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Short sleep linked with high homocysteine for some populations
Short sleep’s association with cardiovascular risk may be mediated in part by elevated homocysteine levels, suggests a new analysis of data from the 2005-2006 National Health and Nutrition Examination Survey (NHANES).
The study, published in the Journal of Clinical Sleep Medicine, found that elevated homocysteine levels were only associated with short sleep duration for some populations, including women, non-Hispanic white individuals, and participants with obesity.
A total of 4,480 NHANES participants had serum homocysteine levels on record and were included in the study; of these, those with self-reported sleep duration of 7 hours had the lowest serum homocysteine levels. Those with the shortest sleep duration – 5 hours or less per night – had the highest homocysteine levels.
When participants were broken into subgroups by such factors as sex, ethnicity/race, and body mass index, the association between extremely short sleep and elevated homocysteine levels was retained for three groups: women, non-Hispanic white participants, and those with BMIs of 30 kg/m2 and higher.
“[T]his finding might suggest increased vulnerability to cardiovascular risk or other atherothrombotic events in these groups in the context of short sleep,” wrote Tien-Yu Chen, MD, of Tri-Service General Hospital, Taipei, Taiwan, and coauthors in the abstract accompanying the study.
In the NHANES questionnaire, participants were asked how much sleep they usually got, in whole hours. Answers were grouped into 5 hours or less, 6 hours, 7 hours, or 8 hours, and 9 hours or more. Serum homocysteine was measured once for each study participant.
Using multivariate linear regression, homocysteine was considered the dependent, continuous variable, and the association between sleep duration and homocysteine was assessed using three models that accounted for confounders. The first and simplest model accounted for age, sex, and race/ethnicity. The second model added BMI, several cardiometabolic laboratory values, and vitamin B6, vitamin B12, and folate levels. The third model included all previous factors and added patient characteristics and comorbidities, such as sleep disorders, mental health service use, cardiovascular disease and cancer diagnoses, and alcohol and tobacco use.
In their analysis, Dr. Chen and colleagues dichotomized homocysteine levels to above or below the 75th percentile of the log homocysteine level, which fell at 9.74 nmol/L.
After adjustment, women, but not men, had an association between short sleep and increased odds of elevated homocysteine (odds ratio, 2.691; P = .010). This association “persisted in fully adjusted models,” wrote Dr. Chen and coauthors.
For individuals with obesity (BMI of 30 or greater), the association between elevated homocysteine and extremely short sleep (5 hours or less) persisted in fully adjusted models (beta = .062; P = .039 for model 3).
When looking at ethnicity, the association between extremely short sleep and elevated homocysteine was only seen among non-Hispanic white participants; again, this association was seen after full adjustment for confounders (beta = .068; P = .032). Small sample sizes limited some of the racial/ethnic analyses, noted the investigators.
Homocysteine, explained Dr. Chen and coauthors, is associated with a variety atherogenic changes, and elevated levels are associated with increased risk for cardiovascular disease and mortality. Short sleep is also associated with increased cardiovascular risk, as is long sleep in some studies.
However, though preliminary work had shown that short sleep had an association with homocysteine levels, the relationship is unclear since that study had many potential cardiovascular confounders, said Dr. Chen and coauthors.
The association between extremely short sleep duration and cardiovascular events has been well established, with increased inflammation playing a potential role, although the reasons for the association are still being elucidated. “Because increased homocysteine levels are considered an independent risk factor for cardiovascular diseases, further studies are needed to better understand the relationships among short sleep duration, homocysteine levels, and cardiovascular events,” the investigators wrote.
Whether menstrual variations in serum homocysteine and sleep may have played a part in the significant association seen in women, but not men, was not ascertainable from the NHANES data, which introduces possible confounding, the authors noted.
Similarly, there may be ethnic differences in baseline serum homocysteine levels, said Dr. Chen and his colleagues.
The study’s strengths include the large sample size and ability to control for many demographic and individual characteristics, including comorbidities. However, sleep duration was based on self-report and did not include information about napping or sleep-wake times. Also, sleep quality was not assessed beyond a question about snoring or snorting and a question about a prior diagnosis of a sleep disorder.
“Further longitudinal investigations concerning the effect of sleep deprivation on homocysteine alteration might help provide a better understanding of the pathogenesis of cardiometabolic risk,” concluded Dr. Chen and colleagues.
One of the coauthors reported financial relationships with multiple pharmaceutical companies and UpToDate. The authors reported no external sources of funding.
SOURCE: Chen T-Y et al. J Clin Sleep Med. 2019;15(1):139-48.
Short sleep’s association with cardiovascular risk may be mediated in part by elevated homocysteine levels, suggests a new analysis of data from the 2005-2006 National Health and Nutrition Examination Survey (NHANES).
The study, published in the Journal of Clinical Sleep Medicine, found that elevated homocysteine levels were only associated with short sleep duration for some populations, including women, non-Hispanic white individuals, and participants with obesity.
A total of 4,480 NHANES participants had serum homocysteine levels on record and were included in the study; of these, those with self-reported sleep duration of 7 hours had the lowest serum homocysteine levels. Those with the shortest sleep duration – 5 hours or less per night – had the highest homocysteine levels.
When participants were broken into subgroups by such factors as sex, ethnicity/race, and body mass index, the association between extremely short sleep and elevated homocysteine levels was retained for three groups: women, non-Hispanic white participants, and those with BMIs of 30 kg/m2 and higher.
“[T]his finding might suggest increased vulnerability to cardiovascular risk or other atherothrombotic events in these groups in the context of short sleep,” wrote Tien-Yu Chen, MD, of Tri-Service General Hospital, Taipei, Taiwan, and coauthors in the abstract accompanying the study.
In the NHANES questionnaire, participants were asked how much sleep they usually got, in whole hours. Answers were grouped into 5 hours or less, 6 hours, 7 hours, or 8 hours, and 9 hours or more. Serum homocysteine was measured once for each study participant.
Using multivariate linear regression, homocysteine was considered the dependent, continuous variable, and the association between sleep duration and homocysteine was assessed using three models that accounted for confounders. The first and simplest model accounted for age, sex, and race/ethnicity. The second model added BMI, several cardiometabolic laboratory values, and vitamin B6, vitamin B12, and folate levels. The third model included all previous factors and added patient characteristics and comorbidities, such as sleep disorders, mental health service use, cardiovascular disease and cancer diagnoses, and alcohol and tobacco use.
In their analysis, Dr. Chen and colleagues dichotomized homocysteine levels to above or below the 75th percentile of the log homocysteine level, which fell at 9.74 nmol/L.
After adjustment, women, but not men, had an association between short sleep and increased odds of elevated homocysteine (odds ratio, 2.691; P = .010). This association “persisted in fully adjusted models,” wrote Dr. Chen and coauthors.
For individuals with obesity (BMI of 30 or greater), the association between elevated homocysteine and extremely short sleep (5 hours or less) persisted in fully adjusted models (beta = .062; P = .039 for model 3).
When looking at ethnicity, the association between extremely short sleep and elevated homocysteine was only seen among non-Hispanic white participants; again, this association was seen after full adjustment for confounders (beta = .068; P = .032). Small sample sizes limited some of the racial/ethnic analyses, noted the investigators.
Homocysteine, explained Dr. Chen and coauthors, is associated with a variety atherogenic changes, and elevated levels are associated with increased risk for cardiovascular disease and mortality. Short sleep is also associated with increased cardiovascular risk, as is long sleep in some studies.
However, though preliminary work had shown that short sleep had an association with homocysteine levels, the relationship is unclear since that study had many potential cardiovascular confounders, said Dr. Chen and coauthors.
The association between extremely short sleep duration and cardiovascular events has been well established, with increased inflammation playing a potential role, although the reasons for the association are still being elucidated. “Because increased homocysteine levels are considered an independent risk factor for cardiovascular diseases, further studies are needed to better understand the relationships among short sleep duration, homocysteine levels, and cardiovascular events,” the investigators wrote.
Whether menstrual variations in serum homocysteine and sleep may have played a part in the significant association seen in women, but not men, was not ascertainable from the NHANES data, which introduces possible confounding, the authors noted.
Similarly, there may be ethnic differences in baseline serum homocysteine levels, said Dr. Chen and his colleagues.
The study’s strengths include the large sample size and ability to control for many demographic and individual characteristics, including comorbidities. However, sleep duration was based on self-report and did not include information about napping or sleep-wake times. Also, sleep quality was not assessed beyond a question about snoring or snorting and a question about a prior diagnosis of a sleep disorder.
“Further longitudinal investigations concerning the effect of sleep deprivation on homocysteine alteration might help provide a better understanding of the pathogenesis of cardiometabolic risk,” concluded Dr. Chen and colleagues.
One of the coauthors reported financial relationships with multiple pharmaceutical companies and UpToDate. The authors reported no external sources of funding.
SOURCE: Chen T-Y et al. J Clin Sleep Med. 2019;15(1):139-48.
Short sleep’s association with cardiovascular risk may be mediated in part by elevated homocysteine levels, suggests a new analysis of data from the 2005-2006 National Health and Nutrition Examination Survey (NHANES).
The study, published in the Journal of Clinical Sleep Medicine, found that elevated homocysteine levels were only associated with short sleep duration for some populations, including women, non-Hispanic white individuals, and participants with obesity.
A total of 4,480 NHANES participants had serum homocysteine levels on record and were included in the study; of these, those with self-reported sleep duration of 7 hours had the lowest serum homocysteine levels. Those with the shortest sleep duration – 5 hours or less per night – had the highest homocysteine levels.
When participants were broken into subgroups by such factors as sex, ethnicity/race, and body mass index, the association between extremely short sleep and elevated homocysteine levels was retained for three groups: women, non-Hispanic white participants, and those with BMIs of 30 kg/m2 and higher.
“[T]his finding might suggest increased vulnerability to cardiovascular risk or other atherothrombotic events in these groups in the context of short sleep,” wrote Tien-Yu Chen, MD, of Tri-Service General Hospital, Taipei, Taiwan, and coauthors in the abstract accompanying the study.
In the NHANES questionnaire, participants were asked how much sleep they usually got, in whole hours. Answers were grouped into 5 hours or less, 6 hours, 7 hours, or 8 hours, and 9 hours or more. Serum homocysteine was measured once for each study participant.
Using multivariate linear regression, homocysteine was considered the dependent, continuous variable, and the association between sleep duration and homocysteine was assessed using three models that accounted for confounders. The first and simplest model accounted for age, sex, and race/ethnicity. The second model added BMI, several cardiometabolic laboratory values, and vitamin B6, vitamin B12, and folate levels. The third model included all previous factors and added patient characteristics and comorbidities, such as sleep disorders, mental health service use, cardiovascular disease and cancer diagnoses, and alcohol and tobacco use.
In their analysis, Dr. Chen and colleagues dichotomized homocysteine levels to above or below the 75th percentile of the log homocysteine level, which fell at 9.74 nmol/L.
After adjustment, women, but not men, had an association between short sleep and increased odds of elevated homocysteine (odds ratio, 2.691; P = .010). This association “persisted in fully adjusted models,” wrote Dr. Chen and coauthors.
For individuals with obesity (BMI of 30 or greater), the association between elevated homocysteine and extremely short sleep (5 hours or less) persisted in fully adjusted models (beta = .062; P = .039 for model 3).
When looking at ethnicity, the association between extremely short sleep and elevated homocysteine was only seen among non-Hispanic white participants; again, this association was seen after full adjustment for confounders (beta = .068; P = .032). Small sample sizes limited some of the racial/ethnic analyses, noted the investigators.
Homocysteine, explained Dr. Chen and coauthors, is associated with a variety atherogenic changes, and elevated levels are associated with increased risk for cardiovascular disease and mortality. Short sleep is also associated with increased cardiovascular risk, as is long sleep in some studies.
However, though preliminary work had shown that short sleep had an association with homocysteine levels, the relationship is unclear since that study had many potential cardiovascular confounders, said Dr. Chen and coauthors.
