

On the campaign trail, Mr. Trump spoke of importing pharmaceuticals from overseas in an effort to control high prices. This policy is no longer part of his online plan. He also proposes allowing the sale of health insurance across state lines.

“It would be giving enrollees in states with stricter regulations the opportunity to circumvent to a looser state, which undermines the state with the stricter regulations,” Dr. Eibner says. “That would really create winners and losers. People who are healthy can buy a policy in a state with looser regulations, and their costs would likely fall. But someone sicker and older, it would be harder.”

Ms. Hoffman defines such a plan as a “race to the bottom.” Without well-established networks of physicians and hospitals, startup costs in new states are prohibitive, and many insurers may not wish to compete across state lines, she adds.

Repeal of the ACA could also limit some of the health benefits it required of plans on the individual market. For example, policymakers might be allowed to strip the contraceptive coverage regulation, which provides for free birth control.

“The reality is a lot of things changing in health care now were changing before the Affordable Care Act passed – PQRS, value-based purchasing, hospital-acquired infections,” Dr. Greeno says. “MACRA will continue the journey away from fee-for-service toward outcome-based models.”

At such a pivotal time, he strongly encourages hospitalists to join SHM if they are not already members and to get involved in SHM’s Grassroots Network.

“For a society of our age – young – and size, we’ve been tremendously impactful in helping with delivery system reform,” Dr. Greeno says. “I think it’s because we’re supporting change, not trying to stop it. We just want it to be intelligent change.”

He also is “convinced” hospitalists will be “critical to the redesign of the health care system. Since we are going to be taking care of the majority of hospitalized adult patients in hospitals, hospitalists want to have our say.” 

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Eibner C. Donald Trump’s health care reform proposals: Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund website. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal. Accessed Nov. 17, 2016.

2. Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Available at: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016.

3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed Nov. 17, 2016.

4. Pollitz K. High-risk pools for uninsurable individuals. Kaiser Family Foundation website. Available at: http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/. Accessed Nov. 17, 2016.

5. How accessible is individual health insurance for consumers in less-than-ideal health? Kaiser Family Foundation website. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-is-individual-health-insurance-for-consumer-in-less-than-perfect-health-report.pdf. Accessed Nov. 17, 2016.

6. The Affordable Care Act and Medicare. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/publications/fund-reports/2015/jun/medicare-affordable-care-act Accessed Nov. 17, 2016.

The New Year brings new leadership in the United States, with President-elect Donald Trump taking office later this month. With a Republican-controlled Congress, party leaders have the opportunity to shape the nation’s policies around conservative ideals. This includes health care.

Since the Affordable Care Act (ACA) was passed in 2010, Republicans have vowed to repeal and replace it. This could be their opportunity.

However, “there is no clear coalescence around specific policy reforms that would replace the Affordable Care Act,” says Christine Eibner, PhD, a senior economist at Rand and a professor at the Pardee Rand Graduate School.

As a candidate, Trump did little to advance policy ideas around health care. Meanwhile, House Speaker Paul Ryan (R-Wis.) and others have, over the years, proposed reforms with which Trump may or may not agree.

Where we stand January 2017

Whether the Republicans can or will repeal the ACA in its entirety and improve it remains unknown. But, the experts say, the landmark law has left its mark on the American health care system.

“Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years,” says Ron Greeno, MD, FCCP, MHM, senior advisor for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect. “There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty.”

In an analysis for the Commonwealth Fund, Dr. Eibner investigated the economic implications of aspects of Trump’s plans as a candidate. Using a computer model that incorporates economic theory and data to simulate the effects of health policy changes, Dr. Eibner found that Trump’s plans (full repeal alone or repeal with tax deductions for health care premiums, Medicaid block grants, or selling health insurance across state lines) would increase the number of uninsured people by 16 million to 25 million, disproportionately impact low-income and sicker patients, expose individual market enrollees to higher out-of-pocket costs, and increase the federal deficit by $0.5 billion to $41 billion.¹ The Congressional Budget Office (CBO) estimates full repeal could increase the federal deficit by $137 billion to $353 billion by 2025.² Rep. Ryan’s plan, A Better Way, proposes providing people more control over their health care, giving tax credits instead of subsidies for premiums, capping the employer-sponsored health insurance tax exclusion, and expanding use of health savings accounts.³ However, Rep. Ryan’s plan “doesn’t reduce the cost of health care. It puts more onus on individuals, and their costs go up,” Ms. Hoffman says. “The weight of that will be more on people who have preexisting conditions.”

Key provisions: A delicate balance

Many people equate the ACA with the individual mandate, which requires nearly all Americans to purchase health insurance or pay a fine. The federal government provides subsidies to enrollees between 138% and 400% of the federal poverty level so their out-of-pocket costs never exceed a defined threshold even if premiums go up. These could be on the chopping block.

