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Kids with MS face higher risk of mental disorders
BOSTON – Children with multiple sclerosis (MS) and related conditions are as much as 10 times more likely than the general population to need to be hospitalized for various psychiatric conditions, a study showed.
“The true prevalence of morbidity is almost certainly higher than suggested by our data,” said study lead author Julia Pakpoor, BM BCh, who presented data from her research at the annual meeting of the American Academy of Neurology.
While several studies have examined links between MS and mental illness in adults, there’s been little research into the topic in children. The number of children with the disease is far from tiny, however. According to the National MS Society, an estimated 8,000-10,000 children have the condition in the United States.
The researchers tracked future psychiatric visits by these patients and compared them with a reference cohort of more than 1.1 million children.
The risks of mental conditions in children with MS, compared with the reference cohort, were as follows: psychotic disorders (relative risk [RR] = 10.76; 95% confidence interval [CI], 2.93-27.63; P less than .001), mood disorders (RR = 2.57; 95% CI, 1.03-5.31; P = .022), and intellectual disability (RR = 6.08; 95% CI, 1.25-17.80; P = .004).
The children with other CNS demyelinating diseases also had higher risk levels, compared with the reference cohort: psychotic disorders (RR = 5.77; 95% CI, 2.48-11.41; P less than .001), anxiety, stress-related, and somatoform disorders that cause symptoms like pain (RR = 2.38; 95% CI, 1.39-3.81; P less than .001); intellectual disability (RR = 6.56; 95% CI, 3.66-10.84; P less than .001), and other behavioral disorders (RR = 8.99; 95% CI, 5.13-14.62; P less than .001).
The researchers also reported evidence of a reverse trend. Children with several mental conditions had greater risk than did the reference cohort to go on to develop CNS demyelinating diseases, specifically anxiety, stress-related, and somatoform disorders (RR = 3.15; 95% CI, 1.70-5.39; P less than .001), ADHD (RR = 3.88; 95% CI, 1.75-7.48; P less than .001), autism (RR = 3.80; 95% CI, 2.05-6.50; P less than .001), intellectual disability (RR = 6.33; 95% CI, 2.86-12.21; P less than .001), and other behavioral disorders (RR = 8.30; 95% CI, 5.17-12.75; P less than .001).
“We detected strong associations, and further associations likely exist,” Dr. Pakpoor said.
She acknowledged that the research is limited because it includes information only about patients admitted to a hospital. “There may be many more with psychiatric conditions that are mild,” she said. “We’re probably detecting cases that are more severe.”
In an interview, Flavia M. Nelson, MD, interim chief of the multiple sclerosis division at the University of Texas Health Science Center at Houston, said she often sees psychiatric conditions in her pediatric patients.
Conditions such as depression and anxiety disorders are common, she said, and the pediatric patients often suffer from isolation. “There’s a lot of fear about what this will do to their lives,” she said. Some patients have even refused to go to college because they fear that “they’ll have a disabling attack and everyone will know.”
As for the link between psychiatric illness and MS, Dr. Nelson said the disorders may develop because stress, fear, and anxiety push young people to their limits. “I had one patient who developed tics and rage,” she said. “That was his way of coping with the disease.”
Dr. Nelson suggested doing cognitive testing on young patients and referring them to counseling, especially in light of the fact that teens often put up walls when they don’t know how to express their feelings. Simply asking questions may not be enough to draw them out, she said, so professional counseling can be helpful.
No specific funding was reported. Dr. Pakpoor reported no relevant disclosures. Dr. Nelson has received personal compensation for activities with Bayer, Sanofi-Genzyme, Genentech, Novartis, Teva, and the Consortium of Multiple Sclerosis Centers. She has received research support from the National Institutes of Health, the National MS Society, and Novartis.
BOSTON – Children with multiple sclerosis (MS) and related conditions are as much as 10 times more likely than the general population to need to be hospitalized for various psychiatric conditions, a study showed.
“The true prevalence of morbidity is almost certainly higher than suggested by our data,” said study lead author Julia Pakpoor, BM BCh, who presented data from her research at the annual meeting of the American Academy of Neurology.
While several studies have examined links between MS and mental illness in adults, there’s been little research into the topic in children. The number of children with the disease is far from tiny, however. According to the National MS Society, an estimated 8,000-10,000 children have the condition in the United States.
The researchers tracked future psychiatric visits by these patients and compared them with a reference cohort of more than 1.1 million children.
The risks of mental conditions in children with MS, compared with the reference cohort, were as follows: psychotic disorders (relative risk [RR] = 10.76; 95% confidence interval [CI], 2.93-27.63; P less than .001), mood disorders (RR = 2.57; 95% CI, 1.03-5.31; P = .022), and intellectual disability (RR = 6.08; 95% CI, 1.25-17.80; P = .004).
The children with other CNS demyelinating diseases also had higher risk levels, compared with the reference cohort: psychotic disorders (RR = 5.77; 95% CI, 2.48-11.41; P less than .001), anxiety, stress-related, and somatoform disorders that cause symptoms like pain (RR = 2.38; 95% CI, 1.39-3.81; P less than .001); intellectual disability (RR = 6.56; 95% CI, 3.66-10.84; P less than .001), and other behavioral disorders (RR = 8.99; 95% CI, 5.13-14.62; P less than .001).
The researchers also reported evidence of a reverse trend. Children with several mental conditions had greater risk than did the reference cohort to go on to develop CNS demyelinating diseases, specifically anxiety, stress-related, and somatoform disorders (RR = 3.15; 95% CI, 1.70-5.39; P less than .001), ADHD (RR = 3.88; 95% CI, 1.75-7.48; P less than .001), autism (RR = 3.80; 95% CI, 2.05-6.50; P less than .001), intellectual disability (RR = 6.33; 95% CI, 2.86-12.21; P less than .001), and other behavioral disorders (RR = 8.30; 95% CI, 5.17-12.75; P less than .001).
“We detected strong associations, and further associations likely exist,” Dr. Pakpoor said.
She acknowledged that the research is limited because it includes information only about patients admitted to a hospital. “There may be many more with psychiatric conditions that are mild,” she said. “We’re probably detecting cases that are more severe.”
In an interview, Flavia M. Nelson, MD, interim chief of the multiple sclerosis division at the University of Texas Health Science Center at Houston, said she often sees psychiatric conditions in her pediatric patients.
Conditions such as depression and anxiety disorders are common, she said, and the pediatric patients often suffer from isolation. “There’s a lot of fear about what this will do to their lives,” she said. Some patients have even refused to go to college because they fear that “they’ll have a disabling attack and everyone will know.”
As for the link between psychiatric illness and MS, Dr. Nelson said the disorders may develop because stress, fear, and anxiety push young people to their limits. “I had one patient who developed tics and rage,” she said. “That was his way of coping with the disease.”
Dr. Nelson suggested doing cognitive testing on young patients and referring them to counseling, especially in light of the fact that teens often put up walls when they don’t know how to express their feelings. Simply asking questions may not be enough to draw them out, she said, so professional counseling can be helpful.
No specific funding was reported. Dr. Pakpoor reported no relevant disclosures. Dr. Nelson has received personal compensation for activities with Bayer, Sanofi-Genzyme, Genentech, Novartis, Teva, and the Consortium of Multiple Sclerosis Centers. She has received research support from the National Institutes of Health, the National MS Society, and Novartis.
BOSTON – Children with multiple sclerosis (MS) and related conditions are as much as 10 times more likely than the general population to need to be hospitalized for various psychiatric conditions, a study showed.