The association between extremely short sleep duration and cardiovascular events has been well established, with increased inflammation playing a potential role, although the reasons for the association are still being elucidated. “Because increased homocysteine levels are considered an independent risk factor for cardiovascular diseases, further studies are needed to better understand the relationships among short sleep duration, homocysteine levels, and cardiovascular events,” the investigators wrote.
Whether menstrual variations in serum homocysteine and sleep may have played a part in the significant association seen in women, but not men, was not ascertainable from the NHANES data, which introduces possible confounding, the authors noted.
Similarly, there may be ethnic differences in baseline serum homocysteine levels, said Dr. Chen and his colleagues.
The study’s strengths include the large sample size and ability to control for many demographic and individual characteristics, including comorbidities. However, sleep duration was based on self-report and did not include information about napping or sleep-wake times. Also, sleep quality was not assessed beyond a question about snoring or snorting and a question about a prior diagnosis of a sleep disorder.
“Further longitudinal investigations concerning the effect of sleep deprivation on homocysteine alteration might help provide a better understanding of the pathogenesis of cardiometabolic risk,” concluded Dr. Chen and colleagues.
One of the coauthors reported financial relationships with multiple pharmaceutical companies and UpToDate. The authors reported no external sources of funding.
SOURCE: Chen T-Y et al. J Clin Sleep Med. 2019;15(1):139-48.
FROM THE JOURNAL OF CLINICAL SLEEP MEDICINE
Key clinical point: Extreme short sleep was associated with high homocysteine levels.
Major finding: In women, extreme short sleep was associated with an odds ratio of 2.691 for elevated homocysteine.
Study details: Analysis of data from 4,480 NHANES participants.
Disclosures: One coauthor reported relationships with multiple pharmaceutical companies and UpToDate. The authors reported no outside sources of funding.
Source: Chen T-Y et al. J Clin Sleep Med. 2019;15(1):139-48.
International survey probes oxygen’s efficacy for cluster headache
According to the results, triptans also are highly effective, with some side effects. Newer medications deserve further study, the researchers said.
To assess the effectiveness and adverse effects of acute cluster headache medications in a large international sample, Stuart M. Pearson, a researcher in the department of psychology at the University of West Georgia in Carrollton, and his coauthors analyzed data from the Cluster Headache Questionnaire. Respondents from more than 50 countries completed the online survey; most were from the United States, the United Kingdom, and Canada. The survey included questions about cluster headache diagnostic criteria and medication effectiveness, complications, and access to medications.
In all, 3,251 subjects participated in the questionnaire, and 2,193 respondents met criteria for the study; 1,604 had cluster headache, and 589 had probable cluster headache. Among the respondents with cluster headache, 68.8% were male, 78.0% had episodic cluster headache, and the average age was 46 years. More than half of respondents reported complete or very effective treatment for triptans (54%) and oxygen (also 54%). The proportion of respondents who reported that ergot derivatives, caffeine or energy drinks, and intranasal ketamine were completely or very effective ranged from 14% to 25%. Patients were less likely to report high levels of efficacy for opioids (6%), intranasal capsaicin (5%), and intranasal lidocaine (2%).
Participants experienced few complications from oxygen, with 99% reporting no or minimal physical and medical complications, and 97% reporting no or minimal psychological and emotional complications. Patients also reported few complications from intranasal lidocaine, intranasal ketamine, intranasal capsaicin, and caffeine and energy drinks. For triptans, 74% of respondents reported no or minimal physical and medical complications, and 85% reported no or minimal psychological and emotional complications.
Among the 139 participants with cluster headache who were aged 65 years or older, responses were similar to those for the entire population. In addition, the 589 respondents with probable cluster headache reported similar efficacy data, compared with respondents with a full diagnosis of cluster headache.
“Oxygen in particular had a high rate of complete effectiveness, a low rate of ineffectiveness, and a low rate of physical, medical, emotional, and psychological side effects,” the investigators said. “However, respondents reported that it was difficult to obtain.”
Limited insurance coverage of oxygen may affect access, even though the treatment has a Level A recommendation for the acute treatment of cluster headache in the American Headache Society guidelines, the authors said. Physicians also may pose a barrier. A prior study found that 12% of providers did not prescribe oxygen for cluster headache because they doubted its efficacy or did not know about it. In addition, there may be concerns that the treatment could be a fire hazard in a patient population that has high rates of smoking, the researchers said.
Limitations of the study include the survey’s use of nonvalidated questions, the lack of a formal clinical diagnosis of cluster headache, and the grouping of all triptans, rather than assessing individual triptan medications, such as sumatriptan subcutaneous, alone.
The study received funding from Autonomic Technologies and Clusterbusters. One of the authors has served as a paid consultant to Eli Lilly as a member of the data monitoring committee for clinical trials of galcanezumab for cluster headache and migraine.
This article was updated 3/7/2019.
SOURCE: Pearson SM et al. Headache. 2019 Jan 11. doi: 10.1111/head.13473.
According to the results, triptans also are highly effective, with some side effects. Newer medications deserve further study, the researchers said.
To assess the effectiveness and adverse effects of acute cluster headache medications in a large international sample, Stuart M. Pearson, a researcher in the department of psychology at the University of West Georgia in Carrollton, and his coauthors analyzed data from the Cluster Headache Questionnaire. Respondents from more than 50 countries completed the online survey; most were from the United States, the United Kingdom, and Canada. The survey included questions about cluster headache diagnostic criteria and medication effectiveness, complications, and access to medications.
In all, 3,251 subjects participated in the questionnaire, and 2,193 respondents met criteria for the study; 1,604 had cluster headache, and 589 had probable cluster headache. Among the respondents with cluster headache, 68.8% were male, 78.0% had episodic cluster headache, and the average age was 46 years. More than half of respondents reported complete or very effective treatment for triptans (54%) and oxygen (also 54%). The proportion of respondents who reported that ergot derivatives, caffeine or energy drinks, and intranasal ketamine were completely or very effective ranged from 14% to 25%. Patients were less likely to report high levels of efficacy for opioids (6%), intranasal capsaicin (5%), and intranasal lidocaine (2%).
Participants experienced few complications from oxygen, with 99% reporting no or minimal physical and medical complications, and 97% reporting no or minimal psychological and emotional complications. Patients also reported few complications from intranasal lidocaine, intranasal ketamine, intranasal capsaicin, and caffeine and energy drinks. For triptans, 74% of respondents reported no or minimal physical and medical complications, and 85% reported no or minimal psychological and emotional complications.
Among the 139 participants with cluster headache who were aged 65 years or older, responses were similar to those for the entire population. In addition, the 589 respondents with probable cluster headache reported similar efficacy data, compared with respondents with a full diagnosis of cluster headache.
“Oxygen in particular had a high rate of complete effectiveness, a low rate of ineffectiveness, and a low rate of physical, medical, emotional, and psychological side effects,” the investigators said. “However, respondents reported that it was difficult to obtain.”
Limited insurance coverage of oxygen may affect access, even though the treatment has a Level A recommendation for the acute treatment of cluster headache in the American Headache Society guidelines, the authors said. Physicians also may pose a barrier. A prior study found that 12% of providers did not prescribe oxygen for cluster headache because they doubted its efficacy or did not know about it. In addition, there may be concerns that the treatment could be a fire hazard in a patient population that has high rates of smoking, the researchers said.
Limitations of the study include the survey’s use of nonvalidated questions, the lack of a formal clinical diagnosis of cluster headache, and the grouping of all triptans, rather than assessing individual triptan medications, such as sumatriptan subcutaneous, alone.
The study received funding from Autonomic Technologies and Clusterbusters. One of the authors has served as a paid consultant to Eli Lilly as a member of the data monitoring committee for clinical trials of galcanezumab for cluster headache and migraine.
This article was updated 3/7/2019.
SOURCE: Pearson SM et al. Headache. 2019 Jan 11. doi: 10.1111/head.13473.
According to the results, triptans also are highly effective, with some side effects. Newer medications deserve further study, the researchers said.
To assess the effectiveness and adverse effects of acute cluster headache medications in a large international sample, Stuart M. Pearson, a researcher in the department of psychology at the University of West Georgia in Carrollton, and his coauthors analyzed data from the Cluster Headache Questionnaire. Respondents from more than 50 countries completed the online survey; most were from the United States, the United Kingdom, and Canada. The survey included questions about cluster headache diagnostic criteria and medication effectiveness, complications, and access to medications.
In all, 3,251 subjects participated in the questionnaire, and 2,193 respondents met criteria for the study; 1,604 had cluster headache, and 589 had probable cluster headache. Among the respondents with cluster headache, 68.8% were male, 78.0% had episodic cluster headache, and the average age was 46 years. More than half of respondents reported complete or very effective treatment for triptans (54%) and oxygen (also 54%). The proportion of respondents who reported that ergot derivatives, caffeine or energy drinks, and intranasal ketamine were completely or very effective ranged from 14% to 25%. Patients were less likely to report high levels of efficacy for opioids (6%), intranasal capsaicin (5%), and intranasal lidocaine (2%).
Participants experienced few complications from oxygen, with 99% reporting no or minimal physical and medical complications, and 97% reporting no or minimal psychological and emotional complications. Patients also reported few complications from intranasal lidocaine, intranasal ketamine, intranasal capsaicin, and caffeine and energy drinks. For triptans, 74% of respondents reported no or minimal physical and medical complications, and 85% reported no or minimal psychological and emotional complications.
Among the 139 participants with cluster headache who were aged 65 years or older, responses were similar to those for the entire population. In addition, the 589 respondents with probable cluster headache reported similar efficacy data, compared with respondents with a full diagnosis of cluster headache.
“Oxygen in particular had a high rate of complete effectiveness, a low rate of ineffectiveness, and a low rate of physical, medical, emotional, and psychological side effects,” the investigators said. “However, respondents reported that it was difficult to obtain.”
Limited insurance coverage of oxygen may affect access, even though the treatment has a Level A recommendation for the acute treatment of cluster headache in the American Headache Society guidelines, the authors said. Physicians also may pose a barrier. A prior study found that 12% of providers did not prescribe oxygen for cluster headache because they doubted its efficacy or did not know about it. In addition, there may be concerns that the treatment could be a fire hazard in a patient population that has high rates of smoking, the researchers said.
Limitations of the study include the survey’s use of nonvalidated questions, the lack of a formal clinical diagnosis of cluster headache, and the grouping of all triptans, rather than assessing individual triptan medications, such as sumatriptan subcutaneous, alone.
The study received funding from Autonomic Technologies and Clusterbusters. One of the authors has served as a paid consultant to Eli Lilly as a member of the data monitoring committee for clinical trials of galcanezumab for cluster headache and migraine.
This article was updated 3/7/2019.
SOURCE: Pearson SM et al. Headache. 2019 Jan 11. doi: 10.1111/head.13473.
FROM HEADACHE
Key clinical point: Oxygen is a highly effective treatment for cluster headache with few complications.
Major finding: More than half of respondents (54%) reported that triptans and oxygen were completely or very effective.
Study details: Analysis of data from 1,604 people with cluster headache who completed the online Cluster Headache Questionnaire.
Disclosures: The study received funding from Autonomic Technologies and Clusterbusters. One of the authors has served as a paid consultant to Eli Lilly as a member of the data monitoring committee for clinical trials of galcanezumab for cluster headache and migraine.
Source: Pearson SM et al. Headache. 2019 Jan 11. doi: 10.1111/head.13473.
In California, opioids most often prescribed in low-income, mostly white areas
There is a higher prevalence of opioid prescribing and opioid-related overdose deaths concentrated in regions with mostly low-income, white residents, compared with regions with high income and the lowest proportion of white residents, according to a new analysis of data on people living in California.
The findings of this study provide further evidence that the opioid epidemic affects a large proportion of low-income white communities (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.6721).
