Mixed Topics

Tanning use disorder is an addiction, and should be added to the DSM-5, Raghav Tripathi and his associates maintained in a letter to the editor of the Journal of the European Academy of Dermatology and Venereology.

Ibrakovic/iStock/Getty Images Plus

“Strong evidence suggests that tanning use disorder should be included in the DSM-5,” they wrote, noting that individuals who show signs of tanning use disorder have problems quitting, and also are more likely to smoke cigarettes, drink alcohol excessively, and engage in other high-risk behaviors.

In the letter, Mr. Tripathi, a medical student at Case Western Reserve University, Cleveland, and his associates also noted that frequent tanners have been found to prefer tanning beds that used UV radiation (UVR) over beds that did not, even though they were blinded to which ones did and did not. Reports of pain relief and improved mood following UVR exposure, withdrawal symptoms upon discontinuation of UVR, and the successful use of opioid antagonists to reduce UVR dependence “underscore the importance of viewing tanning as a use disorder.”

The same “brain circuitry and neurotransmitters involved in the reward pathways of other use disorders” are associated with the addictive characteristics of UVR, they wrote.

In one study, people who were compulsive tanners were found to have an increase in “cerebral blood flow in the mesostriatal reward pathway when exposed to UVR.” In another study, opioid antagonism using naltrexone was found to reduce “UVR preference in frequent tanners.”

Understanding the biologic connections is crucial to advocating for formalization of the condition as a recognized disorder in the DSM-5; classification would not only increase awareness of the condition but also standardize approaches to diagnosis and treatment that are key to improving patient care, the authors wrote. Moreover, inclusion of the disorder in the DSM-5 could help to pave the way for inclusion in the ICD-10, which would have broader implications for limiting the overall harmful effects that tanning poses.

The authors had no relevant financial disclosures to report.

SOURCE: Tripathi R et al. J Eur Acad Dermatol Venereol. 2018 Oct 13. doi: 10.1111/jdv.15286.

Tanning use disorder is an addiction, and should be added to the DSM-5, Raghav Tripathi and his associates maintained in a letter to the editor of the Journal of the European Academy of Dermatology and Venereology.

Ibrakovic/iStock/Getty Images Plus

“Strong evidence suggests that tanning use disorder should be included in the DSM-5,” they wrote, noting that individuals who show signs of tanning use disorder have problems quitting, and also are more likely to smoke cigarettes, drink alcohol excessively, and engage in other high-risk behaviors.

In the letter, Mr. Tripathi, a medical student at Case Western Reserve University, Cleveland, and his associates also noted that frequent tanners have been found to prefer tanning beds that used UV radiation (UVR) over beds that did not, even though they were blinded to which ones did and did not. Reports of pain relief and improved mood following UVR exposure, withdrawal symptoms upon discontinuation of UVR, and the successful use of opioid antagonists to reduce UVR dependence “underscore the importance of viewing tanning as a use disorder.”

The same “brain circuitry and neurotransmitters involved in the reward pathways of other use disorders” are associated with the addictive characteristics of UVR, they wrote.

In one study, people who were compulsive tanners were found to have an increase in “cerebral blood flow in the mesostriatal reward pathway when exposed to UVR.” In another study, opioid antagonism using naltrexone was found to reduce “UVR preference in frequent tanners.”

Understanding the biologic connections is crucial to advocating for formalization of the condition as a recognized disorder in the DSM-5; classification would not only increase awareness of the condition but also standardize approaches to diagnosis and treatment that are key to improving patient care, the authors wrote. Moreover, inclusion of the disorder in the DSM-5 could help to pave the way for inclusion in the ICD-10, which would have broader implications for limiting the overall harmful effects that tanning poses.

The authors had no relevant financial disclosures to report.

SOURCE: Tripathi R et al. J Eur Acad Dermatol Venereol. 2018 Oct 13. doi: 10.1111/jdv.15286.

Tanning use disorder is an addiction, and should be added to the DSM-5, Raghav Tripathi and his associates maintained in a letter to the editor of the Journal of the European Academy of Dermatology and Venereology.

Ibrakovic/iStock/Getty Images Plus

“Strong evidence suggests that tanning use disorder should be included in the DSM-5,” they wrote, noting that individuals who show signs of tanning use disorder have problems quitting, and also are more likely to smoke cigarettes, drink alcohol excessively, and engage in other high-risk behaviors.

In the letter, Mr. Tripathi, a medical student at Case Western Reserve University, Cleveland, and his associates also noted that frequent tanners have been found to prefer tanning beds that used UV radiation (UVR) over beds that did not, even though they were blinded to which ones did and did not. Reports of pain relief and improved mood following UVR exposure, withdrawal symptoms upon discontinuation of UVR, and the successful use of opioid antagonists to reduce UVR dependence “underscore the importance of viewing tanning as a use disorder.”

The same “brain circuitry and neurotransmitters involved in the reward pathways of other use disorders” are associated with the addictive characteristics of UVR, they wrote.

In one study, people who were compulsive tanners were found to have an increase in “cerebral blood flow in the mesostriatal reward pathway when exposed to UVR.” In another study, opioid antagonism using naltrexone was found to reduce “UVR preference in frequent tanners.”

Understanding the biologic connections is crucial to advocating for formalization of the condition as a recognized disorder in the DSM-5; classification would not only increase awareness of the condition but also standardize approaches to diagnosis and treatment that are key to improving patient care, the authors wrote. Moreover, inclusion of the disorder in the DSM-5 could help to pave the way for inclusion in the ICD-10, which would have broader implications for limiting the overall harmful effects that tanning poses.

The authors had no relevant financial disclosures to report.

SOURCE: Tripathi R et al. J Eur Acad Dermatol Venereol. 2018 Oct 13. doi: 10.1111/jdv.15286.

Two events that will impact our practices occurred in November: 1) an election and 2) the Centers for Medicare & Medicaid Services final rule. The election returned us to a split government with Democrats controlling the U.S. House and Republicans controlling the Senate (without a filibuster-proof majority). This means that ACA repeal and dramatic alterations to Medicaid will be off the table. Pressures on ACA’s margins will remain in both the legislative and judicial arms of government. Federal and state governments will continue to try to stabilize the individual markets by using reinsurance and premium support. The number of states expanding Medicaid eligibility will continue to grow (now at 37). There will be further pressure on drug pricing, likely targeted to Part B and 340b drugs. This will affect academic centers and hospital margins substantially.

CMS issued its final rule for the Physician Fee Schedule. AGA and the other GI societies have published a detailed member alert that can be found here. Key points involve simplified documentation for evaluation and management visits, site-neutrality reimbursement for clinic visits, identification of colonoscopy and EGD codes for CMS review, and changes in calculating practice expense, among others. MACRA rules are evolving with further pressure on practices and health systems to evolve into alternative payment models. Commercial insurers are finally near a tipping point in pressing for two-sided risk contracts. Practices should be alert for local and regional pressures around price transparency and narrow networks. Health systems (including academic centers) must plan for margin reductions due to changes in pharmacy reimbursement, network price tiering, a continued shift toward government payers, and other pressures that could drive large systems into the red.

For the first time since 1996, discretionary programs including NIH, CDC, AHRQ, and VA research all have been included in a budget (as opposed to a Continuing Resolution) that was passed by Congress and signed into law. This gives us some stability and predictability; however, the looming (and increasing) budget deficit will prompt Congress to increase fiscal pressure on domestic programs such as Social Security, Medicare, and Medicaid. Stay tuned and stay involved.

John I. Allen, MD, MBA, AGAF
Editor in Chief

Two events that will impact our practices occurred in November: 1) an election and 2) the Centers for Medicare & Medicaid Services final rule. The election returned us to a split government with Democrats controlling the U.S. House and Republicans controlling the Senate (without a filibuster-proof majority). This means that ACA repeal and dramatic alterations to Medicaid will be off the table. Pressures on ACA’s margins will remain in both the legislative and judicial arms of government. Federal and state governments will continue to try to stabilize the individual markets by using reinsurance and premium support. The number of states expanding Medicaid eligibility will continue to grow (now at 37). There will be further pressure on drug pricing, likely targeted to Part B and 340b drugs. This will affect academic centers and hospital margins substantially.

CMS issued its final rule for the Physician Fee Schedule. AGA and the other GI societies have published a detailed member alert that can be found here. Key points involve simplified documentation for evaluation and management visits, site-neutrality reimbursement for clinic visits, identification of colonoscopy and EGD codes for CMS review, and changes in calculating practice expense, among others. MACRA rules are evolving with further pressure on practices and health systems to evolve into alternative payment models. Commercial insurers are finally near a tipping point in pressing for two-sided risk contracts. Practices should be alert for local and regional pressures around price transparency and narrow networks. Health systems (including academic centers) must plan for margin reductions due to changes in pharmacy reimbursement, network price tiering, a continued shift toward government payers, and other pressures that could drive large systems into the red.

For the first time since 1996, discretionary programs including NIH, CDC, AHRQ, and VA research all have been included in a budget (as opposed to a Continuing Resolution) that was passed by Congress and signed into law. This gives us some stability and predictability; however, the looming (and increasing) budget deficit will prompt Congress to increase fiscal pressure on domestic programs such as Social Security, Medicare, and Medicaid. Stay tuned and stay involved.

John I. Allen, MD, MBA, AGAF
Editor in Chief

Two events that will impact our practices occurred in November: 1) an election and 2) the Centers for Medicare & Medicaid Services final rule. The election returned us to a split government with Democrats controlling the U.S. House and Republicans controlling the Senate (without a filibuster-proof majority). This means that ACA repeal and dramatic alterations to Medicaid will be off the table. Pressures on ACA’s margins will remain in both the legislative and judicial arms of government. Federal and state governments will continue to try to stabilize the individual markets by using reinsurance and premium support. The number of states expanding Medicaid eligibility will continue to grow (now at 37). There will be further pressure on drug pricing, likely targeted to Part B and 340b drugs. This will affect academic centers and hospital margins substantially.

CMS issued its final rule for the Physician Fee Schedule. AGA and the other GI societies have published a detailed member alert that can be found here. Key points involve simplified documentation for evaluation and management visits, site-neutrality reimbursement for clinic visits, identification of colonoscopy and EGD codes for CMS review, and changes in calculating practice expense, among others. MACRA rules are evolving with further pressure on practices and health systems to evolve into alternative payment models. Commercial insurers are finally near a tipping point in pressing for two-sided risk contracts. Practices should be alert for local and regional pressures around price transparency and narrow networks. Health systems (including academic centers) must plan for margin reductions due to changes in pharmacy reimbursement, network price tiering, a continued shift toward government payers, and other pressures that could drive large systems into the red.

For the first time since 1996, discretionary programs including NIH, CDC, AHRQ, and VA research all have been included in a budget (as opposed to a Continuing Resolution) that was passed by Congress and signed into law. This gives us some stability and predictability; however, the looming (and increasing) budget deficit will prompt Congress to increase fiscal pressure on domestic programs such as Social Security, Medicare, and Medicaid. Stay tuned and stay involved.

John I. Allen, MD, MBA, AGAF
Editor in Chief

Cecal carcinoma–associated paraneoplastic Sweet’s syndrome

Based on the tomographic appearance of an “apple core”–like lesion in the right lower quadrant, the patient was referred for colonoscopy, which revealed a malignant-appearing cecal mass (Figure D), with biopsies confirming adenocarcinoma; despite these findings, no bowel-related symptoms were reported. The patient underwent laparoscopic right hemicolectomy, after which the skin lesions began to resolve, and corticosteroids were successfully tapered. The overall presentation was consistent with Sweet’s syndrome, with a paraneoplastic etiology being favored given the clinical scenario, including absence of alternative etiologies and dependence on corticosteroids for control of skin disease until resection of the underlying malignancy was performed.