“The true prevalence of morbidity is almost certainly higher than suggested by our data,” said study lead author Julia Pakpoor, BM BCh, who presented data from her research at the annual meeting of the American Academy of Neurology.
While several studies have examined links between MS and mental illness in adults, there’s been little research into the topic in children. The number of children with the disease is far from tiny, however. According to the National MS Society, an estimated 8,000-10,000 children have the condition in the United States.
The researchers tracked future psychiatric visits by these patients and compared them with a reference cohort of more than 1.1 million children.
The risks of mental conditions in children with MS, compared with the reference cohort, were as follows: psychotic disorders (relative risk [RR] = 10.76; 95% confidence interval [CI], 2.93-27.63; P less than .001), mood disorders (RR = 2.57; 95% CI, 1.03-5.31; P = .022), and intellectual disability (RR = 6.08; 95% CI, 1.25-17.80; P = .004).
The children with other CNS demyelinating diseases also had higher risk levels, compared with the reference cohort: psychotic disorders (RR = 5.77; 95% CI, 2.48-11.41; P less than .001), anxiety, stress-related, and somatoform disorders that cause symptoms like pain (RR = 2.38; 95% CI, 1.39-3.81; P less than .001); intellectual disability (RR = 6.56; 95% CI, 3.66-10.84; P less than .001), and other behavioral disorders (RR = 8.99; 95% CI, 5.13-14.62; P less than .001).
The researchers also reported evidence of a reverse trend. Children with several mental conditions had greater risk than did the reference cohort to go on to develop CNS demyelinating diseases, specifically anxiety, stress-related, and somatoform disorders (RR = 3.15; 95% CI, 1.70-5.39; P less than .001), ADHD (RR = 3.88; 95% CI, 1.75-7.48; P less than .001), autism (RR = 3.80; 95% CI, 2.05-6.50; P less than .001), intellectual disability (RR = 6.33; 95% CI, 2.86-12.21; P less than .001), and other behavioral disorders (RR = 8.30; 95% CI, 5.17-12.75; P less than .001).
“We detected strong associations, and further associations likely exist,” Dr. Pakpoor said.
She acknowledged that the research is limited because it includes information only about patients admitted to a hospital. “There may be many more with psychiatric conditions that are mild,” she said. “We’re probably detecting cases that are more severe.”
In an interview, Flavia M. Nelson, MD, interim chief of the multiple sclerosis division at the University of Texas Health Science Center at Houston, said she often sees psychiatric conditions in her pediatric patients.
Conditions such as depression and anxiety disorders are common, she said, and the pediatric patients often suffer from isolation. “There’s a lot of fear about what this will do to their lives,” she said. Some patients have even refused to go to college because they fear that “they’ll have a disabling attack and everyone will know.”
As for the link between psychiatric illness and MS, Dr. Nelson said the disorders may develop because stress, fear, and anxiety push young people to their limits. “I had one patient who developed tics and rage,” she said. “That was his way of coping with the disease.”
Dr. Nelson suggested doing cognitive testing on young patients and referring them to counseling, especially in light of the fact that teens often put up walls when they don’t know how to express their feelings. Simply asking questions may not be enough to draw them out, she said, so professional counseling can be helpful.
No specific funding was reported. Dr. Pakpoor reported no relevant disclosures. Dr. Nelson has received personal compensation for activities with Bayer, Sanofi-Genzyme, Genentech, Novartis, Teva, and the Consortium of Multiple Sclerosis Centers. She has received research support from the National Institutes of Health, the National MS Society, and Novartis.
Key clinical point: Children with MS and similar conditions are at higher risk of a long list of psychiatric disorders.
Major finding:
Data source: An analysis of children admitted to hospitals in England from 1999 to 2011 with MS (n = 201) and other CNS demyelinating diseases (n = 1,097) plus a reference cohort of more than 1.1 million.
Disclosures: No specific funding or disclosures were reported.
Study reveals crazy quilt of laser laws across the United States
SAN DIEGO – Laser hair removal isn’t typically in an office cleaner’s job description. So it’s no wonder that Virginia legislators were spooked when they heard from a constituent who was treated by a spa worker who turned out to be a janitor.
Earlier this year, legislators in the Old Dominion passed a bill limiting laser hair removal procedures to a “properly trained” medical doctor, physician assistant, or nurse practitioner – or a “properly trained” person who is supervised by one of these professionals. Therefore, it’s still possible for a “properly trained” person without a degree of any kind to operate a laser in Virginia.
To the north in New Jersey, the rules are much stricter: Only physicians can perform laser procedures. But in New York, it appears that anyone can fire up a laser and go to work on unwanted hair. And in Florida, nonphysicians can perform laser procedures only if they’re physician assistants or nurse practitioners. But they’re only allowed to remove hair with lasers at a clinic that just performs laser hair removal.
Such is the chaotic state of laser law in the United States, a new study finds. The rules, which vary widely from state to state, are often vague and confusing. And, as Virginia’s new law shows, they’re still evolving. (The study is current as of March 2016.)
She and study coauthor Mathew M. Avram, MD, JD, director of the Laser and Cosmetic Center at Massachusetts General, analyzed regulations in the 50 states regarding the operation of lasers. They reported their findings at the annual meeting of the American Society for Laser Medicine and Surgery.
Dr. DiGiorgio said that laser operator laws address three issues:
1. Who can operate a laser?
At other clinics across the country, nonphysician employees — such as nurse practitioners and registered nurses – often operate lasers. Whether they can legally actually do so isn’t always obvious.
New Jersey is the only state that requires laser operators to be physicians. At the other extreme, 11 states, including Massachusetts, Colorado, Florida, Missouri, New York, and Pennsylvania, have “no” limits on who can perform laser procedures. (At Massachusetts General Hospital, physicians perform all laser procedures.)
So does that mean anyone can perform a laser procedure? It’s not clear. “The laws are a lot more vague than they should be,” Dr. DiGiorgio said in an interview.
Eighteen states allow people to perform laser procedures as part of the “practice of medicine,” although legislation can be vague on what that means. Those states include Illinois, Michigan, Minnesota, North Carolina, and Texas.
Another 19 states, including California, Ohio, Washington, Wisconsin, and now Virginia, have specific limits on who can perform laser procedures. In California, for example, physician assistants and registered nurses – but not licensed vocational nurses – are allowed to use lasers to remove hair, spider veins, and tattoos. Unlicensed medical assistants, cosmetologists, electrologists, and estheticians are not allowed to perform the procedures
2. Can someone delegate laser procedures to someone else?
In nine states, including Iowa and New Hampshire, there’s no oversight of delegation or nonphysicians can delegate procedures to someone else.
In another nine states, certain procedures can be delegated with no physician oversight, such as laser hair removal in Alaska and ablative procedures (to advanced practice registered nurses only) in Utah.
3. Is supervision required of nonphysicians?
Physicians don’t need to supervise certain laser procedures in 11 states, including Hawaii, Oregon, and Vermont, where they can be performed by a nonphysician with no supervision or under supervision by a non-physician.
In 17 states, supervision isn’t always required or it’s under the discretion of the supervising physician. These states include California, Michigan, Pennsylvania, and Wisconsin.
In 11 states, including Illinois and Massachusetts, only certain procedures require on-site supervision. Six states, including Connecticut and Maryland, require on-site physician supervision for all laser procedures, but Dr. DiGiorgio said the requirements can be vague about what “on site” actually means.
Idaho requires the physician to be on site or immediately available, and South Carolina allows registered nurses to perform laser hair and leg vein removal if a physician is on site and can respond within 5 minutes.