“Whereas most epidemics predominate within social minority groups and previous US drug epidemics have typically been concentrated in nonwhite communities, Joseph Friedman, MPH, from the University of California, Los Angeles, and his colleagues wrote in their study. “Our analysis suggests that, at least in California, an important determinant of this phenomenon may be that white individuals have a higher level of exposure than nonwhite individuals to opioid prescriptions on a per capita basis through the health care system.”
Mr. Friedman and his colleagues analyzed 29.7 million prescription drug records from California’s Controlled Substance Utilization Review and Evaluation System in and examined the prevalence of opioids, benzodiazepines, and stimulants by race, ethnicity, and income level in 1,760 zip codes during 2011-2015. The researchers estimated the prevalence of opioid prescriptions in each zip code by calculating the number of people per zip code receiving an opioid prescription divided by the population of the zip code during each year.
Overall, 23.6% of California residents received at least one opioid prescription each year of the study. The researchers found 44.2% of individuals in zip codes with the lowest income but highest proportion of white residents and 16.1% of individuals in areas with the highest income and lowest proportion of white residents had received a minimum of one opioid prescription each year. The prevalence of stimulant prescriptions was 3.8% in zip codes with high income, and a high proportion of white population, compared with a prevalence of 0.6% in areas with low income and a low proportion of white residents. The researchers noted there was no association between income and benzodiazepine prescription, but the prevalence of benzodiazepine prescriptions was 15.7% in zip codes with the highest proportion of white residents, compared with 7.0% in zip codes with a low proportion of white residents.
During the same time period, there were 9,534 opioid overdose deaths in California from causes such as fentanyl, synthetic opioids, and prescription opioids. “Overdose deaths were highly concentrated in lower-income and mostly white areas,” Mr. Friedman and his colleagues wrote. “We observed an approximate 10-fold difference in overdose rates across the race/ethnicity–income gradient in California.”
Although the number of opioids prescribed each year has decreased since 2012, in a research letter published in the same issue noted that the rate of prescribing is still higher than it was in 1999 (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.6989). The authors also pointed out increases in the duration of opioid prescriptions and wide regional variations in opioid prescribing rates.
In their study, Gery P. Guy Jr., PhD, and his colleagues used data from the IQVIA Xponent database from approximately 50,400 retail pharmacies and discovered the average morphine milligram equivalent (MME) per capita had decreased from 641.4 MME per capita in 2015 to 512.6 MME per capita in 2017 (20.1%). The number of opioid prescriptions also decreased from 6.7 per 100 persons in 2015 to 5.0 per 100 persons in 2017 (25.3%). However, during 2015-2017, the average duration of opioid prescriptions increased from 17.7 days to 18.3 days (3.4%), while the median duration increased during the same time from 15.0 days to 20.0 days (33.3%).
While 74.7% of counties reduced the number of opioids prescribed during 2015-2017 and there also were reductions in the rate of high-dose prescribing (76.6%) and overall prescribing rates (74.7%), Dr. Guy of the Centers for Disease Control and Prevention and his colleagues found “substantial variation” in 2017 prescription rates at the county level, with opioids prescribed at 1,061.0 MME per capita at the highest quartile, compared with 182.8 MME per capita at the lowest quartile.
“Recent reductions could be related to policies and strategies aimed at reducing inappropriate prescribing, increased awareness of the risks associated with opioids, and release of the CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016,” Dr. Guy and his colleagues noted.
In an additional article published in the same JAMA Internal Medicine issue, Bennett Allen, a research associate at the New York City Department of Health and Mental Hygiene and his colleagues examined the rate of opioid overdose deaths for non-Hispanic white, non-Hispanic black, Hispanic, and undefined other races in New York (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.7700). They identified 1,487 deaths in 2017, which included 556 white (37.0%), 421 black (28.0%), 455 Hispanic (31.0%), and 55 undefined (4.0%) opioid overdose deaths. There was a higher rate of fentanyl and/or heroin overdose deaths from younger (aged 15-34 years) white New Yorkers (22.2/100,000 persons; 95% confidence interval, 19.0-25.5), compared with younger black New Yorkers (5.8/100,000; 95% CI, 4.0-8.2) and Hispanic (9.7/100,000; 95% CI, 7.6-12.1).
Among older residents (aged 55-84 years), Mr. Allen and his colleagues found higher rates of fentanyl and/or heroin overdose for black New Yorkers (25.4/100,000 persons; 95% CI, 20.9-30.0), compared with older white New Yorkers (9.4/100,000 persons; 95% CI, 7.3-11.8), as well as significantly higher rates of cocaine overdose (25.4/100,000 persons; 95% CI, 20.9-30.0), compared with white (5.1/100,000 persons; 95% CI, 3.6-7.0) and Hispanic residents (11.8/100,000 persons; 95% CI, 8.9-15.4).
“The distinct age distribution and drug involvement of overdose deaths among New York City blacks, Latinos, and whites, along with complementary evidence about drug use trajectories, highlight the need for heterogeneous approaches to treatment and the equitable allocation of treatment and health care resources to reach diverse populations at risk of overdose,” Mr. Allen and his colleagues wrote.
Dr. Schriger reported support from Korein Foundation for his time working on the study by Friedman et al. The other authors reported no conflicts of interest.
The results published by Friedman et al. are a reminder that we can use regional prescribing trends to identify communities most susceptible to the opioid epidemic and give them the resources they need to combat opioid addiction, Vice Adm. Jerome M. Adams, MD, MPH, and Adm. Brett P. Giroir, MD, wrote in a related editorial.
“Discussion of overdose risks and coprescribing of naloxone must become routine if we are to make opioid prescribing safer,” the authors wrote.
Physicians also can help respond to the opioid epidemic outside of prescribing by promoting evidence-based nonopioid and nonpharmaceutical pain treatments, screening their patients for OUD and OUD risks, and acknowledging “that the problem cannot be solved by medical interventions alone.” Individual, environmental, and societal factors also contribute to the opioid epidemic, and physicians are uniquely suited to spearhead efforts aimed at addressing comprehensive opioid misuse.
“Physicians stand out as natural leaders to help solve the crises because of the depth of their knowledge, immediacy of their contact with patients, and relatively high level of respect their profession enjoys,” Dr. Adams and Dr. Giroir wrote. “We thereby call on our nation’s doctors to embrace their roles in the clinic and beyond to help educate communities, bring together stakeholders, and be part of the cultural change to support people living free from addiction.”
Dr. Adams is the 20th surgeon general of the United States at the U.S. Public Health Service and HHS; Dr. Giroir is the 16th U.S. assistant secretary for health at the U.S. Public Health Service and HHS. They reported no relevant conflicts of interest. Their invited commentary accompanied the three related articles in the publication (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.7934 ).
The results published by Friedman et al. are a reminder that we can use regional prescribing trends to identify communities most susceptible to the opioid epidemic and give them the resources they need to combat opioid addiction, Vice Adm. Jerome M. Adams, MD, MPH, and Adm. Brett P. Giroir, MD, wrote in a related editorial.
“Discussion of overdose risks and coprescribing of naloxone must become routine if we are to make opioid prescribing safer,” the authors wrote.
Physicians also can help respond to the opioid epidemic outside of prescribing by promoting evidence-based nonopioid and nonpharmaceutical pain treatments, screening their patients for OUD and OUD risks, and acknowledging “that the problem cannot be solved by medical interventions alone.” Individual, environmental, and societal factors also contribute to the opioid epidemic, and physicians are uniquely suited to spearhead efforts aimed at addressing comprehensive opioid misuse.
“Physicians stand out as natural leaders to help solve the crises because of the depth of their knowledge, immediacy of their contact with patients, and relatively high level of respect their profession enjoys,” Dr. Adams and Dr. Giroir wrote. “We thereby call on our nation’s doctors to embrace their roles in the clinic and beyond to help educate communities, bring together stakeholders, and be part of the cultural change to support people living free from addiction.”
Dr. Adams is the 20th surgeon general of the United States at the U.S. Public Health Service and HHS; Dr. Giroir is the 16th U.S. assistant secretary for health at the U.S. Public Health Service and HHS. They reported no relevant conflicts of interest. Their invited commentary accompanied the three related articles in the publication (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.7934 ).
The results published by Friedman et al. are a reminder that we can use regional prescribing trends to identify communities most susceptible to the opioid epidemic and give them the resources they need to combat opioid addiction, Vice Adm. Jerome M. Adams, MD, MPH, and Adm. Brett P. Giroir, MD, wrote in a related editorial.
“Discussion of overdose risks and coprescribing of naloxone must become routine if we are to make opioid prescribing safer,” the authors wrote.
Physicians also can help respond to the opioid epidemic outside of prescribing by promoting evidence-based nonopioid and nonpharmaceutical pain treatments, screening their patients for OUD and OUD risks, and acknowledging “that the problem cannot be solved by medical interventions alone.” Individual, environmental, and societal factors also contribute to the opioid epidemic, and physicians are uniquely suited to spearhead efforts aimed at addressing comprehensive opioid misuse.
“Physicians stand out as natural leaders to help solve the crises because of the depth of their knowledge, immediacy of their contact with patients, and relatively high level of respect their profession enjoys,” Dr. Adams and Dr. Giroir wrote. “We thereby call on our nation’s doctors to embrace their roles in the clinic and beyond to help educate communities, bring together stakeholders, and be part of the cultural change to support people living free from addiction.”
Dr. Adams is the 20th surgeon general of the United States at the U.S. Public Health Service and HHS; Dr. Giroir is the 16th U.S. assistant secretary for health at the U.S. Public Health Service and HHS. They reported no relevant conflicts of interest. Their invited commentary accompanied the three related articles in the publication (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.7934 ).
There is a higher prevalence of opioid prescribing and opioid-related overdose deaths concentrated in regions with mostly low-income, white residents, compared with regions with high income and the lowest proportion of white residents, according to a new analysis of data on people living in California.
The findings of this study provide further evidence that the opioid epidemic affects a large proportion of low-income white communities (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.6721).
“Whereas most epidemics predominate within social minority groups and previous US drug epidemics have typically been concentrated in nonwhite communities, Joseph Friedman, MPH, from the University of California, Los Angeles, and his colleagues wrote in their study. “Our analysis suggests that, at least in California, an important determinant of this phenomenon may be that white individuals have a higher level of exposure than nonwhite individuals to opioid prescriptions on a per capita basis through the health care system.”
Mr. Friedman and his colleagues analyzed 29.7 million prescription drug records from California’s Controlled Substance Utilization Review and Evaluation System in and examined the prevalence of opioids, benzodiazepines, and stimulants by race, ethnicity, and income level in 1,760 zip codes during 2011-2015. The researchers estimated the prevalence of opioid prescriptions in each zip code by calculating the number of people per zip code receiving an opioid prescription divided by the population of the zip code during each year.
Overall, 23.6% of California residents received at least one opioid prescription each year of the study. The researchers found 44.2% of individuals in zip codes with the lowest income but highest proportion of white residents and 16.1% of individuals in areas with the highest income and lowest proportion of white residents had received a minimum of one opioid prescription each year. The prevalence of stimulant prescriptions was 3.8% in zip codes with high income, and a high proportion of white population, compared with a prevalence of 0.6% in areas with low income and a low proportion of white residents. The researchers noted there was no association between income and benzodiazepine prescription, but the prevalence of benzodiazepine prescriptions was 15.7% in zip codes with the highest proportion of white residents, compared with 7.0% in zip codes with a low proportion of white residents.
During the same time period, there were 9,534 opioid overdose deaths in California from causes such as fentanyl, synthetic opioids, and prescription opioids. “Overdose deaths were highly concentrated in lower-income and mostly white areas,” Mr. Friedman and his colleagues wrote. “We observed an approximate 10-fold difference in overdose rates across the race/ethnicity–income gradient in California.”
Although the number of opioids prescribed each year has decreased since 2012, in a research letter published in the same issue noted that the rate of prescribing is still higher than it was in 1999 (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.6989). The authors also pointed out increases in the duration of opioid prescriptions and wide regional variations in opioid prescribing rates.