AGA Institute

Sweet’s syndrome was first described in a case series of eight patients published in 1964 by the English dermatologist Dr. Robert Douglas Sweet.^1,2 Sweet’s syndrome is characterized by fever, neutrophilia, and sterile erythematous plaques or nodules, which most commonly involve the upper extremities and face and respond to corticosteroid therapy. It may be malignancy associated, drug induced, autoimmune disease related, or idiopathic.^2,3 The pathogenesis of Sweet’s syndrome is unclear, but T-lymphocyte, neutrophil chemotaxis, and cytokine (e.g., interleukin-6 and granulocyte colony–stimulating factor) abnormalities have been suggested.² Diagnosis is based on the clinical presentation and context together with typical dermatopathologic findings, including a dense neutrophilic infiltrate. Skin lesions may be phasic, but persist typically until appropriate therapy (e.g., corticosteroids, chemotherapy) is administered or the offending drug removed. Malignancy-associated (i.e., paraneoplastic) Sweet’s syndrome accounts for approximately 20% of all cases; these primarily involve hematologic malignancies, most commonly leukemia, but adenocarcinomata have also been implicated.³ Recurrence of Sweet’s syndrome can occur and often heralds relapse of the underlying disease.
 

References

1. Sweet RD. An acute febrile neutrophilic dermatosis. Br J Dermatol. 1964;76:349-56.

2. Von den Driesch P. Sweet’s syndrome (acute febrile neutrophilic dermatosis). J Am Acad Dermatol. 1994;31:535-56.

3. Cohen PR. Sweet’s syndrome–a comprehensive review of an acute febrile neutrophilic dermatosis. Orphanet J Rare Dis. 2007;2:34.

Cecal carcinoma–associated paraneoplastic Sweet’s syndrome

Based on the tomographic appearance of an “apple core”–like lesion in the right lower quadrant, the patient was referred for colonoscopy, which revealed a malignant-appearing cecal mass (Figure D), with biopsies confirming adenocarcinoma; despite these findings, no bowel-related symptoms were reported. The patient underwent laparoscopic right hemicolectomy, after which the skin lesions began to resolve, and corticosteroids were successfully tapered. The overall presentation was consistent with Sweet’s syndrome, with a paraneoplastic etiology being favored given the clinical scenario, including absence of alternative etiologies and dependence on corticosteroids for control of skin disease until resection of the underlying malignancy was performed.

AGA Institute

Sweet’s syndrome was first described in a case series of eight patients published in 1964 by the English dermatologist Dr. Robert Douglas Sweet.^1,2 Sweet’s syndrome is characterized by fever, neutrophilia, and sterile erythematous plaques or nodules, which most commonly involve the upper extremities and face and respond to corticosteroid therapy. It may be malignancy associated, drug induced, autoimmune disease related, or idiopathic.^2,3 The pathogenesis of Sweet’s syndrome is unclear, but T-lymphocyte, neutrophil chemotaxis, and cytokine (e.g., interleukin-6 and granulocyte colony–stimulating factor) abnormalities have been suggested.² Diagnosis is based on the clinical presentation and context together with typical dermatopathologic findings, including a dense neutrophilic infiltrate. Skin lesions may be phasic, but persist typically until appropriate therapy (e.g., corticosteroids, chemotherapy) is administered or the offending drug removed. Malignancy-associated (i.e., paraneoplastic) Sweet’s syndrome accounts for approximately 20% of all cases; these primarily involve hematologic malignancies, most commonly leukemia, but adenocarcinomata have also been implicated.³ Recurrence of Sweet’s syndrome can occur and often heralds relapse of the underlying disease.
 

References

1. Sweet RD. An acute febrile neutrophilic dermatosis. Br J Dermatol. 1964;76:349-56.

2. Von den Driesch P. Sweet’s syndrome (acute febrile neutrophilic dermatosis). J Am Acad Dermatol. 1994;31:535-56.

3. Cohen PR. Sweet’s syndrome–a comprehensive review of an acute febrile neutrophilic dermatosis. Orphanet J Rare Dis. 2007;2:34.

Cecal carcinoma–associated paraneoplastic Sweet’s syndrome

Based on the tomographic appearance of an “apple core”–like lesion in the right lower quadrant, the patient was referred for colonoscopy, which revealed a malignant-appearing cecal mass (Figure D), with biopsies confirming adenocarcinoma; despite these findings, no bowel-related symptoms were reported. The patient underwent laparoscopic right hemicolectomy, after which the skin lesions began to resolve, and corticosteroids were successfully tapered. The overall presentation was consistent with Sweet’s syndrome, with a paraneoplastic etiology being favored given the clinical scenario, including absence of alternative etiologies and dependence on corticosteroids for control of skin disease until resection of the underlying malignancy was performed.

AGA Institute

Sweet’s syndrome was first described in a case series of eight patients published in 1964 by the English dermatologist Dr. Robert Douglas Sweet.^1,2 Sweet’s syndrome is characterized by fever, neutrophilia, and sterile erythematous plaques or nodules, which most commonly involve the upper extremities and face and respond to corticosteroid therapy. It may be malignancy associated, drug induced, autoimmune disease related, or idiopathic.^2,3 The pathogenesis of Sweet’s syndrome is unclear, but T-lymphocyte, neutrophil chemotaxis, and cytokine (e.g., interleukin-6 and granulocyte colony–stimulating factor) abnormalities have been suggested.² Diagnosis is based on the clinical presentation and context together with typical dermatopathologic findings, including a dense neutrophilic infiltrate. Skin lesions may be phasic, but persist typically until appropriate therapy (e.g., corticosteroids, chemotherapy) is administered or the offending drug removed. Malignancy-associated (i.e., paraneoplastic) Sweet’s syndrome accounts for approximately 20% of all cases; these primarily involve hematologic malignancies, most commonly leukemia, but adenocarcinomata have also been implicated.³ Recurrence of Sweet’s syndrome can occur and often heralds relapse of the underlying disease.
 

References

1. Sweet RD. An acute febrile neutrophilic dermatosis. Br J Dermatol. 1964;76:349-56.

2. Von den Driesch P. Sweet’s syndrome (acute febrile neutrophilic dermatosis). J Am Acad Dermatol. 1994;31:535-56.

3. Cohen PR. Sweet’s syndrome–a comprehensive review of an acute febrile neutrophilic dermatosis. Orphanet J Rare Dis. 2007;2:34.

When the National Rifle Association responded to an American College of Physicians position paper updating its policy on reducing firearm injuries by telling the physicians to “stay in their lane,” the group got an earful on Twitter.

“Many of the Tweet responses relayed heart-wrenching stories of doctors caring for patients who suffered and died from gun shot wounds,” writes Forbes contributor Bruce Y. Lee, MD, an associate professor of public health at Johns Hopkins University, Baltimore. “Some Tweets included pictures of blood-spattered scenes to emphasize what doctors have to regularly address.”

The NRA’s response to the ACP update led to the creation of the hashtags #ThisISMyLane and #ThisIsOurLane.

“We’re standing there every day seeing this carnage,” says Rebecca Cunningham, MD, an emergency physician at the University of Michigan, Ann Arbor, on the WBUR radio show, “On Point.” Talking to families about gun safety is “absolutely in our lane.” Meanwhile, Dr. Cunningham, principal investigator of Firearm Safety Among Children and Teens, tweeted that 50 women die per month “by gun by intimate partner.”

The twitter account @ThisIsOurLane, described as a group of “medical professionals who care for #GunViolence Victims,” currently has more than 26 million followers.

Japanese concepts offer perspective

Western culture is fueled by immediacy, and as a result, life can feel askew.

“We’re living in the busiest time of history of humanity, and we often do not have enough time to get everything done that we need to,” futurist and trends guru Daniel Levine says in an interview with NBC News. “The promise of technology was that it would handle our work for us and let us hang out more and relax, but the opposite has happened. Rather than helping us slow down, technology is forcing us to move even faster.”

In seeking another way, Mr. Levine cites “a countertrend against the barrage of tasks and technology that we are inundated with everyday. Patience is the other side of the coin of speed, and we’re looking more to [integrate] that into our lives.”

One step might be to take part in the Japanese tea ceremony of wabi-sabi. At the heart of the ceremony is the reality that things are not perfect but that the imperfections can be embraced to provide fulfillment. This attitude can extend to finding acceptance of personal imperfections.

Developing patience also is important. Again, drawing on Japanese culture, the philosophical outlook of Shankankan espouses the beauty found in a slower pace.

“Patience is the understanding that this is a long journey and you can’t rush the process, particularly in the Zen meditation tradition of spiritual ripening,” says author and yoga teacher Kino MacGregor.

Ikigai – self-introspection as to one’s true purpose – is the another pearl of wisdom from Japanese culture. “I think the Western idea of purpose tends to be very focused on what your profession and livelihood are and how to make money,” Ms. MacGregor says. “Ikigai is quite different. It’s about finding what you love and what the world needs. That requires patience in the sense that it won’t be revealed to you in one moment. You’ll need space and time for those answers.”
 

Using animal-assisted therapy for children

A Canadian psychologist is putting her livestock to nontraditional use as part of a mental health therapy program for local children and youth in need.

Kali Eddy, who lives on a range in Saskatchewan, uses her critters to help treat anxiety, depression, and other mental health challenges, according to a report by Global News. “Really, it’s just a technique that I use in addition to traditional therapies,” she explains. “A lot of times in a traditional therapy setting, you’re sitting with a psychologist talking and looking at them in the eye – and sometimes this helps reduce some of that pressure if a client is petting an animal or interacting with an animal.”

As many pet owners can attest, having another living thing to focus on and care for can prove therapeutic. As part of a structured therapy, coming into contact with the animals can encourage conversations about personal struggles.

The tactile mental health program developed by Ms. Eddy has allowed her to use the animals that are part of her life to help her clients. And the need for mental health interventions is pressing: “10-20% of youth are affected by a mental illness or disorder, and I think those statistics are probably even higher because the number of youth who come to us who are diagnosed and struggling,” she says in the interview.
 

Advice for Alzheimer’s caregivers

Caring for a family member with Alzheimer’s disease can be a lonely responsibility, but advice from those who have made the journey can provide a roadmap.

Grieving for the patient while caring for them is important. “You have to learn how to grieve losing someone while they’re still alive,” Amy L. says in an interview with SELF. Amy cared for her father for 3 years until his death from Alzheimer’s in 2015.

“You always think about grief as something that happens once someone passes away, but this illness really changes who they are,” she adds. The knowledge that the disease is progressive and that cognitive and physical functions will spiral downward can be helpful, although very painful.

Trust in the ability to do what is needed for the affected person can prevent second-guessing and guilt later in life. “I wish I had known from the beginning to just listen to and trust myself because I am the only one who knows what it feels like to be in my own circumstance,” Linda G. says.

Having others to talk with is vital. “Connecting with others who know what [we’re] going through and who can offer support and suggestions for dealing with the disease’s various challenges has been very helpful,” explains Peggy M.
 

Global suicide rates down 29%

The number of suicides in the United States has increased since 2000, fueled by white, middle-aged men who have been hard hit by structural changes in the economy. But, according to an article in The Economist, compared with other countries around the world, the United States appears to be the exception. Globally, the suicide rate has dropped by 29% over the same period.

Notable declines have occurred among young women in China and India, middle-aged men in Russia, and elderly people in general. This might reflect increasing urbanization, with the accompanying access to health and mental health services, freedom from suffocating traditions that can spawn despair, and increased human interaction.

Spending on health services is another important factor. “Spending on health services, especially those that most benefit the old and sick, can make a big difference: Fear of chronic pain is one of the things that leads people to seek a quick way out. The remarkable recent fall in suicide among elderly Britons may have happened in part because Britain’s palliative-care system is the best in the world,” the authors write.

“For a few people – those who are terminally ill, in severe pain, and determined to die – suicide may be the least terrible option. In such circumstances, and with firm safeguards, doctors should be allowed to assist. But many of the 800,000 people who kill themselves each year act in haste, and more could be saved with better health services, labor-market policies, and curbs on booze, guns, pesticides, and pills.

“America, in particular, could spare much pain by learning from the progress elsewhere.”

When the National Rifle Association responded to an American College of Physicians position paper updating its policy on reducing firearm injuries by telling the physicians to “stay in their lane,” the group got an earful on Twitter.

