User login
Age of blood doesn’t affect risk of death, study shows
Photo by Elise Amendola
Results of a large, international study suggest the risk of death after transfusion is not significantly affected by the age of blood transfused.
The median storage duration for the fresher blood used in this study was 11 days, and the median storage duration for older blood was 23 days.
The rate of death was 9.1% for the patients who received fresher blood and 8.8% for patients who received older blood (P=0.38).
Researchers reported these and other results from this study in NEJM.
“It’s been a contentious issue, but our study finally puts an end to the question about whether stored blood could be harmful and fresher blood would be better,” said study author Nancy Heddle, of McMaster University in Hamilton, Ontario, Canada.
“Our study provides strong evidence that transfusion of fresh blood does not improve patient outcomes, and this should reassure clinicians that fresher is not better.”
For this study, Heddle and her colleagues enrolled 31,497 adult patients treated at hospitals in Australia, Canada, Israel, and the US. However, 6761 patients did not meet all the enrollment criteria and were excluded after randomization.
A and O blood types
The researchers’ primary analysis included only patients with type A or O blood. Of these 20,858 patients, 6936 were assigned to receive blood stored for a shorter period, and 13,922 were assigned to receive blood stored for a longer period.
The mean storage duration was 13.0 ± 7.6 days in the short-term group and 23.6 ± 8.9 days in the long-term group. The median storage duration was 11 days (range, 8-16) and 23 days (range, 16-31), respectively.
The rate of death was 9.1% (n=634) in the short-term storage group and 8.7% (n=1213) in the long-term storage group. The odds ratio was 1.05 (95% CI, 0.95 to 1.16; P=0.34).
All blood types
The researchers also analyzed patients with any blood type. Of the 24,736 patients studied, 8215 were assigned to receive blood stored for a shorter period, and 16,521 were assigned to receive blood stored for a longer period.
The mean storage duration was 13.4 ± 7.7 days in the short-term group and 23.6 ± 8.9 days in the long-term group. The median storage duration was 11 days (range, 8-17) and 23 days (range, 16-31), respectively.
The rate of death was 9.1% (n=750) in the short-term storage group and 8.8% (n=1446) in the long-term storage group. The odds ratio was 1.04 (95% CI, 0.95 to 1.14; P=0.38).
The researchers said the overall results were similar to those observed in 3 pre-specified high-risk subgroups—patients undergoing cardiovascular surgery, individuals admitted to intensive care, and patients with cancer.
“Advances in blood storage now allow blood to be stored up to 42 days before transfusion, and the usual practice is to use up the blood that has been in storage the longest,” said study author John Eikelboom, MD, also of McMaster University.
“But because there are biochemical, structural, and functional changes in the blood during storage, there had been concerns about the use of ‘older’ blood. This study reassures us that aging is not bad—even for blood.”
The findings of this study are in line with the recently released AABB recommendations on blood transfusion. 
Photo by Elise Amendola
Results of a large, international study suggest the risk of death after transfusion is not significantly affected by the age of blood transfused.
The median storage duration for the fresher blood used in this study was 11 days, and the median storage duration for older blood was 23 days.
The rate of death was 9.1% for the patients who received fresher blood and 8.8% for patients who received older blood (P=0.38).
Researchers reported these and other results from this study in NEJM.
“It’s been a contentious issue, but our study finally puts an end to the question about whether stored blood could be harmful and fresher blood would be better,” said study author Nancy Heddle, of McMaster University in Hamilton, Ontario, Canada.
“Our study provides strong evidence that transfusion of fresh blood does not improve patient outcomes, and this should reassure clinicians that fresher is not better.”
For this study, Heddle and her colleagues enrolled 31,497 adult patients treated at hospitals in Australia, Canada, Israel, and the US. However, 6761 patients did not meet all the enrollment criteria and were excluded after randomization.
A and O blood types
The researchers’ primary analysis included only patients with type A or O blood. Of these 20,858 patients, 6936 were assigned to receive blood stored for a shorter period, and 13,922 were assigned to receive blood stored for a longer period.
The mean storage duration was 13.0 ± 7.6 days in the short-term group and 23.6 ± 8.9 days in the long-term group. The median storage duration was 11 days (range, 8-16) and 23 days (range, 16-31), respectively.
The rate of death was 9.1% (n=634) in the short-term storage group and 8.7% (n=1213) in the long-term storage group. The odds ratio was 1.05 (95% CI, 0.95 to 1.16; P=0.34).
All blood types
The researchers also analyzed patients with any blood type. Of the 24,736 patients studied, 8215 were assigned to receive blood stored for a shorter period, and 16,521 were assigned to receive blood stored for a longer period.
The mean storage duration was 13.4 ± 7.7 days in the short-term group and 23.6 ± 8.9 days in the long-term group. The median storage duration was 11 days (range, 8-17) and 23 days (range, 16-31), respectively.
The rate of death was 9.1% (n=750) in the short-term storage group and 8.8% (n=1446) in the long-term storage group. The odds ratio was 1.04 (95% CI, 0.95 to 1.14; P=0.38).
The researchers said the overall results were similar to those observed in 3 pre-specified high-risk subgroups—patients undergoing cardiovascular surgery, individuals admitted to intensive care, and patients with cancer.
“Advances in blood storage now allow blood to be stored up to 42 days before transfusion, and the usual practice is to use up the blood that has been in storage the longest,” said study author John Eikelboom, MD, also of McMaster University.
“But because there are biochemical, structural, and functional changes in the blood during storage, there had been concerns about the use of ‘older’ blood. This study reassures us that aging is not bad—even for blood.”
The findings of this study are in line with the recently released AABB recommendations on blood transfusion.
Photo by Elise Amendola
Results of a large, international study suggest the risk of death after transfusion is not significantly affected by the age of blood transfused.
The median storage duration for the fresher blood used in this study was 11 days, and the median storage duration for older blood was 23 days.
The rate of death was 9.1% for the patients who received fresher blood and 8.8% for patients who received older blood (P=0.38).
Researchers reported these and other results from this study in NEJM.
“It’s been a contentious issue, but our study finally puts an end to the question about whether stored blood could be harmful and fresher blood would be better,” said study author Nancy Heddle, of McMaster University in Hamilton, Ontario, Canada.
“Our study provides strong evidence that transfusion of fresh blood does not improve patient outcomes, and this should reassure clinicians that fresher is not better.”
For this study, Heddle and her colleagues enrolled 31,497 adult patients treated at hospitals in Australia, Canada, Israel, and the US. However, 6761 patients did not meet all the enrollment criteria and were excluded after randomization.
A and O blood types
The researchers’ primary analysis included only patients with type A or O blood. Of these 20,858 patients, 6936 were assigned to receive blood stored for a shorter period, and 13,922 were assigned to receive blood stored for a longer period.
The mean storage duration was 13.0 ± 7.6 days in the short-term group and 23.6 ± 8.9 days in the long-term group. The median storage duration was 11 days (range, 8-16) and 23 days (range, 16-31), respectively.
The rate of death was 9.1% (n=634) in the short-term storage group and 8.7% (n=1213) in the long-term storage group. The odds ratio was 1.05 (95% CI, 0.95 to 1.16; P=0.34).
All blood types
The researchers also analyzed patients with any blood type. Of the 24,736 patients studied, 8215 were assigned to receive blood stored for a shorter period, and 16,521 were assigned to receive blood stored for a longer period.
The mean storage duration was 13.4 ± 7.7 days in the short-term group and 23.6 ± 8.9 days in the long-term group. The median storage duration was 11 days (range, 8-17) and 23 days (range, 16-31), respectively.
The rate of death was 9.1% (n=750) in the short-term storage group and 8.8% (n=1446) in the long-term storage group. The odds ratio was 1.04 (95% CI, 0.95 to 1.14; P=0.38).
The researchers said the overall results were similar to those observed in 3 pre-specified high-risk subgroups—patients undergoing cardiovascular surgery, individuals admitted to intensive care, and patients with cancer.
“Advances in blood storage now allow blood to be stored up to 42 days before transfusion, and the usual practice is to use up the blood that has been in storage the longest,” said study author John Eikelboom, MD, also of McMaster University.
“But because there are biochemical, structural, and functional changes in the blood during storage, there had been concerns about the use of ‘older’ blood. This study reassures us that aging is not bad—even for blood.”
The findings of this study are in line with the recently released AABB recommendations on blood transfusion.
Compound could treat a range of blood cancers
Image by Ed Uthman
A new compound has shown promise for treating hematologic malignancies and other cancers, according to preclinical research published in Nature.
The compound, known as S63845, targets the BCL2 family protein MCL1.
Investigators said their research on S63845 provides the first clear evidence that inhibiting MCL1 is effective in targeting several cancer types, including leukemia, lymphoma, and multiple myeloma (MM).
“MCL1 is important for many cancers because it is a pro-survival protein that allows the cancerous cells to evade the process of programmed cell death that normally removes cancer cells from the body,” said study author Guillaume Lessene, PhD, of the Walter and Eliza Hall Institute in Melbourne, Australia.
“Extensive studies performed in a variety of cancer models have shown that S63845 potently targets cancer cells dependent on MCL1 for their survival.”
About S63845
Dr Lessene and his colleagues said S63845 binds with high affinity to the BH3-binding groove of MCL1. And the compound kills MCL1-dependent cancer cells by activating the BAX/BAK-dependent mitochondrial apoptotic pathway.
In solid tumors, S63845 often wasn’t effective enough on its own. However, when the compound was combined with various kinase inhibitors, it induced a “potent cytotoxic response” in breast cancer, lung cancer, and melanoma cells.
In hematologic malignancies, S63845 proved effective when given alone.
Myeloma
The investigators said 17 of 25 MM cell lines tested were highly sensitive to S63845 (IC50 < 0.1 μ M), 6 cell lines were moderately sensitive (0.1 μ M < IC50 < 1 μ M), and 2 cell lines were insensitive (IC50 > 1 μ M).
The team also administered S63845 (at 25 mg/kg) to mice with MM. Seven of 8 mice had complete regression at 100 days after treatment.
Lymphoma
The investigators tested S63845 in 11 cell lines representative of human lymphomas. Five were highly sensitive to the compound (IC50 < 0.1 μ M), 3 were moderately sensitive (0.1 μ M < IC50 < 1 μ M), and 3 were insensitive (IC50 > 1 μ M).
The team also tested S63845 in 7 c-MYC-driven human Burkitt lymphoma cell lines and found the compound exhibited “potent cytotoxic activity” in all of them.
The investigators then tested S63845 in a c-MYC-driven mouse lymphoma model. They noted that both tumor cells and normal tissues express mouse MCL1 protein in this model.
Treatment with S63845 (25 mg/kg) for 5 consecutive days cured 70% of these mice, and the investigators said there were no evident side effects in normal tissues.
Leukemia
The investigators tested S63845 in 5 chronic myeloid leukemia cell lines, and none of them were sensitive to the compound.
However, the team also tested S63845 in 8 acute myeloid leukemia (AML) cell lines, and all of them were sensitive to the compound (IC50 4–233 nM).
When S63845 was given to mice with AML (25 mg/kg), 6 of the 8 mice achieved complete remission after 80 days.
The investigators also tested S63845 in 25 freshly derived samples from patients with AML. The team said these samples displayed a wide range of responses to S63845.
The most sensitive samples required 100- to 1000-fold less drug (to induce apoptosis) than the resistant samples or normal CD34+ progenitor cells.
Development/funding
S63845 was discovered through a collaboration between 2 pharmaceutical companies—Servier, which is headquartered in France, and Vernalis (R&D), which is based in the UK.
“[C]linical development of a MCL1 inhibitor should be launched in the near future,” said Olivier Geneste, director of oncology research at Servier.
The current research was supported through a collaboration with Servier and through funding from the National Health and Medical Research Council of Australia, the Leukemia and Lymphoma Society, Cancer Council Victoria, the Kay Kendall Leukemia Fund, Victorian Cancer Agency, Australian Cancer Research Foundation, the Victorian Government Operational Infrastructure Scheme, and the estate of Anthony Redstone.