“We don’t know what the ideal regulation is,” Dr. DiGiorgio said. But she believes laser regulations are crucial to safety, especially as fields such as plastic surgery, ophthalmology, and gynecology embrace cosmetic laser procedures.
Information about state-by-state laser operator laws is available on the American Med Spa Association website.
Dr. DiGiorgio reported no relevant disclosures.
SAN DIEGO – Laser hair removal isn’t typically in an office cleaner’s job description. So it’s no wonder that Virginia legislators were spooked when they heard from a constituent who was treated by a spa worker who turned out to be a janitor.
Earlier this year, legislators in the Old Dominion passed a bill limiting laser hair removal procedures to a “properly trained” medical doctor, physician assistant, or nurse practitioner – or a “properly trained” person who is supervised by one of these professionals. Therefore, it’s still possible for a “properly trained” person without a degree of any kind to operate a laser in Virginia.
To the north in New Jersey, the rules are much stricter: Only physicians can perform laser procedures. But in New York, it appears that anyone can fire up a laser and go to work on unwanted hair. And in Florida, nonphysicians can perform laser procedures only if they’re physician assistants or nurse practitioners. But they’re only allowed to remove hair with lasers at a clinic that just performs laser hair removal.
Such is the chaotic state of laser law in the United States, a new study finds. The rules, which vary widely from state to state, are often vague and confusing. And, as Virginia’s new law shows, they’re still evolving. (The study is current as of March 2016.)
She and study coauthor Mathew M. Avram, MD, JD, director of the Laser and Cosmetic Center at Massachusetts General, analyzed regulations in the 50 states regarding the operation of lasers. They reported their findings at the annual meeting of the American Society for Laser Medicine and Surgery.
Dr. DiGiorgio said that laser operator laws address three issues:
1. Who can operate a laser?
At other clinics across the country, nonphysician employees — such as nurse practitioners and registered nurses – often operate lasers. Whether they can legally actually do so isn’t always obvious.
New Jersey is the only state that requires laser operators to be physicians. At the other extreme, 11 states, including Massachusetts, Colorado, Florida, Missouri, New York, and Pennsylvania, have “no” limits on who can perform laser procedures. (At Massachusetts General Hospital, physicians perform all laser procedures.)
So does that mean anyone can perform a laser procedure? It’s not clear. “The laws are a lot more vague than they should be,” Dr. DiGiorgio said in an interview.
Eighteen states allow people to perform laser procedures as part of the “practice of medicine,” although legislation can be vague on what that means. Those states include Illinois, Michigan, Minnesota, North Carolina, and Texas.
Another 19 states, including California, Ohio, Washington, Wisconsin, and now Virginia, have specific limits on who can perform laser procedures. In California, for example, physician assistants and registered nurses – but not licensed vocational nurses – are allowed to use lasers to remove hair, spider veins, and tattoos. Unlicensed medical assistants, cosmetologists, electrologists, and estheticians are not allowed to perform the procedures
2. Can someone delegate laser procedures to someone else?
In nine states, including Iowa and New Hampshire, there’s no oversight of delegation or nonphysicians can delegate procedures to someone else.
In another nine states, certain procedures can be delegated with no physician oversight, such as laser hair removal in Alaska and ablative procedures (to advanced practice registered nurses only) in Utah.
3. Is supervision required of nonphysicians?
Physicians don’t need to supervise certain laser procedures in 11 states, including Hawaii, Oregon, and Vermont, where they can be performed by a nonphysician with no supervision or under supervision by a non-physician.
In 17 states, supervision isn’t always required or it’s under the discretion of the supervising physician. These states include California, Michigan, Pennsylvania, and Wisconsin.
In 11 states, including Illinois and Massachusetts, only certain procedures require on-site supervision. Six states, including Connecticut and Maryland, require on-site physician supervision for all laser procedures, but Dr. DiGiorgio said the requirements can be vague about what “on site” actually means.
Idaho requires the physician to be on site or immediately available, and South Carolina allows registered nurses to perform laser hair and leg vein removal if a physician is on site and can respond within 5 minutes.
“We don’t know what the ideal regulation is,” Dr. DiGiorgio said. But she believes laser regulations are crucial to safety, especially as fields such as plastic surgery, ophthalmology, and gynecology embrace cosmetic laser procedures.
Information about state-by-state laser operator laws is available on the American Med Spa Association website.
Dr. DiGiorgio reported no relevant disclosures.
SAN DIEGO – Laser hair removal isn’t typically in an office cleaner’s job description. So it’s no wonder that Virginia legislators were spooked when they heard from a constituent who was treated by a spa worker who turned out to be a janitor.
Earlier this year, legislators in the Old Dominion passed a bill limiting laser hair removal procedures to a “properly trained” medical doctor, physician assistant, or nurse practitioner – or a “properly trained” person who is supervised by one of these professionals. Therefore, it’s still possible for a “properly trained” person without a degree of any kind to operate a laser in Virginia.
To the north in New Jersey, the rules are much stricter: Only physicians can perform laser procedures. But in New York, it appears that anyone can fire up a laser and go to work on unwanted hair. And in Florida, nonphysicians can perform laser procedures only if they’re physician assistants or nurse practitioners. But they’re only allowed to remove hair with lasers at a clinic that just performs laser hair removal.
Such is the chaotic state of laser law in the United States, a new study finds. The rules, which vary widely from state to state, are often vague and confusing. And, as Virginia’s new law shows, they’re still evolving. (The study is current as of March 2016.)
She and study coauthor Mathew M. Avram, MD, JD, director of the Laser and Cosmetic Center at Massachusetts General, analyzed regulations in the 50 states regarding the operation of lasers. They reported their findings at the annual meeting of the American Society for Laser Medicine and Surgery.
Dr. DiGiorgio said that laser operator laws address three issues:
1. Who can operate a laser?
At other clinics across the country, nonphysician employees — such as nurse practitioners and registered nurses – often operate lasers. Whether they can legally actually do so isn’t always obvious.
New Jersey is the only state that requires laser operators to be physicians. At the other extreme, 11 states, including Massachusetts, Colorado, Florida, Missouri, New York, and Pennsylvania, have “no” limits on who can perform laser procedures. (At Massachusetts General Hospital, physicians perform all laser procedures.)
So does that mean anyone can perform a laser procedure? It’s not clear. “The laws are a lot more vague than they should be,” Dr. DiGiorgio said in an interview.
Eighteen states allow people to perform laser procedures as part of the “practice of medicine,” although legislation can be vague on what that means. Those states include Illinois, Michigan, Minnesota, North Carolina, and Texas.
Another 19 states, including California, Ohio, Washington, Wisconsin, and now Virginia, have specific limits on who can perform laser procedures. In California, for example, physician assistants and registered nurses – but not licensed vocational nurses – are allowed to use lasers to remove hair, spider veins, and tattoos. Unlicensed medical assistants, cosmetologists, electrologists, and estheticians are not allowed to perform the procedures
2. Can someone delegate laser procedures to someone else?
In nine states, including Iowa and New Hampshire, there’s no oversight of delegation or nonphysicians can delegate procedures to someone else.
In another nine states, certain procedures can be delegated with no physician oversight, such as laser hair removal in Alaska and ablative procedures (to advanced practice registered nurses only) in Utah.
3. Is supervision required of nonphysicians?
Physicians don’t need to supervise certain laser procedures in 11 states, including Hawaii, Oregon, and Vermont, where they can be performed by a nonphysician with no supervision or under supervision by a non-physician.
In 17 states, supervision isn’t always required or it’s under the discretion of the supervising physician. These states include California, Michigan, Pennsylvania, and Wisconsin.