“Many of the Tweet responses relayed heart-wrenching stories of doctors caring for patients who suffered and died from gun shot wounds,” writes Forbes contributor Bruce Y. Lee, MD, an associate professor of public health at Johns Hopkins University, Baltimore. “Some Tweets included pictures of blood-spattered scenes to emphasize what doctors have to regularly address.”

The NRA’s response to the ACP update led to the creation of the hashtags #ThisISMyLane and #ThisIsOurLane.

“We’re standing there every day seeing this carnage,” says Rebecca Cunningham, MD, an emergency physician at the University of Michigan, Ann Arbor, on the WBUR radio show, “On Point.” Talking to families about gun safety is “absolutely in our lane.” Meanwhile, Dr. Cunningham, principal investigator of Firearm Safety Among Children and Teens, tweeted that 50 women die per month “by gun by intimate partner.”

The twitter account @ThisIsOurLane, described as a group of “medical professionals who care for #GunViolence Victims,” currently has more than 26 million followers.

Japanese concepts offer perspective

Western culture is fueled by immediacy, and as a result, life can feel askew.

“We’re living in the busiest time of history of humanity, and we often do not have enough time to get everything done that we need to,” futurist and trends guru Daniel Levine says in an interview with NBC News. “The promise of technology was that it would handle our work for us and let us hang out more and relax, but the opposite has happened. Rather than helping us slow down, technology is forcing us to move even faster.”

In seeking another way, Mr. Levine cites “a countertrend against the barrage of tasks and technology that we are inundated with everyday. Patience is the other side of the coin of speed, and we’re looking more to [integrate] that into our lives.”

One step might be to take part in the Japanese tea ceremony of wabi-sabi. At the heart of the ceremony is the reality that things are not perfect but that the imperfections can be embraced to provide fulfillment. This attitude can extend to finding acceptance of personal imperfections.

Developing patience also is important. Again, drawing on Japanese culture, the philosophical outlook of Shankankan espouses the beauty found in a slower pace.

“Patience is the understanding that this is a long journey and you can’t rush the process, particularly in the Zen meditation tradition of spiritual ripening,” says author and yoga teacher Kino MacGregor.

Ikigai – self-introspection as to one’s true purpose – is the another pearl of wisdom from Japanese culture. “I think the Western idea of purpose tends to be very focused on what your profession and livelihood are and how to make money,” Ms. MacGregor says. “Ikigai is quite different. It’s about finding what you love and what the world needs. That requires patience in the sense that it won’t be revealed to you in one moment. You’ll need space and time for those answers.”
 

Using animal-assisted therapy for children

A Canadian psychologist is putting her livestock to nontraditional use as part of a mental health therapy program for local children and youth in need.

Kali Eddy, who lives on a range in Saskatchewan, uses her critters to help treat anxiety, depression, and other mental health challenges, according to a report by Global News. “Really, it’s just a technique that I use in addition to traditional therapies,” she explains. “A lot of times in a traditional therapy setting, you’re sitting with a psychologist talking and looking at them in the eye – and sometimes this helps reduce some of that pressure if a client is petting an animal or interacting with an animal.”

As many pet owners can attest, having another living thing to focus on and care for can prove therapeutic. As part of a structured therapy, coming into contact with the animals can encourage conversations about personal struggles.

The tactile mental health program developed by Ms. Eddy has allowed her to use the animals that are part of her life to help her clients. And the need for mental health interventions is pressing: “10-20% of youth are affected by a mental illness or disorder, and I think those statistics are probably even higher because the number of youth who come to us who are diagnosed and struggling,” she says in the interview.
 

Advice for Alzheimer’s caregivers

Caring for a family member with Alzheimer’s disease can be a lonely responsibility, but advice from those who have made the journey can provide a roadmap.

Grieving for the patient while caring for them is important. “You have to learn how to grieve losing someone while they’re still alive,” Amy L. says in an interview with SELF. Amy cared for her father for 3 years until his death from Alzheimer’s in 2015.

“You always think about grief as something that happens once someone passes away, but this illness really changes who they are,” she adds. The knowledge that the disease is progressive and that cognitive and physical functions will spiral downward can be helpful, although very painful.

Trust in the ability to do what is needed for the affected person can prevent second-guessing and guilt later in life. “I wish I had known from the beginning to just listen to and trust myself because I am the only one who knows what it feels like to be in my own circumstance,” Linda G. says.

Having others to talk with is vital. “Connecting with others who know what [we’re] going through and who can offer support and suggestions for dealing with the disease’s various challenges has been very helpful,” explains Peggy M.
 

Global suicide rates down 29%

The number of suicides in the United States has increased since 2000, fueled by white, middle-aged men who have been hard hit by structural changes in the economy. But, according to an article in The Economist, compared with other countries around the world, the United States appears to be the exception. Globally, the suicide rate has dropped by 29% over the same period.

Notable declines have occurred among young women in China and India, middle-aged men in Russia, and elderly people in general. This might reflect increasing urbanization, with the accompanying access to health and mental health services, freedom from suffocating traditions that can spawn despair, and increased human interaction.

Spending on health services is another important factor. “Spending on health services, especially those that most benefit the old and sick, can make a big difference: Fear of chronic pain is one of the things that leads people to seek a quick way out. The remarkable recent fall in suicide among elderly Britons may have happened in part because Britain’s palliative-care system is the best in the world,” the authors write.

“For a few people – those who are terminally ill, in severe pain, and determined to die – suicide may be the least terrible option. In such circumstances, and with firm safeguards, doctors should be allowed to assist. But many of the 800,000 people who kill themselves each year act in haste, and more could be saved with better health services, labor-market policies, and curbs on booze, guns, pesticides, and pills.

“America, in particular, could spare much pain by learning from the progress elsewhere.”

When the National Rifle Association responded to an American College of Physicians position paper updating its policy on reducing firearm injuries by telling the physicians to “stay in their lane,” the group got an earful on Twitter.

“Many of the Tweet responses relayed heart-wrenching stories of doctors caring for patients who suffered and died from gun shot wounds,” writes Forbes contributor Bruce Y. Lee, MD, an associate professor of public health at Johns Hopkins University, Baltimore. “Some Tweets included pictures of blood-spattered scenes to emphasize what doctors have to regularly address.”

The NRA’s response to the ACP update led to the creation of the hashtags #ThisISMyLane and #ThisIsOurLane.

“We’re standing there every day seeing this carnage,” says Rebecca Cunningham, MD, an emergency physician at the University of Michigan, Ann Arbor, on the WBUR radio show, “On Point.” Talking to families about gun safety is “absolutely in our lane.” Meanwhile, Dr. Cunningham, principal investigator of Firearm Safety Among Children and Teens, tweeted that 50 women die per month “by gun by intimate partner.”

The twitter account @ThisIsOurLane, described as a group of “medical professionals who care for #GunViolence Victims,” currently has more than 26 million followers.

Japanese concepts offer perspective

Western culture is fueled by immediacy, and as a result, life can feel askew.

“We’re living in the busiest time of history of humanity, and we often do not have enough time to get everything done that we need to,” futurist and trends guru Daniel Levine says in an interview with NBC News. “The promise of technology was that it would handle our work for us and let us hang out more and relax, but the opposite has happened. Rather than helping us slow down, technology is forcing us to move even faster.”

In seeking another way, Mr. Levine cites “a countertrend against the barrage of tasks and technology that we are inundated with everyday. Patience is the other side of the coin of speed, and we’re looking more to [integrate] that into our lives.”

One step might be to take part in the Japanese tea ceremony of wabi-sabi. At the heart of the ceremony is the reality that things are not perfect but that the imperfections can be embraced to provide fulfillment. This attitude can extend to finding acceptance of personal imperfections.

Developing patience also is important. Again, drawing on Japanese culture, the philosophical outlook of Shankankan espouses the beauty found in a slower pace.

“Patience is the understanding that this is a long journey and you can’t rush the process, particularly in the Zen meditation tradition of spiritual ripening,” says author and yoga teacher Kino MacGregor.

Ikigai – self-introspection as to one’s true purpose – is the another pearl of wisdom from Japanese culture. “I think the Western idea of purpose tends to be very focused on what your profession and livelihood are and how to make money,” Ms. MacGregor says. “Ikigai is quite different. It’s about finding what you love and what the world needs. That requires patience in the sense that it won’t be revealed to you in one moment. You’ll need space and time for those answers.”
 

Using animal-assisted therapy for children

A Canadian psychologist is putting her livestock to nontraditional use as part of a mental health therapy program for local children and youth in need.

Kali Eddy, who lives on a range in Saskatchewan, uses her critters to help treat anxiety, depression, and other mental health challenges, according to a report by Global News. “Really, it’s just a technique that I use in addition to traditional therapies,” she explains. “A lot of times in a traditional therapy setting, you’re sitting with a psychologist talking and looking at them in the eye – and sometimes this helps reduce some of that pressure if a client is petting an animal or interacting with an animal.”

As many pet owners can attest, having another living thing to focus on and care for can prove therapeutic. As part of a structured therapy, coming into contact with the animals can encourage conversations about personal struggles.

The tactile mental health program developed by Ms. Eddy has allowed her to use the animals that are part of her life to help her clients. And the need for mental health interventions is pressing: “10-20% of youth are affected by a mental illness or disorder, and I think those statistics are probably even higher because the number of youth who come to us who are diagnosed and struggling,” she says in the interview.
 

Advice for Alzheimer’s caregivers

Caring for a family member with Alzheimer’s disease can be a lonely responsibility, but advice from those who have made the journey can provide a roadmap.

Grieving for the patient while caring for them is important. “You have to learn how to grieve losing someone while they’re still alive,” Amy L. says in an interview with SELF. Amy cared for her father for 3 years until his death from Alzheimer’s in 2015.

“You always think about grief as something that happens once someone passes away, but this illness really changes who they are,” she adds. The knowledge that the disease is progressive and that cognitive and physical functions will spiral downward can be helpful, although very painful.

Trust in the ability to do what is needed for the affected person can prevent second-guessing and guilt later in life. “I wish I had known from the beginning to just listen to and trust myself because I am the only one who knows what it feels like to be in my own circumstance,” Linda G. says.

Having others to talk with is vital. “Connecting with others who know what [we’re] going through and who can offer support and suggestions for dealing with the disease’s various challenges has been very helpful,” explains Peggy M.
 

Global suicide rates down 29%

The number of suicides in the United States has increased since 2000, fueled by white, middle-aged men who have been hard hit by structural changes in the economy. But, according to an article in The Economist, compared with other countries around the world, the United States appears to be the exception. Globally, the suicide rate has dropped by 29% over the same period.

Notable declines have occurred among young women in China and India, middle-aged men in Russia, and elderly people in general. This might reflect increasing urbanization, with the accompanying access to health and mental health services, freedom from suffocating traditions that can spawn despair, and increased human interaction.

Spending on health services is another important factor. “Spending on health services, especially those that most benefit the old and sick, can make a big difference: Fear of chronic pain is one of the things that leads people to seek a quick way out. The remarkable recent fall in suicide among elderly Britons may have happened in part because Britain’s palliative-care system is the best in the world,” the authors write.

“For a few people – those who are terminally ill, in severe pain, and determined to die – suicide may be the least terrible option. In such circumstances, and with firm safeguards, doctors should be allowed to assist. But many of the 800,000 people who kill themselves each year act in haste, and more could be saved with better health services, labor-market policies, and curbs on booze, guns, pesticides, and pills.

“America, in particular, could spare much pain by learning from the progress elsewhere.”

CHICAGO – The big news regarding Lyme disease at the annual meeting of the American College of Rheumatology was a report that hamstring tendon calcification is extremely common among patients who have persistent Lyme arthritis despite having undergone appropriate antibiotic therapy.

“This is a fascinating study,” Robert A. Kalish, MD, a Lyme disease expert not involved in the research, said regarding the report by Sheila L. Arvikar, MD, and her coworkers at Massachusetts General Hospital, Boston.

One implication of this finding by a renowned group of Lyme disease researchers is that persistent posttreatment Lyme arthritis may in many cases be due to ongoing immunostimulation by spirochete remains located in hamstring tendons, a privileged, relatively avascular site where the foreign material may be able to evade immune clearance.