Image by Ed Uthman
A new compound has shown promise for treating hematologic malignancies and other cancers, according to preclinical research published in Nature.
The compound, known as S63845, targets the BCL2 family protein MCL1.
Investigators said their research on S63845 provides the first clear evidence that inhibiting MCL1 is effective in targeting several cancer types, including leukemia, lymphoma, and multiple myeloma (MM).
“MCL1 is important for many cancers because it is a pro-survival protein that allows the cancerous cells to evade the process of programmed cell death that normally removes cancer cells from the body,” said study author Guillaume Lessene, PhD, of the Walter and Eliza Hall Institute in Melbourne, Australia.
“Extensive studies performed in a variety of cancer models have shown that S63845 potently targets cancer cells dependent on MCL1 for their survival.”
About S63845
Dr Lessene and his colleagues said S63845 binds with high affinity to the BH3-binding groove of MCL1. And the compound kills MCL1-dependent cancer cells by activating the BAX/BAK-dependent mitochondrial apoptotic pathway.
In solid tumors, S63845 often wasn’t effective enough on its own. However, when the compound was combined with various kinase inhibitors, it induced a “potent cytotoxic response” in breast cancer, lung cancer, and melanoma cells.
In hematologic malignancies, S63845 proved effective when given alone.
Myeloma
The investigators said 17 of 25 MM cell lines tested were highly sensitive to S63845 (IC50 < 0.1 μ M), 6 cell lines were moderately sensitive (0.1 μ M < IC50 < 1 μ M), and 2 cell lines were insensitive (IC50 > 1 μ M).
The team also administered S63845 (at 25 mg/kg) to mice with MM. Seven of 8 mice had complete regression at 100 days after treatment.
Lymphoma
The investigators tested S63845 in 11 cell lines representative of human lymphomas. Five were highly sensitive to the compound (IC50 < 0.1 μ M), 3 were moderately sensitive (0.1 μ M < IC50 < 1 μ M), and 3 were insensitive (IC50 > 1 μ M).
The team also tested S63845 in 7 c-MYC-driven human Burkitt lymphoma cell lines and found the compound exhibited “potent cytotoxic activity” in all of them.
The investigators then tested S63845 in a c-MYC-driven mouse lymphoma model. They noted that both tumor cells and normal tissues express mouse MCL1 protein in this model.
Treatment with S63845 (25 mg/kg) for 5 consecutive days cured 70% of these mice, and the investigators said there were no evident side effects in normal tissues.
Leukemia
The investigators tested S63845 in 5 chronic myeloid leukemia cell lines, and none of them were sensitive to the compound.
However, the team also tested S63845 in 8 acute myeloid leukemia (AML) cell lines, and all of them were sensitive to the compound (IC50 4–233 nM).
When S63845 was given to mice with AML (25 mg/kg), 6 of the 8 mice achieved complete remission after 80 days.
The investigators also tested S63845 in 25 freshly derived samples from patients with AML. The team said these samples displayed a wide range of responses to S63845.
The most sensitive samples required 100- to 1000-fold less drug (to induce apoptosis) than the resistant samples or normal CD34+ progenitor cells.
Development/funding
S63845 was discovered through a collaboration between 2 pharmaceutical companies—Servier, which is headquartered in France, and Vernalis (R&D), which is based in the UK.
“[C]linical development of a MCL1 inhibitor should be launched in the near future,” said Olivier Geneste, director of oncology research at Servier.
The current research was supported through a collaboration with Servier and through funding from the National Health and Medical Research Council of Australia, the Leukemia and Lymphoma Society, Cancer Council Victoria, the Kay Kendall Leukemia Fund, Victorian Cancer Agency, Australian Cancer Research Foundation, the Victorian Government Operational Infrastructure Scheme, and the estate of Anthony Redstone.
Image by Ed Uthman
A new compound has shown promise for treating hematologic malignancies and other cancers, according to preclinical research published in Nature.
The compound, known as S63845, targets the BCL2 family protein MCL1.
Investigators said their research on S63845 provides the first clear evidence that inhibiting MCL1 is effective in targeting several cancer types, including leukemia, lymphoma, and multiple myeloma (MM).
“MCL1 is important for many cancers because it is a pro-survival protein that allows the cancerous cells to evade the process of programmed cell death that normally removes cancer cells from the body,” said study author Guillaume Lessene, PhD, of the Walter and Eliza Hall Institute in Melbourne, Australia.
“Extensive studies performed in a variety of cancer models have shown that S63845 potently targets cancer cells dependent on MCL1 for their survival.”
About S63845
Dr Lessene and his colleagues said S63845 binds with high affinity to the BH3-binding groove of MCL1. And the compound kills MCL1-dependent cancer cells by activating the BAX/BAK-dependent mitochondrial apoptotic pathway.
In solid tumors, S63845 often wasn’t effective enough on its own. However, when the compound was combined with various kinase inhibitors, it induced a “potent cytotoxic response” in breast cancer, lung cancer, and melanoma cells.
In hematologic malignancies, S63845 proved effective when given alone.
Myeloma
The investigators said 17 of 25 MM cell lines tested were highly sensitive to S63845 (IC50 < 0.1 μ M), 6 cell lines were moderately sensitive (0.1 μ M < IC50 < 1 μ M), and 2 cell lines were insensitive (IC50 > 1 μ M).
The team also administered S63845 (at 25 mg/kg) to mice with MM. Seven of 8 mice had complete regression at 100 days after treatment.
Lymphoma
The investigators tested S63845 in 11 cell lines representative of human lymphomas. Five were highly sensitive to the compound (IC50 < 0.1 μ M), 3 were moderately sensitive (0.1 μ M < IC50 < 1 μ M), and 3 were insensitive (IC50 > 1 μ M).
The team also tested S63845 in 7 c-MYC-driven human Burkitt lymphoma cell lines and found the compound exhibited “potent cytotoxic activity” in all of them.
The investigators then tested S63845 in a c-MYC-driven mouse lymphoma model. They noted that both tumor cells and normal tissues express mouse MCL1 protein in this model.
Treatment with S63845 (25 mg/kg) for 5 consecutive days cured 70% of these mice, and the investigators said there were no evident side effects in normal tissues.
Leukemia
The investigators tested S63845 in 5 chronic myeloid leukemia cell lines, and none of them were sensitive to the compound.
However, the team also tested S63845 in 8 acute myeloid leukemia (AML) cell lines, and all of them were sensitive to the compound (IC50 4–233 nM).
When S63845 was given to mice with AML (25 mg/kg), 6 of the 8 mice achieved complete remission after 80 days.
The investigators also tested S63845 in 25 freshly derived samples from patients with AML. The team said these samples displayed a wide range of responses to S63845.
The most sensitive samples required 100- to 1000-fold less drug (to induce apoptosis) than the resistant samples or normal CD34+ progenitor cells.
Development/funding
S63845 was discovered through a collaboration between 2 pharmaceutical companies—Servier, which is headquartered in France, and Vernalis (R&D), which is based in the UK.
“[C]linical development of a MCL1 inhibitor should be launched in the near future,” said Olivier Geneste, director of oncology research at Servier.
The current research was supported through a collaboration with Servier and through funding from the National Health and Medical Research Council of Australia, the Leukemia and Lymphoma Society, Cancer Council Victoria, the Kay Kendall Leukemia Fund, Victorian Cancer Agency, Australian Cancer Research Foundation, the Victorian Government Operational Infrastructure Scheme, and the estate of Anthony Redstone.
High Blood Pressure Still Places Millions of U.S. Adults at Risk
As many as 5 million older Americans are at risk because they aren’t taking their blood pressure medicine properly, according to a Vital Signs report.
CDC researchers analyzed data from more than 18.5 million people enrolled in Medicare Advantage or Original Medicare with Part D prescription drug coverage during 2014. Among their findings:
- Seven out of 10 adults aged 65 and older have high blood pressure, but nearly half don’t have it under control.
- American Indians/Alaska Natives, blacks, and Hispanics are more likely to not take their blood pressure medicine as directed.
- Southern U.S. states, Puerto Rico, and the U.S. Virgin Islands had the highest overall rates of not taking medicine as directed.North Dakota, Wisconsin, and Minnesota had the highest rates of adherence.
The CDC gave examples of how health care systems and providers can help:
- Simplify blood pressure treatments by offering 90-day refills and combination medicines, coordinating pill refills for the same date, and prescribing generic medicines.
- Involve the whole health care team at several points of care to ensure patients are taking medicine as directed, answer questions, and provide counseling.
- Encourage the use of home blood pressure monitors and easy-to-use tools, such as mobile apps to track and share readings.
As many as 5 million older Americans are at risk because they aren’t taking their blood pressure medicine properly, according to a Vital Signs report.
CDC researchers analyzed data from more than 18.5 million people enrolled in Medicare Advantage or Original Medicare with Part D prescription drug coverage during 2014. Among their findings:
- Seven out of 10 adults aged 65 and older have high blood pressure, but nearly half don’t have it under control.
- American Indians/Alaska Natives, blacks, and Hispanics are more likely to not take their blood pressure medicine as directed.
- Southern U.S. states, Puerto Rico, and the U.S. Virgin Islands had the highest overall rates of not taking medicine as directed.North Dakota, Wisconsin, and Minnesota had the highest rates of adherence.
The CDC gave examples of how health care systems and providers can help:
- Simplify blood pressure treatments by offering 90-day refills and combination medicines, coordinating pill refills for the same date, and prescribing generic medicines.
- Involve the whole health care team at several points of care to ensure patients are taking medicine as directed, answer questions, and provide counseling.
- Encourage the use of home blood pressure monitors and easy-to-use tools, such as mobile apps to track and share readings.
As many as 5 million older Americans are at risk because they aren’t taking their blood pressure medicine properly, according to a Vital Signs report.
CDC researchers analyzed data from more than 18.5 million people enrolled in Medicare Advantage or Original Medicare with Part D prescription drug coverage during 2014. Among their findings:
- Seven out of 10 adults aged 65 and older have high blood pressure, but nearly half don’t have it under control.
- American Indians/Alaska Natives, blacks, and Hispanics are more likely to not take their blood pressure medicine as directed.
- Southern U.S. states, Puerto Rico, and the U.S. Virgin Islands had the highest overall rates of not taking medicine as directed.North Dakota, Wisconsin, and Minnesota had the highest rates of adherence.
The CDC gave examples of how health care systems and providers can help:
- Simplify blood pressure treatments by offering 90-day refills and combination medicines, coordinating pill refills for the same date, and prescribing generic medicines.
- Involve the whole health care team at several points of care to ensure patients are taking medicine as directed, answer questions, and provide counseling.
- Encourage the use of home blood pressure monitors and easy-to-use tools, such as mobile apps to track and share readings.
Tap the power of words when counseling about divorce
SAN FRANCISCO – By choosing your words carefully, counseling families about divorce can tactfully address sensitive issues and help parents and children better cope with this life transition, Nerissa S. Bauer, MD, said at the annual meeting of the American Academy of Pediatrics.
About one in five children born within a marriage and one in two of those born within a cohabiting union will experience breakup of that relationship by the age of 9 years, she said.
You must, therefore, be prepared to monitor for and identify outcomes that commonly result from divorce, and to counsel families about how to help children cope and manage. Yet, you may feel uneasy or ill-prepared to do so.
“Turn this thought of ‘I wasn’t trained for this’ into ‘I can help,’ ” recommended Dr. Bauer, who is a specialist in behavioral pediatrics at the Indiana University in Indianapolis.
Risk and protective factors
Divorce can have an impact on all facets of a child’s life: behavior, physical and mental health, academic performance, social relationships, delinquency, substance use, and more. A variety of factors determine how well kids adjust to this stressor, for better or worse.
Marital conflict, both during and after divorce, is a more important predictor than the divorce itself. “The biggest risk factor to consider is the ongoing parental fighting and how that plays out,” Dr. Bauer elaborated. Although parents may report that they try to limit altercations in front of their children, kids usually sense what is going on anyway.
“One of the ways that I like to phrase this when I’m trying to figure out how bad the conflict is in the household is, ‘Has Johnny ever witnessed your arguments, and if so, have those arguments ever been more than just yelling?’ Or another way to say it is, ‘How do adults in your home resolve conflicts?’ ” she shared.