“The last bill Congress passed to repeal the Affordable Care Act, which Obama vetoed, repealed the individual mandate and subsidies for people to buy insurance,” Ms. Hoffman says. “If they do repeal it, private insurance through the exchanges will crumble.”

Mr. Trump’s tax deductions to offset premium costs are based on income, making them more generous for higher-income earners than low-income ones, Hoffman adds.

And … Medicare

The other entitlement program facing abrupt change is Medicare, typically considered the third rail of American politics.

“This is the hot political moment,” Ms. Hoffman says. “This is the point where the Republicans think they can tick off their wish list. For many Republicans, this kind of entitlement program is the opposite of what they believe in.”

Though Mr. Trump has said before he would not alter Medicare, he remained quiet on this point in the aftermath of the election. Repealing the ACA would affect Medicare by potentially reopening the Part D prescription drug doughnut hole and eliminating some of the savings provisions in the law. In fact, the CBO estimates Medicare’s direct spending would increase $802 billion between 2016 and 2025.¹ Rep. Ryan has talked about privatizing Medicare by offering seniors who rely on it vouchers to apply toward private insurance.

“At the highest level, it’s moving Medicare from a defined benefit to a defined contribution program,” Ms. Hoffman says. “It shifts financial risk from the federal government onto beneficiaries. If Medicare spending continues to grow faster than the rest of the economy, Medicare beneficiaries will pay more and more.”

Seniors may also find themselves rationing or skimping on care.

Despite Rep. Ryan’s statements to the contrary, Medicare is not broken because of the ACA, Ms. Hoffman says. Its solvency has been prolonged, and though the reasons are not clear, Medicare spending has slowed since the passage of the ACA.⁶

MACRA launch

Another key factor in the health care policy landscape is MACRA, the Medicare Access and CHIP Reauthorization Act, which fundamentally shifts the way the government administrates and reimburses physicians for health care. MACRA begins in 2017. Dr. Greeno is concerned that changes to the ACA will impact the testing of payment models CMS is testing.

“There are hundreds of hospitals and thousands of physicians already invested in different models, so I don’t expect anybody has any desire to pull the rug from under physicians who are testing alternative payment models [APMs],” he says. “MACRA was passed on a strong bipartisan vote, and it created an APM track. Obviously, Congress intended APM models to continue to expand.”

Dr. Greeno says hospitalists are helping “shape these models,” working with the CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to ensure physicians participate in APMs and feel engaged rather than being a worker in a model someone else controls.”

On the campaign trail, Mr. Trump spoke of importing pharmaceuticals from overseas in an effort to control high prices. This policy is no longer part of his online plan. He also proposes allowing the sale of health insurance across state lines.

“It would be giving enrollees in states with stricter regulations the opportunity to circumvent to a looser state, which undermines the state with the stricter regulations,” Dr. Eibner says. “That would really create winners and losers. People who are healthy can buy a policy in a state with looser regulations, and their costs would likely fall. But someone sicker and older, it would be harder.”

Ms. Hoffman defines such a plan as a “race to the bottom.” Without well-established networks of physicians and hospitals, startup costs in new states are prohibitive, and many insurers may not wish to compete across state lines, she adds.

Repeal of the ACA could also limit some of the health benefits it required of plans on the individual market. For example, policymakers might be allowed to strip the contraceptive coverage regulation, which provides for free birth control.

“The reality is a lot of things changing in health care now were changing before the Affordable Care Act passed – PQRS, value-based purchasing, hospital-acquired infections,” Dr. Greeno says. “MACRA will continue the journey away from fee-for-service toward outcome-based models.”

At such a pivotal time, he strongly encourages hospitalists to join SHM if they are not already members and to get involved in SHM’s Grassroots Network.

“For a society of our age – young – and size, we’ve been tremendously impactful in helping with delivery system reform,” Dr. Greeno says. “I think it’s because we’re supporting change, not trying to stop it. We just want it to be intelligent change.”

He also is “convinced” hospitalists will be “critical to the redesign of the health care system. Since we are going to be taking care of the majority of hospitalized adult patients in hospitals, hospitalists want to have our say.” 

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Eibner C. Donald Trump’s health care reform proposals: Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund website. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal. Accessed Nov. 17, 2016.

2. Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Available at: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016.

3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed Nov. 17, 2016.

4. Pollitz K. High-risk pools for uninsurable individuals. Kaiser Family Foundation website. Available at: http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/. Accessed Nov. 17, 2016.

5. How accessible is individual health insurance for consumers in less-than-ideal health? Kaiser Family Foundation website. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-is-individual-health-insurance-for-consumer-in-less-than-perfect-health-report.pdf. Accessed Nov. 17, 2016.

6. The Affordable Care Act and Medicare. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/publications/fund-reports/2015/jun/medicare-affordable-care-act Accessed Nov. 17, 2016.