In their study, Gery P. Guy Jr., PhD, and his colleagues used data from the IQVIA Xponent database from approximately 50,400 retail pharmacies and discovered the average morphine milligram equivalent (MME) per capita had decreased from 641.4 MME per capita in 2015 to 512.6 MME per capita in 2017 (20.1%). The number of opioid prescriptions also decreased from 6.7 per 100 persons in 2015 to 5.0 per 100 persons in 2017 (25.3%). However, during 2015-2017, the average duration of opioid prescriptions increased from 17.7 days to 18.3 days (3.4%), while the median duration increased during the same time from 15.0 days to 20.0 days (33.3%).
While 74.7% of counties reduced the number of opioids prescribed during 2015-2017 and there also were reductions in the rate of high-dose prescribing (76.6%) and overall prescribing rates (74.7%), Dr. Guy of the Centers for Disease Control and Prevention and his colleagues found “substantial variation” in 2017 prescription rates at the county level, with opioids prescribed at 1,061.0 MME per capita at the highest quartile, compared with 182.8 MME per capita at the lowest quartile.
“Recent reductions could be related to policies and strategies aimed at reducing inappropriate prescribing, increased awareness of the risks associated with opioids, and release of the CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016,” Dr. Guy and his colleagues noted.
In an additional article published in the same JAMA Internal Medicine issue, Bennett Allen, a research associate at the New York City Department of Health and Mental Hygiene and his colleagues examined the rate of opioid overdose deaths for non-Hispanic white, non-Hispanic black, Hispanic, and undefined other races in New York (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.7700). They identified 1,487 deaths in 2017, which included 556 white (37.0%), 421 black (28.0%), 455 Hispanic (31.0%), and 55 undefined (4.0%) opioid overdose deaths. There was a higher rate of fentanyl and/or heroin overdose deaths from younger (aged 15-34 years) white New Yorkers (22.2/100,000 persons; 95% confidence interval, 19.0-25.5), compared with younger black New Yorkers (5.8/100,000; 95% CI, 4.0-8.2) and Hispanic (9.7/100,000; 95% CI, 7.6-12.1).
Among older residents (aged 55-84 years), Mr. Allen and his colleagues found higher rates of fentanyl and/or heroin overdose for black New Yorkers (25.4/100,000 persons; 95% CI, 20.9-30.0), compared with older white New Yorkers (9.4/100,000 persons; 95% CI, 7.3-11.8), as well as significantly higher rates of cocaine overdose (25.4/100,000 persons; 95% CI, 20.9-30.0), compared with white (5.1/100,000 persons; 95% CI, 3.6-7.0) and Hispanic residents (11.8/100,000 persons; 95% CI, 8.9-15.4).
“The distinct age distribution and drug involvement of overdose deaths among New York City blacks, Latinos, and whites, along with complementary evidence about drug use trajectories, highlight the need for heterogeneous approaches to treatment and the equitable allocation of treatment and health care resources to reach diverse populations at risk of overdose,” Mr. Allen and his colleagues wrote.
Dr. Schriger reported support from Korein Foundation for his time working on the study by Friedman et al. The other authors reported no conflicts of interest.
There is a higher prevalence of opioid prescribing and opioid-related overdose deaths concentrated in regions with mostly low-income, white residents, compared with regions with high income and the lowest proportion of white residents, according to a new analysis of data on people living in California.
The findings of this study provide further evidence that the opioid epidemic affects a large proportion of low-income white communities (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.6721).
“Whereas most epidemics predominate within social minority groups and previous US drug epidemics have typically been concentrated in nonwhite communities, Joseph Friedman, MPH, from the University of California, Los Angeles, and his colleagues wrote in their study. “Our analysis suggests that, at least in California, an important determinant of this phenomenon may be that white individuals have a higher level of exposure than nonwhite individuals to opioid prescriptions on a per capita basis through the health care system.”
Mr. Friedman and his colleagues analyzed 29.7 million prescription drug records from California’s Controlled Substance Utilization Review and Evaluation System in and examined the prevalence of opioids, benzodiazepines, and stimulants by race, ethnicity, and income level in 1,760 zip codes during 2011-2015. The researchers estimated the prevalence of opioid prescriptions in each zip code by calculating the number of people per zip code receiving an opioid prescription divided by the population of the zip code during each year.
Overall, 23.6% of California residents received at least one opioid prescription each year of the study. The researchers found 44.2% of individuals in zip codes with the lowest income but highest proportion of white residents and 16.1% of individuals in areas with the highest income and lowest proportion of white residents had received a minimum of one opioid prescription each year. The prevalence of stimulant prescriptions was 3.8% in zip codes with high income, and a high proportion of white population, compared with a prevalence of 0.6% in areas with low income and a low proportion of white residents. The researchers noted there was no association between income and benzodiazepine prescription, but the prevalence of benzodiazepine prescriptions was 15.7% in zip codes with the highest proportion of white residents, compared with 7.0% in zip codes with a low proportion of white residents.
During the same time period, there were 9,534 opioid overdose deaths in California from causes such as fentanyl, synthetic opioids, and prescription opioids. “Overdose deaths were highly concentrated in lower-income and mostly white areas,” Mr. Friedman and his colleagues wrote. “We observed an approximate 10-fold difference in overdose rates across the race/ethnicity–income gradient in California.”
Although the number of opioids prescribed each year has decreased since 2012, in a research letter published in the same issue noted that the rate of prescribing is still higher than it was in 1999 (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.6989). The authors also pointed out increases in the duration of opioid prescriptions and wide regional variations in opioid prescribing rates.
In their study, Gery P. Guy Jr., PhD, and his colleagues used data from the IQVIA Xponent database from approximately 50,400 retail pharmacies and discovered the average morphine milligram equivalent (MME) per capita had decreased from 641.4 MME per capita in 2015 to 512.6 MME per capita in 2017 (20.1%). The number of opioid prescriptions also decreased from 6.7 per 100 persons in 2015 to 5.0 per 100 persons in 2017 (25.3%). However, during 2015-2017, the average duration of opioid prescriptions increased from 17.7 days to 18.3 days (3.4%), while the median duration increased during the same time from 15.0 days to 20.0 days (33.3%).
While 74.7% of counties reduced the number of opioids prescribed during 2015-2017 and there also were reductions in the rate of high-dose prescribing (76.6%) and overall prescribing rates (74.7%), Dr. Guy of the Centers for Disease Control and Prevention and his colleagues found “substantial variation” in 2017 prescription rates at the county level, with opioids prescribed at 1,061.0 MME per capita at the highest quartile, compared with 182.8 MME per capita at the lowest quartile.
“Recent reductions could be related to policies and strategies aimed at reducing inappropriate prescribing, increased awareness of the risks associated with opioids, and release of the CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016,” Dr. Guy and his colleagues noted.
In an additional article published in the same JAMA Internal Medicine issue, Bennett Allen, a research associate at the New York City Department of Health and Mental Hygiene and his colleagues examined the rate of opioid overdose deaths for non-Hispanic white, non-Hispanic black, Hispanic, and undefined other races in New York (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.7700). They identified 1,487 deaths in 2017, which included 556 white (37.0%), 421 black (28.0%), 455 Hispanic (31.0%), and 55 undefined (4.0%) opioid overdose deaths. There was a higher rate of fentanyl and/or heroin overdose deaths from younger (aged 15-34 years) white New Yorkers (22.2/100,000 persons; 95% confidence interval, 19.0-25.5), compared with younger black New Yorkers (5.8/100,000; 95% CI, 4.0-8.2) and Hispanic (9.7/100,000; 95% CI, 7.6-12.1).
Among older residents (aged 55-84 years), Mr. Allen and his colleagues found higher rates of fentanyl and/or heroin overdose for black New Yorkers (25.4/100,000 persons; 95% CI, 20.9-30.0), compared with older white New Yorkers (9.4/100,000 persons; 95% CI, 7.3-11.8), as well as significantly higher rates of cocaine overdose (25.4/100,000 persons; 95% CI, 20.9-30.0), compared with white (5.1/100,000 persons; 95% CI, 3.6-7.0) and Hispanic residents (11.8/100,000 persons; 95% CI, 8.9-15.4).
“The distinct age distribution and drug involvement of overdose deaths among New York City blacks, Latinos, and whites, along with complementary evidence about drug use trajectories, highlight the need for heterogeneous approaches to treatment and the equitable allocation of treatment and health care resources to reach diverse populations at risk of overdose,” Mr. Allen and his colleagues wrote.
Dr. Schriger reported support from Korein Foundation for his time working on the study by Friedman et al. The other authors reported no conflicts of interest.
FROM JAMA INTERNAL MEDICINE
Key clinical point: The most common users of opioids according to prescription drug records are residents of mostly low-income, white neighborhoods.
Major finding: Compared with 23.6% of all Californians, 44.2% of individuals in zip codes containing mostly low-income, white residents had at least one opioid prescription each year, compared with 16.1% of individuals in high-income zip codes with the lowest population of white residents.
Study details: An analysis of 29.7 million opioid prescription drug records by race and income in California during 2011-2015.
Disclosures: Dr. Schriger reported support from the Korein Foundation for his time working on the study by Friedman et al. The other authors from Friedman et al. reported no conflicts of interest.
FDA issues warnings to companies selling illegal Alzheimer’s treatments
The Food and Drug Administration has issued warning letters to 12 companies and advisory letters to 5 companies illegally selling more than 58 products claiming to treat Alzheimer’s disease.
The products, many of which are marketed as dietary supplements, are being sold in a variety of forms, including tablets, capsules, and oils. These drugs are either unapproved or mislabeled and claim to prevent, treat, or cure Alzheimer’s disease, as well as a number of other serious diseases and health conditions, in violation of the Federal Food, Drug, and Cosmetic Act.
“Alzheimer’s is a challenging disease that, unfortunately, has no cure. Any products making unproven drug claims could mislead consumers to believe that such therapies exist and keep them from accessing therapies that are known to help support the symptoms of the disease, or worse, as some fraudulent treatments can cause serious or even fatal injuries,” FDA Commissioner Scott Gottlieb, MD, said in a press release.
In an additional statement, Dr. Gottlieb detailed several new strategies for improving the safety and accuracy of dietary supplements, including efforts to more rapidly communicate to the public potential safety issues with dietary supplement products and to establish a flexible regulatory framework that promotes innovation and upholds product safety.
The Food and Drug Administration has issued warning letters to 12 companies and advisory letters to 5 companies illegally selling more than 58 products claiming to treat Alzheimer’s disease.
The products, many of which are marketed as dietary supplements, are being sold in a variety of forms, including tablets, capsules, and oils. These drugs are either unapproved or mislabeled and claim to prevent, treat, or cure Alzheimer’s disease, as well as a number of other serious diseases and health conditions, in violation of the Federal Food, Drug, and Cosmetic Act.
“Alzheimer’s is a challenging disease that, unfortunately, has no cure. Any products making unproven drug claims could mislead consumers to believe that such therapies exist and keep them from accessing therapies that are known to help support the symptoms of the disease, or worse, as some fraudulent treatments can cause serious or even fatal injuries,” FDA Commissioner Scott Gottlieb, MD, said in a press release.
In an additional statement, Dr. Gottlieb detailed several new strategies for improving the safety and accuracy of dietary supplements, including efforts to more rapidly communicate to the public potential safety issues with dietary supplement products and to establish a flexible regulatory framework that promotes innovation and upholds product safety.
The Food and Drug Administration has issued warning letters to 12 companies and advisory letters to 5 companies illegally selling more than 58 products claiming to treat Alzheimer’s disease.
The products, many of which are marketed as dietary supplements, are being sold in a variety of forms, including tablets, capsules, and oils. These drugs are either unapproved or mislabeled and claim to prevent, treat, or cure Alzheimer’s disease, as well as a number of other serious diseases and health conditions, in violation of the Federal Food, Drug, and Cosmetic Act.