Divorce may negatively affect children through its impact on the household’s socioeconomic status too. For example, the standard of living often declines and the mother’s economic resources can take a hit, possibly forcing a move to a less expensive neighborhood with weaker schools and more crime.
To sound parents out on this sensitive issue, “You can say something like, ‘I’m really sorry that you’re going through this right now. Sometimes, it can cause a lot of stress and strain, especially when it comes to making ends meet, making sure you can get food on the table, and making sure you’re paying the bills. Do you have worries like this now?’ ” Dr. Bauer suggested.
Factors that are known to protect children from adverse divorce outcomes include a good relationship with at least one parent or caregiver, parental warmth, sibling support, and for teens, good self-esteem and peer support. Joint custody with shared decision making and greater paternal involvement also are protective.
“I like to say, ‘So I can understand how this affects your daily life, can you describe what your current arrangements are between you and your ex?’ just to sort of probe into that custody situation,” she said. “Or, ‘How are you (parents) handling this?’ ”
Surveillance and monitoring
“Perform surveillance on family structure and conflict at all well-child visits, as well as with any new family that comes to your practice,” Dr. Bauer recommended. You can do this by simply chatting with the family or by using screening tools such as the Family Psychosocial Screen or the Finding Your ACE Score.
Once you know that a family is dealing with divorce, perform ongoing monitoring for warning signs in the child: sleep problems; school problems, such as poor concentration, acting out, or not doing schoolwork; angry outbursts; withdrawal; and no longer participating in activities once enjoyed.
You may worry about getting dragged into the conflict. “You may feel that you’re in this position of being the mediator, but that’s not really your role. And you shouldn’t offer legal advice,” she cautioned. “You should make it clear that although you are there to support the child and the parents, your role is really to monitor how the child responds and adjusts.”
Parents will sometimes ask whether and how best to tell their children about the divorce. “I oftentimes coach parents to use kid-friendly terms, saying things such as, ‘Mommy and Daddy are having a hard time getting along, and you’ve probably noticed we argue or fight a lot.’ Just throwing it out there and pausing and waiting to see what the child says, and then always following that by answering their questions as they bring them up,” Dr. Bauer said.
Parents should be counseled not to rush children as they will vary in the time needed to process information. Additionally, they should be forewarned that children’s reactions can vary widely and that their feelings can change and resurface at any moment, particularly as they mature and at events that stir up emotions.
Messages of reassurance are essential. “The messages should always contain, ‘We are always going to be your parents no matter what’ and ‘We love you no matter what,’ and probably the most important, ‘This is not your fault.’ This is a message that kids need to hear again and again,” Dr. Bauer said.
Ongoing counseling
Over time, parents may consult you about specific situations that arise because of the divorce. For example, they may become frustrated by differences in how things are handled in the two households.
“The most important message to convey is that we can control only what we can control,” Dr. Bauer said. “Regardless of divorce or separation, kids thrive on structure and routine. Divorce is often messy, and it sometimes means that families have to find a new rhythm between households, but routines in each house should be as consistent as possible.”
Acrimony between the mother and father may persist or escalate. As children don’t want to have to choose between parents, parents should be encouraged not to undermine or talk negatively about each other in front of the child. If necessary, you can arrange to have time separately with parents to allow them to air their grievances.
If parents give permission to broach the topic of divorce, you can role model conversational strategies during visits. “You can say something like, ‘I understand there are a lot of changes going on. Through it all, your mom and dad will always be your parents. I know this isn’t easy for anybody, especially for you. Kids in this situation feel a lot of things from sadness to anger but know that you can always talk to me or your parents about your feelings,’” Dr. Bauer elaborated.
“Listening is key,” she stressed; therefore, parents should be encouraged to just sit in silence and let their children process their feelings. “In these types of situations, there’s no right or wrong: When the child has feelings, they have feelings. We can’t force them to feel a certain way, we have to acknowledge that. So tell parents to try this: ‘Thanks for telling me how you feel. I want you to know that you can always come to me when you feel this way.’ See what happens.”
Parents should be advised not to be too quick to dismiss their child’s concerns, Dr. Bauer recommended. “So, instead of saying, ‘Oh honey, you don’t have to worry about that, I’ll take care of it,’ try this: ‘It sounds like you are sad and upset right now. What can I do to help?’ Sometimes a kid will say, ‘I don’t know,’ but that’s okay. Then the parent can respond in kind and say, ‘I don’t know either, but how about a hug? Let’s start there.’ ”
Some kids simply aren’t talkers and shouldn’t be forced to share, she pointed out. This group can be given other ways to express their feelings, such as journaling, drawing, art, music, yoga, or writing a letter that they then throw away or put in a drawer.
Finally, “reminding parents that even giving children a little control with daily things – what they wear, how they do their chores, and homework, and what to make for dinner – can also help,” she noted. “Those little things can represent a lot for children who don’t feel like they have any control.”
Building resources
Explore various media and online tools to develop a set of resources on divorce for families, Dr. Bauer recommended.
Books on the topic can be great conversation starters, and many are available for various age-groups, she noted. Examples include “Was It the Chocolate Pudding? A Story for Little Kids About Divorce” (Washington: Magination Press, 2005) for ages 4-7 years, “Divorced but Still My Parents” (Longmont, Colo. : Springboard Publications, 1997) for ages 6-12 years, and “My Mom and Dad Don’t Live Together Anymore: A Drawing Book for Children of Separated or Divorced Parents” (Washington: Magination Press, 2002) for ages 8-12 years.
Sesame Street has a toolkit on divorce that offers printable materials, songs, and an app that features conversation starters and vignettes, according to Dr. Bauer; go to sesamestreet.org and type in “divorce.” Additionally, the documentary SPLIT at splitfilm.org follows real families going through divorce and helps show the child’s perspective.
When parents ask about legal references, they can be referred to the UpToParents website, a free resource and curriculum developed by attorneys on topics such as divorce, in both English and Spanish.
Finally, familiarize yourself with resources available in your local community, such as divorce education programs, and services offered for divorce and custody mediation, so that you can link parents to them as needed.
Dr. Bauer said she has no relevant financial disclosures.
SAN FRANCISCO – By choosing your words carefully, counseling families about divorce can tactfully address sensitive issues and help parents and children better cope with this life transition, Nerissa S. Bauer, MD, said at the annual meeting of the American Academy of Pediatrics.
About one in five children born within a marriage and one in two of those born within a cohabiting union will experience breakup of that relationship by the age of 9 years, she said.
You must, therefore, be prepared to monitor for and identify outcomes that commonly result from divorce, and to counsel families about how to help children cope and manage. Yet, you may feel uneasy or ill-prepared to do so.
“Turn this thought of ‘I wasn’t trained for this’ into ‘I can help,’ ” recommended Dr. Bauer, who is a specialist in behavioral pediatrics at the Indiana University in Indianapolis.
Risk and protective factors
Divorce can have an impact on all facets of a child’s life: behavior, physical and mental health, academic performance, social relationships, delinquency, substance use, and more. A variety of factors determine how well kids adjust to this stressor, for better or worse.
Marital conflict, both during and after divorce, is a more important predictor than the divorce itself. “The biggest risk factor to consider is the ongoing parental fighting and how that plays out,” Dr. Bauer elaborated. Although parents may report that they try to limit altercations in front of their children, kids usually sense what is going on anyway.
“One of the ways that I like to phrase this when I’m trying to figure out how bad the conflict is in the household is, ‘Has Johnny ever witnessed your arguments, and if so, have those arguments ever been more than just yelling?’ Or another way to say it is, ‘How do adults in your home resolve conflicts?’ ” she shared.
Divorce may negatively affect children through its impact on the household’s socioeconomic status too. For example, the standard of living often declines and the mother’s economic resources can take a hit, possibly forcing a move to a less expensive neighborhood with weaker schools and more crime.
To sound parents out on this sensitive issue, “You can say something like, ‘I’m really sorry that you’re going through this right now. Sometimes, it can cause a lot of stress and strain, especially when it comes to making ends meet, making sure you can get food on the table, and making sure you’re paying the bills. Do you have worries like this now?’ ” Dr. Bauer suggested.
Factors that are known to protect children from adverse divorce outcomes include a good relationship with at least one parent or caregiver, parental warmth, sibling support, and for teens, good self-esteem and peer support. Joint custody with shared decision making and greater paternal involvement also are protective.
“I like to say, ‘So I can understand how this affects your daily life, can you describe what your current arrangements are between you and your ex?’ just to sort of probe into that custody situation,” she said. “Or, ‘How are you (parents) handling this?’ ”
Surveillance and monitoring
“Perform surveillance on family structure and conflict at all well-child visits, as well as with any new family that comes to your practice,” Dr. Bauer recommended. You can do this by simply chatting with the family or by using screening tools such as the Family Psychosocial Screen or the Finding Your ACE Score.
Once you know that a family is dealing with divorce, perform ongoing monitoring for warning signs in the child: sleep problems; school problems, such as poor concentration, acting out, or not doing schoolwork; angry outbursts; withdrawal; and no longer participating in activities once enjoyed.
You may worry about getting dragged into the conflict. “You may feel that you’re in this position of being the mediator, but that’s not really your role. And you shouldn’t offer legal advice,” she cautioned. “You should make it clear that although you are there to support the child and the parents, your role is really to monitor how the child responds and adjusts.”
Parents will sometimes ask whether and how best to tell their children about the divorce. “I oftentimes coach parents to use kid-friendly terms, saying things such as, ‘Mommy and Daddy are having a hard time getting along, and you’ve probably noticed we argue or fight a lot.’ Just throwing it out there and pausing and waiting to see what the child says, and then always following that by answering their questions as they bring them up,” Dr. Bauer said.
Parents should be counseled not to rush children as they will vary in the time needed to process information. Additionally, they should be forewarned that children’s reactions can vary widely and that their feelings can change and resurface at any moment, particularly as they mature and at events that stir up emotions.
Messages of reassurance are essential. “The messages should always contain, ‘We are always going to be your parents no matter what’ and ‘We love you no matter what,’ and probably the most important, ‘This is not your fault.’ This is a message that kids need to hear again and again,” Dr. Bauer said.
Ongoing counseling
Over time, parents may consult you about specific situations that arise because of the divorce. For example, they may become frustrated by differences in how things are handled in the two households.
“The most important message to convey is that we can control only what we can control,” Dr. Bauer said. “Regardless of divorce or separation, kids thrive on structure and routine. Divorce is often messy, and it sometimes means that families have to find a new rhythm between households, but routines in each house should be as consistent as possible.”
Acrimony between the mother and father may persist or escalate. As children don’t want to have to choose between parents, parents should be encouraged not to undermine or talk negatively about each other in front of the child. If necessary, you can arrange to have time separately with parents to allow them to air their grievances.
If parents give permission to broach the topic of divorce, you can role model conversational strategies during visits. “You can say something like, ‘I understand there are a lot of changes going on. Through it all, your mom and dad will always be your parents. I know this isn’t easy for anybody, especially for you. Kids in this situation feel a lot of things from sadness to anger but know that you can always talk to me or your parents about your feelings,’” Dr. Bauer elaborated.
“Listening is key,” she stressed; therefore, parents should be encouraged to just sit in silence and let their children process their feelings. “In these types of situations, there’s no right or wrong: When the child has feelings, they have feelings. We can’t force them to feel a certain way, we have to acknowledge that. So tell parents to try this: ‘Thanks for telling me how you feel. I want you to know that you can always come to me when you feel this way.’ See what happens.”
Parents should be advised not to be too quick to dismiss their child’s concerns, Dr. Bauer recommended. “So, instead of saying, ‘Oh honey, you don’t have to worry about that, I’ll take care of it,’ try this: ‘It sounds like you are sad and upset right now. What can I do to help?’ Sometimes a kid will say, ‘I don’t know,’ but that’s okay. Then the parent can respond in kind and say, ‘I don’t know either, but how about a hug? Let’s start there.’ ”
Some kids simply aren’t talkers and shouldn’t be forced to share, she pointed out. This group can be given other ways to express their feelings, such as journaling, drawing, art, music, yoga, or writing a letter that they then throw away or put in a drawer.