Over the last 2 decades, the number of teen females involved in competitive sports has skyrocketed. Research studies continue to show that girls involved in sports have better self-esteem and reduce the risk of obesity.But this involvement in competitive sports has not come without a cost. Recent studies have shown that females are four to six times more likely to tear their anterior cruciate ligament (ACL) than are their male counterparts playing the same sport.^1,2 But why is this? And can it be prevented?

Researchers have spent countless hours studying videos to better determine why females are at greater risk. Their findings showed that there were many contributing factors for the difference between the sexes. The general mechanics that put the ACL at risk are landing on an extended knee, the center of mass being off the base, and internal rotation and adduction of the knee. These combined movements put the ACL at its most vulnerable position.

Reference

1. Pediatrics. 2014 May;133(5):e1437-50

2. Bull Hosp Jt Dis. 2000;59(4):217-26

3. Clin Biomech (Bristol, Avon). 2006 Dec;21(10):1060-6

4. Am J Phys Med Rehabil. 2005 Feb;84(2):122-30

5. Am J Sports Med. 2008 Aug;36(8):1476-83

6. Curr Womens Health Rep. 2001 Dec;1(3):218-24

Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at [email protected].

Over the last 2 decades, the number of teen females involved in competitive sports has skyrocketed. Research studies continue to show that girls involved in sports have better self-esteem and reduce the risk of obesity.But this involvement in competitive sports has not come without a cost. Recent studies have shown that females are four to six times more likely to tear their anterior cruciate ligament (ACL) than are their male counterparts playing the same sport.^1,2 But why is this? And can it be prevented?

Researchers have spent countless hours studying videos to better determine why females are at greater risk. Their findings showed that there were many contributing factors for the difference between the sexes. The general mechanics that put the ACL at risk are landing on an extended knee, the center of mass being off the base, and internal rotation and adduction of the knee. These combined movements put the ACL at its most vulnerable position.

Reference

1. Pediatrics. 2014 May;133(5):e1437-50

2. Bull Hosp Jt Dis. 2000;59(4):217-26

3. Clin Biomech (Bristol, Avon). 2006 Dec;21(10):1060-6

4. Am J Phys Med Rehabil. 2005 Feb;84(2):122-30

5. Am J Sports Med. 2008 Aug;36(8):1476-83

6. Curr Womens Health Rep. 2001 Dec;1(3):218-24

Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at [email protected].

Over the last 2 decades, the number of teen females involved in competitive sports has skyrocketed. Research studies continue to show that girls involved in sports have better self-esteem and reduce the risk of obesity.But this involvement in competitive sports has not come without a cost. Recent studies have shown that females are four to six times more likely to tear their anterior cruciate ligament (ACL) than are their male counterparts playing the same sport.^1,2 But why is this? And can it be prevented?

Researchers have spent countless hours studying videos to better determine why females are at greater risk. Their findings showed that there were many contributing factors for the difference between the sexes. The general mechanics that put the ACL at risk are landing on an extended knee, the center of mass being off the base, and internal rotation and adduction of the knee. These combined movements put the ACL at its most vulnerable position.

Reference

1. Pediatrics. 2014 May;133(5):e1437-50

2. Bull Hosp Jt Dis. 2000;59(4):217-26

3. Clin Biomech (Bristol, Avon). 2006 Dec;21(10):1060-6

4. Am J Phys Med Rehabil. 2005 Feb;84(2):122-30

5. Am J Sports Med. 2008 Aug;36(8):1476-83

6. Curr Womens Health Rep. 2001 Dec;1(3):218-24

Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at [email protected].

NEW ORLEANS – Depression increases the risk of stroke in patients with atrial fibrillation, Bruno B. Lima, MD, reported at the American Heart Association scientific sessions.

This novel finding from what’s believed to be the first prospective observational study to examine the association between depression and stroke risk in patients with atrial fibrillation (AF) raises the exciting possibility that systematic screening for depression and provision of effective antidepressant therapy in affected AF patients could reduce their risk of stroke. But clinical trials will be necessary to answer that question, noted Dr. Lima of the University of Pittsburgh.

[email protected]

NEW ORLEANS – Depression increases the risk of stroke in patients with atrial fibrillation, Bruno B. Lima, MD, reported at the American Heart Association scientific sessions.

This novel finding from what’s believed to be the first prospective observational study to examine the association between depression and stroke risk in patients with atrial fibrillation (AF) raises the exciting possibility that systematic screening for depression and provision of effective antidepressant therapy in affected AF patients could reduce their risk of stroke. But clinical trials will be necessary to answer that question, noted Dr. Lima of the University of Pittsburgh.

[email protected]

NEW ORLEANS – Depression increases the risk of stroke in patients with atrial fibrillation, Bruno B. Lima, MD, reported at the American Heart Association scientific sessions.

This novel finding from what’s believed to be the first prospective observational study to examine the association between depression and stroke risk in patients with atrial fibrillation (AF) raises the exciting possibility that systematic screening for depression and provision of effective antidepressant therapy in affected AF patients could reduce their risk of stroke. But clinical trials will be necessary to answer that question, noted Dr. Lima of the University of Pittsburgh.