“Alzheimer’s is a challenging disease that, unfortunately, has no cure. Any products making unproven drug claims could mislead consumers to believe that such therapies exist and keep them from accessing therapies that are known to help support the symptoms of the disease, or worse, as some fraudulent treatments can cause serious or even fatal injuries,” FDA Commissioner Scott Gottlieb, MD, said in a press release.
In an additional statement, Dr. Gottlieb detailed several new strategies for improving the safety and accuracy of dietary supplements, including efforts to more rapidly communicate to the public potential safety issues with dietary supplement products and to establish a flexible regulatory framework that promotes innovation and upholds product safety.
Terminating an employee
I’ve written more than once about the private practitioner’s least favorite task. Now, new federal worker protection laws are making terminations even more difficult, even when they’re justified; however, that’s still no excuse for keeping an employee that should be replaced.
Once you make the decision to replace an employee, be sure that you have legitimate grounds and assemble as much documentation as you can. Record all terminable transgressions in the employee’s permanent record and document all verbal and written warnings. This is essential; you must be prepared to prove that your reasons for termination were legal.
Former employees will sometimes charge that any of a number of their civil rights were violated. For example, federal law prohibits you from firing anyone because of race, gender, national origin, disability, religion, or age – if the employee is over 40. You cannot fire a woman because she is pregnant or recently gave birth. Other illegal reasons include assertion of antidiscrimination rights, refusing to take a lie detector test, and reporting Occupational Safety and Health Administration violations.
You also can’t terminate someone for refusing to commit an illegal act – such as filing false insurance claims – or for exercising a legal right – such as voting or participating in a political demonstration.
While you cannot fire an alcohol abuser unless he or she is caught drinking at work, many forms of illegal drug use are legitimate causes for termination. Other laws may apply, depending on where you live. When in doubt, contact your attorney, state labor department, or fair employment office.
If a fired employee alleges that he or she was fired for any of these illegal reasons and you do not have convincing documentation to counter the charge, you may find yourself defending your actions in court. If you anticipate such problems, you can ask the employee to sign a waiver of future litigation in exchange for a concession from you – such as extra severance pay or a promise not to contest an unemployment application. Also, consider adding employment practices liability insurance – which I covered in detail a few months ago – to your umbrella policy, since lawsuits are always a possibility, despite all efforts to prevent them.
Once you have all your legal ducks in a row, don’t procrastinate. Get it over with first thing on Monday morning. If you wait until Friday afternoon, you will worry about the dreaded task all week long, and the fired employee will stew about it all weekend. Ask your manager or another trusted employee to be present to reduce the risk of subsequent disputes over what was discussed.
I’ve been asked to share exactly what I say; so for what it’s worth, here it is: “We have called you in to discuss a difficult issue. You know that we have not been happy with your performance. We are still not happy with it, despite all the discussions we have had, and we feel that you can do better elsewhere. So today we will part company, and I wish you the best of luck in your future endeavors. Here is your severance check. I hope there are no hard feelings.”
There will, of course, be hard feelings, despite all your “hopes,” but that cannot be helped. The point is to be quick, firm, and decisive. Get it over with and allow everyone to move on. Make it clear, when necessary, that the decision has already been made, so arguing or pleading will change nothing.
Be sure to get all your office keys back – or change the locks if you cannot. Back up all important computer files and change all your passwords. Most employees know more of them than you would ever suspect.
Finally, call the staff together and explain everything. They should hear it from you, not some distorted version via the rumor mill. You don’t have to divulge every detail, but do explain how the termination will affect everyone else. Responsibilities will need to be shifted until a replacement can be hired, and all employees should understand that.
If you are asked in the future to give a reference or write a letter of recommendation for the terminated employee, be sure that everything you say is truthful and well documented.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
I’ve written more than once about the private practitioner’s least favorite task. Now, new federal worker protection laws are making terminations even more difficult, even when they’re justified; however, that’s still no excuse for keeping an employee that should be replaced.
Once you make the decision to replace an employee, be sure that you have legitimate grounds and assemble as much documentation as you can. Record all terminable transgressions in the employee’s permanent record and document all verbal and written warnings. This is essential; you must be prepared to prove that your reasons for termination were legal.
Former employees will sometimes charge that any of a number of their civil rights were violated. For example, federal law prohibits you from firing anyone because of race, gender, national origin, disability, religion, or age – if the employee is over 40. You cannot fire a woman because she is pregnant or recently gave birth. Other illegal reasons include assertion of antidiscrimination rights, refusing to take a lie detector test, and reporting Occupational Safety and Health Administration violations.
You also can’t terminate someone for refusing to commit an illegal act – such as filing false insurance claims – or for exercising a legal right – such as voting or participating in a political demonstration.
While you cannot fire an alcohol abuser unless he or she is caught drinking at work, many forms of illegal drug use are legitimate causes for termination. Other laws may apply, depending on where you live. When in doubt, contact your attorney, state labor department, or fair employment office.
If a fired employee alleges that he or she was fired for any of these illegal reasons and you do not have convincing documentation to counter the charge, you may find yourself defending your actions in court. If you anticipate such problems, you can ask the employee to sign a waiver of future litigation in exchange for a concession from you – such as extra severance pay or a promise not to contest an unemployment application. Also, consider adding employment practices liability insurance – which I covered in detail a few months ago – to your umbrella policy, since lawsuits are always a possibility, despite all efforts to prevent them.
Once you have all your legal ducks in a row, don’t procrastinate. Get it over with first thing on Monday morning. If you wait until Friday afternoon, you will worry about the dreaded task all week long, and the fired employee will stew about it all weekend. Ask your manager or another trusted employee to be present to reduce the risk of subsequent disputes over what was discussed.
I’ve been asked to share exactly what I say; so for what it’s worth, here it is: “We have called you in to discuss a difficult issue. You know that we have not been happy with your performance. We are still not happy with it, despite all the discussions we have had, and we feel that you can do better elsewhere. So today we will part company, and I wish you the best of luck in your future endeavors. Here is your severance check. I hope there are no hard feelings.”
There will, of course, be hard feelings, despite all your “hopes,” but that cannot be helped. The point is to be quick, firm, and decisive. Get it over with and allow everyone to move on. Make it clear, when necessary, that the decision has already been made, so arguing or pleading will change nothing.
Be sure to get all your office keys back – or change the locks if you cannot. Back up all important computer files and change all your passwords. Most employees know more of them than you would ever suspect.
Finally, call the staff together and explain everything. They should hear it from you, not some distorted version via the rumor mill. You don’t have to divulge every detail, but do explain how the termination will affect everyone else. Responsibilities will need to be shifted until a replacement can be hired, and all employees should understand that.
If you are asked in the future to give a reference or write a letter of recommendation for the terminated employee, be sure that everything you say is truthful and well documented.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
I’ve written more than once about the private practitioner’s least favorite task. Now, new federal worker protection laws are making terminations even more difficult, even when they’re justified; however, that’s still no excuse for keeping an employee that should be replaced.
Once you make the decision to replace an employee, be sure that you have legitimate grounds and assemble as much documentation as you can. Record all terminable transgressions in the employee’s permanent record and document all verbal and written warnings. This is essential; you must be prepared to prove that your reasons for termination were legal.
Former employees will sometimes charge that any of a number of their civil rights were violated. For example, federal law prohibits you from firing anyone because of race, gender, national origin, disability, religion, or age – if the employee is over 40. You cannot fire a woman because she is pregnant or recently gave birth. Other illegal reasons include assertion of antidiscrimination rights, refusing to take a lie detector test, and reporting Occupational Safety and Health Administration violations.
You also can’t terminate someone for refusing to commit an illegal act – such as filing false insurance claims – or for exercising a legal right – such as voting or participating in a political demonstration.
While you cannot fire an alcohol abuser unless he or she is caught drinking at work, many forms of illegal drug use are legitimate causes for termination. Other laws may apply, depending on where you live. When in doubt, contact your attorney, state labor department, or fair employment office.
If a fired employee alleges that he or she was fired for any of these illegal reasons and you do not have convincing documentation to counter the charge, you may find yourself defending your actions in court. If you anticipate such problems, you can ask the employee to sign a waiver of future litigation in exchange for a concession from you – such as extra severance pay or a promise not to contest an unemployment application. Also, consider adding employment practices liability insurance – which I covered in detail a few months ago – to your umbrella policy, since lawsuits are always a possibility, despite all efforts to prevent them.
Once you have all your legal ducks in a row, don’t procrastinate. Get it over with first thing on Monday morning. If you wait until Friday afternoon, you will worry about the dreaded task all week long, and the fired employee will stew about it all weekend. Ask your manager or another trusted employee to be present to reduce the risk of subsequent disputes over what was discussed.
I’ve been asked to share exactly what I say; so for what it’s worth, here it is: “We have called you in to discuss a difficult issue. You know that we have not been happy with your performance. We are still not happy with it, despite all the discussions we have had, and we feel that you can do better elsewhere. So today we will part company, and I wish you the best of luck in your future endeavors. Here is your severance check. I hope there are no hard feelings.”
There will, of course, be hard feelings, despite all your “hopes,” but that cannot be helped. The point is to be quick, firm, and decisive. Get it over with and allow everyone to move on. Make it clear, when necessary, that the decision has already been made, so arguing or pleading will change nothing.
Be sure to get all your office keys back – or change the locks if you cannot. Back up all important computer files and change all your passwords. Most employees know more of them than you would ever suspect.
Finally, call the staff together and explain everything. They should hear it from you, not some distorted version via the rumor mill. You don’t have to divulge every detail, but do explain how the termination will affect everyone else. Responsibilities will need to be shifted until a replacement can be hired, and all employees should understand that.
If you are asked in the future to give a reference or write a letter of recommendation for the terminated employee, be sure that everything you say is truthful and well documented.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.
Pregnant women want genome guidance
Also today, a look at asthma, obesity, and the risk for severe sleep apnea in children, new questions about the role that antinuclear antibodies are playing in systemic lupus erythematosus, and the lifetime cost of tobacco is nearly $2 million per smoker.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Also today, a look at asthma, obesity, and the risk for severe sleep apnea in children, new questions about the role that antinuclear antibodies are playing in systemic lupus erythematosus, and the lifetime cost of tobacco is nearly $2 million per smoker.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Also today, a look at asthma, obesity, and the risk for severe sleep apnea in children, new questions about the role that antinuclear antibodies are playing in systemic lupus erythematosus, and the lifetime cost of tobacco is nearly $2 million per smoker.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
SGLT2s for heart failure first, diabetes second
Also today, influenza activity hits a seasonal high, the U.S. Supreme Court halts a Louisiana abortion law from taking effect, and cilostazol plus aspirin or clopidogrel reduces the risk of recurrent stroke.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Also today, influenza activity hits a seasonal high, the U.S. Supreme Court halts a Louisiana abortion law from taking effect, and cilostazol plus aspirin or clopidogrel reduces the risk of recurrent stroke.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Also today, influenza activity hits a seasonal high, the U.S. Supreme Court halts a Louisiana abortion law from taking effect, and cilostazol plus aspirin or clopidogrel reduces the risk of recurrent stroke.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
High prevalence of sleep problems in children with autism spectrum disorder
Children with a diagnosis of autism spectrum disorder or another developmental delay or disorder that includes autistic characteristics are twice as likely to have sleeping problems, a multisite case-control study has found.
The findings match up with previous similar studies, but this study is among the largest to measure sleeping problems in children with autism spectrum disorder (ASD) with two control groups.
“ including physiologic differences, sleep disorders, developmental comorbidities, medical comorbidities causing sleep disruption, communication impairments, and behavioral disturbances,” Ann M. Reynolds, MD, of the University of Colorado and Children’s Hospital Colorado, both in Aurora, and her associates reported in Pediatrics.
“Children with ASD are more likely to have anxiety, which may predispose them to sleep problems,” the authors added.