Finally, “reminding parents that even giving children a little control with daily things – what they wear, how they do their chores, and homework, and what to make for dinner – can also help,” she noted. “Those little things can represent a lot for children who don’t feel like they have any control.”
Building resources
Explore various media and online tools to develop a set of resources on divorce for families, Dr. Bauer recommended.
Books on the topic can be great conversation starters, and many are available for various age-groups, she noted. Examples include “Was It the Chocolate Pudding? A Story for Little Kids About Divorce” (Washington: Magination Press, 2005) for ages 4-7 years, “Divorced but Still My Parents” (Longmont, Colo. : Springboard Publications, 1997) for ages 6-12 years, and “My Mom and Dad Don’t Live Together Anymore: A Drawing Book for Children of Separated or Divorced Parents” (Washington: Magination Press, 2002) for ages 8-12 years.
Sesame Street has a toolkit on divorce that offers printable materials, songs, and an app that features conversation starters and vignettes, according to Dr. Bauer; go to sesamestreet.org and type in “divorce.” Additionally, the documentary SPLIT at splitfilm.org follows real families going through divorce and helps show the child’s perspective.
When parents ask about legal references, they can be referred to the UpToParents website, a free resource and curriculum developed by attorneys on topics such as divorce, in both English and Spanish.
Finally, familiarize yourself with resources available in your local community, such as divorce education programs, and services offered for divorce and custody mediation, so that you can link parents to them as needed.
Dr. Bauer said she has no relevant financial disclosures.
SAN FRANCISCO – By choosing your words carefully, counseling families about divorce can tactfully address sensitive issues and help parents and children better cope with this life transition, Nerissa S. Bauer, MD, said at the annual meeting of the American Academy of Pediatrics.
About one in five children born within a marriage and one in two of those born within a cohabiting union will experience breakup of that relationship by the age of 9 years, she said.
You must, therefore, be prepared to monitor for and identify outcomes that commonly result from divorce, and to counsel families about how to help children cope and manage. Yet, you may feel uneasy or ill-prepared to do so.
“Turn this thought of ‘I wasn’t trained for this’ into ‘I can help,’ ” recommended Dr. Bauer, who is a specialist in behavioral pediatrics at the Indiana University in Indianapolis.
Risk and protective factors
Divorce can have an impact on all facets of a child’s life: behavior, physical and mental health, academic performance, social relationships, delinquency, substance use, and more. A variety of factors determine how well kids adjust to this stressor, for better or worse.
Marital conflict, both during and after divorce, is a more important predictor than the divorce itself. “The biggest risk factor to consider is the ongoing parental fighting and how that plays out,” Dr. Bauer elaborated. Although parents may report that they try to limit altercations in front of their children, kids usually sense what is going on anyway.
“One of the ways that I like to phrase this when I’m trying to figure out how bad the conflict is in the household is, ‘Has Johnny ever witnessed your arguments, and if so, have those arguments ever been more than just yelling?’ Or another way to say it is, ‘How do adults in your home resolve conflicts?’ ” she shared.
Divorce may negatively affect children through its impact on the household’s socioeconomic status too. For example, the standard of living often declines and the mother’s economic resources can take a hit, possibly forcing a move to a less expensive neighborhood with weaker schools and more crime.
To sound parents out on this sensitive issue, “You can say something like, ‘I’m really sorry that you’re going through this right now. Sometimes, it can cause a lot of stress and strain, especially when it comes to making ends meet, making sure you can get food on the table, and making sure you’re paying the bills. Do you have worries like this now?’ ” Dr. Bauer suggested.
Factors that are known to protect children from adverse divorce outcomes include a good relationship with at least one parent or caregiver, parental warmth, sibling support, and for teens, good self-esteem and peer support. Joint custody with shared decision making and greater paternal involvement also are protective.
“I like to say, ‘So I can understand how this affects your daily life, can you describe what your current arrangements are between you and your ex?’ just to sort of probe into that custody situation,” she said. “Or, ‘How are you (parents) handling this?’ ”
Surveillance and monitoring
“Perform surveillance on family structure and conflict at all well-child visits, as well as with any new family that comes to your practice,” Dr. Bauer recommended. You can do this by simply chatting with the family or by using screening tools such as the Family Psychosocial Screen or the Finding Your ACE Score.
Once you know that a family is dealing with divorce, perform ongoing monitoring for warning signs in the child: sleep problems; school problems, such as poor concentration, acting out, or not doing schoolwork; angry outbursts; withdrawal; and no longer participating in activities once enjoyed.
You may worry about getting dragged into the conflict. “You may feel that you’re in this position of being the mediator, but that’s not really your role. And you shouldn’t offer legal advice,” she cautioned. “You should make it clear that although you are there to support the child and the parents, your role is really to monitor how the child responds and adjusts.”
Parents will sometimes ask whether and how best to tell their children about the divorce. “I oftentimes coach parents to use kid-friendly terms, saying things such as, ‘Mommy and Daddy are having a hard time getting along, and you’ve probably noticed we argue or fight a lot.’ Just throwing it out there and pausing and waiting to see what the child says, and then always following that by answering their questions as they bring them up,” Dr. Bauer said.
Parents should be counseled not to rush children as they will vary in the time needed to process information. Additionally, they should be forewarned that children’s reactions can vary widely and that their feelings can change and resurface at any moment, particularly as they mature and at events that stir up emotions.
Messages of reassurance are essential. “The messages should always contain, ‘We are always going to be your parents no matter what’ and ‘We love you no matter what,’ and probably the most important, ‘This is not your fault.’ This is a message that kids need to hear again and again,” Dr. Bauer said.
Ongoing counseling
Over time, parents may consult you about specific situations that arise because of the divorce. For example, they may become frustrated by differences in how things are handled in the two households.
“The most important message to convey is that we can control only what we can control,” Dr. Bauer said. “Regardless of divorce or separation, kids thrive on structure and routine. Divorce is often messy, and it sometimes means that families have to find a new rhythm between households, but routines in each house should be as consistent as possible.”
Acrimony between the mother and father may persist or escalate. As children don’t want to have to choose between parents, parents should be encouraged not to undermine or talk negatively about each other in front of the child. If necessary, you can arrange to have time separately with parents to allow them to air their grievances.
If parents give permission to broach the topic of divorce, you can role model conversational strategies during visits. “You can say something like, ‘I understand there are a lot of changes going on. Through it all, your mom and dad will always be your parents. I know this isn’t easy for anybody, especially for you. Kids in this situation feel a lot of things from sadness to anger but know that you can always talk to me or your parents about your feelings,’” Dr. Bauer elaborated.
“Listening is key,” she stressed; therefore, parents should be encouraged to just sit in silence and let their children process their feelings. “In these types of situations, there’s no right or wrong: When the child has feelings, they have feelings. We can’t force them to feel a certain way, we have to acknowledge that. So tell parents to try this: ‘Thanks for telling me how you feel. I want you to know that you can always come to me when you feel this way.’ See what happens.”
Parents should be advised not to be too quick to dismiss their child’s concerns, Dr. Bauer recommended. “So, instead of saying, ‘Oh honey, you don’t have to worry about that, I’ll take care of it,’ try this: ‘It sounds like you are sad and upset right now. What can I do to help?’ Sometimes a kid will say, ‘I don’t know,’ but that’s okay. Then the parent can respond in kind and say, ‘I don’t know either, but how about a hug? Let’s start there.’ ”
Some kids simply aren’t talkers and shouldn’t be forced to share, she pointed out. This group can be given other ways to express their feelings, such as journaling, drawing, art, music, yoga, or writing a letter that they then throw away or put in a drawer.
Finally, “reminding parents that even giving children a little control with daily things – what they wear, how they do their chores, and homework, and what to make for dinner – can also help,” she noted. “Those little things can represent a lot for children who don’t feel like they have any control.”
Building resources
Explore various media and online tools to develop a set of resources on divorce for families, Dr. Bauer recommended.
Books on the topic can be great conversation starters, and many are available for various age-groups, she noted. Examples include “Was It the Chocolate Pudding? A Story for Little Kids About Divorce” (Washington: Magination Press, 2005) for ages 4-7 years, “Divorced but Still My Parents” (Longmont, Colo. : Springboard Publications, 1997) for ages 6-12 years, and “My Mom and Dad Don’t Live Together Anymore: A Drawing Book for Children of Separated or Divorced Parents” (Washington: Magination Press, 2002) for ages 8-12 years.
Sesame Street has a toolkit on divorce that offers printable materials, songs, and an app that features conversation starters and vignettes, according to Dr. Bauer; go to sesamestreet.org and type in “divorce.” Additionally, the documentary SPLIT at splitfilm.org follows real families going through divorce and helps show the child’s perspective.
When parents ask about legal references, they can be referred to the UpToParents website, a free resource and curriculum developed by attorneys on topics such as divorce, in both English and Spanish.
Finally, familiarize yourself with resources available in your local community, such as divorce education programs, and services offered for divorce and custody mediation, so that you can link parents to them as needed.
Dr. Bauer said she has no relevant financial disclosures.
EXPERT ANALYSIS FROM AAP 16
‘Doc in a box’ vs.’tele-teaming’: Contending models of telepsychiatric care
As articulated by Steve Daviss, MD, DFAPA, in the inaugural column of Techiatry, the adoption and diffusion of telepsychiatry (live two-way interactive videoconferencing) have not been as rapid and universal as expected from those of us immersed in the field.
Despite having yet to achieve its full promise, telepsychiatry has reached maturity, and is being widely deployed and used across multiple systems, settings, and applications, albeit at times in an uneven, unsystematic manner. Emerging over the past decade of development are two distinct models/approaches to telepsychiatry, which I refer to as “doc in a box” and “tele-teaming.” Those models coexist, compete, and conflict within and across organizations. The dynamic between those two models highlights a larger emergent dialogue within psychiatry around psychiatrists’ core clinical roles and functions in our evolving health care systems.
The doc in a box model, as captured in early telepsychiatry services in the 1990s and early 2000s, focused on the virtual insertion of a solo psychiatrist into a distant setting. The services involved core psychiatric activities, such as diagnosis and assessment, with a heavy emphasis on pharmacologic management.
Not surprisingly, those services paralleled what was occurring for the rest of psychiatry at the time and were driven by the closer alignment of psychiatry with a biologic framework – and most importantly, reimbursement models that favored pharmacologic interventions and management. The subsequent rise of viable commercial telepsychiatry companies has continued offering this model driven by demands of the marketplace. While there is a legitimate place and need for such services, the phrase “doc in a box” narrows the scope of psychiatric practice, and reinforces current systems of health care structure and funding.
I proffer the phrase “tele-teaming” to denote telepsychiatric care that virtually embeds a psychiatrist as a member of a care team at a distant location. The use of telepsychiatry in integrated care is the clearest example of this. In integrated care, a psychiatrist works as part of a larger behavioral and medical team that may include case managers, social workers, psychologists, nurses, and family physicians to render care to patients in primary care clinics. The psychiatrist performs consultative, direct care, and supervisory roles in the context of the integrated care team, focusing on more holistic and population-based approaches to treatment.
Telepsychiatry, as well as other technologies (for example, electronic medical records, email, and patient registries), enables and enhances integrated care. Telepsychiatry allows smaller primary care practices, which on their own could not support a full-time psychiatrist, to create a full virtual team across multiple sites.
Tele-teaming as a concept is not limited to integrated care. Other notable examples include the use of telepsychiatry in substance rehabilitation facilities, long-term nursing homes, and psychiatric emergency services as a component of ERs. Tele-teaming and doc in a box models are not about the settings or populations to which they provide care, but the structure and philosophy of the psychiatric service.
As an illustration, imagine a rural community mental health center whose long-term psychiatric care provider retires. The center could set up a contract with a psychiatrist to provide medication management services for its patients through telepsychiatry. The psychiatrist, armed with a pen or eprescribing credentials, could provide several days a week of medication management. Treatment planning, therapy, and care coordination could be segmented off to other providers from the center (psychologists, social workers, and case managers). The psychiatrist’s time could be maximized by having the psychiatrist manage prescriptions, with communication between the patients’ various providers through a shared electronic medical record, as in the doc in a box model.