[email protected]

NEW ORLEANS – Results of a first-of-its-kind nationwide U.K. cardiac disease screening program in the general population of teens and young adults indicate that incorporating a 12-lead ECG alongside history and physical examination not only increases the diagnostic yield for conditions predisposing to sudden cardiac death, but it’s actually cost saving, compared with screening by history and physical exam alone, Harshil Dhutia, MD, said at the American Heart Association scientific sessions.

Current practice in the United Kingdom and most other western countries, including the United States, is to screen for cardiac disease in the general population of young people by history and physical exam alone. Only those with symptoms or a positive family history on the initial screen go on to a more comprehensive evaluation including an ECG. The ECG isn’t part of the initial screen primarily because of cost concerns. However, those concerns are based upon conjecture. The diagnostic and financial implications of routine screening by 12-lead ECG in the general population of young people hadn’t been examined prior to the nationwide U.K. screening program – and the results of the U.K. project indicate it’s time for a change in policy, according to Dr. Dhutia, a cardiology research fellow at St. George’s University in London.

The screening project, known as the Cardiac Risk in the Young Program, included 26,900 subjects aged 14-35 years without known cardiovascular disease who responded to public service announcements and voluntarily presented for screening at schools, community centers, and health centers across the U.K. during 2011-2013. The mean age of the subjects was 19.4 years, roughly two-thirds were male, and 90% were white. All screening was performed by cardiologists who followed the AHA protocol for history-taking, performed the physical exam, and followed the European Society of Cardiology 2010 recommendations for ECG interpretation. Individuals with a positive screen were referred to their local hospital for further investigation. Participants were prospectively followed for 2 years.

“This was the first study of comprehensive cardiovascular screening of young individuals outside competitive sport,” Dr. Dhutia noted.

Among the key findings: 3.5% of subjects were deemed by their screening cardiologist to have an abnormal history and/or physical exam warranting further investigation, 8.1% had an abnormal 12-lead ECG, and 0.5% had both. Overall, 11.7% of subjects underwent echocardiography to confirm or refute a diagnosis of cardiac disease, 1.7% underwent Holter monitoring, 1.7% had an exercise stress test, and 0.9% underwent cardiac MRI.

At 2 years of follow-up, 87 individuals, or 0.3% of the overall study cohort, had been diagnosed with a serious cardiac disease predisposing to sudden cardiac death.

“The vast majority of these individuals were asymptomatic and diagnosed on the basis of an ECG abnormality,” Dr. Dhutia observed.

Indeed, 72 of the 87 patients with serious cardiac disease were diagnosed on the basis on their abnormal ECG. This tool proved particularly helpful in identifying individuals with cardiomyopathies or congenital accessory pathways, such as Wolff-Parkinson-White syndrome or long QT syndrome. At 2 years of follow-up, 42 of these 72 patients were on disease-modifying therapies beyond lifestyle interventions, most commonly ablation procedures or antiarrhythmic medication.

The history and physical exam was useful in identifying young people with channelopathies or Marfan syndrome. Roughly half of individuals identified by history and physical exam as having serious cardiac disease were on antiarrhythmic medication – or, less commonly, pacemaker therapy – at 2 years follow-up.

The overall cost per individual screened using history, physical exam, and ECG amounted to $110 on the basis of U.K. National Health Service rates. The cost per serious cardiac condition identified was $33,927. In contrast, the average cost per serious cardiac diagnosis under the current U.K. protocol of screening youth by history and physical exam only is 67% greater, at $56,597.

“Inclusion of ECG to history and physical examination is associated with a significantly improved diagnostic yield and superior economic profile. These findings have the potential to influence health care policy and certainly suggest that the National Health Service framework in the United Kingdom is counterintuitive and may warrant revision,” he concluded.

Session moderator Nisha Parikh, MD, of the University of California, San Francisco, asked if Dr. Dhutia and his coinvestigators had identified any characteristics associated with serious occult cardiac disease in adolescents and young adults that would permit a more refined, selective approach to screening.

Not in the general population of nearly 27,000 subjects in the U.K. study, he replied. Competitive athletes are a different story, though.

“In competitive athletes, certainly individuals who play stop/start sports such as basketball or football [soccer], appear to be at higher risk, especially those of Afro-Caribbean origin. The incidence of sudden cardiac death in Afro-Caribbean basketball players is 1 in 3,000,” according to Dr. Dhutia, who discussed his findings in a video interview.

He reported receiving a small research grant for his study from the Cardiac Risk in the Young Program, a U.K. charitable organization.

[email protected]
 

NEW ORLEANS – Results of a first-of-its-kind nationwide U.K. cardiac disease screening program in the general population of teens and young adults indicate that incorporating a 12-lead ECG alongside history and physical examination not only increases the diagnostic yield for conditions predisposing to sudden cardiac death, but it’s actually cost saving, compared with screening by history and physical exam alone, Harshil Dhutia, MD, said at the American Heart Association scientific sessions.