In 11 states, including Illinois and Massachusetts, only certain procedures require on-site supervision. Six states, including Connecticut and Maryland, require on-site physician supervision for all laser procedures, but Dr. DiGiorgio said the requirements can be vague about what “on site” actually means.
Idaho requires the physician to be on site or immediately available, and South Carolina allows registered nurses to perform laser hair and leg vein removal if a physician is on site and can respond within 5 minutes.
“We don’t know what the ideal regulation is,” Dr. DiGiorgio said. But she believes laser regulations are crucial to safety, especially as fields such as plastic surgery, ophthalmology, and gynecology embrace cosmetic laser procedures.
Information about state-by-state laser operator laws is available on the American Med Spa Association website.
Dr. DiGiorgio reported no relevant disclosures.
AT LASER 2017
Key clinical point:
Major finding: The study found wide variations in who can operate lasers, and in regulations regarding the delegation and supervision of laser treatments in the different states.
Data source: Analysis of regulations in the 50 states regarding the operation of lasers.
Disclosures: Dr. DiGiorgio reported no relevant disclosures
Hospital infections top WHO’s list of priority pathogens
The World Health Organization is urging governments to focus antibiotic research efforts on a list of urgent bacterial threats, topped by several increasingly powerful superbugs that cause hospital-based infections and other potentially deadly conditions.
The WHO listed the top 20 bacteria that it believes are most harmful to human health, other than mycobacteria such as Mycobacterium tuberculosis, which causes tuberculosis. The germ was not included in the list because it’s generally accepted to be the most urgent priority for new antibiotic research and development, Marie-Paule Kieny, PhD, a WHO assistant director, said at a press conference.
The priority list is needed because the antibiotic pipeline is “practically dry,” thanks to scientific research challenges and a lack of financial incentives, according to Dr. Kieny. “Antibiotics are generally used for the short term, unlike therapies for chronic diseases, which bring in much higher returns on investment,” she said. The list “is intended to signal to the scientific community and the pharmaceutical industry the areas they should focus on to address urgent public health threats.”
The WHO list begins with Priority 1/“Critical” pathogens that it believes most urgently need to be targeted through antibiotic research and development: Acinetobacter baumannii, carbapenem-resistant; Pseudomonas aeruginosa, carbapenem-resistant; and Enterobacteriaceae (including Klebsiella pneumonia, Escherichia coli, Enterobacter spp., Serratia spp., Proteus spp., Providencia spp., and Morganella spp.), carbapenem-resistant, extended-spectrum beta-lactamase–producing.
“These bacteria are responsible for severe infections and high mortality rates, mostly in hospitalized patients, transplant recipients, those receiving chemotherapy, or patients in intensive care units,” Dr. Kieny said. “While these bacteria are not widespread and do not generally affect healthy individuals, the burden for patients and society is now alarming – and new, effective therapies are imperative.”
Priority 2/”High” pathogens are Enterococcus faecium, vancomycin-resistant; Staphylococcus aureus, methicillin-resistant, vancomycin intermediate and resistant; Helicobacter pylori, clarithromycin-resistant; Campylobacter, fluoroquinolone-resistant; Salmonella spp., fluoroquinolone-resistant; Neisseria gonorrhoeae, third-generation cephalosporin-resistant and fluoroquinolone-resistant.
Pathogens in this category can infect healthy individuals, Dr. Kieny noted. “These infections, although not associated with significant mortality, have a dramatic health and economic impact on communities and, in particular, in low-income countries.”
Priority 3/”Medium” pathogens are Streptococcus pneumoniae, penicillin–non-susceptible; Haemophilus influenzae, ampicillin-resistant; and Shigella spp., fluoroquinolone-resistant.
These pathogens “represent a threat because of increasing resistance but still have some effective antibiotic options available,” Dr. Kieny said.
According to a statement provided by the WHO, the priority list doesn’t include streptococcus A and B or chlamydia, because resistance hasn’t reached the level of a public health threat.
One goal of the list is to focus attention on the development of small-market, gram-negative drugs that combat hospital-based infections, explained Nicola Magrini, MD, a WHO scientist who also spoke at the press conference.
Over the last decade, he said, the pipeline has instead focused more on gram-positive agents – mostly linked to beta-lactamase – that have wider market potential and generate less resistance.
“From a clinical point of view, these multidrug-resistant gram-negative clinical trials are very difficult and expensive to do, more than for gram-positive,” noted Evelina Tacconelli, MD, PhD, a contributor to the WHO report. “Because when we talk about gram-negative, we need to cover multiple pathogens and not just one or two, as in the case of gram-positive.”
Dr. Magrini said he couldn’t provide estimates about how many people worldwide are affected by the listed pathogens. However, he said a full report with numbers will be released by June.
It does appear that patients with severe infection from antibiotic-resistant germs face a mortality rate of up to 60%, while extended-spectrum beta-lactamase–positive E. coli accounts for up to 70% of urinary tract infections in many countries, explained Dr. Tacconelli, head of the division of infectious diseases at the University of Tübingen, Germany.
“Even if we don’t know exactly how many,” she said, “we are talking about millions of people affected.”
The World Health Organization is urging governments to focus antibiotic research efforts on a list of urgent bacterial threats, topped by several increasingly powerful superbugs that cause hospital-based infections and other potentially deadly conditions.
The WHO listed the top 20 bacteria that it believes are most harmful to human health, other than mycobacteria such as Mycobacterium tuberculosis, which causes tuberculosis. The germ was not included in the list because it’s generally accepted to be the most urgent priority for new antibiotic research and development, Marie-Paule Kieny, PhD, a WHO assistant director, said at a press conference.
The priority list is needed because the antibiotic pipeline is “practically dry,” thanks to scientific research challenges and a lack of financial incentives, according to Dr. Kieny. “Antibiotics are generally used for the short term, unlike therapies for chronic diseases, which bring in much higher returns on investment,” she said. The list “is intended to signal to the scientific community and the pharmaceutical industry the areas they should focus on to address urgent public health threats.”
The WHO list begins with Priority 1/“Critical” pathogens that it believes most urgently need to be targeted through antibiotic research and development: Acinetobacter baumannii, carbapenem-resistant; Pseudomonas aeruginosa, carbapenem-resistant; and Enterobacteriaceae (including Klebsiella pneumonia, Escherichia coli, Enterobacter spp., Serratia spp., Proteus spp., Providencia spp., and Morganella spp.), carbapenem-resistant, extended-spectrum beta-lactamase–producing.
“These bacteria are responsible for severe infections and high mortality rates, mostly in hospitalized patients, transplant recipients, those receiving chemotherapy, or patients in intensive care units,” Dr. Kieny said. “While these bacteria are not widespread and do not generally affect healthy individuals, the burden for patients and society is now alarming – and new, effective therapies are imperative.”
Priority 2/”High” pathogens are Enterococcus faecium, vancomycin-resistant; Staphylococcus aureus, methicillin-resistant, vancomycin intermediate and resistant; Helicobacter pylori, clarithromycin-resistant; Campylobacter, fluoroquinolone-resistant; Salmonella spp., fluoroquinolone-resistant; Neisseria gonorrhoeae, third-generation cephalosporin-resistant and fluoroquinolone-resistant.
Pathogens in this category can infect healthy individuals, Dr. Kieny noted. “These infections, although not associated with significant mortality, have a dramatic health and economic impact on communities and, in particular, in low-income countries.”
Priority 3/”Medium” pathogens are Streptococcus pneumoniae, penicillin–non-susceptible; Haemophilus influenzae, ampicillin-resistant; and Shigella spp., fluoroquinolone-resistant.