The study evaluated sleep habits and problems in 1,987 children aged 2-5 years. The study population included 522 children with ASD, 228 children with other developmental delays and disorders that have ASD characteristics, 534 children with other developmental delays and disorders, and 703 children from the general population.
Parents completed the Children Sleep Habits Questionnaire (CSHQ), a 33-item assessment tool typically used with a total score cutoff of 41 and above for identification of children with sleep disorders. The researchers also used a second, more conservative cutoff of 48 – the cutoff for the highest quartile in the general population group – to avoid overidentification with the lower cutoff.
Scores were adjusted for maternal education and race/ethnicity, family income, child age and sex, and child cognitive scores on the Mullen Scales of Early Learning (MSEL). The researchers also adjusted for genetic and/or neurologic diagnoses, including Down syndrome, fragile X, Rett syndrome, tuberous sclerosis, cerebral palsy, and neurofibromatosis.
Autistic children tended to have lower MSEL scores than the other children. Both the autistic children and those with other developmental disorders and delays were more likely than those in the general population to have neurologic or genetic conditions.
Based on a cutoff score of 48, autistic children had more than double the odds of sleep problems, compared with children in the general population (adjusted odds ratio, 2.37; P = .001) and children with other developmental delays (aOR, 2.12; P = .001).
With a cutoff of 41, ASD children’s odds of sleep problems were 1.45 times greater than the general population (P = .023) and 1.75 times greater than those with developmental delays (P = .001).
But children with developmental delays who displayed autistic characteristics did not have not significantly different prevalence of sleep problems than children with ASD had.
“The phenotypic overlay between children with ASD and children with developmental delay with ASD [characteristics] may explain the similarities in sleep disturbance among these two groups,” the authors wrote. Both groups have “higher rates of obsessive-compulsive symptoms, self-injurious behavior, ADHD symptoms, and developmental and communication impairments” than children with developmental delays without autistic characteristics.
The research was funded by the Centers for Disease Control and Prevention, the National Institutes of Health, and the National Center for Advancing Translational Sciences Colorado Clinical and Translational Science Award. Dr Reynolds consults for Ovid Therapeutics regarding evaluation of sleep severity and improvement in clinical trials. No other authors had disclosures.
SOURCE: Reynolds AM et al. Pediatrics. 2019 Feb. 11. doi: 10.1542/peds.2018-0492.
We can help reduce night waking and improve sleep onset within 5-15 weeks after parents have been trained. “Successful behavioral programs include bedtime fading, teaching healthy sleep practices, and increasing a child’s physical activity during the day,” Catherine Lord, PhD, wrote. Although research supports melatonin as an effective intervention for helping children fall asleep and sleep longer, the high percentage of children in the study already taking melatonin reveals its limitations. “Thus, it is recommended that families try behavioral programs before trials with melatonin,” she wrote.
But families and providers can only work together to address sleep issues if providers ask about sleep concerns, help families implement interventions, and follow up with progress. “In most cases, this help does not have to come from sleep experts, but does require dedicated time and effort using the now-growing base of evidence about effective interventions,” she concluded.
These comments are condensed from an editorial (Pediatrics. 2019 Feb 11. doi: 10.1542/peds.2018-2629) by Dr. Lord , a professor of psychiatry and biobehavioral sciences at the University of California Los Angeles. Dr. Lord reports royalties from diagnostic instruments used in this study that were donated to a not-for-profit agency. She is supported by grants from the National Institutes of Health and Simons Foundation Autism Research Initiative.
We can help reduce night waking and improve sleep onset within 5-15 weeks after parents have been trained. “Successful behavioral programs include bedtime fading, teaching healthy sleep practices, and increasing a child’s physical activity during the day,” Catherine Lord, PhD, wrote. Although research supports melatonin as an effective intervention for helping children fall asleep and sleep longer, the high percentage of children in the study already taking melatonin reveals its limitations. “Thus, it is recommended that families try behavioral programs before trials with melatonin,” she wrote.
But families and providers can only work together to address sleep issues if providers ask about sleep concerns, help families implement interventions, and follow up with progress. “In most cases, this help does not have to come from sleep experts, but does require dedicated time and effort using the now-growing base of evidence about effective interventions,” she concluded.
These comments are condensed from an editorial (Pediatrics. 2019 Feb 11. doi: 10.1542/peds.2018-2629) by Dr. Lord , a professor of psychiatry and biobehavioral sciences at the University of California Los Angeles. Dr. Lord reports royalties from diagnostic instruments used in this study that were donated to a not-for-profit agency. She is supported by grants from the National Institutes of Health and Simons Foundation Autism Research Initiative.
We can help reduce night waking and improve sleep onset within 5-15 weeks after parents have been trained. “Successful behavioral programs include bedtime fading, teaching healthy sleep practices, and increasing a child’s physical activity during the day,” Catherine Lord, PhD, wrote. Although research supports melatonin as an effective intervention for helping children fall asleep and sleep longer, the high percentage of children in the study already taking melatonin reveals its limitations. “Thus, it is recommended that families try behavioral programs before trials with melatonin,” she wrote.
But families and providers can only work together to address sleep issues if providers ask about sleep concerns, help families implement interventions, and follow up with progress. “In most cases, this help does not have to come from sleep experts, but does require dedicated time and effort using the now-growing base of evidence about effective interventions,” she concluded.
These comments are condensed from an editorial (Pediatrics. 2019 Feb 11. doi: 10.1542/peds.2018-2629) by Dr. Lord , a professor of psychiatry and biobehavioral sciences at the University of California Los Angeles. Dr. Lord reports royalties from diagnostic instruments used in this study that were donated to a not-for-profit agency. She is supported by grants from the National Institutes of Health and Simons Foundation Autism Research Initiative.
Children with a diagnosis of autism spectrum disorder or another developmental delay or disorder that includes autistic characteristics are twice as likely to have sleeping problems, a multisite case-control study has found.
The findings match up with previous similar studies, but this study is among the largest to measure sleeping problems in children with autism spectrum disorder (ASD) with two control groups.
“ including physiologic differences, sleep disorders, developmental comorbidities, medical comorbidities causing sleep disruption, communication impairments, and behavioral disturbances,” Ann M. Reynolds, MD, of the University of Colorado and Children’s Hospital Colorado, both in Aurora, and her associates reported in Pediatrics.
“Children with ASD are more likely to have anxiety, which may predispose them to sleep problems,” the authors added.
The study evaluated sleep habits and problems in 1,987 children aged 2-5 years. The study population included 522 children with ASD, 228 children with other developmental delays and disorders that have ASD characteristics, 534 children with other developmental delays and disorders, and 703 children from the general population.
Parents completed the Children Sleep Habits Questionnaire (CSHQ), a 33-item assessment tool typically used with a total score cutoff of 41 and above for identification of children with sleep disorders. The researchers also used a second, more conservative cutoff of 48 – the cutoff for the highest quartile in the general population group – to avoid overidentification with the lower cutoff.
Scores were adjusted for maternal education and race/ethnicity, family income, child age and sex, and child cognitive scores on the Mullen Scales of Early Learning (MSEL). The researchers also adjusted for genetic and/or neurologic diagnoses, including Down syndrome, fragile X, Rett syndrome, tuberous sclerosis, cerebral palsy, and neurofibromatosis.
Autistic children tended to have lower MSEL scores than the other children. Both the autistic children and those with other developmental disorders and delays were more likely than those in the general population to have neurologic or genetic conditions.
Based on a cutoff score of 48, autistic children had more than double the odds of sleep problems, compared with children in the general population (adjusted odds ratio, 2.37; P = .001) and children with other developmental delays (aOR, 2.12; P = .001).
With a cutoff of 41, ASD children’s odds of sleep problems were 1.45 times greater than the general population (P = .023) and 1.75 times greater than those with developmental delays (P = .001).
But children with developmental delays who displayed autistic characteristics did not have not significantly different prevalence of sleep problems than children with ASD had.
“The phenotypic overlay between children with ASD and children with developmental delay with ASD [characteristics] may explain the similarities in sleep disturbance among these two groups,” the authors wrote. Both groups have “higher rates of obsessive-compulsive symptoms, self-injurious behavior, ADHD symptoms, and developmental and communication impairments” than children with developmental delays without autistic characteristics.
The research was funded by the Centers for Disease Control and Prevention, the National Institutes of Health, and the National Center for Advancing Translational Sciences Colorado Clinical and Translational Science Award. Dr Reynolds consults for Ovid Therapeutics regarding evaluation of sleep severity and improvement in clinical trials. No other authors had disclosures.
SOURCE: Reynolds AM et al. Pediatrics. 2019 Feb. 11. doi: 10.1542/peds.2018-0492.
Children with a diagnosis of autism spectrum disorder or another developmental delay or disorder that includes autistic characteristics are twice as likely to have sleeping problems, a multisite case-control study has found.
The findings match up with previous similar studies, but this study is among the largest to measure sleeping problems in children with autism spectrum disorder (ASD) with two control groups.
“ including physiologic differences, sleep disorders, developmental comorbidities, medical comorbidities causing sleep disruption, communication impairments, and behavioral disturbances,” Ann M. Reynolds, MD, of the University of Colorado and Children’s Hospital Colorado, both in Aurora, and her associates reported in Pediatrics.
“Children with ASD are more likely to have anxiety, which may predispose them to sleep problems,” the authors added.
The study evaluated sleep habits and problems in 1,987 children aged 2-5 years. The study population included 522 children with ASD, 228 children with other developmental delays and disorders that have ASD characteristics, 534 children with other developmental delays and disorders, and 703 children from the general population.
Parents completed the Children Sleep Habits Questionnaire (CSHQ), a 33-item assessment tool typically used with a total score cutoff of 41 and above for identification of children with sleep disorders. The researchers also used a second, more conservative cutoff of 48 – the cutoff for the highest quartile in the general population group – to avoid overidentification with the lower cutoff.
Scores were adjusted for maternal education and race/ethnicity, family income, child age and sex, and child cognitive scores on the Mullen Scales of Early Learning (MSEL). The researchers also adjusted for genetic and/or neurologic diagnoses, including Down syndrome, fragile X, Rett syndrome, tuberous sclerosis, cerebral palsy, and neurofibromatosis.
Autistic children tended to have lower MSEL scores than the other children. Both the autistic children and those with other developmental disorders and delays were more likely than those in the general population to have neurologic or genetic conditions.
Based on a cutoff score of 48, autistic children had more than double the odds of sleep problems, compared with children in the general population (adjusted odds ratio, 2.37; P = .001) and children with other developmental delays (aOR, 2.12; P = .001).
With a cutoff of 41, ASD children’s odds of sleep problems were 1.45 times greater than the general population (P = .023) and 1.75 times greater than those with developmental delays (P = .001).
But children with developmental delays who displayed autistic characteristics did not have not significantly different prevalence of sleep problems than children with ASD had.
“The phenotypic overlay between children with ASD and children with developmental delay with ASD [characteristics] may explain the similarities in sleep disturbance among these two groups,” the authors wrote. Both groups have “higher rates of obsessive-compulsive symptoms, self-injurious behavior, ADHD symptoms, and developmental and communication impairments” than children with developmental delays without autistic characteristics.
The research was funded by the Centers for Disease Control and Prevention, the National Institutes of Health, and the National Center for Advancing Translational Sciences Colorado Clinical and Translational Science Award. Dr Reynolds consults for Ovid Therapeutics regarding evaluation of sleep severity and improvement in clinical trials. No other authors had disclosures.
SOURCE: Reynolds AM et al. Pediatrics. 2019 Feb. 11. doi: 10.1542/peds.2018-0492.
FROM PEDIATRICS
Key clinical point: Sleeping problems are over twice as common in autistic children than in children in the general population.
Major finding: Children with ASD had 2.37 greater odds of sleep problems than did typically developing children.
Study details: Data from the Children Sleep Habits Questionnaire for 1,987 children, either typically developing, diagnosed with autism spectrum disorder, or diagnosed with other developmental disabilities.