Current practice in the United Kingdom and most other western countries, including the United States, is to screen for cardiac disease in the general population of young people by history and physical exam alone. Only those with symptoms or a positive family history on the initial screen go on to a more comprehensive evaluation including an ECG. The ECG isn’t part of the initial screen primarily because of cost concerns. However, those concerns are based upon conjecture. The diagnostic and financial implications of routine screening by 12-lead ECG in the general population of young people hadn’t been examined prior to the nationwide U.K. screening program – and the results of the U.K. project indicate it’s time for a change in policy, according to Dr. Dhutia, a cardiology research fellow at St. George’s University in London.

The screening project, known as the Cardiac Risk in the Young Program, included 26,900 subjects aged 14-35 years without known cardiovascular disease who responded to public service announcements and voluntarily presented for screening at schools, community centers, and health centers across the U.K. during 2011-2013. The mean age of the subjects was 19.4 years, roughly two-thirds were male, and 90% were white. All screening was performed by cardiologists who followed the AHA protocol for history-taking, performed the physical exam, and followed the European Society of Cardiology 2010 recommendations for ECG interpretation. Individuals with a positive screen were referred to their local hospital for further investigation. Participants were prospectively followed for 2 years.

“This was the first study of comprehensive cardiovascular screening of young individuals outside competitive sport,” Dr. Dhutia noted.

Among the key findings: 3.5% of subjects were deemed by their screening cardiologist to have an abnormal history and/or physical exam warranting further investigation, 8.1% had an abnormal 12-lead ECG, and 0.5% had both. Overall, 11.7% of subjects underwent echocardiography to confirm or refute a diagnosis of cardiac disease, 1.7% underwent Holter monitoring, 1.7% had an exercise stress test, and 0.9% underwent cardiac MRI.

At 2 years of follow-up, 87 individuals, or 0.3% of the overall study cohort, had been diagnosed with a serious cardiac disease predisposing to sudden cardiac death.

“The vast majority of these individuals were asymptomatic and diagnosed on the basis of an ECG abnormality,” Dr. Dhutia observed.

Indeed, 72 of the 87 patients with serious cardiac disease were diagnosed on the basis on their abnormal ECG. This tool proved particularly helpful in identifying individuals with cardiomyopathies or congenital accessory pathways, such as Wolff-Parkinson-White syndrome or long QT syndrome. At 2 years of follow-up, 42 of these 72 patients were on disease-modifying therapies beyond lifestyle interventions, most commonly ablation procedures or antiarrhythmic medication.

The history and physical exam was useful in identifying young people with channelopathies or Marfan syndrome. Roughly half of individuals identified by history and physical exam as having serious cardiac disease were on antiarrhythmic medication – or, less commonly, pacemaker therapy – at 2 years follow-up.

The overall cost per individual screened using history, physical exam, and ECG amounted to $110 on the basis of U.K. National Health Service rates. The cost per serious cardiac condition identified was $33,927. In contrast, the average cost per serious cardiac diagnosis under the current U.K. protocol of screening youth by history and physical exam only is 67% greater, at $56,597.

“Inclusion of ECG to history and physical examination is associated with a significantly improved diagnostic yield and superior economic profile. These findings have the potential to influence health care policy and certainly suggest that the National Health Service framework in the United Kingdom is counterintuitive and may warrant revision,” he concluded.

Session moderator Nisha Parikh, MD, of the University of California, San Francisco, asked if Dr. Dhutia and his coinvestigators had identified any characteristics associated with serious occult cardiac disease in adolescents and young adults that would permit a more refined, selective approach to screening.

Not in the general population of nearly 27,000 subjects in the U.K. study, he replied. Competitive athletes are a different story, though.

“In competitive athletes, certainly individuals who play stop/start sports such as basketball or football [soccer], appear to be at higher risk, especially those of Afro-Caribbean origin. The incidence of sudden cardiac death in Afro-Caribbean basketball players is 1 in 3,000,” according to Dr. Dhutia, who discussed his findings in a video interview.

He reported receiving a small research grant for his study from the Cardiac Risk in the Young Program, a U.K. charitable organization.

[email protected]
 

NEW ORLEANS – Results of a first-of-its-kind nationwide U.K. cardiac disease screening program in the general population of teens and young adults indicate that incorporating a 12-lead ECG alongside history and physical examination not only increases the diagnostic yield for conditions predisposing to sudden cardiac death, but it’s actually cost saving, compared with screening by history and physical exam alone, Harshil Dhutia, MD, said at the American Heart Association scientific sessions.

Current practice in the United Kingdom and most other western countries, including the United States, is to screen for cardiac disease in the general population of young people by history and physical exam alone. Only those with symptoms or a positive family history on the initial screen go on to a more comprehensive evaluation including an ECG. The ECG isn’t part of the initial screen primarily because of cost concerns. However, those concerns are based upon conjecture. The diagnostic and financial implications of routine screening by 12-lead ECG in the general population of young people hadn’t been examined prior to the nationwide U.K. screening program – and the results of the U.K. project indicate it’s time for a change in policy, according to Dr. Dhutia, a cardiology research fellow at St. George’s University in London.