Also, as Dr. Arvikar pointed out in her presentation, calcific tendinopathy implies prior inflammation or degenerative changes. Thus, these calcific hamstring abnormalities implicate the hamstring tendons as a potential initial site of infection by hematogenously-spread Borrelia burgdorferi during the prearthritis phase of Lyme disease.

A further implication of the study is the possibility that hamstring tendon calcification could serve as a useful diagnostic aid in distinguishing Lyme arthritis from arthritis due to other causes. In the study, hamstring calcific tendinopathy was found in 28 of 31 adults and children with Lyme arthritis, 3 of 22 with knee osteoarthritis, and 1 of 14 patients with inflammatory arthritis, Dr. Arvikar noted.

She and her coinvestigators evaluated tendon pathology in their retrospective study of patients at the Massachusetts General Hospital Rheumatology Musculoskeletal Ultrasound Clinic. They used ultrasound because they have found it offers far better spatial resolution of calcification than does MRI or x-rays. The semimembranosus tendon was the hamstring tendon that most commonly exhibited calcification, although 11 patients with Lyme arthritis also had involvement of the semitendinosus tendon, compared with none of the controls with osteoarthritis or inflammatory arthritis.

In the eight patients with serial ultrasound evaluations over a period of up to 12 months, the calcification persisted but the symptoms of tendinitis and synovitis improved.

Dr. Arvikar and her colleagues are expanding the scope of their ongoing study by examining patients whose Lyme arthritis is milder than that of the initial population, including patients who haven’t yet received antibiotics. They are also evaluating more controls with inflammatory arthritis.

In a separate presentation, Dr. Kalish noted that Lyme arthritis, the manifestation of Lyme disease of greatest interest to rheumatologists, occurs in about 60% of untreated patients, with onset a mean of 6 months after the tick bite. It typically entails recurrent mono- or oligoarthritis of large joints. The knee is involved in roughly 95% of cases.

The natural history of untreated Lyme arthritis is a spontaneous resolution rate of 10%-20% per year. Since the 1980s, however, 4 weeks of oral doxycycline or amoxicillin has been the treatment of choice. About 10% of patients with Lyme arthritis continue to have active synovitis 3 months after their course of antibiotics.

“There are some patients you give the treatment to and their arthritis just melts away in a month, but some, no matter what you do with antibiotics, continue to have synovitis, often developing a highly proliferative palpable synovitis that is really gunked up and features obliterative microvascular lesions,” observed Dr. Kalish, a rheumatologist at Tufts University in Boston.

Dr. Kalish said that persistent posttreatment Lyme arthritis is most often due to a self-perpetuating immune response after the spirochete has been killed by antibiotics. He noted that patients with certain HLA-DRB1 haplotypes are more likely to experience persistent Lyme arthritis after standard recommended courses of antibiotics, and these DRB1 alleles correlate closely with the shared epitope associated with increased susceptibility to rheumatoid arthritis. Several candidate autoantigens have already been identified.

He noted that the Massachusetts General group, in an earlier study, demonstrated that the presence of B. burgdorferi DNA by PCR in synovial fluid from patients with persistent Lyme arthritis after antibiotic therapy was not a reliable indicator of active joint infection (Arthritis Rheum. 2011 Aug;63[8]:2238-47).

“This was a paradigm change for me in seeing this study, because prior to that I had used PCR somewhat to guide treatment and make management decisions,” Dr. Kalish said.

What’s a reasonable treatment strategy in patients with persistent Lyme arthritis despite 30 days of oral antibiotics? Dr. Kalish favors an algorithm similar to one published by Dr. Arvikar and Allen C. Steere, MD (Infect Dis Clin North Am. 2015 Jun;29[2]:269-80). In the case of mild persistent arthritis, he opts for another 30 days of oral doxycycline. If the arthritis is moderate or severe, he goes with either another 30 days of doxycycline or 30 days of intravenous ceftriaxone.

If the arthritis still hasn’t resolved despite two 30-day rounds of antibiotic therapy, he prescribes an NSAID or hydroxychloroquine if the persistent arthritis is mild, or methotrexate if it’s moderate to severe. And if the arthritis still persists after 3-6 months of disease-modifying antirheumatic drug therapy, he’ll consider synovectomy, which has a good success rate.

Neither Dr. Arvikar nor Dr. Kalish reported having any financial conflicts regarding their presentations.

[email protected]

SOURCE: Arvikar SL et al. Arthritis Rheumatol. 2018;70(Suppl 10): Abstract 950.

CHICAGO – The big news regarding Lyme disease at the annual meeting of the American College of Rheumatology was a report that hamstring tendon calcification is extremely common among patients who have persistent Lyme arthritis despite having undergone appropriate antibiotic therapy.

“This is a fascinating study,” Robert A. Kalish, MD, a Lyme disease expert not involved in the research, said regarding the report by Sheila L. Arvikar, MD, and her coworkers at Massachusetts General Hospital, Boston.

One implication of this finding by a renowned group of Lyme disease researchers is that persistent posttreatment Lyme arthritis may in many cases be due to ongoing immunostimulation by spirochete remains located in hamstring tendons, a privileged, relatively avascular site where the foreign material may be able to evade immune clearance.

Also, as Dr. Arvikar pointed out in her presentation, calcific tendinopathy implies prior inflammation or degenerative changes. Thus, these calcific hamstring abnormalities implicate the hamstring tendons as a potential initial site of infection by hematogenously-spread Borrelia burgdorferi during the prearthritis phase of Lyme disease.

A further implication of the study is the possibility that hamstring tendon calcification could serve as a useful diagnostic aid in distinguishing Lyme arthritis from arthritis due to other causes. In the study, hamstring calcific tendinopathy was found in 28 of 31 adults and children with Lyme arthritis, 3 of 22 with knee osteoarthritis, and 1 of 14 patients with inflammatory arthritis, Dr. Arvikar noted.

She and her coinvestigators evaluated tendon pathology in their retrospective study of patients at the Massachusetts General Hospital Rheumatology Musculoskeletal Ultrasound Clinic. They used ultrasound because they have found it offers far better spatial resolution of calcification than does MRI or x-rays. The semimembranosus tendon was the hamstring tendon that most commonly exhibited calcification, although 11 patients with Lyme arthritis also had involvement of the semitendinosus tendon, compared with none of the controls with osteoarthritis or inflammatory arthritis.

In the eight patients with serial ultrasound evaluations over a period of up to 12 months, the calcification persisted but the symptoms of tendinitis and synovitis improved.

Dr. Arvikar and her colleagues are expanding the scope of their ongoing study by examining patients whose Lyme arthritis is milder than that of the initial population, including patients who haven’t yet received antibiotics. They are also evaluating more controls with inflammatory arthritis.

In a separate presentation, Dr. Kalish noted that Lyme arthritis, the manifestation of Lyme disease of greatest interest to rheumatologists, occurs in about 60% of untreated patients, with onset a mean of 6 months after the tick bite. It typically entails recurrent mono- or oligoarthritis of large joints. The knee is involved in roughly 95% of cases.

The natural history of untreated Lyme arthritis is a spontaneous resolution rate of 10%-20% per year. Since the 1980s, however, 4 weeks of oral doxycycline or amoxicillin has been the treatment of choice. About 10% of patients with Lyme arthritis continue to have active synovitis 3 months after their course of antibiotics.

“There are some patients you give the treatment to and their arthritis just melts away in a month, but some, no matter what you do with antibiotics, continue to have synovitis, often developing a highly proliferative palpable synovitis that is really gunked up and features obliterative microvascular lesions,” observed Dr. Kalish, a rheumatologist at Tufts University in Boston.

Dr. Kalish said that persistent posttreatment Lyme arthritis is most often due to a self-perpetuating immune response after the spirochete has been killed by antibiotics. He noted that patients with certain HLA-DRB1 haplotypes are more likely to experience persistent Lyme arthritis after standard recommended courses of antibiotics, and these DRB1 alleles correlate closely with the shared epitope associated with increased susceptibility to rheumatoid arthritis. Several candidate autoantigens have already been identified.

He noted that the Massachusetts General group, in an earlier study, demonstrated that the presence of B. burgdorferi DNA by PCR in synovial fluid from patients with persistent Lyme arthritis after antibiotic therapy was not a reliable indicator of active joint infection (Arthritis Rheum. 2011 Aug;63[8]:2238-47).

“This was a paradigm change for me in seeing this study, because prior to that I had used PCR somewhat to guide treatment and make management decisions,” Dr. Kalish said.

What’s a reasonable treatment strategy in patients with persistent Lyme arthritis despite 30 days of oral antibiotics? Dr. Kalish favors an algorithm similar to one published by Dr. Arvikar and Allen C. Steere, MD (Infect Dis Clin North Am. 2015 Jun;29[2]:269-80). In the case of mild persistent arthritis, he opts for another 30 days of oral doxycycline. If the arthritis is moderate or severe, he goes with either another 30 days of doxycycline or 30 days of intravenous ceftriaxone.

If the arthritis still hasn’t resolved despite two 30-day rounds of antibiotic therapy, he prescribes an NSAID or hydroxychloroquine if the persistent arthritis is mild, or methotrexate if it’s moderate to severe. And if the arthritis still persists after 3-6 months of disease-modifying antirheumatic drug therapy, he’ll consider synovectomy, which has a good success rate.

Neither Dr. Arvikar nor Dr. Kalish reported having any financial conflicts regarding their presentations.

[email protected]

SOURCE: Arvikar SL et al. Arthritis Rheumatol. 2018;70(Suppl 10): Abstract 950.

CHICAGO – The big news regarding Lyme disease at the annual meeting of the American College of Rheumatology was a report that hamstring tendon calcification is extremely common among patients who have persistent Lyme arthritis despite having undergone appropriate antibiotic therapy.

“This is a fascinating study,” Robert A. Kalish, MD, a Lyme disease expert not involved in the research, said regarding the report by Sheila L. Arvikar, MD, and her coworkers at Massachusetts General Hospital, Boston.

One implication of this finding by a renowned group of Lyme disease researchers is that persistent posttreatment Lyme arthritis may in many cases be due to ongoing immunostimulation by spirochete remains located in hamstring tendons, a privileged, relatively avascular site where the foreign material may be able to evade immune clearance.

Also, as Dr. Arvikar pointed out in her presentation, calcific tendinopathy implies prior inflammation or degenerative changes. Thus, these calcific hamstring abnormalities implicate the hamstring tendons as a potential initial site of infection by hematogenously-spread Borrelia burgdorferi during the prearthritis phase of Lyme disease.

A further implication of the study is the possibility that hamstring tendon calcification could serve as a useful diagnostic aid in distinguishing Lyme arthritis from arthritis due to other causes. In the study, hamstring calcific tendinopathy was found in 28 of 31 adults and children with Lyme arthritis, 3 of 22 with knee osteoarthritis, and 1 of 14 patients with inflammatory arthritis, Dr. Arvikar noted.

She and her coinvestigators evaluated tendon pathology in their retrospective study of patients at the Massachusetts General Hospital Rheumatology Musculoskeletal Ultrasound Clinic. They used ultrasound because they have found it offers far better spatial resolution of calcification than does MRI or x-rays. The semimembranosus tendon was the hamstring tendon that most commonly exhibited calcification, although 11 patients with Lyme arthritis also had involvement of the semitendinosus tendon, compared with none of the controls with osteoarthritis or inflammatory arthritis.

In the eight patients with serial ultrasound evaluations over a period of up to 12 months, the calcification persisted but the symptoms of tendinitis and synovitis improved.

Dr. Arvikar and her colleagues are expanding the scope of their ongoing study by examining patients whose Lyme arthritis is milder than that of the initial population, including patients who haven’t yet received antibiotics. They are also evaluating more controls with inflammatory arthritis.

In a separate presentation, Dr. Kalish noted that Lyme arthritis, the manifestation of Lyme disease of greatest interest to rheumatologists, occurs in about 60% of untreated patients, with onset a mean of 6 months after the tick bite. It typically entails recurrent mono- or oligoarthritis of large joints. The knee is involved in roughly 95% of cases.