Alternatively, the center could set up a service where the psychiatrist became a virtual team member working to provide complete assessments, treatment planning, supervision, and psychiatric consultation, as well as pharmacologic management. Although in this scenario, the psychiatrist still could devote time to managing prescriptions, she/he also could spend time in team meetings, supervision, and seeing patients, often with her colleagues. In addition, the psychiatrist could work to coordinate care beyond the EMR, for example, through tele-teaming. Either of these scenarios can and do occur with in-person care as well, and the choice of which model to use would not be decided by the technology but by the underlying health care system in which it is being used.
Telepsychiatry begins to become transformative when it’s leveraged to shift, change, or innovate the model of care delivery. Historically, telepsychiatry has been thought of as a solution to patient access issues and as a way to address workforce shortages. The real promise of telepsychiatry in the form of tele-teaming is how it can begin to fundamentally change how care is delivered. The triple aim calls for decreased costs, improved health care for individuals, and a focus on population health.
We know that most Americans with major mental health issues will be seen in primary care, and that providing behavioral health care in primary care settings leads to lower overall health care costs, and improved behavioral and general health outcomes. Telepsychiatry will be essential in the further dissemination and expansion of integrated care, not only in rural and underserved areas, but across large health care systems. Tele-teaming will be essential in other arenas as well, as psychiatry faces the future challenges of an aging and decreasing (per capita) workforce. Team approaches help maximize psychiatrists’ role in the health care system, and help magnify the number of patients their skills and training can support.
Team approaches also help to broaden the scope of psychiatric practice and reclaim psychiatry’s place within the house of medicine. Telepsychiatry, if structured correctly, helps increase flexibility for psychiatrists. It expands the settings available to practice and provides more opportunities to engage in team-based care. Both the doc in a box and tele-teaming models have arisen from forces in the health care marketplace. The differing application of those two models across and within health care systems illustrates overall tensions within psychiatry about the current and future roles of psychiatrists.
Telepsychiatry is a powerful tool that can be leveraged to shape models of psychiatric care delivery or reinforce our existing structures. Which models are embraced will affect how psychiatry continues to evolve and address the challenges before the specialty.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry, and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center and associate professor of psychiatry at the University of Colorado at Denver, Aurora.
As articulated by Steve Daviss, MD, DFAPA, in the inaugural column of Techiatry, the adoption and diffusion of telepsychiatry (live two-way interactive videoconferencing) have not been as rapid and universal as expected from those of us immersed in the field.
Despite having yet to achieve its full promise, telepsychiatry has reached maturity, and is being widely deployed and used across multiple systems, settings, and applications, albeit at times in an uneven, unsystematic manner. Emerging over the past decade of development are two distinct models/approaches to telepsychiatry, which I refer to as “doc in a box” and “tele-teaming.” Those models coexist, compete, and conflict within and across organizations. The dynamic between those two models highlights a larger emergent dialogue within psychiatry around psychiatrists’ core clinical roles and functions in our evolving health care systems.
The doc in a box model, as captured in early telepsychiatry services in the 1990s and early 2000s, focused on the virtual insertion of a solo psychiatrist into a distant setting. The services involved core psychiatric activities, such as diagnosis and assessment, with a heavy emphasis on pharmacologic management.
Not surprisingly, those services paralleled what was occurring for the rest of psychiatry at the time and were driven by the closer alignment of psychiatry with a biologic framework – and most importantly, reimbursement models that favored pharmacologic interventions and management. The subsequent rise of viable commercial telepsychiatry companies has continued offering this model driven by demands of the marketplace. While there is a legitimate place and need for such services, the phrase “doc in a box” narrows the scope of psychiatric practice, and reinforces current systems of health care structure and funding.
I proffer the phrase “tele-teaming” to denote telepsychiatric care that virtually embeds a psychiatrist as a member of a care team at a distant location. The use of telepsychiatry in integrated care is the clearest example of this. In integrated care, a psychiatrist works as part of a larger behavioral and medical team that may include case managers, social workers, psychologists, nurses, and family physicians to render care to patients in primary care clinics. The psychiatrist performs consultative, direct care, and supervisory roles in the context of the integrated care team, focusing on more holistic and population-based approaches to treatment.
Telepsychiatry, as well as other technologies (for example, electronic medical records, email, and patient registries), enables and enhances integrated care. Telepsychiatry allows smaller primary care practices, which on their own could not support a full-time psychiatrist, to create a full virtual team across multiple sites.
Tele-teaming as a concept is not limited to integrated care. Other notable examples include the use of telepsychiatry in substance rehabilitation facilities, long-term nursing homes, and psychiatric emergency services as a component of ERs. Tele-teaming and doc in a box models are not about the settings or populations to which they provide care, but the structure and philosophy of the psychiatric service.
As an illustration, imagine a rural community mental health center whose long-term psychiatric care provider retires. The center could set up a contract with a psychiatrist to provide medication management services for its patients through telepsychiatry. The psychiatrist, armed with a pen or eprescribing credentials, could provide several days a week of medication management. Treatment planning, therapy, and care coordination could be segmented off to other providers from the center (psychologists, social workers, and case managers). The psychiatrist’s time could be maximized by having the psychiatrist manage prescriptions, with communication between the patients’ various providers through a shared electronic medical record, as in the doc in a box model.
Alternatively, the center could set up a service where the psychiatrist became a virtual team member working to provide complete assessments, treatment planning, supervision, and psychiatric consultation, as well as pharmacologic management. Although in this scenario, the psychiatrist still could devote time to managing prescriptions, she/he also could spend time in team meetings, supervision, and seeing patients, often with her colleagues. In addition, the psychiatrist could work to coordinate care beyond the EMR, for example, through tele-teaming. Either of these scenarios can and do occur with in-person care as well, and the choice of which model to use would not be decided by the technology but by the underlying health care system in which it is being used.
Telepsychiatry begins to become transformative when it’s leveraged to shift, change, or innovate the model of care delivery. Historically, telepsychiatry has been thought of as a solution to patient access issues and as a way to address workforce shortages. The real promise of telepsychiatry in the form of tele-teaming is how it can begin to fundamentally change how care is delivered. The triple aim calls for decreased costs, improved health care for individuals, and a focus on population health.
We know that most Americans with major mental health issues will be seen in primary care, and that providing behavioral health care in primary care settings leads to lower overall health care costs, and improved behavioral and general health outcomes. Telepsychiatry will be essential in the further dissemination and expansion of integrated care, not only in rural and underserved areas, but across large health care systems. Tele-teaming will be essential in other arenas as well, as psychiatry faces the future challenges of an aging and decreasing (per capita) workforce. Team approaches help maximize psychiatrists’ role in the health care system, and help magnify the number of patients their skills and training can support.
Team approaches also help to broaden the scope of psychiatric practice and reclaim psychiatry’s place within the house of medicine. Telepsychiatry, if structured correctly, helps increase flexibility for psychiatrists. It expands the settings available to practice and provides more opportunities to engage in team-based care. Both the doc in a box and tele-teaming models have arisen from forces in the health care marketplace. The differing application of those two models across and within health care systems illustrates overall tensions within psychiatry about the current and future roles of psychiatrists.
Telepsychiatry is a powerful tool that can be leveraged to shape models of psychiatric care delivery or reinforce our existing structures. Which models are embraced will affect how psychiatry continues to evolve and address the challenges before the specialty.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry, and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center and associate professor of psychiatry at the University of Colorado at Denver, Aurora.
As articulated by Steve Daviss, MD, DFAPA, in the inaugural column of Techiatry, the adoption and diffusion of telepsychiatry (live two-way interactive videoconferencing) have not been as rapid and universal as expected from those of us immersed in the field.
Despite having yet to achieve its full promise, telepsychiatry has reached maturity, and is being widely deployed and used across multiple systems, settings, and applications, albeit at times in an uneven, unsystematic manner. Emerging over the past decade of development are two distinct models/approaches to telepsychiatry, which I refer to as “doc in a box” and “tele-teaming.” Those models coexist, compete, and conflict within and across organizations. The dynamic between those two models highlights a larger emergent dialogue within psychiatry around psychiatrists’ core clinical roles and functions in our evolving health care systems.
The doc in a box model, as captured in early telepsychiatry services in the 1990s and early 2000s, focused on the virtual insertion of a solo psychiatrist into a distant setting. The services involved core psychiatric activities, such as diagnosis and assessment, with a heavy emphasis on pharmacologic management.
Not surprisingly, those services paralleled what was occurring for the rest of psychiatry at the time and were driven by the closer alignment of psychiatry with a biologic framework – and most importantly, reimbursement models that favored pharmacologic interventions and management. The subsequent rise of viable commercial telepsychiatry companies has continued offering this model driven by demands of the marketplace. While there is a legitimate place and need for such services, the phrase “doc in a box” narrows the scope of psychiatric practice, and reinforces current systems of health care structure and funding.
I proffer the phrase “tele-teaming” to denote telepsychiatric care that virtually embeds a psychiatrist as a member of a care team at a distant location. The use of telepsychiatry in integrated care is the clearest example of this. In integrated care, a psychiatrist works as part of a larger behavioral and medical team that may include case managers, social workers, psychologists, nurses, and family physicians to render care to patients in primary care clinics. The psychiatrist performs consultative, direct care, and supervisory roles in the context of the integrated care team, focusing on more holistic and population-based approaches to treatment.
Telepsychiatry, as well as other technologies (for example, electronic medical records, email, and patient registries), enables and enhances integrated care. Telepsychiatry allows smaller primary care practices, which on their own could not support a full-time psychiatrist, to create a full virtual team across multiple sites.
Tele-teaming as a concept is not limited to integrated care. Other notable examples include the use of telepsychiatry in substance rehabilitation facilities, long-term nursing homes, and psychiatric emergency services as a component of ERs. Tele-teaming and doc in a box models are not about the settings or populations to which they provide care, but the structure and philosophy of the psychiatric service.
As an illustration, imagine a rural community mental health center whose long-term psychiatric care provider retires. The center could set up a contract with a psychiatrist to provide medication management services for its patients through telepsychiatry. The psychiatrist, armed with a pen or eprescribing credentials, could provide several days a week of medication management. Treatment planning, therapy, and care coordination could be segmented off to other providers from the center (psychologists, social workers, and case managers). The psychiatrist’s time could be maximized by having the psychiatrist manage prescriptions, with communication between the patients’ various providers through a shared electronic medical record, as in the doc in a box model.
Alternatively, the center could set up a service where the psychiatrist became a virtual team member working to provide complete assessments, treatment planning, supervision, and psychiatric consultation, as well as pharmacologic management. Although in this scenario, the psychiatrist still could devote time to managing prescriptions, she/he also could spend time in team meetings, supervision, and seeing patients, often with her colleagues. In addition, the psychiatrist could work to coordinate care beyond the EMR, for example, through tele-teaming. Either of these scenarios can and do occur with in-person care as well, and the choice of which model to use would not be decided by the technology but by the underlying health care system in which it is being used.
Telepsychiatry begins to become transformative when it’s leveraged to shift, change, or innovate the model of care delivery. Historically, telepsychiatry has been thought of as a solution to patient access issues and as a way to address workforce shortages. The real promise of telepsychiatry in the form of tele-teaming is how it can begin to fundamentally change how care is delivered. The triple aim calls for decreased costs, improved health care for individuals, and a focus on population health.
We know that most Americans with major mental health issues will be seen in primary care, and that providing behavioral health care in primary care settings leads to lower overall health care costs, and improved behavioral and general health outcomes. Telepsychiatry will be essential in the further dissemination and expansion of integrated care, not only in rural and underserved areas, but across large health care systems. Tele-teaming will be essential in other arenas as well, as psychiatry faces the future challenges of an aging and decreasing (per capita) workforce. Team approaches help maximize psychiatrists’ role in the health care system, and help magnify the number of patients their skills and training can support.