The screening project, known as the Cardiac Risk in the Young Program, included 26,900 subjects aged 14-35 years without known cardiovascular disease who responded to public service announcements and voluntarily presented for screening at schools, community centers, and health centers across the U.K. during 2011-2013. The mean age of the subjects was 19.4 years, roughly two-thirds were male, and 90% were white. All screening was performed by cardiologists who followed the AHA protocol for history-taking, performed the physical exam, and followed the European Society of Cardiology 2010 recommendations for ECG interpretation. Individuals with a positive screen were referred to their local hospital for further investigation. Participants were prospectively followed for 2 years.

“This was the first study of comprehensive cardiovascular screening of young individuals outside competitive sport,” Dr. Dhutia noted.

Among the key findings: 3.5% of subjects were deemed by their screening cardiologist to have an abnormal history and/or physical exam warranting further investigation, 8.1% had an abnormal 12-lead ECG, and 0.5% had both. Overall, 11.7% of subjects underwent echocardiography to confirm or refute a diagnosis of cardiac disease, 1.7% underwent Holter monitoring, 1.7% had an exercise stress test, and 0.9% underwent cardiac MRI.

At 2 years of follow-up, 87 individuals, or 0.3% of the overall study cohort, had been diagnosed with a serious cardiac disease predisposing to sudden cardiac death.

“The vast majority of these individuals were asymptomatic and diagnosed on the basis of an ECG abnormality,” Dr. Dhutia observed.

Indeed, 72 of the 87 patients with serious cardiac disease were diagnosed on the basis on their abnormal ECG. This tool proved particularly helpful in identifying individuals with cardiomyopathies or congenital accessory pathways, such as Wolff-Parkinson-White syndrome or long QT syndrome. At 2 years of follow-up, 42 of these 72 patients were on disease-modifying therapies beyond lifestyle interventions, most commonly ablation procedures or antiarrhythmic medication.

The history and physical exam was useful in identifying young people with channelopathies or Marfan syndrome. Roughly half of individuals identified by history and physical exam as having serious cardiac disease were on antiarrhythmic medication – or, less commonly, pacemaker therapy – at 2 years follow-up.

The overall cost per individual screened using history, physical exam, and ECG amounted to $110 on the basis of U.K. National Health Service rates. The cost per serious cardiac condition identified was $33,927. In contrast, the average cost per serious cardiac diagnosis under the current U.K. protocol of screening youth by history and physical exam only is 67% greater, at $56,597.

“Inclusion of ECG to history and physical examination is associated with a significantly improved diagnostic yield and superior economic profile. These findings have the potential to influence health care policy and certainly suggest that the National Health Service framework in the United Kingdom is counterintuitive and may warrant revision,” he concluded.

Session moderator Nisha Parikh, MD, of the University of California, San Francisco, asked if Dr. Dhutia and his coinvestigators had identified any characteristics associated with serious occult cardiac disease in adolescents and young adults that would permit a more refined, selective approach to screening.

Not in the general population of nearly 27,000 subjects in the U.K. study, he replied. Competitive athletes are a different story, though.

“In competitive athletes, certainly individuals who play stop/start sports such as basketball or football [soccer], appear to be at higher risk, especially those of Afro-Caribbean origin. The incidence of sudden cardiac death in Afro-Caribbean basketball players is 1 in 3,000,” according to Dr. Dhutia, who discussed his findings in a video interview.

He reported receiving a small research grant for his study from the Cardiac Risk in the Young Program, a U.K. charitable organization.

[email protected]
 

SAN DIEGO – Adding daratumumab (D) to lenalidomide and dexamethasone (Rd) significantly improved outcomes in relapsed and refractory multiple myeloma, even when patients had previously received lenalidomide, were refractory to bortezomib, or had high-risk tumor cytogenetics, based on updated analyses from the multicenter, randomized, phase III, open-label POLLUX trial.

The findings underscore the “significant benefit of combining daratumumab with lenalidomide and dexamethasone for relapsed or refractory multiple myeloma,” said lead investigator Philippe Moreau, MD, of University Hospital Hotel-Dieu in Nantes, France.

Amy Karon/Frontline Medical News

SAN DIEGO – Adding daratumumab (D) to lenalidomide and dexamethasone (Rd) significantly improved outcomes in relapsed and refractory multiple myeloma, even when patients had previously received lenalidomide, were refractory to bortezomib, or had high-risk tumor cytogenetics, based on updated analyses from the multicenter, randomized, phase III, open-label POLLUX trial.

The findings underscore the “significant benefit of combining daratumumab with lenalidomide and dexamethasone for relapsed or refractory multiple myeloma,” said lead investigator Philippe Moreau, MD, of University Hospital Hotel-Dieu in Nantes, France.