The natural history of untreated Lyme arthritis is a spontaneous resolution rate of 10%-20% per year. Since the 1980s, however, 4 weeks of oral doxycycline or amoxicillin has been the treatment of choice. About 10% of patients with Lyme arthritis continue to have active synovitis 3 months after their course of antibiotics.

“There are some patients you give the treatment to and their arthritis just melts away in a month, but some, no matter what you do with antibiotics, continue to have synovitis, often developing a highly proliferative palpable synovitis that is really gunked up and features obliterative microvascular lesions,” observed Dr. Kalish, a rheumatologist at Tufts University in Boston.

Dr. Kalish said that persistent posttreatment Lyme arthritis is most often due to a self-perpetuating immune response after the spirochete has been killed by antibiotics. He noted that patients with certain HLA-DRB1 haplotypes are more likely to experience persistent Lyme arthritis after standard recommended courses of antibiotics, and these DRB1 alleles correlate closely with the shared epitope associated with increased susceptibility to rheumatoid arthritis. Several candidate autoantigens have already been identified.

He noted that the Massachusetts General group, in an earlier study, demonstrated that the presence of B. burgdorferi DNA by PCR in synovial fluid from patients with persistent Lyme arthritis after antibiotic therapy was not a reliable indicator of active joint infection (Arthritis Rheum. 2011 Aug;63[8]:2238-47).

“This was a paradigm change for me in seeing this study, because prior to that I had used PCR somewhat to guide treatment and make management decisions,” Dr. Kalish said.

What’s a reasonable treatment strategy in patients with persistent Lyme arthritis despite 30 days of oral antibiotics? Dr. Kalish favors an algorithm similar to one published by Dr. Arvikar and Allen C. Steere, MD (Infect Dis Clin North Am. 2015 Jun;29[2]:269-80). In the case of mild persistent arthritis, he opts for another 30 days of oral doxycycline. If the arthritis is moderate or severe, he goes with either another 30 days of doxycycline or 30 days of intravenous ceftriaxone.

If the arthritis still hasn’t resolved despite two 30-day rounds of antibiotic therapy, he prescribes an NSAID or hydroxychloroquine if the persistent arthritis is mild, or methotrexate if it’s moderate to severe. And if the arthritis still persists after 3-6 months of disease-modifying antirheumatic drug therapy, he’ll consider synovectomy, which has a good success rate.

Neither Dr. Arvikar nor Dr. Kalish reported having any financial conflicts regarding their presentations.

[email protected]

SOURCE: Arvikar SL et al. Arthritis Rheumatol. 2018;70(Suppl 10): Abstract 950.

The NIH and DoD are working on a new database that aims to establish the number of people in the US living with limb loss and to provide insight on their challenges and needs.

The Limb Loss and Preservation Registry, expected to be operational in 2020, will address a “significant public health knowledge gap,” said Dr. Alison Cernich, director of the National Center for Medical Rehabilitation Research. She says the information housed in the database will be vital to preventing limb loss, improving amputation surgeries, refining rehabilitation approaches, and guiding the development of devices for people who have lost limbs. Researchers will be able to sort the data by age, gender, and type of limb loss.

The National Institute of Child Health and Human Development has awarded a 5-year contract, capped at $5 million, to the Mayo Clinic to develop and launch the registry.

The NIH and DoD chose to join resources because there are not enough amputations within the DoD alone to provide a suitable sample for statistically valid conclusions, Dr. Cernich said. Moreover, data available from the DoD and the VA do not include service members who leave the military and seek care in the private sector. Cernich says the partnership between federal agencies will allow them to collect data that will “inform research and improve the lives of all citizens coping with limb loss.”

The NIH and DoD are working on a new database that aims to establish the number of people in the US living with limb loss and to provide insight on their challenges and needs.

The Limb Loss and Preservation Registry, expected to be operational in 2020, will address a “significant public health knowledge gap,” said Dr. Alison Cernich, director of the National Center for Medical Rehabilitation Research. She says the information housed in the database will be vital to preventing limb loss, improving amputation surgeries, refining rehabilitation approaches, and guiding the development of devices for people who have lost limbs. Researchers will be able to sort the data by age, gender, and type of limb loss.

The National Institute of Child Health and Human Development has awarded a 5-year contract, capped at $5 million, to the Mayo Clinic to develop and launch the registry.

The NIH and DoD chose to join resources because there are not enough amputations within the DoD alone to provide a suitable sample for statistically valid conclusions, Dr. Cernich said. Moreover, data available from the DoD and the VA do not include service members who leave the military and seek care in the private sector. Cernich says the partnership between federal agencies will allow them to collect data that will “inform research and improve the lives of all citizens coping with limb loss.”

The NIH and DoD are working on a new database that aims to establish the number of people in the US living with limb loss and to provide insight on their challenges and needs.

The Limb Loss and Preservation Registry, expected to be operational in 2020, will address a “significant public health knowledge gap,” said Dr. Alison Cernich, director of the National Center for Medical Rehabilitation Research. She says the information housed in the database will be vital to preventing limb loss, improving amputation surgeries, refining rehabilitation approaches, and guiding the development of devices for people who have lost limbs. Researchers will be able to sort the data by age, gender, and type of limb loss.

The National Institute of Child Health and Human Development has awarded a 5-year contract, capped at $5 million, to the Mayo Clinic to develop and launch the registry.

The NIH and DoD chose to join resources because there are not enough amputations within the DoD alone to provide a suitable sample for statistically valid conclusions, Dr. Cernich said. Moreover, data available from the DoD and the VA do not include service members who leave the military and seek care in the private sector. Cernich says the partnership between federal agencies will allow them to collect data that will “inform research and improve the lives of all citizens coping with limb loss.”

U.S. life expectancy is down while drug overdose and suicide are up sharply. Also today, an increase of less-distressed patients is driving an increase in outpatient services, the American Society of Hematology releases new guidelines on VTE ahead of ASH 2018 and commentary from Francis Collins, MD, denouncing reports from China on CRISPR-cas9 editing on embryos.
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U.S. life expectancy is down while drug overdose and suicide are up sharply. Also today, an increase of less-distressed patients is driving an increase in outpatient services, the American Society of Hematology releases new guidelines on VTE ahead of ASH 2018 and commentary from Francis Collins, MD, denouncing reports from China on CRISPR-cas9 editing on embryos.
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Google Podcasts
Spotify
 

U.S. life expectancy is down while drug overdose and suicide are up sharply. Also today, an increase of less-distressed patients is driving an increase in outpatient services, the American Society of Hematology releases new guidelines on VTE ahead of ASH 2018 and commentary from Francis Collins, MD, denouncing reports from China on CRISPR-cas9 editing on embryos.
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Apple Podcasts
Google Podcasts
Spotify
 

AUSTIN, TEX. – More than one-quarter of inmates executed during a recent 7-year period had a history confirming or suggesting they had a mental illness that might have called their competence for execution into question, according to new research.

Capital punishment remains legal in 31 U.S. states. In Ford v. Wainwright, the U.S. Supreme Court ruled in 1986 that executing a person lacking competence violates the Eighth Amendment, yet many people with a history of mental illness have been executed, said Paulina Riess, MD, of the BronxCare Health System in New York, and her colleagues.

The question of appropriately determining whether someone is competent enough to be executed also is controversial, Dr. Riess and her colleagues noted in their research abstract at the annual meeting of the American Academy of Psychiatry and the Law. “The decision of whether one is competent ultimately falls into the hands of a forensic evaluator whose opinion should represent a clear and detailed explanation of a prison’s understanding, awareness, and comprehension of the pending execution.”

The researchers sought to determine how many death row inmates executed between 2010 and 2017 had a mental illness or disability diagnosis, had received a psychotropic medication, or both. They also collected data on inmates’ age, race, instant offense, method of execution, and years spent on death row.

When the authors searched the literature for an evidence-based tool to provide “information regarding any history of mental illness pertaining to executed prisoners,” they found none and therefore relied on media coverage for their data on history of mental illness or disability or psychotropic medication treatment.

They found that 26% had a history of psychiatric illness, mental disability, or treatment with psychiatric medications.

Among 273 people executed from 2010-2017, all but 5 were men. Texas had the most executions at 80, followed by Florida (27), Georgia (23), Ohio (22), Oklahoma (21), and Alabama (17). Other states in the analysis included Arizona, Arkansas, Idaho, Louisiana, Mississippi, South Carolina, South Dakota, Utah, and Virginia.

Five of the inmates were aged older than 70 years, and seven were under 30 years old. Most were aged 31-40 years (73 inmates) or 40-50 years (108 inmates). The racial breakdown was 147 whites, 90 blacks, 35 Hispanics, and 1 Native American.

Lethal injection was the method of execution for all – except one who died by firing squad and two who died by electrocution. Seven inmates had been convicted for mass murder or serial killing (one of whom also had a robbery conviction). The others all had homicide convictions, 61 of whom had at least one other conviction in addition to homicide – predominantly robbery or rape.

Of those with information available, 117 inmates spent 11-20 years on death row, 64 spent 21-30 years, and 15 spent 31-40 years. Only five inmates spent fewer than 5 years on death row, and 49 inmates spent 5-10 years.

The need to rely on media reports for data collection is a limitation of the study. “While gathering demographic information, team members unanimously reported a history of trauma in a large portion of those executed during the 7-year span examined,” the authors reported. “This is another limitation as trauma history could have been included as a separate variable.”

No disclosures were reported.

AUSTIN, TEX. – More than one-quarter of inmates executed during a recent 7-year period had a history confirming or suggesting they had a mental illness that might have called their competence for execution into question, according to new research.

Capital punishment remains legal in 31 U.S. states. In Ford v. Wainwright, the U.S. Supreme Court ruled in 1986 that executing a person lacking competence violates the Eighth Amendment, yet many people with a history of mental illness have been executed, said Paulina Riess, MD, of the BronxCare Health System in New York, and her colleagues.

The question of appropriately determining whether someone is competent enough to be executed also is controversial, Dr. Riess and her colleagues noted in their research abstract at the annual meeting of the American Academy of Psychiatry and the Law. “The decision of whether one is competent ultimately falls into the hands of a forensic evaluator whose opinion should represent a clear and detailed explanation of a prison’s understanding, awareness, and comprehension of the pending execution.”

The researchers sought to determine how many death row inmates executed between 2010 and 2017 had a mental illness or disability diagnosis, had received a psychotropic medication, or both. They also collected data on inmates’ age, race, instant offense, method of execution, and years spent on death row.

When the authors searched the literature for an evidence-based tool to provide “information regarding any history of mental illness pertaining to executed prisoners,” they found none and therefore relied on media coverage for their data on history of mental illness or disability or psychotropic medication treatment.

They found that 26% had a history of psychiatric illness, mental disability, or treatment with psychiatric medications.

Among 273 people executed from 2010-2017, all but 5 were men. Texas had the most executions at 80, followed by Florida (27), Georgia (23), Ohio (22), Oklahoma (21), and Alabama (17). Other states in the analysis included Arizona, Arkansas, Idaho, Louisiana, Mississippi, South Carolina, South Dakota, Utah, and Virginia.

Five of the inmates were aged older than 70 years, and seven were under 30 years old. Most were aged 31-40 years (73 inmates) or 40-50 years (108 inmates). The racial breakdown was 147 whites, 90 blacks, 35 Hispanics, and 1 Native American.

Lethal injection was the method of execution for all – except one who died by firing squad and two who died by electrocution. Seven inmates had been convicted for mass murder or serial killing (one of whom also had a robbery conviction). The others all had homicide convictions, 61 of whom had at least one other conviction in addition to homicide – predominantly robbery or rape.

Of those with information available, 117 inmates spent 11-20 years on death row, 64 spent 21-30 years, and 15 spent 31-40 years. Only five inmates spent fewer than 5 years on death row, and 49 inmates spent 5-10 years.