Team approaches also help to broaden the scope of psychiatric practice and reclaim psychiatry’s place within the house of medicine. Telepsychiatry, if structured correctly, helps increase flexibility for psychiatrists. It expands the settings available to practice and provides more opportunities to engage in team-based care. Both the doc in a box and tele-teaming models have arisen from forces in the health care marketplace. The differing application of those two models across and within health care systems illustrates overall tensions within psychiatry about the current and future roles of psychiatrists.
Telepsychiatry is a powerful tool that can be leveraged to shape models of psychiatric care delivery or reinforce our existing structures. Which models are embraced will affect how psychiatry continues to evolve and address the challenges before the specialty.
Dr. Shore chairs the American Psychiatric Association’s Committee on Telepsychiatry, and is director of telemedicine at the Helen & Arthur E. Johnson Depression Center and associate professor of psychiatry at the University of Colorado at Denver, Aurora.
Inhaled antibiotic for bronchiectasis shows promise
AT CHEST 2016
LOS ANGELES – Long-term inhaled ciprofloxacin therapy appears to be a safe and effective treatment option in patients with bronchiectasis, results from an international phase III trial showed.
“This is really exciting; it’s the first large study of an inhaled antibiotic to show a benefit in this population,” study investigator Kevin Winthrop, MD, said in an interview prior to the annual meeting of the American College of Chest Physicians. “There’s a tremendous unmet need and a lot of these patients have daily struggles and their quality of life is low. To have something that would improve that would be a benefit for patients and physicians alike.”
Compared with patients in the placebo arm, those in the ciprofloxacin dry powder for inhalation (DPI) 14-day on/off arm experienced a significantly prolonged time to first exacerbation (a mean of 336 days versus 186 days, respectively; adjusted hazard ratio, 0.53; P = .0005) and a significantly reduced exacerbation frequency over 48 weeks (a mean of 0.78 vs. 1.42; adjusted incident rate of 0.61; P = .0061). A nonsignificant trend in favor of ciprofloxacin DPI was observed for both primary endpoints among patients in the 28-day on/off arm (time to first exacerbation: HR, 0.73; P = .065; frequency of exacerbations: adjusted incidence rate ratio, 0.98; P = .89).
Treatment-emergent adverse events and adverse events leading to discontinuation were similar across treatment groups (82% in the ciprofloxacin DPI 14-day on/off arm, 83% in the ciprofloxacin DPI 28-day on/off arm, and 83% in the pooled placebo arm. The rates of serious adverse events were also similar in the three treatment groups (17%, 20%, and 23%, respectively). “Tolerability markers like hoarseness, bronchospasm, shortness of breath, or increased cough were similar between the treatment arms,” said Dr. Winthrop, who is an infectious diseases specialist at Oregon Health and Science University, Portland.“The safety profile looks really good. There were no typical fluoroquinolone types of problems such as tendinopathy reported.”
A follow-up trial known as RESPIRE 2 is ongoing. RESPIRE 1 was funded by Bayer. Dr. Winthrop disclosed that he is a consultant for the company.
This article was updated on 10/25/2016 at 9:51 AM Est
AT CHEST 2016
LOS ANGELES – Long-term inhaled ciprofloxacin therapy appears to be a safe and effective treatment option in patients with bronchiectasis, results from an international phase III trial showed.
“This is really exciting; it’s the first large study of an inhaled antibiotic to show a benefit in this population,” study investigator Kevin Winthrop, MD, said in an interview prior to the annual meeting of the American College of Chest Physicians. “There’s a tremendous unmet need and a lot of these patients have daily struggles and their quality of life is low. To have something that would improve that would be a benefit for patients and physicians alike.”
Compared with patients in the placebo arm, those in the ciprofloxacin dry powder for inhalation (DPI) 14-day on/off arm experienced a significantly prolonged time to first exacerbation (a mean of 336 days versus 186 days, respectively; adjusted hazard ratio, 0.53; P = .0005) and a significantly reduced exacerbation frequency over 48 weeks (a mean of 0.78 vs. 1.42; adjusted incident rate of 0.61; P = .0061). A nonsignificant trend in favor of ciprofloxacin DPI was observed for both primary endpoints among patients in the 28-day on/off arm (time to first exacerbation: HR, 0.73; P = .065; frequency of exacerbations: adjusted incidence rate ratio, 0.98; P = .89).
Treatment-emergent adverse events and adverse events leading to discontinuation were similar across treatment groups (82% in the ciprofloxacin DPI 14-day on/off arm, 83% in the ciprofloxacin DPI 28-day on/off arm, and 83% in the pooled placebo arm. The rates of serious adverse events were also similar in the three treatment groups (17%, 20%, and 23%, respectively). “Tolerability markers like hoarseness, bronchospasm, shortness of breath, or increased cough were similar between the treatment arms,” said Dr. Winthrop, who is an infectious diseases specialist at Oregon Health and Science University, Portland.“The safety profile looks really good. There were no typical fluoroquinolone types of problems such as tendinopathy reported.”
A follow-up trial known as RESPIRE 2 is ongoing. RESPIRE 1 was funded by Bayer. Dr. Winthrop disclosed that he is a consultant for the company.
This article was updated on 10/25/2016 at 9:51 AM Est
AT CHEST 2016
LOS ANGELES – Long-term inhaled ciprofloxacin therapy appears to be a safe and effective treatment option in patients with bronchiectasis, results from an international phase III trial showed.
“This is really exciting; it’s the first large study of an inhaled antibiotic to show a benefit in this population,” study investigator Kevin Winthrop, MD, said in an interview prior to the annual meeting of the American College of Chest Physicians. “There’s a tremendous unmet need and a lot of these patients have daily struggles and their quality of life is low. To have something that would improve that would be a benefit for patients and physicians alike.”
Compared with patients in the placebo arm, those in the ciprofloxacin dry powder for inhalation (DPI) 14-day on/off arm experienced a significantly prolonged time to first exacerbation (a mean of 336 days versus 186 days, respectively; adjusted hazard ratio, 0.53; P = .0005) and a significantly reduced exacerbation frequency over 48 weeks (a mean of 0.78 vs. 1.42; adjusted incident rate of 0.61; P = .0061). A nonsignificant trend in favor of ciprofloxacin DPI was observed for both primary endpoints among patients in the 28-day on/off arm (time to first exacerbation: HR, 0.73; P = .065; frequency of exacerbations: adjusted incidence rate ratio, 0.98; P = .89).
Treatment-emergent adverse events and adverse events leading to discontinuation were similar across treatment groups (82% in the ciprofloxacin DPI 14-day on/off arm, 83% in the ciprofloxacin DPI 28-day on/off arm, and 83% in the pooled placebo arm. The rates of serious adverse events were also similar in the three treatment groups (17%, 20%, and 23%, respectively). “Tolerability markers like hoarseness, bronchospasm, shortness of breath, or increased cough were similar between the treatment arms,” said Dr. Winthrop, who is an infectious diseases specialist at Oregon Health and Science University, Portland.“The safety profile looks really good. There were no typical fluoroquinolone types of problems such as tendinopathy reported.”
A follow-up trial known as RESPIRE 2 is ongoing. RESPIRE 1 was funded by Bayer. Dr. Winthrop disclosed that he is a consultant for the company.
This article was updated on 10/25/2016 at 9:51 AM Est
Key clinical point:
Major finding: Compared with patients in the placebo arm, those in the ciprofloxacin 14-day on/off arm experienced a significantly prolonged time to first exacerbation (a mean of 336 days vs. 186 days, respectively; adjusted hazard ratio, 0.53; P = .0005).
Data source: A multicenter study of 416 patients who were randomized 2:1 to ciprofloxacin 32.5 mg or placebo administered twice per day using a pocket-sized inhaler as a cyclical regimen of either 14 days on/off drug or 28 days on/off drug, for 48 weeks.
Disclosures: RESPIRE 1 was funded by Bayer. Dr. Winthrop disclosed that he is a consultant for the company.
Guideline: Supplemental, dietary calcium both heart safe
Both dietary and supplemental calcium should be considered safe for the cardiovascular system as long as total intake doesn’t exceed 2,000-2,500 mg/day – the maximal tolerable level defined by the National Academy of Medicine, according to an updated Clinical Practice Guideline published online October 24 in Annals of Internal Medicine.
For generally healthy patients who don’t consume adequate calcium and take supplements, either alone or in combination with vitamin D, to prevent osteoporosis and related fractures, “discontinuation of supplemental calcium for safety reasons is not necessary and may be harmful to bone health,” said Stephen L. Kopecky, MD, of the Mayo Clinic, Rochester Minn., and his associates on the expert panel that wrote the new guideline.
The National Osteoporosis Foundation (NOF) and the American Society for Preventive Cardiology (ASPC) commissioned an independent review of the current evidence to update the Evidence Report and assembled the expert panel to write the guideline based on the new findings (Ann Intern Med. 2016 Oct 24. doi: 10.7326/M16-1743).
Separately, Mei Chung, PhD, of the department of public health and community medicine, and her associates at Tufts University, Boston, reviewed 4 recent randomized clinical trials, 1 nested case-control study, and 26 cohort studies that assessed the effects of calcium intake on 17 health outcomes in generally healthy adults of all ages. None of the studies evaluated cardiovascular disease risk as a primary outcome. “We conclude that calcium intake (from either food or supplement sources) at levels within the recommended tolerable upper intake range (2,000-2,500 mg/d) are not associated with CVD risks in generally healthy adults,” they said.
“Although a few trials and cohort studies reported increased risks with higher calcium intake, risk estimates in most of those studies were small (10% relative risk) and not considered clinically important, even if they were statistically significant,” Dr. Chung and her associates added (Ann Int Med. 2016 Oct 24. doi: 10.7326/M16-1165).
According to the guideline, “The NOF and the ASPC now adopt the position that there is moderate-quality evidence that calcium with or without vitamin D intake from food or supplements has no relationship (beneficial or harmful) with the risk for cardiovascular or cerebrovascular disease, mortality, or all-cause mortality in generally healthy adults at this time.”
In addition, “Currently, no established biological mechanism supports and association between calcium and cardiovascular disease,” Dr. Kopecky and his associates on the expert panel noted.
The volume of literature on the subject of calcium’s potential harmful cardiovascular disease effects appears to be robust, with the largest meta-analysis to date including 18 studies with 64,000 participants. But this evidence base has some limitations, chief among them the fact that none of the studies was designed to evaluate CVD as a primary outcome.
In addition, concerns about harmful cardiovascular effects arose after most of the trials had already been initiated, so unpublished data on those outcomes were collected and adjudicated retrospectively. In addition, many of the participants showed poor long-term treatment adherence, making it difficult to interpret the data.
Karen L. Margolis, MD, of HealthPartners Institute in Minneapolis and JoAnn E. Manson, MD, DrPH, of Brigham and Women’s Hospital and Harvard Medical School, both in Boston, made these remarks in an editorial accompanying the new Clinical Practice Guideline (Ann Intern Med. 2016 Oct 24. doi: 10.7326/M16-2193). Their financial disclosures are available at www.acponline.org.
The volume of literature on the subject of calcium’s potential harmful cardiovascular disease effects appears to be robust, with the largest meta-analysis to date including 18 studies with 64,000 participants. But this evidence base has some limitations, chief among them the fact that none of the studies was designed to evaluate CVD as a primary outcome.
In addition, concerns about harmful cardiovascular effects arose after most of the trials had already been initiated, so unpublished data on those outcomes were collected and adjudicated retrospectively. In addition, many of the participants showed poor long-term treatment adherence, making it difficult to interpret the data.
Karen L. Margolis, MD, of HealthPartners Institute in Minneapolis and JoAnn E. Manson, MD, DrPH, of Brigham and Women’s Hospital and Harvard Medical School, both in Boston, made these remarks in an editorial accompanying the new Clinical Practice Guideline (Ann Intern Med. 2016 Oct 24. doi: 10.7326/M16-2193). Their financial disclosures are available at www.acponline.org.
The volume of literature on the subject of calcium’s potential harmful cardiovascular disease effects appears to be robust, with the largest meta-analysis to date including 18 studies with 64,000 participants. But this evidence base has some limitations, chief among them the fact that none of the studies was designed to evaluate CVD as a primary outcome.