Amy Karon/Frontline Medical News

SAN DIEGO – Adding daratumumab (D) to lenalidomide and dexamethasone (Rd) significantly improved outcomes in relapsed and refractory multiple myeloma, even when patients had previously received lenalidomide, were refractory to bortezomib, or had high-risk tumor cytogenetics, based on updated analyses from the multicenter, randomized, phase III, open-label POLLUX trial.

The findings underscore the “significant benefit of combining daratumumab with lenalidomide and dexamethasone for relapsed or refractory multiple myeloma,” said lead investigator Philippe Moreau, MD, of University Hospital Hotel-Dieu in Nantes, France.

Amy Karon/Frontline Medical News

HOUSTON – A significant proportion of epilepsy patients in the United States are not taking newer antiepileptic medications, results from a pilot study suggested.

The finding comes from the Connectors Project, a collaboration between the Epilepsy Foundation and UCB Pharma that is intended to improve epilepsy patient care in underserved areas of the United States. One aim of the project is to evaluate the current status and geographic variations of antiepileptic drug (AED) use to identify regions where epilepsy care might be improved.

Doug Brunk/Frontline Medical News

[email protected]

HOUSTON – A significant proportion of epilepsy patients in the United States are not taking newer antiepileptic medications, results from a pilot study suggested.

The finding comes from the Connectors Project, a collaboration between the Epilepsy Foundation and UCB Pharma that is intended to improve epilepsy patient care in underserved areas of the United States. One aim of the project is to evaluate the current status and geographic variations of antiepileptic drug (AED) use to identify regions where epilepsy care might be improved.

Doug Brunk/Frontline Medical News

[email protected]

HOUSTON – A significant proportion of epilepsy patients in the United States are not taking newer antiepileptic medications, results from a pilot study suggested.

The finding comes from the Connectors Project, a collaboration between the Epilepsy Foundation and UCB Pharma that is intended to improve epilepsy patient care in underserved areas of the United States. One aim of the project is to evaluate the current status and geographic variations of antiepileptic drug (AED) use to identify regions where epilepsy care might be improved.

Doug Brunk/Frontline Medical News

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Access Dr. Burkman's Webcasts on contraception:

• Contraceptive considerations for women with headache and migraine
• Hormonal contraception and risk of venous thromboembolism
• Oral contraceptives and breast cancer: What’s the risk?
• Factors that contribute to overall contraceptive efficacy and risks
• Obesity and contraceptive efficacy and risks 
• How to use the CDC's online tools to manage complex cases in contraception

Helpful resources for your practice:

• United States Medical Eligibility Criteria for Contraceptive Use, 2016
• United States Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2010
• Summary Chart of US Medical Eligibility for Contraceptive Use
• Book recommendation: Allen RH, Cwiak CA, eds. Contraception for the medically challenging patient. New York, New York: Springer New York; 2014.

Access Dr. Burkman's Webcasts on contraception:

• Contraceptive considerations for women with headache and migraine
• Hormonal contraception and risk of venous thromboembolism
• Oral contraceptives and breast cancer: What’s the risk?
• Factors that contribute to overall contraceptive efficacy and risks
• Obesity and contraceptive efficacy and risks 
• How to use the CDC's online tools to manage complex cases in contraception

Helpful resources for your practice:

• United States Medical Eligibility Criteria for Contraceptive Use, 2016
• United States Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2010
• Summary Chart of US Medical Eligibility for Contraceptive Use
• Book recommendation: Allen RH, Cwiak CA, eds. Contraception for the medically challenging patient. New York, New York: Springer New York; 2014.

Access Dr. Burkman's Webcasts on contraception:

• Contraceptive considerations for women with headache and migraine
• Hormonal contraception and risk of venous thromboembolism
• Oral contraceptives and breast cancer: What’s the risk?
• Factors that contribute to overall contraceptive efficacy and risks
• Obesity and contraceptive efficacy and risks 
• How to use the CDC's online tools to manage complex cases in contraception

Helpful resources for your practice:

• United States Medical Eligibility Criteria for Contraceptive Use, 2016
• United States Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2010
• Summary Chart of US Medical Eligibility for Contraceptive Use
• Book recommendation: Allen RH, Cwiak CA, eds. Contraception for the medically challenging patient. New York, New York: Springer New York; 2014.

HOUSTON – About one in three children diagnosed with new-onset epilepsy presents with psychiatric diagnoses at the onset, results from a single-center study showed.

The finding “tells us that when kids are coming in, even if they’re only having psychiatric symptoms at their onset of epilepsy, they should be referred for some treatment to help them possibly mitigate the development of these psychiatric diagnoses in the first year,” lead study author Julia Doss, PsyD, said in an interview at annual meeting of the American Epilepsy Society.