The need to rely on media reports for data collection is a limitation of the study. “While gathering demographic information, team members unanimously reported a history of trauma in a large portion of those executed during the 7-year span examined,” the authors reported. “This is another limitation as trauma history could have been included as a separate variable.”

No disclosures were reported.

AUSTIN, TEX. – More than one-quarter of inmates executed during a recent 7-year period had a history confirming or suggesting they had a mental illness that might have called their competence for execution into question, according to new research.

Capital punishment remains legal in 31 U.S. states. In Ford v. Wainwright, the U.S. Supreme Court ruled in 1986 that executing a person lacking competence violates the Eighth Amendment, yet many people with a history of mental illness have been executed, said Paulina Riess, MD, of the BronxCare Health System in New York, and her colleagues.

The question of appropriately determining whether someone is competent enough to be executed also is controversial, Dr. Riess and her colleagues noted in their research abstract at the annual meeting of the American Academy of Psychiatry and the Law. “The decision of whether one is competent ultimately falls into the hands of a forensic evaluator whose opinion should represent a clear and detailed explanation of a prison’s understanding, awareness, and comprehension of the pending execution.”

The researchers sought to determine how many death row inmates executed between 2010 and 2017 had a mental illness or disability diagnosis, had received a psychotropic medication, or both. They also collected data on inmates’ age, race, instant offense, method of execution, and years spent on death row.

When the authors searched the literature for an evidence-based tool to provide “information regarding any history of mental illness pertaining to executed prisoners,” they found none and therefore relied on media coverage for their data on history of mental illness or disability or psychotropic medication treatment.

They found that 26% had a history of psychiatric illness, mental disability, or treatment with psychiatric medications.

Among 273 people executed from 2010-2017, all but 5 were men. Texas had the most executions at 80, followed by Florida (27), Georgia (23), Ohio (22), Oklahoma (21), and Alabama (17). Other states in the analysis included Arizona, Arkansas, Idaho, Louisiana, Mississippi, South Carolina, South Dakota, Utah, and Virginia.

Five of the inmates were aged older than 70 years, and seven were under 30 years old. Most were aged 31-40 years (73 inmates) or 40-50 years (108 inmates). The racial breakdown was 147 whites, 90 blacks, 35 Hispanics, and 1 Native American.

Lethal injection was the method of execution for all – except one who died by firing squad and two who died by electrocution. Seven inmates had been convicted for mass murder or serial killing (one of whom also had a robbery conviction). The others all had homicide convictions, 61 of whom had at least one other conviction in addition to homicide – predominantly robbery or rape.

Of those with information available, 117 inmates spent 11-20 years on death row, 64 spent 21-30 years, and 15 spent 31-40 years. Only five inmates spent fewer than 5 years on death row, and 49 inmates spent 5-10 years.

The need to rely on media reports for data collection is a limitation of the study. “While gathering demographic information, team members unanimously reported a history of trauma in a large portion of those executed during the 7-year span examined,” the authors reported. “This is another limitation as trauma history could have been included as a separate variable.”

No disclosures were reported.

From AHA 2018, an analysis gives clue to how empagliflozin cuts cardiovascular risk, and study findings challenge cholesterol guidelines for patients with type 1 diabetes. Also, we take a closer look at how smoke-free policies affect blood pressure, and how magazine-ranked “Best Hospitals” actually perform.

Subscribe to Cardiocast wherever you get your podcasts.
Amazon Alexa
Apple Podcasts

From AHA 2018, an analysis gives clue to how empagliflozin cuts cardiovascular risk, and study findings challenge cholesterol guidelines for patients with type 1 diabetes. Also, we take a closer look at how smoke-free policies affect blood pressure, and how magazine-ranked “Best Hospitals” actually perform.

Subscribe to Cardiocast wherever you get your podcasts.
Amazon Alexa
Apple Podcasts

From AHA 2018, an analysis gives clue to how empagliflozin cuts cardiovascular risk, and study findings challenge cholesterol guidelines for patients with type 1 diabetes. Also, we take a closer look at how smoke-free policies affect blood pressure, and how magazine-ranked “Best Hospitals” actually perform.

Subscribe to Cardiocast wherever you get your podcasts.
Amazon Alexa
Apple Podcasts

Amputation: Resistance is not futile!

What’s in a toe you may ask? Why worry about saving it? Just amputate and move on ...

Not so! I implore you to resist the desire. We vascular surgeons are accustomed to cutting off toes, even feet and legs. But when it comes to diabetic feet please reconsider. Just because there is osteomyelitis, I argue that does not necessitate amputation.

We all agree that ischemic gangrene and black mummified digits are beyond salvage. That’s not what my concern is. My focus is nonhealing ulcers with underlying osteomyelitis. Whether ischemic in etiology or neuropathic (or both), give salvage a try.

Why is this so important? My opponent will try to convince you that it’s not. He’ll try to sell you on how well people walk after amputation and that functional outcomes are great. But think beyond that for a second.

Amputation changes the foot architecture and weight distribution. In a person with neuropathy, this only predisposes them to more ulcers. More ulcers will mean more infection, which will lead to more amputations. This finally culminates in a major amputation.

In one reported study,¹ researchers followed more than 200,000 diabetics from 2010 until 2013. While the risk of amputation overall was relatively small (0.36% for major and 0.56% for minor amputations), prior minor amputation increased the risk of major amputation 10-fold and increased the risk of another minor (below-ankle) amputation 20-fold. Of those who had a major amputation, 57% died over the 3 years. This is not insignificant.

This does not also consider the morbidity and impact on lifestyle and quality of life for these patients. Many may not walk. Some will be relegated to nursing homes. Some will suffer from phantom limb pain. Many may never return to work. Even more will have difficulty with their daily lives, not to mention the psychological recovery also required.

The foot seems to be the only place where amputation as first-line therapy for osteomyelitis is accepted. We don’t do a hip disarticulation for ischial pressure sores with osteomyelitis. Calvarial osteomyelitis is also treated with antibiotics. I implore you: Don’t treat toes like vestigial organs.

Granted, there are subsets of patients who would benefit from amputations. A patient with painful Charcot foot may elect to have a below-knee amputation and move on with life. Another who has lost jobs or significant time due to recurrence of osteomyelitis may progress. A patient with severe sepsis and infection into a joint may need amputation.

But what other treatment options are there? I’m glad you inquired.

I primarily treat diabetic feet by treating the soft tissue envelope. Even if a patient presents with midfoot infection or necrotizing soft tissue infection, I treat it like a good old-fashioned abscess or necrotizing fasciitis:

1) Drain pus

2) Resect the dead stuff

3) Supportive care (antibiotics, fluids, aggressive wound care, etc.)

I try to leave the bones intact. When bone is exposed I take biopsies for culture and pathology. Any bone destroyed by the infection is focally debrided. I also take a specimen of the “bone margin” that I’m leaving behind and I send this to pathology looking for residual acute osteomyelitis. These steps are important as they dictate duration and choice of antibiotic therapy. This is in keeping with the consensus recommendations published in 2016.²

Even chronic wounds get a similar approach. If there is granulation, let it granulate and see if it will fill the wound. “Just because osteomyelitis is there, it doesn’t mean that for the toe we won’t care!”

There are exceptions of course. If the soft tissue is severely affected so the phalynx protrudes like something from the movie “Coco,” probably that should be amputated. Repeat offenders also may progress to amputation. But otherwise, hold off and give it a chance.

For the inpatient, aggressive irrigation of the wounds using the Veraflo system promotes granulation, even for short hospital stays of 1 week or less. Any ischemic component is worked up and addressed with percutaneous or open revascularization. We treat with prolonged antibiotics, and in questionable cases err on the side of giving long-term courses. These wounds need to be offloaded for tasks of daily living (going to the bathroom, making a sandwich, etc.) but otherwise we instruct patients to be effectively non–weight-bearing on that limb.

We also refer patients for hyperbaric therapy frequently. Now if you’re done groaning, I assure you this is not phony medicine. There is growing evidence to support not only improved rates of healing, but also significant cost savings and improved quality of life.³

In young patients or those with large defects, we also involve plastic and reconstructive surgery for secondary closure approaches (free flaps, adjacent tissue transfers, local autogenous or prosthetic grafting [Integra, Stravix, Dermacell, etc.] or other advanced techniques). This is particularly important in plantar wounds that will need to bear weight in the future, or in young patients for improved functional and cosmetic outcomes. For smaller wounds, we often use dermal/subdermal graft substitutes ourselves.

Even still, in nonambulatory or chronically debilitated and medically high-risk patients, maybe a different option is palliative wound care with or without antibiotics. A nonoperative approach to allow individuals to live the rest of their remaining days without undergoing a morbid and disfiguring amputation is not unreasonable. Many families are thankful for this option when given it. In the absence of refractory pain or overwhelming sepsis, we just let the wound do what it will do, understanding that someday the plan may change. This allows patients to continue to treat the wound without escalation to surgery or resorting to amputation.

In the end, just like we vascular surgeons tailor our “holistic” approach to the needs and desires of a single particular patient, we should approach wounds with a similar attitude. The presence of osteomyelitis in and of itself should not prompt one to bypass an entire algorithm, go straight to amputation, do not pass “Go” or “collect $200” (although the professional fee for a toe amputation is probably around $200). With a multidisciplinary and multimodal approach, and vested patients, salvage is possible in the majority of cases.
 

References

1. Diabetologia. 2018 Mar;61(3):626-35.

2. Diabet Foot Ankle. 2016 Jul 12. doi: 10.3402/dfa.v7.30079.

3. Int J Technol Assess Health Care. 2008 Spring;24(2):178-83.
 

Dr. Issam Koleilat is assistant professor and associate program director, Vascular Surgery Residency and Fellowship, Division of Vascular Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, New York. He had no relevant disclosures.

Amputation: Often the best option

For many years there has been debate about the best management strategy for diabetic foot infection including osteomyelitis. The principles of appropriate antibiotics, surgical debridement, good wound care, and proper offloading will always remain. There are no randomized controlled trials of medical vs. surgical management of diabetic foot ulceration with osteomyelitis.

We now have a number of widely accepted ways to define wounds including Wagner and the SVS-adopted WIFI score. Historical papers are somewhat plagued by heterogeneity in the wounds included. This is even more apparent with any attempted meta-analyses. I think everyone would agree that the superficial toe wound with minimal cellulitis is best managed medically. The issue at hand is the profoundly neuropathic diabetic often with underlying anatomic abnormality and osteomyelitis. My esteemed colleague would suggest that we are too quick to pull a trigger and amputate a toe with underlying osteomyelitis.

I think the initial item for debate is the technique of diagnosis of osteomyelitis. We have multiple ways this is reported. Plain x-ray, bone scan, MRI, and “clinical osteomyelitis” are among the alternative ways osteomyelitis is diagnosed. The reliability of the last is the most variable because clinical osteomyelitis ranges from “probes close to bone” to exposed bone visible protruding from the wound bed. Given the variability of diagnostic techniques, the literature is an amalgam of clinical scenarios and difficult to navigate in a way to affect treatment decisions.

In addition, the medical treatment for osteomyelitis is highly variable. This commonly involves tunneled catheter insertion and 6 weeks to 3 months of IV antibiotics. In some institutions antibiotics are tailored to “wound culture.” Several of our infectious disease specialists prefer bone culture and pathology of bone demonstrating an acute destructive process. Obviously, this often requires surgical debridement to obtain a specimen. Antibiotic duration recommendations may vary from 1 week (if all infected bone is resected) to 90 days if a standalone antibiotic management is selected. Chronic osteomyelitis has a reinfection rate of up to 30%.¹

Medical management is not without risk. These risks include recurring infection with resistant organisms, wound deterioration, gastrointestinal complications (Clostridium difficile), catheter-related complications, and acute kidney injury. A recent paper found over 30% of patients treated medically for osteomyelitis developed acute kidney injury. These patients had more frequent hospitalization, recurring ulceration, and infection.² We have all experienced the patient with multiple hospitalizations and episodic AKI that culminates in ESRD requiring hemodialysis.