In addition, concerns about harmful cardiovascular effects arose after most of the trials had already been initiated, so unpublished data on those outcomes were collected and adjudicated retrospectively. In addition, many of the participants showed poor long-term treatment adherence, making it difficult to interpret the data.
Karen L. Margolis, MD, of HealthPartners Institute in Minneapolis and JoAnn E. Manson, MD, DrPH, of Brigham and Women’s Hospital and Harvard Medical School, both in Boston, made these remarks in an editorial accompanying the new Clinical Practice Guideline (Ann Intern Med. 2016 Oct 24. doi: 10.7326/M16-2193). Their financial disclosures are available at www.acponline.org.
Both dietary and supplemental calcium should be considered safe for the cardiovascular system as long as total intake doesn’t exceed 2,000-2,500 mg/day – the maximal tolerable level defined by the National Academy of Medicine, according to an updated Clinical Practice Guideline published online October 24 in Annals of Internal Medicine.
For generally healthy patients who don’t consume adequate calcium and take supplements, either alone or in combination with vitamin D, to prevent osteoporosis and related fractures, “discontinuation of supplemental calcium for safety reasons is not necessary and may be harmful to bone health,” said Stephen L. Kopecky, MD, of the Mayo Clinic, Rochester Minn., and his associates on the expert panel that wrote the new guideline.
The National Osteoporosis Foundation (NOF) and the American Society for Preventive Cardiology (ASPC) commissioned an independent review of the current evidence to update the Evidence Report and assembled the expert panel to write the guideline based on the new findings (Ann Intern Med. 2016 Oct 24. doi: 10.7326/M16-1743).
Separately, Mei Chung, PhD, of the department of public health and community medicine, and her associates at Tufts University, Boston, reviewed 4 recent randomized clinical trials, 1 nested case-control study, and 26 cohort studies that assessed the effects of calcium intake on 17 health outcomes in generally healthy adults of all ages. None of the studies evaluated cardiovascular disease risk as a primary outcome. “We conclude that calcium intake (from either food or supplement sources) at levels within the recommended tolerable upper intake range (2,000-2,500 mg/d) are not associated with CVD risks in generally healthy adults,” they said.
“Although a few trials and cohort studies reported increased risks with higher calcium intake, risk estimates in most of those studies were small (10% relative risk) and not considered clinically important, even if they were statistically significant,” Dr. Chung and her associates added (Ann Int Med. 2016 Oct 24. doi: 10.7326/M16-1165).
According to the guideline, “The NOF and the ASPC now adopt the position that there is moderate-quality evidence that calcium with or without vitamin D intake from food or supplements has no relationship (beneficial or harmful) with the risk for cardiovascular or cerebrovascular disease, mortality, or all-cause mortality in generally healthy adults at this time.”
In addition, “Currently, no established biological mechanism supports and association between calcium and cardiovascular disease,” Dr. Kopecky and his associates on the expert panel noted.
Both dietary and supplemental calcium should be considered safe for the cardiovascular system as long as total intake doesn’t exceed 2,000-2,500 mg/day – the maximal tolerable level defined by the National Academy of Medicine, according to an updated Clinical Practice Guideline published online October 24 in Annals of Internal Medicine.
For generally healthy patients who don’t consume adequate calcium and take supplements, either alone or in combination with vitamin D, to prevent osteoporosis and related fractures, “discontinuation of supplemental calcium for safety reasons is not necessary and may be harmful to bone health,” said Stephen L. Kopecky, MD, of the Mayo Clinic, Rochester Minn., and his associates on the expert panel that wrote the new guideline.
The National Osteoporosis Foundation (NOF) and the American Society for Preventive Cardiology (ASPC) commissioned an independent review of the current evidence to update the Evidence Report and assembled the expert panel to write the guideline based on the new findings (Ann Intern Med. 2016 Oct 24. doi: 10.7326/M16-1743).
Separately, Mei Chung, PhD, of the department of public health and community medicine, and her associates at Tufts University, Boston, reviewed 4 recent randomized clinical trials, 1 nested case-control study, and 26 cohort studies that assessed the effects of calcium intake on 17 health outcomes in generally healthy adults of all ages. None of the studies evaluated cardiovascular disease risk as a primary outcome. “We conclude that calcium intake (from either food or supplement sources) at levels within the recommended tolerable upper intake range (2,000-2,500 mg/d) are not associated with CVD risks in generally healthy adults,” they said.
“Although a few trials and cohort studies reported increased risks with higher calcium intake, risk estimates in most of those studies were small (10% relative risk) and not considered clinically important, even if they were statistically significant,” Dr. Chung and her associates added (Ann Int Med. 2016 Oct 24. doi: 10.7326/M16-1165).
According to the guideline, “The NOF and the ASPC now adopt the position that there is moderate-quality evidence that calcium with or without vitamin D intake from food or supplements has no relationship (beneficial or harmful) with the risk for cardiovascular or cerebrovascular disease, mortality, or all-cause mortality in generally healthy adults at this time.”
In addition, “Currently, no established biological mechanism supports and association between calcium and cardiovascular disease,” Dr. Kopecky and his associates on the expert panel noted.
COPD spirometry use suboptimal in primary care
LOS ANGELES – Spirometry is the standard for diagnosing chronic obstructive pulmonary disease, but it’s underused and misused in primary care, according to investigators from the Corpus Christi (Tex.) Medical Center.
The conclusion is based on a review of just 65 patients from internal medicine and family practice clinics near the medical center, but “I do think this [pattern] is representative of what we are seeing in every primary care office. This has been a problem [documented] in the literature for a decade, and it remains a problem,” said lead investigator Stephen Eikermann, DO, an internal medicine resident at the center.
Meanwhile, of those diagnosed by spirometry, 32% didn’t meet the gold-standard Global Initiative for Chronic Obstructive Lung Disease (GOLD) diagnostic criteria by having a postbronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) of less than 70%. Clinicians might not have known that postbronchodilator values are the ones that matter. “People who have asthma are being tagged as having COPD,” and once that diagnosis is in the chart, it’s hard to remove, even when patients improve. “With the COPD readmission penalty in place, an erroneous diagnosis of COPD [has] significant financial risks,” Dr. Eikermann said.
“Misdiagnosis leads to significant financial consequences and puts patients at risk for osteoporotic fractures and malignant arrhythmias. It’s a problem of education.” Busy practitioners might not have had time to catch the latest 2015 GOLD standards, he said.
The guidelines state that COPD should be considered in any patient who has dyspnea, chronic cough, or sputum production, plus smoking or other risks. “Spirometry is required to make the diagnosis.”
To help, Dr. Eikermann and his colleagues plan lectures and a quick reference handout, and maybe a smartphone app. They also plan to remind practitioners that Medicare pays at a reasonable rate for spirometry.
The 65 patients in the study were about evenly split between men and women, and were 70 years old, on average. They had about 34 pack-years of smoking, and some were still smoking despite being on home oxygen.
Men were less likely to have spirometry than women; older subjects and current smokers – as opposed to former smokers – were, too. The risk of COPD increases with age and smoking, so the finding was puzzling. For unknown reasons, “there appears to be a bias against ordering spirometry” for some patients, Dr. Eikermann said.
There was no outside funding for the work, and the investigators had no disclosures.
LOS ANGELES – Spirometry is the standard for diagnosing chronic obstructive pulmonary disease, but it’s underused and misused in primary care, according to investigators from the Corpus Christi (Tex.) Medical Center.
The conclusion is based on a review of just 65 patients from internal medicine and family practice clinics near the medical center, but “I do think this [pattern] is representative of what we are seeing in every primary care office. This has been a problem [documented] in the literature for a decade, and it remains a problem,” said lead investigator Stephen Eikermann, DO, an internal medicine resident at the center.
Meanwhile, of those diagnosed by spirometry, 32% didn’t meet the gold-standard Global Initiative for Chronic Obstructive Lung Disease (GOLD) diagnostic criteria by having a postbronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) of less than 70%. Clinicians might not have known that postbronchodilator values are the ones that matter. “People who have asthma are being tagged as having COPD,” and once that diagnosis is in the chart, it’s hard to remove, even when patients improve. “With the COPD readmission penalty in place, an erroneous diagnosis of COPD [has] significant financial risks,” Dr. Eikermann said.
“Misdiagnosis leads to significant financial consequences and puts patients at risk for osteoporotic fractures and malignant arrhythmias. It’s a problem of education.” Busy practitioners might not have had time to catch the latest 2015 GOLD standards, he said.
The guidelines state that COPD should be considered in any patient who has dyspnea, chronic cough, or sputum production, plus smoking or other risks. “Spirometry is required to make the diagnosis.”
To help, Dr. Eikermann and his colleagues plan lectures and a quick reference handout, and maybe a smartphone app. They also plan to remind practitioners that Medicare pays at a reasonable rate for spirometry.
The 65 patients in the study were about evenly split between men and women, and were 70 years old, on average. They had about 34 pack-years of smoking, and some were still smoking despite being on home oxygen.
Men were less likely to have spirometry than women; older subjects and current smokers – as opposed to former smokers – were, too. The risk of COPD increases with age and smoking, so the finding was puzzling. For unknown reasons, “there appears to be a bias against ordering spirometry” for some patients, Dr. Eikermann said.
There was no outside funding for the work, and the investigators had no disclosures.
LOS ANGELES – Spirometry is the standard for diagnosing chronic obstructive pulmonary disease, but it’s underused and misused in primary care, according to investigators from the Corpus Christi (Tex.) Medical Center.
The conclusion is based on a review of just 65 patients from internal medicine and family practice clinics near the medical center, but “I do think this [pattern] is representative of what we are seeing in every primary care office. This has been a problem [documented] in the literature for a decade, and it remains a problem,” said lead investigator Stephen Eikermann, DO, an internal medicine resident at the center.
Meanwhile, of those diagnosed by spirometry, 32% didn’t meet the gold-standard Global Initiative for Chronic Obstructive Lung Disease (GOLD) diagnostic criteria by having a postbronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) of less than 70%. Clinicians might not have known that postbronchodilator values are the ones that matter. “People who have asthma are being tagged as having COPD,” and once that diagnosis is in the chart, it’s hard to remove, even when patients improve. “With the COPD readmission penalty in place, an erroneous diagnosis of COPD [has] significant financial risks,” Dr. Eikermann said.
“Misdiagnosis leads to significant financial consequences and puts patients at risk for osteoporotic fractures and malignant arrhythmias. It’s a problem of education.” Busy practitioners might not have had time to catch the latest 2015 GOLD standards, he said.
The guidelines state that COPD should be considered in any patient who has dyspnea, chronic cough, or sputum production, plus smoking or other risks. “Spirometry is required to make the diagnosis.”
To help, Dr. Eikermann and his colleagues plan lectures and a quick reference handout, and maybe a smartphone app. They also plan to remind practitioners that Medicare pays at a reasonable rate for spirometry.
The 65 patients in the study were about evenly split between men and women, and were 70 years old, on average. They had about 34 pack-years of smoking, and some were still smoking despite being on home oxygen.
Men were less likely to have spirometry than women; older subjects and current smokers – as opposed to former smokers – were, too. The risk of COPD increases with age and smoking, so the finding was puzzling. For unknown reasons, “there appears to be a bias against ordering spirometry” for some patients, Dr. Eikermann said.
There was no outside funding for the work, and the investigators had no disclosures.
Key clinical point:
Major finding: Only 29% of patients diagnosed with chronic obstructive pulmonary disease (COPD) at two clinics underwent spirometry. Of those diagnosed by spirometry, 32% didn’t meet the gold-standard Global Initiative for Chronic Obstructive Lung Disease (GOLD) diagnostic criteria by having a postbronchodilator FEV1/FVC of less than 70%.
Data source: Review of 65 COPD cases treated at two primary care clinics.
Disclosures: There was no outside funding for the work, and the investigators had no disclosures.
MOC debate heats up
The American Board of Internal Medicine (ABIM) recently unveiled its first attempt to revitalize the maintenance of certification (MOC) program with pathway alternatives to the 10-year exam. While AGA has advocated for MOC reform and welcomed the efforts of the ABIM in responding to demands for change, we object to the pathways proposed by ABIM, which fall short of our principles of individualization, lifelong education, and low-stakes testing.