Doug Brunk/Frontline Medical News

[email protected]

HOUSTON – About one in three children diagnosed with new-onset epilepsy presents with psychiatric diagnoses at the onset, results from a single-center study showed.

The finding “tells us that when kids are coming in, even if they’re only having psychiatric symptoms at their onset of epilepsy, they should be referred for some treatment to help them possibly mitigate the development of these psychiatric diagnoses in the first year,” lead study author Julia Doss, PsyD, said in an interview at annual meeting of the American Epilepsy Society.

Doug Brunk/Frontline Medical News

[email protected]

HOUSTON – About one in three children diagnosed with new-onset epilepsy presents with psychiatric diagnoses at the onset, results from a single-center study showed.

The finding “tells us that when kids are coming in, even if they’re only having psychiatric symptoms at their onset of epilepsy, they should be referred for some treatment to help them possibly mitigate the development of these psychiatric diagnoses in the first year,” lead study author Julia Doss, PsyD, said in an interview at annual meeting of the American Epilepsy Society.

Doug Brunk/Frontline Medical News

[email protected]

NEW ORLEANS – Women who experience peripartum cardiomyopathy or any of a variety of hypertensive disorders in pregnancy are at sharply increased risk of acute MI, stroke, or new-onset heart failure beginning within just a few years, Rima Arnaout, MD, reported at the American Heart Association scientific sessions.

“Our study supports the idea that women who have cardiovascular complications in pregnancy really need to be monitored closely for potential primary prevention of cardiovascular events,” said Dr. Arnaout of the University of California, San Francisco.

At a session devoted to “big data” studies in cardiovascular medicine, she presented one of the biggest: a retrospective cohort study of 1.66 million pregnancies during 2005-2009 in California women without any history of congenital or valvular heart disease or prepregnancy cardiovascular events. The California database was created as part of the U.S. Agency for Healthcare Research and Quality’s comprehensive Healthcare Cost and Utilization Project, which included more than 95% of the state’s hospitals. Women who experienced an MI or a stroke, or who were diagnosed with heart failure, during a median of 2.7 years and a maximum of 6 years of follow-up post pregnancy were identified via ICD-9 codes.

There were 111,202 cases of various forms of hypertension in pregnancy, for a 6.9% incidence. Peripartum cardiomyopathy was diagnosed in 562 women, for a rate of 3.5 cases per 10,000 pregnancies.

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NEW ORLEANS – Women who experience peripartum cardiomyopathy or any of a variety of hypertensive disorders in pregnancy are at sharply increased risk of acute MI, stroke, or new-onset heart failure beginning within just a few years, Rima Arnaout, MD, reported at the American Heart Association scientific sessions.

“Our study supports the idea that women who have cardiovascular complications in pregnancy really need to be monitored closely for potential primary prevention of cardiovascular events,” said Dr. Arnaout of the University of California, San Francisco.

At a session devoted to “big data” studies in cardiovascular medicine, she presented one of the biggest: a retrospective cohort study of 1.66 million pregnancies during 2005-2009 in California women without any history of congenital or valvular heart disease or prepregnancy cardiovascular events. The California database was created as part of the U.S. Agency for Healthcare Research and Quality’s comprehensive Healthcare Cost and Utilization Project, which included more than 95% of the state’s hospitals. Women who experienced an MI or a stroke, or who were diagnosed with heart failure, during a median of 2.7 years and a maximum of 6 years of follow-up post pregnancy were identified via ICD-9 codes.

There were 111,202 cases of various forms of hypertension in pregnancy, for a 6.9% incidence. Peripartum cardiomyopathy was diagnosed in 562 women, for a rate of 3.5 cases per 10,000 pregnancies.

[email protected]
 

NEW ORLEANS – Women who experience peripartum cardiomyopathy or any of a variety of hypertensive disorders in pregnancy are at sharply increased risk of acute MI, stroke, or new-onset heart failure beginning within just a few years, Rima Arnaout, MD, reported at the American Heart Association scientific sessions.

“Our study supports the idea that women who have cardiovascular complications in pregnancy really need to be monitored closely for potential primary prevention of cardiovascular events,” said Dr. Arnaout of the University of California, San Francisco.

At a session devoted to “big data” studies in cardiovascular medicine, she presented one of the biggest: a retrospective cohort study of 1.66 million pregnancies during 2005-2009 in California women without any history of congenital or valvular heart disease or prepregnancy cardiovascular events. The California database was created as part of the U.S. Agency for Healthcare Research and Quality’s comprehensive Healthcare Cost and Utilization Project, which included more than 95% of the state’s hospitals. Women who experienced an MI or a stroke, or who were diagnosed with heart failure, during a median of 2.7 years and a maximum of 6 years of follow-up post pregnancy were identified via ICD-9 codes.

There were 111,202 cases of various forms of hypertension in pregnancy, for a 6.9% incidence. Peripartum cardiomyopathy was diagnosed in 562 women, for a rate of 3.5 cases per 10,000 pregnancies.

[email protected]