If the argument is with good follow-up these patients will ultimately experience preservation of the toe, I would take the stance that in our patient population of diabetics presenting with foot ulcer and osteomyelitis the average hemoglobin A1c is over 9. Although this is not only related to patient compliance, in many instances this is a large piece of the puzzle. It is hard to infer that suddenly with biopsy-proven osteomyelitis the patient will become compliant with medical management of the disease process. Certainly, in some circumstances, this is the case. There are a number of studies with a wide range of findings on HbA^1c as it relates to predictive value of wound healing.

There are various studies comparing surgical to medical management for osteomyelitis. Limb salvage is contingent upon location (forefoot, midfoot, hindfoot), the extent of infection, and patient comorbidities. The conclusion of the majority of these studies is that a standalone antibiotic treatment algorithm results in greater limb loss. Patients with peripheral occlusive disease and preadmission antibiotic use have been shown to have decreased wound healing. Minor amputation has been shown to be protective from mortality, risk of major amputation, and unfavorable discharge in patients admitted with a diagnosis of osteomyelitis.³ The major limb amputation rate for antibiotics alone is 20%-30% according to two trials with duration of antibiotics of 3 months.^4,5 The available randomized trials tend to exclude patients with severe infection (poorly defined), those with PAD, or those with severe comorbid conditions.

Cost of treatment is even more poorly delineated. Obviously, surgical treatment is not without cost to the health care system. Toe amputation especially when including the metatarsal head shifts pressure points and in the neuropathic patient may lead to recurrent ulceration. The average outpatient cost per patient per ulcer is often over $30,000. The goal of surgical treatment can be defined as trying to maintain the greatest degree of function with the least risk. Removing infected bone (i.e., minor amputation) limits exposure to prolonged antibiotic treatment and hopefully lessens recurring ulceration and hospitalization. This is only one piece of the puzzle, however. A multidisciplinary approach with endocrinology, infectious disease, and orthotics for offloading are keys to decrease future ulceration.

Although I do not advocate for widespread toe carnage as suggested by Dr. Koleilat, I do think liberal application of minor amputation to limit hospital stay, limit antibiotic duration and its inherent risk, and possibly affect readmission is often in the best interest of the patient and the system as a whole. Obviously, based on the variable reports in the literature there cannot be a single approach to these patients and the treatment must be individualized based on extent of infection, compliance of the patient, access to multidisciplinary care, and comorbid conditions.
 

References

1. World J Diabetes. 2017 Apr 15;8(4):135-42.

2. Diabetes Res Clin Pract. 2018 Jan;135:58-64.

3. Ann Surg. 2005;241(6):885-94.

4. Am J Med. 1987 Oct;83(4):653-60.

5. Am J Med.1989 Jun;86(6 Pt 2):801-8.

Dr. Mark P. Androes is division chief, vascular surgery, Greenville (S.C.) Health System. He had no relevant disclosures.

Amputation: Resistance is not futile!

What’s in a toe you may ask? Why worry about saving it? Just amputate and move on ...

Not so! I implore you to resist the desire. We vascular surgeons are accustomed to cutting off toes, even feet and legs. But when it comes to diabetic feet please reconsider. Just because there is osteomyelitis, I argue that does not necessitate amputation.

We all agree that ischemic gangrene and black mummified digits are beyond salvage. That’s not what my concern is. My focus is nonhealing ulcers with underlying osteomyelitis. Whether ischemic in etiology or neuropathic (or both), give salvage a try.

Why is this so important? My opponent will try to convince you that it’s not. He’ll try to sell you on how well people walk after amputation and that functional outcomes are great. But think beyond that for a second.

Amputation changes the foot architecture and weight distribution. In a person with neuropathy, this only predisposes them to more ulcers. More ulcers will mean more infection, which will lead to more amputations. This finally culminates in a major amputation.

In one reported study,¹ researchers followed more than 200,000 diabetics from 2010 until 2013. While the risk of amputation overall was relatively small (0.36% for major and 0.56% for minor amputations), prior minor amputation increased the risk of major amputation 10-fold and increased the risk of another minor (below-ankle) amputation 20-fold. Of those who had a major amputation, 57% died over the 3 years. This is not insignificant.

This does not also consider the morbidity and impact on lifestyle and quality of life for these patients. Many may not walk. Some will be relegated to nursing homes. Some will suffer from phantom limb pain. Many may never return to work. Even more will have difficulty with their daily lives, not to mention the psychological recovery also required.

The foot seems to be the only place where amputation as first-line therapy for osteomyelitis is accepted. We don’t do a hip disarticulation for ischial pressure sores with osteomyelitis. Calvarial osteomyelitis is also treated with antibiotics. I implore you: Don’t treat toes like vestigial organs.

Granted, there are subsets of patients who would benefit from amputations. A patient with painful Charcot foot may elect to have a below-knee amputation and move on with life. Another who has lost jobs or significant time due to recurrence of osteomyelitis may progress. A patient with severe sepsis and infection into a joint may need amputation.

But what other treatment options are there? I’m glad you inquired.

I primarily treat diabetic feet by treating the soft tissue envelope. Even if a patient presents with midfoot infection or necrotizing soft tissue infection, I treat it like a good old-fashioned abscess or necrotizing fasciitis:

1) Drain pus

2) Resect the dead stuff

3) Supportive care (antibiotics, fluids, aggressive wound care, etc.)

I try to leave the bones intact. When bone is exposed I take biopsies for culture and pathology. Any bone destroyed by the infection is focally debrided. I also take a specimen of the “bone margin” that I’m leaving behind and I send this to pathology looking for residual acute osteomyelitis. These steps are important as they dictate duration and choice of antibiotic therapy. This is in keeping with the consensus recommendations published in 2016.²

Even chronic wounds get a similar approach. If there is granulation, let it granulate and see if it will fill the wound. “Just because osteomyelitis is there, it doesn’t mean that for the toe we won’t care!”

There are exceptions of course. If the soft tissue is severely affected so the phalynx protrudes like something from the movie “Coco,” probably that should be amputated. Repeat offenders also may progress to amputation. But otherwise, hold off and give it a chance.

For the inpatient, aggressive irrigation of the wounds using the Veraflo system promotes granulation, even for short hospital stays of 1 week or less. Any ischemic component is worked up and addressed with percutaneous or open revascularization. We treat with prolonged antibiotics, and in questionable cases err on the side of giving long-term courses. These wounds need to be offloaded for tasks of daily living (going to the bathroom, making a sandwich, etc.) but otherwise we instruct patients to be effectively non–weight-bearing on that limb.

We also refer patients for hyperbaric therapy frequently. Now if you’re done groaning, I assure you this is not phony medicine. There is growing evidence to support not only improved rates of healing, but also significant cost savings and improved quality of life.³

In young patients or those with large defects, we also involve plastic and reconstructive surgery for secondary closure approaches (free flaps, adjacent tissue transfers, local autogenous or prosthetic grafting [Integra, Stravix, Dermacell, etc.] or other advanced techniques). This is particularly important in plantar wounds that will need to bear weight in the future, or in young patients for improved functional and cosmetic outcomes. For smaller wounds, we often use dermal/subdermal graft substitutes ourselves.

Even still, in nonambulatory or chronically debilitated and medically high-risk patients, maybe a different option is palliative wound care with or without antibiotics. A nonoperative approach to allow individuals to live the rest of their remaining days without undergoing a morbid and disfiguring amputation is not unreasonable. Many families are thankful for this option when given it. In the absence of refractory pain or overwhelming sepsis, we just let the wound do what it will do, understanding that someday the plan may change. This allows patients to continue to treat the wound without escalation to surgery or resorting to amputation.

In the end, just like we vascular surgeons tailor our “holistic” approach to the needs and desires of a single particular patient, we should approach wounds with a similar attitude. The presence of osteomyelitis in and of itself should not prompt one to bypass an entire algorithm, go straight to amputation, do not pass “Go” or “collect $200” (although the professional fee for a toe amputation is probably around $200). With a multidisciplinary and multimodal approach, and vested patients, salvage is possible in the majority of cases.
 

References

1. Diabetologia. 2018 Mar;61(3):626-35.

2. Diabet Foot Ankle. 2016 Jul 12. doi: 10.3402/dfa.v7.30079.

3. Int J Technol Assess Health Care. 2008 Spring;24(2):178-83.
 

Dr. Issam Koleilat is assistant professor and associate program director, Vascular Surgery Residency and Fellowship, Division of Vascular Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, New York. He had no relevant disclosures.

Amputation: Often the best option

For many years there has been debate about the best management strategy for diabetic foot infection including osteomyelitis. The principles of appropriate antibiotics, surgical debridement, good wound care, and proper offloading will always remain. There are no randomized controlled trials of medical vs. surgical management of diabetic foot ulceration with osteomyelitis.

We now have a number of widely accepted ways to define wounds including Wagner and the SVS-adopted WIFI score. Historical papers are somewhat plagued by heterogeneity in the wounds included. This is even more apparent with any attempted meta-analyses. I think everyone would agree that the superficial toe wound with minimal cellulitis is best managed medically. The issue at hand is the profoundly neuropathic diabetic often with underlying anatomic abnormality and osteomyelitis. My esteemed colleague would suggest that we are too quick to pull a trigger and amputate a toe with underlying osteomyelitis.

I think the initial item for debate is the technique of diagnosis of osteomyelitis. We have multiple ways this is reported. Plain x-ray, bone scan, MRI, and “clinical osteomyelitis” are among the alternative ways osteomyelitis is diagnosed. The reliability of the last is the most variable because clinical osteomyelitis ranges from “probes close to bone” to exposed bone visible protruding from the wound bed. Given the variability of diagnostic techniques, the literature is an amalgam of clinical scenarios and difficult to navigate in a way to affect treatment decisions.

In addition, the medical treatment for osteomyelitis is highly variable. This commonly involves tunneled catheter insertion and 6 weeks to 3 months of IV antibiotics. In some institutions antibiotics are tailored to “wound culture.” Several of our infectious disease specialists prefer bone culture and pathology of bone demonstrating an acute destructive process. Obviously, this often requires surgical debridement to obtain a specimen. Antibiotic duration recommendations may vary from 1 week (if all infected bone is resected) to 90 days if a standalone antibiotic management is selected. Chronic osteomyelitis has a reinfection rate of up to 30%.¹

Medical management is not without risk. These risks include recurring infection with resistant organisms, wound deterioration, gastrointestinal complications (Clostridium difficile), catheter-related complications, and acute kidney injury. A recent paper found over 30% of patients treated medically for osteomyelitis developed acute kidney injury. These patients had more frequent hospitalization, recurring ulceration, and infection.² We have all experienced the patient with multiple hospitalizations and episodic AKI that culminates in ESRD requiring hemodialysis.

If the argument is with good follow-up these patients will ultimately experience preservation of the toe, I would take the stance that in our patient population of diabetics presenting with foot ulcer and osteomyelitis the average hemoglobin A1c is over 9. Although this is not only related to patient compliance, in many instances this is a large piece of the puzzle. It is hard to infer that suddenly with biopsy-proven osteomyelitis the patient will become compliant with medical management of the disease process. Certainly, in some circumstances, this is the case. There are a number of studies with a wide range of findings on HbA^1c as it relates to predictive value of wound healing.

There are various studies comparing surgical to medical management for osteomyelitis. Limb salvage is contingent upon location (forefoot, midfoot, hindfoot), the extent of infection, and patient comorbidities. The conclusion of the majority of these studies is that a standalone antibiotic treatment algorithm results in greater limb loss. Patients with peripheral occlusive disease and preadmission antibiotic use have been shown to have decreased wound healing. Minor amputation has been shown to be protective from mortality, risk of major amputation, and unfavorable discharge in patients admitted with a diagnosis of osteomyelitis.³ The major limb amputation rate for antibiotics alone is 20%-30% according to two trials with duration of antibiotics of 3 months.^4,5 The available randomized trials tend to exclude patients with severe infection (poorly defined), those with PAD, or those with severe comorbid conditions.