Disclosures: The research was funded by the Centers for Disease Control and Prevention, the National Institutes of Health, and the National Center for Advancing Translational Sciences Colorado Clinical and Translational Science Award. Dr. Reynolds consults for Ovid Therapeutics regarding evaluation of sleep severity and improvement in clinical trials. No other authors had disclosures.
Source: Reynolds AM et al. Pediatrics. 2019 Feb 11. doi: 10.1542/peds.2018-0492.
Most U.S. tPA-eligible stroke patients now get treated within an hour
HONOLULU – The speed at which eligible U.S. patients with acute ischemic stroke receive thrombolytic therapy has surged in recent years, and .
By the second half of last year, 75% of acute ischemic stroke patients treated at any of the 913 U.S. hospitals in the Get With The Guidelines-Stroke program received intravenous tissue plasminogen activator (tPA; Alteplase) within 60 minutes of their hospital arrival (their door-to-needle time (DTN), and 52% received tPA with a DTN time of 45 minutes or less. These levels met the treatment-speed goals set by the second phase of the Target: Stroke program, which called for delivering tPA to 75% of appropriate stroke patients within a DTN time of 60 minutes, and within 45 minutes in at least 50% of patients, Gregg C. Fonarow, MD, and his associates reported at the International Stroke Conference, sponsored by the American Heart Association.
The analyses they reported also documented how these most recent gains in thrombolytic speed played out in improved patient outcomes. During phase 2 of Target: Stroke, which ran from January 2014 to September 2018, 85,078 U.S. patients received tPA at one of the participating hospitals. During those 4 years, the rate of in-hospital mortality was 6.0%, half the patients were discharged home, 53% could ambulate independently, and the rate of intracerebral hemorrhage (ICH) was 3.5%. The researchers compared these clinical event rates with the rates from 24,603 tPA-treated patients during 2003-2009, before the Target: Stroke campaign began. After adjustment for many potential confounders, the more recently treated cohort had a 31% relative risk reduction in in-hospital mortality, a 43% relative increase in being discharged home, a 40% relative increase in independent ambulation, and a 32% relative risk reduction in the rate of symptomatic ICH. All these between-group differences were statistically significant.
“We were hoping that, by improving DTN times we could achieve improved outcomes, but often in quality-improvement research – even when the process of care improves – the gains in outcomes don’t necessarily match expectations. Fortunately, with Target: Stroke, the remarkable improvements in timely treatment translated to remarkable improvements in clinical outcomes,” Dr. Fonarow said in an interview. “These are substantial, clinically relevant improvements in clinical outcomes for patients with acute ischemic stroke. As a result of the program, more than 100,000 acute ischemic stroke patients received much more timely acute ischemic stroke care and achieved far better clinical outcomes.”
During the 2003-2018 period reviewed, the percentage of presenting acute ischemic stroke patients who received tPA treatment at the 913 Get With The Guidelines hospitals that participated in the Target: Stroke program (and so had reviewable data) throughout all three periods rose from 6% during 2003-2009 (prestudy) to 8% during 2010-2013 (phase 1), and to 12% during 2014-2018 (phase 2). The percentages of these patients who received the drug within 60 minutes were 27% during 2003-2009, 43% during 2010-2013, and 68% during the entire 2014-2018 period, culminating in the 75% rate during July-September 2018, reported Dr. Fonarow, professor of medicine and cochief of cardiology at the University of California, Los Angeles.
Dr. Fonarow attributed the drop in the rate of ICH – from 5.7% during 2003-2009, to 4.4% during 2010-2013, and down to 3.5% during 2014-2018 – to the faster delivery of tPA. “With faster treatment, there is less ischemic brain and vascular damage and thus a lower likelihood of ICH as a complication of tPA,” he explained.
The Target: Stroke program achieved these gains in speedier thrombolytic treatment (and better recognition of eligible patients) through educational and promotional activities including dissemination of best practices. Notable best practices have included EMS prenotification of hospitals before they arrive with a stroke patient, direct transport of patients to a brain imaging scanner, premix of tPA, initiation of tPA in the brain imaging suite, and prompt data feedback, Dr. Fonarow said.
The Get With The Guidelines-Stroke and Target: Stroke programs now involve more than 2,100 U.S. hospitals, and they are able to deliver emergency care to roughly 70% of U.S. acute ischemic stroke patients, he noted.
With achievement of Target: Stroke’s phase 2 goals, the program announced its launch of a third phase, with new treatment goals: Initiation of thrombolytic treatment to 85% of eligible patients within 60 minutes, to 75% within 45 minutes, and to 50% within 30 minutes. The phase 3 Target: Stroke program also for the first time includes treatment goals for delivery of endovascular thrombectomy treatment.
SOURCE: Fonarow GC et al. ISC 2019, Abstract LBP9.
The Target: Stroke and Get With The Guidelines-Stroke programs should be commended for the very impressive achievements they have made in improved delivery of thrombolytic therapy to acute ischemic stroke patients. What’s happened over the past decade in the speed of delivery of tissue plasminogen activator for treating U.S. stroke patients has been a real success story.
Programs like Get With The Guidelines and Target: Stroke have proven their value, but a significant barrier remains to bringing this program to all U.S. stroke patients and to all U.S. hospitals that treat stroke patients. That barrier is resources. Participating hospitals need to meet certain data-collection standards, but some U.S. hospitals do not have the resources to do this.
Bruce Ovbiagele, MD , is a neurologist and chief of staff for the San Francisco Veterans Affairs Health Care System. He had no disclosures. He made these comments in an interview.
The Target: Stroke and Get With The Guidelines-Stroke programs should be commended for the very impressive achievements they have made in improved delivery of thrombolytic therapy to acute ischemic stroke patients. What’s happened over the past decade in the speed of delivery of tissue plasminogen activator for treating U.S. stroke patients has been a real success story.
Programs like Get With The Guidelines and Target: Stroke have proven their value, but a significant barrier remains to bringing this program to all U.S. stroke patients and to all U.S. hospitals that treat stroke patients. That barrier is resources. Participating hospitals need to meet certain data-collection standards, but some U.S. hospitals do not have the resources to do this.
Bruce Ovbiagele, MD , is a neurologist and chief of staff for the San Francisco Veterans Affairs Health Care System. He had no disclosures. He made these comments in an interview.
The Target: Stroke and Get With The Guidelines-Stroke programs should be commended for the very impressive achievements they have made in improved delivery of thrombolytic therapy to acute ischemic stroke patients. What’s happened over the past decade in the speed of delivery of tissue plasminogen activator for treating U.S. stroke patients has been a real success story.
Programs like Get With The Guidelines and Target: Stroke have proven their value, but a significant barrier remains to bringing this program to all U.S. stroke patients and to all U.S. hospitals that treat stroke patients. That barrier is resources. Participating hospitals need to meet certain data-collection standards, but some U.S. hospitals do not have the resources to do this.
Bruce Ovbiagele, MD , is a neurologist and chief of staff for the San Francisco Veterans Affairs Health Care System. He had no disclosures. He made these comments in an interview.
HONOLULU – The speed at which eligible U.S. patients with acute ischemic stroke receive thrombolytic therapy has surged in recent years, and .
By the second half of last year, 75% of acute ischemic stroke patients treated at any of the 913 U.S. hospitals in the Get With The Guidelines-Stroke program received intravenous tissue plasminogen activator (tPA; Alteplase) within 60 minutes of their hospital arrival (their door-to-needle time (DTN), and 52% received tPA with a DTN time of 45 minutes or less. These levels met the treatment-speed goals set by the second phase of the Target: Stroke program, which called for delivering tPA to 75% of appropriate stroke patients within a DTN time of 60 minutes, and within 45 minutes in at least 50% of patients, Gregg C. Fonarow, MD, and his associates reported at the International Stroke Conference, sponsored by the American Heart Association.
The analyses they reported also documented how these most recent gains in thrombolytic speed played out in improved patient outcomes. During phase 2 of Target: Stroke, which ran from January 2014 to September 2018, 85,078 U.S. patients received tPA at one of the participating hospitals. During those 4 years, the rate of in-hospital mortality was 6.0%, half the patients were discharged home, 53% could ambulate independently, and the rate of intracerebral hemorrhage (ICH) was 3.5%. The researchers compared these clinical event rates with the rates from 24,603 tPA-treated patients during 2003-2009, before the Target: Stroke campaign began. After adjustment for many potential confounders, the more recently treated cohort had a 31% relative risk reduction in in-hospital mortality, a 43% relative increase in being discharged home, a 40% relative increase in independent ambulation, and a 32% relative risk reduction in the rate of symptomatic ICH. All these between-group differences were statistically significant.
“We were hoping that, by improving DTN times we could achieve improved outcomes, but often in quality-improvement research – even when the process of care improves – the gains in outcomes don’t necessarily match expectations. Fortunately, with Target: Stroke, the remarkable improvements in timely treatment translated to remarkable improvements in clinical outcomes,” Dr. Fonarow said in an interview. “These are substantial, clinically relevant improvements in clinical outcomes for patients with acute ischemic stroke. As a result of the program, more than 100,000 acute ischemic stroke patients received much more timely acute ischemic stroke care and achieved far better clinical outcomes.”
During the 2003-2018 period reviewed, the percentage of presenting acute ischemic stroke patients who received tPA treatment at the 913 Get With The Guidelines hospitals that participated in the Target: Stroke program (and so had reviewable data) throughout all three periods rose from 6% during 2003-2009 (prestudy) to 8% during 2010-2013 (phase 1), and to 12% during 2014-2018 (phase 2). The percentages of these patients who received the drug within 60 minutes were 27% during 2003-2009, 43% during 2010-2013, and 68% during the entire 2014-2018 period, culminating in the 75% rate during July-September 2018, reported Dr. Fonarow, professor of medicine and cochief of cardiology at the University of California, Los Angeles.
Dr. Fonarow attributed the drop in the rate of ICH – from 5.7% during 2003-2009, to 4.4% during 2010-2013, and down to 3.5% during 2014-2018 – to the faster delivery of tPA. “With faster treatment, there is less ischemic brain and vascular damage and thus a lower likelihood of ICH as a complication of tPA,” he explained.
The Target: Stroke program achieved these gains in speedier thrombolytic treatment (and better recognition of eligible patients) through educational and promotional activities including dissemination of best practices. Notable best practices have included EMS prenotification of hospitals before they arrive with a stroke patient, direct transport of patients to a brain imaging scanner, premix of tPA, initiation of tPA in the brain imaging suite, and prompt data feedback, Dr. Fonarow said.
The Get With The Guidelines-Stroke and Target: Stroke programs now involve more than 2,100 U.S. hospitals, and they are able to deliver emergency care to roughly 70% of U.S. acute ischemic stroke patients, he noted.
With achievement of Target: Stroke’s phase 2 goals, the program announced its launch of a third phase, with new treatment goals: Initiation of thrombolytic treatment to 85% of eligible patients within 60 minutes, to 75% within 45 minutes, and to 50% within 30 minutes. The phase 3 Target: Stroke program also for the first time includes treatment goals for delivery of endovascular thrombectomy treatment.
SOURCE: Fonarow GC et al. ISC 2019, Abstract LBP9.
HONOLULU – The speed at which eligible U.S. patients with acute ischemic stroke receive thrombolytic therapy has surged in recent years, and .
By the second half of last year, 75% of acute ischemic stroke patients treated at any of the 913 U.S. hospitals in the Get With The Guidelines-Stroke program received intravenous tissue plasminogen activator (tPA; Alteplase) within 60 minutes of their hospital arrival (their door-to-needle time (DTN), and 52% received tPA with a DTN time of 45 minutes or less. These levels met the treatment-speed goals set by the second phase of the Target: Stroke program, which called for delivering tPA to 75% of appropriate stroke patients within a DTN time of 60 minutes, and within 45 minutes in at least 50% of patients, Gregg C. Fonarow, MD, and his associates reported at the International Stroke Conference, sponsored by the American Heart Association.