These pathogens “represent a threat because of increasing resistance but still have some effective antibiotic options available,” Dr. Kieny said.
According to a statement provided by the WHO, the priority list doesn’t include streptococcus A and B or chlamydia, because resistance hasn’t reached the level of a public health threat.
One goal of the list is to focus attention on the development of small-market, gram-negative drugs that combat hospital-based infections, explained Nicola Magrini, MD, a WHO scientist who also spoke at the press conference.
Over the last decade, he said, the pipeline has instead focused more on gram-positive agents – mostly linked to beta-lactamase – that have wider market potential and generate less resistance.
“From a clinical point of view, these multidrug-resistant gram-negative clinical trials are very difficult and expensive to do, more than for gram-positive,” noted Evelina Tacconelli, MD, PhD, a contributor to the WHO report. “Because when we talk about gram-negative, we need to cover multiple pathogens and not just one or two, as in the case of gram-positive.”
Dr. Magrini said he couldn’t provide estimates about how many people worldwide are affected by the listed pathogens. However, he said a full report with numbers will be released by June.
It does appear that patients with severe infection from antibiotic-resistant germs face a mortality rate of up to 60%, while extended-spectrum beta-lactamase–positive E. coli accounts for up to 70% of urinary tract infections in many countries, explained Dr. Tacconelli, head of the division of infectious diseases at the University of Tübingen, Germany.
“Even if we don’t know exactly how many,” she said, “we are talking about millions of people affected.”
The World Health Organization is urging governments to focus antibiotic research efforts on a list of urgent bacterial threats, topped by several increasingly powerful superbugs that cause hospital-based infections and other potentially deadly conditions.
The WHO listed the top 20 bacteria that it believes are most harmful to human health, other than mycobacteria such as Mycobacterium tuberculosis, which causes tuberculosis. The germ was not included in the list because it’s generally accepted to be the most urgent priority for new antibiotic research and development, Marie-Paule Kieny, PhD, a WHO assistant director, said at a press conference.
The priority list is needed because the antibiotic pipeline is “practically dry,” thanks to scientific research challenges and a lack of financial incentives, according to Dr. Kieny. “Antibiotics are generally used for the short term, unlike therapies for chronic diseases, which bring in much higher returns on investment,” she said. The list “is intended to signal to the scientific community and the pharmaceutical industry the areas they should focus on to address urgent public health threats.”
The WHO list begins with Priority 1/“Critical” pathogens that it believes most urgently need to be targeted through antibiotic research and development: Acinetobacter baumannii, carbapenem-resistant; Pseudomonas aeruginosa, carbapenem-resistant; and Enterobacteriaceae (including Klebsiella pneumonia, Escherichia coli, Enterobacter spp., Serratia spp., Proteus spp., Providencia spp., and Morganella spp.), carbapenem-resistant, extended-spectrum beta-lactamase–producing.
“These bacteria are responsible for severe infections and high mortality rates, mostly in hospitalized patients, transplant recipients, those receiving chemotherapy, or patients in intensive care units,” Dr. Kieny said. “While these bacteria are not widespread and do not generally affect healthy individuals, the burden for patients and society is now alarming – and new, effective therapies are imperative.”
Priority 2/”High” pathogens are Enterococcus faecium, vancomycin-resistant; Staphylococcus aureus, methicillin-resistant, vancomycin intermediate and resistant; Helicobacter pylori, clarithromycin-resistant; Campylobacter, fluoroquinolone-resistant; Salmonella spp., fluoroquinolone-resistant; Neisseria gonorrhoeae, third-generation cephalosporin-resistant and fluoroquinolone-resistant.
Pathogens in this category can infect healthy individuals, Dr. Kieny noted. “These infections, although not associated with significant mortality, have a dramatic health and economic impact on communities and, in particular, in low-income countries.”
Priority 3/”Medium” pathogens are Streptococcus pneumoniae, penicillin–non-susceptible; Haemophilus influenzae, ampicillin-resistant; and Shigella spp., fluoroquinolone-resistant.
These pathogens “represent a threat because of increasing resistance but still have some effective antibiotic options available,” Dr. Kieny said.
According to a statement provided by the WHO, the priority list doesn’t include streptococcus A and B or chlamydia, because resistance hasn’t reached the level of a public health threat.
One goal of the list is to focus attention on the development of small-market, gram-negative drugs that combat hospital-based infections, explained Nicola Magrini, MD, a WHO scientist who also spoke at the press conference.
Over the last decade, he said, the pipeline has instead focused more on gram-positive agents – mostly linked to beta-lactamase – that have wider market potential and generate less resistance.
“From a clinical point of view, these multidrug-resistant gram-negative clinical trials are very difficult and expensive to do, more than for gram-positive,” noted Evelina Tacconelli, MD, PhD, a contributor to the WHO report. “Because when we talk about gram-negative, we need to cover multiple pathogens and not just one or two, as in the case of gram-positive.”
Dr. Magrini said he couldn’t provide estimates about how many people worldwide are affected by the listed pathogens. However, he said a full report with numbers will be released by June.
It does appear that patients with severe infection from antibiotic-resistant germs face a mortality rate of up to 60%, while extended-spectrum beta-lactamase–positive E. coli accounts for up to 70% of urinary tract infections in many countries, explained Dr. Tacconelli, head of the division of infectious diseases at the University of Tübingen, Germany.
“Even if we don’t know exactly how many,” she said, “we are talking about millions of people affected.”
VIDEO: Stroke risk in women deserves greater attention
BOSTON – Texas neurologist Louise McCullough, MD, PhD, is determined to help women live longer by urging neurologists to focus on the unique risks and needs involved.
Dr. McCullough, chief of neurology at Memorial Hermann Hospital in Houston, told a plenary audience at the annual meeting of the American Academy of Neurology that both biological and social factors contribute to conditions, such as atrial fibrillation, that are more dangerous in females than in males.
For example, women are less likely than men to be taking blood thinners, she said, possibly because doctors assume they’re frail even when they’ll confirm – if only someone asks – that they haven’t fallen.
At the same time, she said, women with atrial fibrillation are twice as likely as their male counterparts to suffer a stroke. “You need to screen older women for a-fib and have a much lower threshold for treatment.”
Isolation can be another contributing factor to the stroke gender gap, she said. “Women are often living alone – they’ve outlived their spouses; they don’t live near their children; they may not have access to rapid care.”
These factors, she said, may even contribute to the smaller presence of women in clinical trials.
Dr. McCullough discussed these issues and more in a video interview at the meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
BOSTON – Texas neurologist Louise McCullough, MD, PhD, is determined to help women live longer by urging neurologists to focus on the unique risks and needs involved.
Dr. McCullough, chief of neurology at Memorial Hermann Hospital in Houston, told a plenary audience at the annual meeting of the American Academy of Neurology that both biological and social factors contribute to conditions, such as atrial fibrillation, that are more dangerous in females than in males.
For example, women are less likely than men to be taking blood thinners, she said, possibly because doctors assume they’re frail even when they’ll confirm – if only someone asks – that they haven’t fallen.
At the same time, she said, women with atrial fibrillation are twice as likely as their male counterparts to suffer a stroke. “You need to screen older women for a-fib and have a much lower threshold for treatment.”
Isolation can be another contributing factor to the stroke gender gap, she said. “Women are often living alone – they’ve outlived their spouses; they don’t live near their children; they may not have access to rapid care.”
These factors, she said, may even contribute to the smaller presence of women in clinical trials.
Dr. McCullough discussed these issues and more in a video interview at the meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
BOSTON – Texas neurologist Louise McCullough, MD, PhD, is determined to help women live longer by urging neurologists to focus on the unique risks and needs involved.