Cost of treatment is even more poorly delineated. Obviously, surgical treatment is not without cost to the health care system. Toe amputation especially when including the metatarsal head shifts pressure points and in the neuropathic patient may lead to recurrent ulceration. The average outpatient cost per patient per ulcer is often over $30,000. The goal of surgical treatment can be defined as trying to maintain the greatest degree of function with the least risk. Removing infected bone (i.e., minor amputation) limits exposure to prolonged antibiotic treatment and hopefully lessens recurring ulceration and hospitalization. This is only one piece of the puzzle, however. A multidisciplinary approach with endocrinology, infectious disease, and orthotics for offloading are keys to decrease future ulceration.

Although I do not advocate for widespread toe carnage as suggested by Dr. Koleilat, I do think liberal application of minor amputation to limit hospital stay, limit antibiotic duration and its inherent risk, and possibly affect readmission is often in the best interest of the patient and the system as a whole. Obviously, based on the variable reports in the literature there cannot be a single approach to these patients and the treatment must be individualized based on extent of infection, compliance of the patient, access to multidisciplinary care, and comorbid conditions.
 

References

1. World J Diabetes. 2017 Apr 15;8(4):135-42.

2. Diabetes Res Clin Pract. 2018 Jan;135:58-64.

3. Ann Surg. 2005;241(6):885-94.

4. Am J Med. 1987 Oct;83(4):653-60.

5. Am J Med.1989 Jun;86(6 Pt 2):801-8.

Dr. Mark P. Androes is division chief, vascular surgery, Greenville (S.C.) Health System. He had no relevant disclosures.

Amputation: Resistance is not futile!

What’s in a toe you may ask? Why worry about saving it? Just amputate and move on ...

Not so! I implore you to resist the desire. We vascular surgeons are accustomed to cutting off toes, even feet and legs. But when it comes to diabetic feet please reconsider. Just because there is osteomyelitis, I argue that does not necessitate amputation.

We all agree that ischemic gangrene and black mummified digits are beyond salvage. That’s not what my concern is. My focus is nonhealing ulcers with underlying osteomyelitis. Whether ischemic in etiology or neuropathic (or both), give salvage a try.

Why is this so important? My opponent will try to convince you that it’s not. He’ll try to sell you on how well people walk after amputation and that functional outcomes are great. But think beyond that for a second.

Amputation changes the foot architecture and weight distribution. In a person with neuropathy, this only predisposes them to more ulcers. More ulcers will mean more infection, which will lead to more amputations. This finally culminates in a major amputation.

In one reported study,¹ researchers followed more than 200,000 diabetics from 2010 until 2013. While the risk of amputation overall was relatively small (0.36% for major and 0.56% for minor amputations), prior minor amputation increased the risk of major amputation 10-fold and increased the risk of another minor (below-ankle) amputation 20-fold. Of those who had a major amputation, 57% died over the 3 years. This is not insignificant.

This does not also consider the morbidity and impact on lifestyle and quality of life for these patients. Many may not walk. Some will be relegated to nursing homes. Some will suffer from phantom limb pain. Many may never return to work. Even more will have difficulty with their daily lives, not to mention the psychological recovery also required.

The foot seems to be the only place where amputation as first-line therapy for osteomyelitis is accepted. We don’t do a hip disarticulation for ischial pressure sores with osteomyelitis. Calvarial osteomyelitis is also treated with antibiotics. I implore you: Don’t treat toes like vestigial organs.

Granted, there are subsets of patients who would benefit from amputations. A patient with painful Charcot foot may elect to have a below-knee amputation and move on with life. Another who has lost jobs or significant time due to recurrence of osteomyelitis may progress. A patient with severe sepsis and infection into a joint may need amputation.

But what other treatment options are there? I’m glad you inquired.

I primarily treat diabetic feet by treating the soft tissue envelope. Even if a patient presents with midfoot infection or necrotizing soft tissue infection, I treat it like a good old-fashioned abscess or necrotizing fasciitis:

1) Drain pus

2) Resect the dead stuff

3) Supportive care (antibiotics, fluids, aggressive wound care, etc.)

I try to leave the bones intact. When bone is exposed I take biopsies for culture and pathology. Any bone destroyed by the infection is focally debrided. I also take a specimen of the “bone margin” that I’m leaving behind and I send this to pathology looking for residual acute osteomyelitis. These steps are important as they dictate duration and choice of antibiotic therapy. This is in keeping with the consensus recommendations published in 2016.²

Even chronic wounds get a similar approach. If there is granulation, let it granulate and see if it will fill the wound. “Just because osteomyelitis is there, it doesn’t mean that for the toe we won’t care!”

There are exceptions of course. If the soft tissue is severely affected so the phalynx protrudes like something from the movie “Coco,” probably that should be amputated. Repeat offenders also may progress to amputation. But otherwise, hold off and give it a chance.

For the inpatient, aggressive irrigation of the wounds using the Veraflo system promotes granulation, even for short hospital stays of 1 week or less. Any ischemic component is worked up and addressed with percutaneous or open revascularization. We treat with prolonged antibiotics, and in questionable cases err on the side of giving long-term courses. These wounds need to be offloaded for tasks of daily living (going to the bathroom, making a sandwich, etc.) but otherwise we instruct patients to be effectively non–weight-bearing on that limb.

We also refer patients for hyperbaric therapy frequently. Now if you’re done groaning, I assure you this is not phony medicine. There is growing evidence to support not only improved rates of healing, but also significant cost savings and improved quality of life.³

In young patients or those with large defects, we also involve plastic and reconstructive surgery for secondary closure approaches (free flaps, adjacent tissue transfers, local autogenous or prosthetic grafting [Integra, Stravix, Dermacell, etc.] or other advanced techniques). This is particularly important in plantar wounds that will need to bear weight in the future, or in young patients for improved functional and cosmetic outcomes. For smaller wounds, we often use dermal/subdermal graft substitutes ourselves.

Even still, in nonambulatory or chronically debilitated and medically high-risk patients, maybe a different option is palliative wound care with or without antibiotics. A nonoperative approach to allow individuals to live the rest of their remaining days without undergoing a morbid and disfiguring amputation is not unreasonable. Many families are thankful for this option when given it. In the absence of refractory pain or overwhelming sepsis, we just let the wound do what it will do, understanding that someday the plan may change. This allows patients to continue to treat the wound without escalation to surgery or resorting to amputation.

In the end, just like we vascular surgeons tailor our “holistic” approach to the needs and desires of a single particular patient, we should approach wounds with a similar attitude. The presence of osteomyelitis in and of itself should not prompt one to bypass an entire algorithm, go straight to amputation, do not pass “Go” or “collect $200” (although the professional fee for a toe amputation is probably around $200). With a multidisciplinary and multimodal approach, and vested patients, salvage is possible in the majority of cases.
 

References

1. Diabetologia. 2018 Mar;61(3):626-35.

2. Diabet Foot Ankle. 2016 Jul 12. doi: 10.3402/dfa.v7.30079.

3. Int J Technol Assess Health Care. 2008 Spring;24(2):178-83.
 

Dr. Issam Koleilat is assistant professor and associate program director, Vascular Surgery Residency and Fellowship, Division of Vascular Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, New York. He had no relevant disclosures.

Amputation: Often the best option

For many years there has been debate about the best management strategy for diabetic foot infection including osteomyelitis. The principles of appropriate antibiotics, surgical debridement, good wound care, and proper offloading will always remain. There are no randomized controlled trials of medical vs. surgical management of diabetic foot ulceration with osteomyelitis.

We now have a number of widely accepted ways to define wounds including Wagner and the SVS-adopted WIFI score. Historical papers are somewhat plagued by heterogeneity in the wounds included. This is even more apparent with any attempted meta-analyses. I think everyone would agree that the superficial toe wound with minimal cellulitis is best managed medically. The issue at hand is the profoundly neuropathic diabetic often with underlying anatomic abnormality and osteomyelitis. My esteemed colleague would suggest that we are too quick to pull a trigger and amputate a toe with underlying osteomyelitis.

I think the initial item for debate is the technique of diagnosis of osteomyelitis. We have multiple ways this is reported. Plain x-ray, bone scan, MRI, and “clinical osteomyelitis” are among the alternative ways osteomyelitis is diagnosed. The reliability of the last is the most variable because clinical osteomyelitis ranges from “probes close to bone” to exposed bone visible protruding from the wound bed. Given the variability of diagnostic techniques, the literature is an amalgam of clinical scenarios and difficult to navigate in a way to affect treatment decisions.

In addition, the medical treatment for osteomyelitis is highly variable. This commonly involves tunneled catheter insertion and 6 weeks to 3 months of IV antibiotics. In some institutions antibiotics are tailored to “wound culture.” Several of our infectious disease specialists prefer bone culture and pathology of bone demonstrating an acute destructive process. Obviously, this often requires surgical debridement to obtain a specimen. Antibiotic duration recommendations may vary from 1 week (if all infected bone is resected) to 90 days if a standalone antibiotic management is selected. Chronic osteomyelitis has a reinfection rate of up to 30%.¹

Medical management is not without risk. These risks include recurring infection with resistant organisms, wound deterioration, gastrointestinal complications (Clostridium difficile), catheter-related complications, and acute kidney injury. A recent paper found over 30% of patients treated medically for osteomyelitis developed acute kidney injury. These patients had more frequent hospitalization, recurring ulceration, and infection.² We have all experienced the patient with multiple hospitalizations and episodic AKI that culminates in ESRD requiring hemodialysis.

If the argument is with good follow-up these patients will ultimately experience preservation of the toe, I would take the stance that in our patient population of diabetics presenting with foot ulcer and osteomyelitis the average hemoglobin A1c is over 9. Although this is not only related to patient compliance, in many instances this is a large piece of the puzzle. It is hard to infer that suddenly with biopsy-proven osteomyelitis the patient will become compliant with medical management of the disease process. Certainly, in some circumstances, this is the case. There are a number of studies with a wide range of findings on HbA^1c as it relates to predictive value of wound healing.

There are various studies comparing surgical to medical management for osteomyelitis. Limb salvage is contingent upon location (forefoot, midfoot, hindfoot), the extent of infection, and patient comorbidities. The conclusion of the majority of these studies is that a standalone antibiotic treatment algorithm results in greater limb loss. Patients with peripheral occlusive disease and preadmission antibiotic use have been shown to have decreased wound healing. Minor amputation has been shown to be protective from mortality, risk of major amputation, and unfavorable discharge in patients admitted with a diagnosis of osteomyelitis.³ The major limb amputation rate for antibiotics alone is 20%-30% according to two trials with duration of antibiotics of 3 months.^4,5 The available randomized trials tend to exclude patients with severe infection (poorly defined), those with PAD, or those with severe comorbid conditions.

Cost of treatment is even more poorly delineated. Obviously, surgical treatment is not without cost to the health care system. Toe amputation especially when including the metatarsal head shifts pressure points and in the neuropathic patient may lead to recurrent ulceration. The average outpatient cost per patient per ulcer is often over $30,000. The goal of surgical treatment can be defined as trying to maintain the greatest degree of function with the least risk. Removing infected bone (i.e., minor amputation) limits exposure to prolonged antibiotic treatment and hopefully lessens recurring ulceration and hospitalization. This is only one piece of the puzzle, however. A multidisciplinary approach with endocrinology, infectious disease, and orthotics for offloading are keys to decrease future ulceration.

Although I do not advocate for widespread toe carnage as suggested by Dr. Koleilat, I do think liberal application of minor amputation to limit hospital stay, limit antibiotic duration and its inherent risk, and possibly affect readmission is often in the best interest of the patient and the system as a whole. Obviously, based on the variable reports in the literature there cannot be a single approach to these patients and the treatment must be individualized based on extent of infection, compliance of the patient, access to multidisciplinary care, and comorbid conditions.
 

References

1. World J Diabetes. 2017 Apr 15;8(4):135-42.

2. Diabetes Res Clin Pract. 2018 Jan;135:58-64.

3. Ann Surg. 2005;241(6):885-94.

4. Am J Med. 1987 Oct;83(4):653-60.

5. Am J Med.1989 Jun;86(6 Pt 2):801-8.

Dr. Mark P. Androes is division chief, vascular surgery, Greenville (S.C.) Health System. He had no relevant disclosures.