ABIM proposes to replace the 10-year exam with either a 2- (or 5-) year alternative MOC pathway. Every 2 (or 5) years, diplomates can take a single, 2- (or 5-) hour open-book exam, from their office or home. The exam would provide granular feedback on learning objectives in need of remediation. The exam is promoted as “low-stakes” since failure does not result in immediate loss of certification. Rather, the diplomate has the opportunity to take the next exam and, if they pass, continue on the pathway. Failure of two exams in a row means the diplomate must pass the traditional 10-year exam before continuing the MOC pathway.
AGA joined unanimously with other GI societies and the majority of other internal medicine societies in rejecting both proposed pathways as unacceptable in their present format.
AGA’s liaison to the ABIM Liaison Committee on Certification and Recertification (LCCR), Art DeCross, MD, outlined AGA’s issues with the proposal on the AGA Community in late September and kicked off a lively discussion about the future of MOC. Visit the AGA Community at community.gasto.org to read or join the conversation.
Additionally, here are two key things to know:
1. Regarding state legislation, AGA President Tim Wang, MD, notes that “We’re monitoring legislative actions in various states and note that there would need to be commitment to the same approach by all 50 states in order to have the necessary impact to completely unlink MOC certification from hospital and insurance credentialing for AGA members. So instead, AGA is focusing our work on national advocacy, which is where we can have the most impact.”
2. While there is a lot of activity related to reforming MOC, the time horizon for changes is long. Dr. DeCross notes that “members really should plan on continuing their current, standard MOC pathway process, including taking their recertification examinations, if they want to retain that credential at this time.”
This conversation is the latest in a long advocacy campaign lead by AGA to push ABIM to reform MOC. Learn more at www.gastro.org/career-center/maintenance-of-certification.
The American Board of Internal Medicine (ABIM) recently unveiled its first attempt to revitalize the maintenance of certification (MOC) program with pathway alternatives to the 10-year exam. While AGA has advocated for MOC reform and welcomed the efforts of the ABIM in responding to demands for change, we object to the pathways proposed by ABIM, which fall short of our principles of individualization, lifelong education, and low-stakes testing.
ABIM proposes to replace the 10-year exam with either a 2- (or 5-) year alternative MOC pathway. Every 2 (or 5) years, diplomates can take a single, 2- (or 5-) hour open-book exam, from their office or home. The exam would provide granular feedback on learning objectives in need of remediation. The exam is promoted as “low-stakes” since failure does not result in immediate loss of certification. Rather, the diplomate has the opportunity to take the next exam and, if they pass, continue on the pathway. Failure of two exams in a row means the diplomate must pass the traditional 10-year exam before continuing the MOC pathway.
AGA joined unanimously with other GI societies and the majority of other internal medicine societies in rejecting both proposed pathways as unacceptable in their present format.
AGA’s liaison to the ABIM Liaison Committee on Certification and Recertification (LCCR), Art DeCross, MD, outlined AGA’s issues with the proposal on the AGA Community in late September and kicked off a lively discussion about the future of MOC. Visit the AGA Community at community.gasto.org to read or join the conversation.
Additionally, here are two key things to know:
1. Regarding state legislation, AGA President Tim Wang, MD, notes that “We’re monitoring legislative actions in various states and note that there would need to be commitment to the same approach by all 50 states in order to have the necessary impact to completely unlink MOC certification from hospital and insurance credentialing for AGA members. So instead, AGA is focusing our work on national advocacy, which is where we can have the most impact.”
2. While there is a lot of activity related to reforming MOC, the time horizon for changes is long. Dr. DeCross notes that “members really should plan on continuing their current, standard MOC pathway process, including taking their recertification examinations, if they want to retain that credential at this time.”
This conversation is the latest in a long advocacy campaign lead by AGA to push ABIM to reform MOC. Learn more at www.gastro.org/career-center/maintenance-of-certification.
The American Board of Internal Medicine (ABIM) recently unveiled its first attempt to revitalize the maintenance of certification (MOC) program with pathway alternatives to the 10-year exam. While AGA has advocated for MOC reform and welcomed the efforts of the ABIM in responding to demands for change, we object to the pathways proposed by ABIM, which fall short of our principles of individualization, lifelong education, and low-stakes testing.
ABIM proposes to replace the 10-year exam with either a 2- (or 5-) year alternative MOC pathway. Every 2 (or 5) years, diplomates can take a single, 2- (or 5-) hour open-book exam, from their office or home. The exam would provide granular feedback on learning objectives in need of remediation. The exam is promoted as “low-stakes” since failure does not result in immediate loss of certification. Rather, the diplomate has the opportunity to take the next exam and, if they pass, continue on the pathway. Failure of two exams in a row means the diplomate must pass the traditional 10-year exam before continuing the MOC pathway.
AGA joined unanimously with other GI societies and the majority of other internal medicine societies in rejecting both proposed pathways as unacceptable in their present format.
AGA’s liaison to the ABIM Liaison Committee on Certification and Recertification (LCCR), Art DeCross, MD, outlined AGA’s issues with the proposal on the AGA Community in late September and kicked off a lively discussion about the future of MOC. Visit the AGA Community at community.gasto.org to read or join the conversation.
Additionally, here are two key things to know:
1. Regarding state legislation, AGA President Tim Wang, MD, notes that “We’re monitoring legislative actions in various states and note that there would need to be commitment to the same approach by all 50 states in order to have the necessary impact to completely unlink MOC certification from hospital and insurance credentialing for AGA members. So instead, AGA is focusing our work on national advocacy, which is where we can have the most impact.”
2. While there is a lot of activity related to reforming MOC, the time horizon for changes is long. Dr. DeCross notes that “members really should plan on continuing their current, standard MOC pathway process, including taking their recertification examinations, if they want to retain that credential at this time.”
This conversation is the latest in a long advocacy campaign lead by AGA to push ABIM to reform MOC. Learn more at www.gastro.org/career-center/maintenance-of-certification.
Lung cancer screening found effective in a community hospital
LOS ANGELES – Lung cancer screening with low-dose CT scans in a community hospital setting replicates results from international and multicenter trials when it comes to diagnosing early-stage lung cancer, findings from a single-center study showed.
“It’s too early in our experience to say that we’re saving lives, but the fact that we’re detecting early lung cancers in the predicted percentages is good for community hospitals that are wondering, ‘Is it worth it to screen for lung cancer? Can we do it?’ ” Richard P. Salzano Jr., MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians.
In July 2013, the 130-bed Griffin Hospital launched a lung cancer screening program codirected by a pulmonologist and a cardiothoracic surgeon. All low-dose CT scans were read by two designated radiologists. Dr. Salzano reported results from 514 patients enrolled in the program between July 2013 and December 2015. A total of nine lung cancers were detected. Seven (78%) were stage I or II lung cancers, and the remaining two (22%) were stage II or IV, results that are in line with data from the I-ELCAP and NLST trials.
In another component of the study, the researchers randomly selected 101 patients from the lung cancer screening program to answer questions by telephone intended to quantify their anxiety about lung cancer before and after participating in the program, attitudes about smoking behaviors, and general impressions of the screening process. On a scale of 0-10, with 10 being “very anxious,” Dr. Salzano reported that the mean anxiety level about lung cancer fell from a level of 4.69 before screening to 3.87 afterward, a difference that reached statistical significance, with a P value of .014. “None of the patients reported negative impacts of the program,” he added. “They reported a general improvement in their well-being as a result of participating in the program.” In addition, of the 53 respondents who were current smokers upon enrolling in the screening program, five quit after intake, and the remaining 48 indicated that they were “more likely to quit” as a result of being enrolled.
“Community hospitals need to embrace lung screening,” Dr. Salzano concluded. “The findings from the large studies are transferable. It’s helping your patients in terms of their attitudes about lung cancer, about smoking cessation, and about improving their wellness.”
He reported having no relevant financial disclosures.
LOS ANGELES – Lung cancer screening with low-dose CT scans in a community hospital setting replicates results from international and multicenter trials when it comes to diagnosing early-stage lung cancer, findings from a single-center study showed.
“It’s too early in our experience to say that we’re saving lives, but the fact that we’re detecting early lung cancers in the predicted percentages is good for community hospitals that are wondering, ‘Is it worth it to screen for lung cancer? Can we do it?’ ” Richard P. Salzano Jr., MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians.
In July 2013, the 130-bed Griffin Hospital launched a lung cancer screening program codirected by a pulmonologist and a cardiothoracic surgeon. All low-dose CT scans were read by two designated radiologists. Dr. Salzano reported results from 514 patients enrolled in the program between July 2013 and December 2015. A total of nine lung cancers were detected. Seven (78%) were stage I or II lung cancers, and the remaining two (22%) were stage II or IV, results that are in line with data from the I-ELCAP and NLST trials.
In another component of the study, the researchers randomly selected 101 patients from the lung cancer screening program to answer questions by telephone intended to quantify their anxiety about lung cancer before and after participating in the program, attitudes about smoking behaviors, and general impressions of the screening process. On a scale of 0-10, with 10 being “very anxious,” Dr. Salzano reported that the mean anxiety level about lung cancer fell from a level of 4.69 before screening to 3.87 afterward, a difference that reached statistical significance, with a P value of .014. “None of the patients reported negative impacts of the program,” he added. “They reported a general improvement in their well-being as a result of participating in the program.” In addition, of the 53 respondents who were current smokers upon enrolling in the screening program, five quit after intake, and the remaining 48 indicated that they were “more likely to quit” as a result of being enrolled.
“Community hospitals need to embrace lung screening,” Dr. Salzano concluded. “The findings from the large studies are transferable. It’s helping your patients in terms of their attitudes about lung cancer, about smoking cessation, and about improving their wellness.”
He reported having no relevant financial disclosures.
LOS ANGELES – Lung cancer screening with low-dose CT scans in a community hospital setting replicates results from international and multicenter trials when it comes to diagnosing early-stage lung cancer, findings from a single-center study showed.
“It’s too early in our experience to say that we’re saving lives, but the fact that we’re detecting early lung cancers in the predicted percentages is good for community hospitals that are wondering, ‘Is it worth it to screen for lung cancer? Can we do it?’ ” Richard P. Salzano Jr., MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians.
In July 2013, the 130-bed Griffin Hospital launched a lung cancer screening program codirected by a pulmonologist and a cardiothoracic surgeon. All low-dose CT scans were read by two designated radiologists. Dr. Salzano reported results from 514 patients enrolled in the program between July 2013 and December 2015. A total of nine lung cancers were detected. Seven (78%) were stage I or II lung cancers, and the remaining two (22%) were stage II or IV, results that are in line with data from the I-ELCAP and NLST trials.
In another component of the study, the researchers randomly selected 101 patients from the lung cancer screening program to answer questions by telephone intended to quantify their anxiety about lung cancer before and after participating in the program, attitudes about smoking behaviors, and general impressions of the screening process. On a scale of 0-10, with 10 being “very anxious,” Dr. Salzano reported that the mean anxiety level about lung cancer fell from a level of 4.69 before screening to 3.87 afterward, a difference that reached statistical significance, with a P value of .014. “None of the patients reported negative impacts of the program,” he added. “They reported a general improvement in their well-being as a result of participating in the program.” In addition, of the 53 respondents who were current smokers upon enrolling in the screening program, five quit after intake, and the remaining 48 indicated that they were “more likely to quit” as a result of being enrolled.
“Community hospitals need to embrace lung screening,” Dr. Salzano concluded. “The findings from the large studies are transferable. It’s helping your patients in terms of their attitudes about lung cancer, about smoking cessation, and about improving their wellness.”
He reported having no relevant financial disclosures.
AT CHEST 2016
Key clinical point:
Major finding: Of nine lung cancers detected, seven (78%) were stage I or II lung cancers and the remaining two (22%) were stage II or IV.
Data source: Results from 514 patients enrolled in a community hospital–based lung cancer screening program between July 2013 and December 2015.
Disclosures: Dr. Salzano reported having no relevant financial disclosures.