Dr. McCullough, chief of neurology at Memorial Hermann Hospital in Houston, told a plenary audience at the annual meeting of the American Academy of Neurology that both biological and social factors contribute to conditions, such as atrial fibrillation, that are more dangerous in females than in males.
For example, women are less likely than men to be taking blood thinners, she said, possibly because doctors assume they’re frail even when they’ll confirm – if only someone asks – that they haven’t fallen.
At the same time, she said, women with atrial fibrillation are twice as likely as their male counterparts to suffer a stroke. “You need to screen older women for a-fib and have a much lower threshold for treatment.”
Isolation can be another contributing factor to the stroke gender gap, she said. “Women are often living alone – they’ve outlived their spouses; they don’t live near their children; they may not have access to rapid care.”
These factors, she said, may even contribute to the smaller presence of women in clinical trials.
Dr. McCullough discussed these issues and more in a video interview at the meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT AAN 2017
Parkinson’s patients’ quality of life improves after deep brain stimulation
BOSTON– Early results from an industry-funded registry of Parkinson’s disease patients who underwent deep brain stimulation (DBS) reveal that their quality-of-life scores grew by 22% at 6 months.
Patients, their caregivers, and their clinicians all overwhelmingly reported improvement.
The study, which examined two types of technology that are not approved in the United States, aims to fill a gap in DBS research: How do patients fare in normal conditions – “real life” – outside of clinical trials?
While DBS has been widely used for many years, “much of the available information is from controlled trials that usually select the best possible patients – relatively young and in the condition to go through a clinical trial. There’s less information about people who may not be in the best possible shape,” said Michele Tagliati, MD, professor and director of movement disorders at Cedars-Sinai Medical Center in Los Angeles. He did not take part in the study but is familiar with its findings.
The study’s lead author, Günther Deuschl, MD, PhD, of University Hospital Schleswig-Holstein, released preliminary findings at the annual meeting of the American Academy of Neurology.
The researchers have enrolled 203 patients who were treated with Boston Scientific’s Vercise DBS system, which is not approved for use in the United States. The researchers plan to track patients for 3 years.
“This is the first such industry-sponsored registry, which addresses a need in the field to track DBS practice and outcomes across multiple centers,” said Mark Richardson, MD, PhD, associate professor and director of epilepsy and movement disorders surgery at the University of Pittsburgh Medical Center. He did not take part in the study but is familiar with its findings.
The average age of participants is 59 years, which Dr. Deuschl said is a bit younger than many other studies, and 69% are male. Eighty-five serious adverse events were reported in 52 patients; 57 were not linked to the procedure. One patient died of a surgery-related hematoma.
At 6 months, patients reported a 22% improvement (P less than .0001) on the Parkinson’s Disease Questionnaire (PDQ-39), Dr. Deuschl said, and that level was sustained at 1 year.
That level of improvement is significant, Dr. Richardson said in an interview.
“Previous randomized, controlled trials have shown that patients who are candidates for DBS but who continue medical management alone are most likely to have no improvement at all on any quality of life measures,” he said. In addition, “6 months is fairly short, and some patients likely have not reached stable stimulation programming and effectiveness.”
The researchers also reported that more than 90% of patients, their clinicians, and their caregivers reported improvement.
This kind of study is valuable in light of skepticism about DBS, which is used to treat patients who do not respond to medication, Dr. Tagliati noted.
“Despite 15 years of [Food and Drug Administration] approval, there is still some form of resistance out there in referring patients with Parkinson’s at the right time when they can still fully benefit from the procedure,” he said. “Registries have this potential great benefit in terms of awareness and reassuring people.”
As for the high rating of improvement, Dr. Tagliati said it reflects what he sees in the clinic.
“Barring complications, we have very substantial satisfaction in our patients, definitely in the short term after DBS,” he said. “Over the long term, the picture is more difficult to read.”
Dr. Deuschl said researchers would like to add hundreds more patients to the study, and they hope to gain data about the differences between the results from standard and directional-lead DBS systems.
Boston Scientific funded the study, and some of the authors work for the company.
Dr. Richardson reported receiving research grant funding from Medtronic. Dr. Tagliati reported receiving funding from Abbott, Boston Scientific, Medtronic, and all DBS manufacturers, and his clinic is an investigational center for the Vercise DBS system. Dr. Deuschl reported receiving consulting fees from Boston Scientific, grant funding from Medtronic, lecture fees from Almirall and Novartis, and royalties from Thieme Publishers.
BOSTON– Early results from an industry-funded registry of Parkinson’s disease patients who underwent deep brain stimulation (DBS) reveal that their quality-of-life scores grew by 22% at 6 months.
Patients, their caregivers, and their clinicians all overwhelmingly reported improvement.
The study, which examined two types of technology that are not approved in the United States, aims to fill a gap in DBS research: How do patients fare in normal conditions – “real life” – outside of clinical trials?
While DBS has been widely used for many years, “much of the available information is from controlled trials that usually select the best possible patients – relatively young and in the condition to go through a clinical trial. There’s less information about people who may not be in the best possible shape,” said Michele Tagliati, MD, professor and director of movement disorders at Cedars-Sinai Medical Center in Los Angeles. He did not take part in the study but is familiar with its findings.
The study’s lead author, Günther Deuschl, MD, PhD, of University Hospital Schleswig-Holstein, released preliminary findings at the annual meeting of the American Academy of Neurology.
The researchers have enrolled 203 patients who were treated with Boston Scientific’s Vercise DBS system, which is not approved for use in the United States. The researchers plan to track patients for 3 years.
“This is the first such industry-sponsored registry, which addresses a need in the field to track DBS practice and outcomes across multiple centers,” said Mark Richardson, MD, PhD, associate professor and director of epilepsy and movement disorders surgery at the University of Pittsburgh Medical Center. He did not take part in the study but is familiar with its findings.
The average age of participants is 59 years, which Dr. Deuschl said is a bit younger than many other studies, and 69% are male. Eighty-five serious adverse events were reported in 52 patients; 57 were not linked to the procedure. One patient died of a surgery-related hematoma.
At 6 months, patients reported a 22% improvement (P less than .0001) on the Parkinson’s Disease Questionnaire (PDQ-39), Dr. Deuschl said, and that level was sustained at 1 year.
That level of improvement is significant, Dr. Richardson said in an interview.
“Previous randomized, controlled trials have shown that patients who are candidates for DBS but who continue medical management alone are most likely to have no improvement at all on any quality of life measures,” he said. In addition, “6 months is fairly short, and some patients likely have not reached stable stimulation programming and effectiveness.”
The researchers also reported that more than 90% of patients, their clinicians, and their caregivers reported improvement.
This kind of study is valuable in light of skepticism about DBS, which is used to treat patients who do not respond to medication, Dr. Tagliati noted.
“Despite 15 years of [Food and Drug Administration] approval, there is still some form of resistance out there in referring patients with Parkinson’s at the right time when they can still fully benefit from the procedure,” he said. “Registries have this potential great benefit in terms of awareness and reassuring people.”
As for the high rating of improvement, Dr. Tagliati said it reflects what he sees in the clinic.
“Barring complications, we have very substantial satisfaction in our patients, definitely in the short term after DBS,” he said. “Over the long term, the picture is more difficult to read.”
Dr. Deuschl said researchers would like to add hundreds more patients to the study, and they hope to gain data about the differences between the results from standard and directional-lead DBS systems.
Boston Scientific funded the study, and some of the authors work for the company.