The analyses they reported also documented how these most recent gains in thrombolytic speed played out in improved patient outcomes. During phase 2 of Target: Stroke, which ran from January 2014 to September 2018, 85,078 U.S. patients received tPA at one of the participating hospitals. During those 4 years, the rate of in-hospital mortality was 6.0%, half the patients were discharged home, 53% could ambulate independently, and the rate of intracerebral hemorrhage (ICH) was 3.5%. The researchers compared these clinical event rates with the rates from 24,603 tPA-treated patients during 2003-2009, before the Target: Stroke campaign began. After adjustment for many potential confounders, the more recently treated cohort had a 31% relative risk reduction in in-hospital mortality, a 43% relative increase in being discharged home, a 40% relative increase in independent ambulation, and a 32% relative risk reduction in the rate of symptomatic ICH. All these between-group differences were statistically significant.
“We were hoping that, by improving DTN times we could achieve improved outcomes, but often in quality-improvement research – even when the process of care improves – the gains in outcomes don’t necessarily match expectations. Fortunately, with Target: Stroke, the remarkable improvements in timely treatment translated to remarkable improvements in clinical outcomes,” Dr. Fonarow said in an interview. “These are substantial, clinically relevant improvements in clinical outcomes for patients with acute ischemic stroke. As a result of the program, more than 100,000 acute ischemic stroke patients received much more timely acute ischemic stroke care and achieved far better clinical outcomes.”
During the 2003-2018 period reviewed, the percentage of presenting acute ischemic stroke patients who received tPA treatment at the 913 Get With The Guidelines hospitals that participated in the Target: Stroke program (and so had reviewable data) throughout all three periods rose from 6% during 2003-2009 (prestudy) to 8% during 2010-2013 (phase 1), and to 12% during 2014-2018 (phase 2). The percentages of these patients who received the drug within 60 minutes were 27% during 2003-2009, 43% during 2010-2013, and 68% during the entire 2014-2018 period, culminating in the 75% rate during July-September 2018, reported Dr. Fonarow, professor of medicine and cochief of cardiology at the University of California, Los Angeles.
Dr. Fonarow attributed the drop in the rate of ICH – from 5.7% during 2003-2009, to 4.4% during 2010-2013, and down to 3.5% during 2014-2018 – to the faster delivery of tPA. “With faster treatment, there is less ischemic brain and vascular damage and thus a lower likelihood of ICH as a complication of tPA,” he explained.
The Target: Stroke program achieved these gains in speedier thrombolytic treatment (and better recognition of eligible patients) through educational and promotional activities including dissemination of best practices. Notable best practices have included EMS prenotification of hospitals before they arrive with a stroke patient, direct transport of patients to a brain imaging scanner, premix of tPA, initiation of tPA in the brain imaging suite, and prompt data feedback, Dr. Fonarow said.
The Get With The Guidelines-Stroke and Target: Stroke programs now involve more than 2,100 U.S. hospitals, and they are able to deliver emergency care to roughly 70% of U.S. acute ischemic stroke patients, he noted.
With achievement of Target: Stroke’s phase 2 goals, the program announced its launch of a third phase, with new treatment goals: Initiation of thrombolytic treatment to 85% of eligible patients within 60 minutes, to 75% within 45 minutes, and to 50% within 30 minutes. The phase 3 Target: Stroke program also for the first time includes treatment goals for delivery of endovascular thrombectomy treatment.
SOURCE: Fonarow GC et al. ISC 2019, Abstract LBP9.
REPORTING FROM ISC 2019
Key clinical point: In late 2018, the Target: Stroke program met its phase 2 goal for timely delivery of thrombolytic therapy to acute ischemic stroke patients.
Major finding: In September 2018, 75% of eligible stroke patients underwent thrombolysis within 60 minutes of hospital arrival, and 52% within 45 minutes.
Study details: Review of data collected from 154,221 U.S. stroke patients treated with thrombolysis during 2003-2018.
Disclosures: Target: Stroke has received funding from Boehringer Ingelheim, Janssen, Bristol-Myers Squibb/Sanofi, and Merck. Dr. Fonarow had no relevant disclosures.
Source: Fonarow GC et al. ISC 2019, Abstract LBP9.
In search of an ear
On our way up north to go backcountry skiing with another couple, we stopped at a roadside restaurant/tavern for lunch. We seated ourselves and, after a long 10 minutes, our waitperson arrived like a tornado, looking frazzled. She offered an apology and the first installment of her tale of woe. Before taking our order, she explained it all began when her car wouldn’t start, and then her day care provider called to say that she was sick and our server would have to find some other arrangement for the day. When our meal finally arrived, it looked appetizing but didn’t quite match our order. Again, our waitperson apologized, adding that it has been a particularly hard week because her husband was out of town and not around to help with her three children.
Had we been dining at a high-end restaurant with a white tablecloth and a candle, we would have considered our server’s behavior unprofessional and off-putting. However, we were in no hurry as the light snow had turned to a ski-unfriendly drizzle. While our original intent had been to simply have lunch, we accepted our role as a sympathetic audience for this unfortunate woman. In fact, we asked a few open-ended questions to help the cathartic process along.
The need to share one’s troubles seems to be a universal human trait. Our server had no illusions that we were going to provide any solutions to her problems. Nor was she seeking any expression of sympathy beyond our patience. However, I’m sure that unburdening herself by telling the story made her feel better, at least temporarily. Hopefully, there would be additional understanding diners to help her through the day.
For many people, the workplace serves as a therapeutic outlet where they can share their troubles and concerns. At times, the whining can be annoying to coworkers but in general, woe sharing is a harmless and valuable perk of having a job. Unless, of course, one’s job is primarily serving the public.
As physicians we are accustomed listening to our patients’ troubles. However, our job is not one of those that affords much opportunity to unburden ourselves of our own concerns. The patients assume that we are the problem solvers and don’t have any of our own. Or, if we do have some troubles, their office visit is not the time for us to share them.
The occasional sharing, such as that we are running late because we’ve had a flat on the way to the office, is harmless and can remind patients that we are human. But one must be careful stay off the slippery slope that leads to unprofessional oversharing.
Without that luxury of a workplace that allows for occasional catharsis, physicians have an additional risk for burnout. There are no easy solutions. Sharing with patients is unprofessional. Our peers are as busy as we are and probably don’t have the time to listen. Or at least they don’t seem to have the time. And then there is that ego-vulnerability issue where we are hesitant to reveal to anyone, be they staff or peers, that we have a soft underbelly.
I don’t have any easy answers to the problem beyond the usual suggestion that, Personally, I have to admit that, when my bad day was the result of an accumulation of minor bumps, I would follow our waitperson’s example and share them selectively with patients whom I deluded myself into believing had the time and concern to listen. It probably was unprofessional, but it made me feel better.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.
On our way up north to go backcountry skiing with another couple, we stopped at a roadside restaurant/tavern for lunch. We seated ourselves and, after a long 10 minutes, our waitperson arrived like a tornado, looking frazzled. She offered an apology and the first installment of her tale of woe. Before taking our order, she explained it all began when her car wouldn’t start, and then her day care provider called to say that she was sick and our server would have to find some other arrangement for the day. When our meal finally arrived, it looked appetizing but didn’t quite match our order. Again, our waitperson apologized, adding that it has been a particularly hard week because her husband was out of town and not around to help with her three children.
Had we been dining at a high-end restaurant with a white tablecloth and a candle, we would have considered our server’s behavior unprofessional and off-putting. However, we were in no hurry as the light snow had turned to a ski-unfriendly drizzle. While our original intent had been to simply have lunch, we accepted our role as a sympathetic audience for this unfortunate woman. In fact, we asked a few open-ended questions to help the cathartic process along.
The need to share one’s troubles seems to be a universal human trait. Our server had no illusions that we were going to provide any solutions to her problems. Nor was she seeking any expression of sympathy beyond our patience. However, I’m sure that unburdening herself by telling the story made her feel better, at least temporarily. Hopefully, there would be additional understanding diners to help her through the day.
For many people, the workplace serves as a therapeutic outlet where they can share their troubles and concerns. At times, the whining can be annoying to coworkers but in general, woe sharing is a harmless and valuable perk of having a job. Unless, of course, one’s job is primarily serving the public.
As physicians we are accustomed listening to our patients’ troubles. However, our job is not one of those that affords much opportunity to unburden ourselves of our own concerns. The patients assume that we are the problem solvers and don’t have any of our own. Or, if we do have some troubles, their office visit is not the time for us to share them.
The occasional sharing, such as that we are running late because we’ve had a flat on the way to the office, is harmless and can remind patients that we are human. But one must be careful stay off the slippery slope that leads to unprofessional oversharing.
Without that luxury of a workplace that allows for occasional catharsis, physicians have an additional risk for burnout. There are no easy solutions. Sharing with patients is unprofessional. Our peers are as busy as we are and probably don’t have the time to listen. Or at least they don’t seem to have the time. And then there is that ego-vulnerability issue where we are hesitant to reveal to anyone, be they staff or peers, that we have a soft underbelly.
I don’t have any easy answers to the problem beyond the usual suggestion that, Personally, I have to admit that, when my bad day was the result of an accumulation of minor bumps, I would follow our waitperson’s example and share them selectively with patients whom I deluded myself into believing had the time and concern to listen. It probably was unprofessional, but it made me feel better.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.
On our way up north to go backcountry skiing with another couple, we stopped at a roadside restaurant/tavern for lunch. We seated ourselves and, after a long 10 minutes, our waitperson arrived like a tornado, looking frazzled. She offered an apology and the first installment of her tale of woe. Before taking our order, she explained it all began when her car wouldn’t start, and then her day care provider called to say that she was sick and our server would have to find some other arrangement for the day. When our meal finally arrived, it looked appetizing but didn’t quite match our order. Again, our waitperson apologized, adding that it has been a particularly hard week because her husband was out of town and not around to help with her three children.
Had we been dining at a high-end restaurant with a white tablecloth and a candle, we would have considered our server’s behavior unprofessional and off-putting. However, we were in no hurry as the light snow had turned to a ski-unfriendly drizzle. While our original intent had been to simply have lunch, we accepted our role as a sympathetic audience for this unfortunate woman. In fact, we asked a few open-ended questions to help the cathartic process along.
The need to share one’s troubles seems to be a universal human trait. Our server had no illusions that we were going to provide any solutions to her problems. Nor was she seeking any expression of sympathy beyond our patience. However, I’m sure that unburdening herself by telling the story made her feel better, at least temporarily. Hopefully, there would be additional understanding diners to help her through the day.
For many people, the workplace serves as a therapeutic outlet where they can share their troubles and concerns. At times, the whining can be annoying to coworkers but in general, woe sharing is a harmless and valuable perk of having a job. Unless, of course, one’s job is primarily serving the public.
As physicians we are accustomed listening to our patients’ troubles. However, our job is not one of those that affords much opportunity to unburden ourselves of our own concerns. The patients assume that we are the problem solvers and don’t have any of our own. Or, if we do have some troubles, their office visit is not the time for us to share them.
The occasional sharing, such as that we are running late because we’ve had a flat on the way to the office, is harmless and can remind patients that we are human. But one must be careful stay off the slippery slope that leads to unprofessional oversharing.
Without that luxury of a workplace that allows for occasional catharsis, physicians have an additional risk for burnout. There are no easy solutions. Sharing with patients is unprofessional. Our peers are as busy as we are and probably don’t have the time to listen. Or at least they don’t seem to have the time. And then there is that ego-vulnerability issue where we are hesitant to reveal to anyone, be they staff or peers, that we have a soft underbelly.
I don’t have any easy answers to the problem beyond the usual suggestion that, Personally, I have to admit that, when my bad day was the result of an accumulation of minor bumps, I would follow our waitperson’s example and share them selectively with patients whom I deluded myself into believing had the time and concern to listen. It probably was unprofessional, but it made me feel better.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.