Dr. Richardson reported receiving research grant funding from Medtronic. Dr. Tagliati reported receiving funding from Abbott, Boston Scientific, Medtronic, and all DBS manufacturers, and his clinic is an investigational center for the Vercise DBS system. Dr. Deuschl reported receiving consulting fees from Boston Scientific, grant funding from Medtronic, lecture fees from Almirall and Novartis, and royalties from Thieme Publishers.
BOSTON– Early results from an industry-funded registry of Parkinson’s disease patients who underwent deep brain stimulation (DBS) reveal that their quality-of-life scores grew by 22% at 6 months.
Patients, their caregivers, and their clinicians all overwhelmingly reported improvement.
The study, which examined two types of technology that are not approved in the United States, aims to fill a gap in DBS research: How do patients fare in normal conditions – “real life” – outside of clinical trials?
While DBS has been widely used for many years, “much of the available information is from controlled trials that usually select the best possible patients – relatively young and in the condition to go through a clinical trial. There’s less information about people who may not be in the best possible shape,” said Michele Tagliati, MD, professor and director of movement disorders at Cedars-Sinai Medical Center in Los Angeles. He did not take part in the study but is familiar with its findings.
The study’s lead author, Günther Deuschl, MD, PhD, of University Hospital Schleswig-Holstein, released preliminary findings at the annual meeting of the American Academy of Neurology.
The researchers have enrolled 203 patients who were treated with Boston Scientific’s Vercise DBS system, which is not approved for use in the United States. The researchers plan to track patients for 3 years.
“This is the first such industry-sponsored registry, which addresses a need in the field to track DBS practice and outcomes across multiple centers,” said Mark Richardson, MD, PhD, associate professor and director of epilepsy and movement disorders surgery at the University of Pittsburgh Medical Center. He did not take part in the study but is familiar with its findings.
The average age of participants is 59 years, which Dr. Deuschl said is a bit younger than many other studies, and 69% are male. Eighty-five serious adverse events were reported in 52 patients; 57 were not linked to the procedure. One patient died of a surgery-related hematoma.
At 6 months, patients reported a 22% improvement (P less than .0001) on the Parkinson’s Disease Questionnaire (PDQ-39), Dr. Deuschl said, and that level was sustained at 1 year.
That level of improvement is significant, Dr. Richardson said in an interview.
“Previous randomized, controlled trials have shown that patients who are candidates for DBS but who continue medical management alone are most likely to have no improvement at all on any quality of life measures,” he said. In addition, “6 months is fairly short, and some patients likely have not reached stable stimulation programming and effectiveness.”
The researchers also reported that more than 90% of patients, their clinicians, and their caregivers reported improvement.
This kind of study is valuable in light of skepticism about DBS, which is used to treat patients who do not respond to medication, Dr. Tagliati noted.
“Despite 15 years of [Food and Drug Administration] approval, there is still some form of resistance out there in referring patients with Parkinson’s at the right time when they can still fully benefit from the procedure,” he said. “Registries have this potential great benefit in terms of awareness and reassuring people.”
As for the high rating of improvement, Dr. Tagliati said it reflects what he sees in the clinic.
“Barring complications, we have very substantial satisfaction in our patients, definitely in the short term after DBS,” he said. “Over the long term, the picture is more difficult to read.”
Dr. Deuschl said researchers would like to add hundreds more patients to the study, and they hope to gain data about the differences between the results from standard and directional-lead DBS systems.
Boston Scientific funded the study, and some of the authors work for the company.
Dr. Richardson reported receiving research grant funding from Medtronic. Dr. Tagliati reported receiving funding from Abbott, Boston Scientific, Medtronic, and all DBS manufacturers, and his clinic is an investigational center for the Vercise DBS system. Dr. Deuschl reported receiving consulting fees from Boston Scientific, grant funding from Medtronic, lecture fees from Almirall and Novartis, and royalties from Thieme Publishers.
Nitrous oxide linked to less pain in tattoo removal
SAN DIEGO – The results of a small, single-site study suggest that nitrous oxide (NO) can play a significant role in reducing pain during laser tattoo removal.
“Nitrous oxide is a safe and effective option for patients, particularly those who have large tattoos that can’t be adequately numbed with injections or topical numbing,” the study’s lead author, Jared Mallalieu, DO, said in an interview. “NO has allowed us to treat larger tattoos – full sleeve or large back tattoos – in a single setting, which has made treatment more convenient for patients.”
Patients fared better on pain measures when they received NO, compared with topical and injectable anesthetics, according to Dr. Mallalieu, a cosmetic surgeon at the Laser Center of Maryland, Severna Park. The results were so dramatic that EMLA cream is now rarely used for patients in his clinic, although injectable lidocaine is used on smaller tattoos (smaller than 5 inches by 5 inches), he said.
The use of NO comes with challenges, however, in terms of the extra time and patient monitoring required, he said.
Dr. Mallalieu and his associates reported the results in an e-poster at the annual meeting of the American Society for Laser Medicine and Surgery.
Laser tattoo removal can be an agonizing process. “Patients describe it as being significantly more painful than getting a tattoo,” Dr. Mallalieu said. “The intense pain only lasts during the treatment,” he said, “though many patients will note some discomfort for a few hours after a treatment session.”
Most clinics use a topical cream, such as lidocaine/prilocaine (EMLA) or topical benzocaine/lidocaine/tetracaine (BLT), as an anesthetic for these procedures. “Our center has also used 1% lidocaine with epinephrine in small doses of up to 7 mg/kg,” he said. “The injections are much better than the cream.”
Sometimes the clinic uses a device that blows cold air on the skin, which “helps a little,” he added.
For the study, conducted in 2014, 23 laser tattoo removal patients were surveyed about their pain levels using a 1-10 scale, after undergoing a total of 41 single-location procedures.
The average pain rating during the procedure was 9.1 for those treated only with lidocaine/prilocaine, 5.4 for injections of lidocaine with epinephrine alone, and 6.8 for both lidocaine/prilocaine and lidocaine with epinephrine injections.
The average pain rating for NO alone was 2.6, and was 3.6 for those who received both the injection treatment and lidocaine/prilocaine. Three of 12 NO patients reported anxiety.
Another benefit is that patients can drive after receiving NO, unlike other anesthetics, which leave patients sedated, he said. “Levels of NO are titrated to keep the patient sedated, but breathing on their own,” and patients can be easily woken up within moments of stopping the NO.
However, the use of NO requires more time to set up and more monitoring, he added. The average treatment time for procedures with NO was 27 minutes compared with 4 minutes for the other procedure, and “the patient is put on a monitor that measures pulse rate and oxygenation levels,” which not only takes more time, but requires additional staff to watch the patient. “Also, it takes about 3-5 minutes to slowly the titrate the NO to a perfect level.”
The study points out that physicians at the clinic are the only ones who perform the procedures that use NO, but at many clinics, nonphysicians perform tattoo removals.
As for cost, “NO and oxygen tanks are rather inexpensive to purchase and maintain, and there are various small units which serve to titrate the gas,” Dr. Mallalieu said. “We do charge our patients a small fee because of the added personnel and time cost associated with the procedure. As tattoo removal is considered a cosmetic procedure, insurance doesn’t come into play.”
Training to administer NO brings up the issue of what is allowed in the state, he said. Physicians can give sedation to patients, “but some states may limit the degree to which a patient can be sedated in an office. If the physician has a certified operating room, this is not a problem,” he added. “Because dentists commonly use NO, we followed the American Dental Association guidelines ... As we employ an anesthesiologist, we were quite familiar with it. That said, the administration of NO is not complex and [is] easily mastered.”
Dr. Mallalieu reported no relevant disclosures.
SAN DIEGO – The results of a small, single-site study suggest that nitrous oxide (NO) can play a significant role in reducing pain during laser tattoo removal.
“Nitrous oxide is a safe and effective option for patients, particularly those who have large tattoos that can’t be adequately numbed with injections or topical numbing,” the study’s lead author, Jared Mallalieu, DO, said in an interview. “NO has allowed us to treat larger tattoos – full sleeve or large back tattoos – in a single setting, which has made treatment more convenient for patients.”
Patients fared better on pain measures when they received NO, compared with topical and injectable anesthetics, according to Dr. Mallalieu, a cosmetic surgeon at the Laser Center of Maryland, Severna Park. The results were so dramatic that EMLA cream is now rarely used for patients in his clinic, although injectable lidocaine is used on smaller tattoos (smaller than 5 inches by 5 inches), he said.
The use of NO comes with challenges, however, in terms of the extra time and patient monitoring required, he said.
Dr. Mallalieu and his associates reported the results in an e-poster at the annual meeting of the American Society for Laser Medicine and Surgery.
Laser tattoo removal can be an agonizing process. “Patients describe it as being significantly more painful than getting a tattoo,” Dr. Mallalieu said. “The intense pain only lasts during the treatment,” he said, “though many patients will note some discomfort for a few hours after a treatment session.”
Most clinics use a topical cream, such as lidocaine/prilocaine (EMLA) or topical benzocaine/lidocaine/tetracaine (BLT), as an anesthetic for these procedures. “Our center has also used 1% lidocaine with epinephrine in small doses of up to 7 mg/kg,” he said. “The injections are much better than the cream.”
Sometimes the clinic uses a device that blows cold air on the skin, which “helps a little,” he added.
For the study, conducted in 2014, 23 laser tattoo removal patients were surveyed about their pain levels using a 1-10 scale, after undergoing a total of 41 single-location procedures.
The average pain rating during the procedure was 9.1 for those treated only with lidocaine/prilocaine, 5.4 for injections of lidocaine with epinephrine alone, and 6.8 for both lidocaine/prilocaine and lidocaine with epinephrine injections.
The average pain rating for NO alone was 2.6, and was 3.6 for those who received both the injection treatment and lidocaine/prilocaine. Three of 12 NO patients reported anxiety.
Another benefit is that patients can drive after receiving NO, unlike other anesthetics, which leave patients sedated, he said. “Levels of NO are titrated to keep the patient sedated, but breathing on their own,” and patients can be easily woken up within moments of stopping the NO.
However, the use of NO requires more time to set up and more monitoring, he added. The average treatment time for procedures with NO was 27 minutes compared with 4 minutes for the other procedure, and “the patient is put on a monitor that measures pulse rate and oxygenation levels,” which not only takes more time, but requires additional staff to watch the patient. “Also, it takes about 3-5 minutes to slowly the titrate the NO to a perfect level.”
The study points out that physicians at the clinic are the only ones who perform the procedures that use NO, but at many clinics, nonphysicians perform tattoo removals.
As for cost, “NO and oxygen tanks are rather inexpensive to purchase and maintain, and there are various small units which serve to titrate the gas,” Dr. Mallalieu said. “We do charge our patients a small fee because of the added personnel and time cost associated with the procedure. As tattoo removal is considered a cosmetic procedure, insurance doesn’t come into play.”
Training to administer NO brings up the issue of what is allowed in the state, he said. Physicians can give sedation to patients, “but some states may limit the degree to which a patient can be sedated in an office. If the physician has a certified operating room, this is not a problem,” he added. “Because dentists commonly use NO, we followed the American Dental Association guidelines ... As we employ an anesthesiologist, we were quite familiar with it. That said, the administration of NO is not complex and [is] easily mastered.”
Dr. Mallalieu reported no relevant disclosures.
SAN DIEGO – The results of a small, single-site study suggest that nitrous oxide (NO) can play a significant role in reducing pain during laser tattoo removal.
“Nitrous oxide is a safe and effective option for patients, particularly those who have large tattoos that can’t be adequately numbed with injections or topical numbing,” the study’s lead author, Jared Mallalieu, DO, said in an interview. “NO has allowed us to treat larger tattoos – full sleeve or large back tattoos – in a single setting, which has made treatment more convenient for patients.”
Patients fared better on pain measures when they received NO, compared with topical and injectable anesthetics, according to Dr. Mallalieu, a cosmetic surgeon at the Laser Center of Maryland, Severna Park. The results were so dramatic that EMLA cream is now rarely used for patients in his clinic, although injectable lidocaine is used on smaller tattoos (smaller than 5 inches by 5 inches), he said.
The use of NO comes with challenges, however, in terms of the extra time and patient monitoring required, he said.
Dr. Mallalieu and his associates reported the results in an e-poster at the annual meeting of the American Society for Laser Medicine and Surgery.
Laser tattoo removal can be an agonizing process. “Patients describe it as being significantly more painful than getting a tattoo,” Dr. Mallalieu said. “The intense pain only lasts during the treatment,” he said, “though many patients will note some discomfort for a few hours after a treatment session.”
Most clinics use a topical cream, such as lidocaine/prilocaine (EMLA) or topical benzocaine/lidocaine/tetracaine (BLT), as an anesthetic for these procedures. “Our center has also used 1% lidocaine with epinephrine in small doses of up to 7 mg/kg,” he said. “The injections are much better than the cream.”
Sometimes the clinic uses a device that blows cold air on the skin, which “helps a little,” he added.
For the study, conducted in 2014, 23 laser tattoo removal patients were surveyed about their pain levels using a 1-10 scale, after undergoing a total of 41 single-location procedures.
The average pain rating during the procedure was 9.1 for those treated only with lidocaine/prilocaine, 5.4 for injections of lidocaine with epinephrine alone, and 6.8 for both lidocaine/prilocaine and lidocaine with epinephrine injections.
The average pain rating for NO alone was 2.6, and was 3.6 for those who received both the injection treatment and lidocaine/prilocaine. Three of 12 NO patients reported anxiety.
Another benefit is that patients can drive after receiving NO, unlike other anesthetics, which leave patients sedated, he said. “Levels of NO are titrated to keep the patient sedated, but breathing on their own,” and patients can be easily woken up within moments of stopping the NO.
However, the use of NO requires more time to set up and more monitoring, he added. The average treatment time for procedures with NO was 27 minutes compared with 4 minutes for the other procedure, and “the patient is put on a monitor that measures pulse rate and oxygenation levels,” which not only takes more time, but requires additional staff to watch the patient. “Also, it takes about 3-5 minutes to slowly the titrate the NO to a perfect level.”
The study points out that physicians at the clinic are the only ones who perform the procedures that use NO, but at many clinics, nonphysicians perform tattoo removals.
As for cost, “NO and oxygen tanks are rather inexpensive to purchase and maintain, and there are various small units which serve to titrate the gas,” Dr. Mallalieu said. “We do charge our patients a small fee because of the added personnel and time cost associated with the procedure. As tattoo removal is considered a cosmetic procedure, insurance doesn’t come into play.”
Training to administer NO brings up the issue of what is allowed in the state, he said. Physicians can give sedation to patients, “but some states may limit the degree to which a patient can be sedated in an office. If the physician has a certified operating room, this is not a problem,” he added. “Because dentists commonly use NO, we followed the American Dental Association guidelines ... As we employ an anesthesiologist, we were quite familiar with it. That said, the administration of NO is not complex and [is] easily mastered.”
Dr. Mallalieu reported no relevant disclosures.
Intervention may help stem weight gain tied to antipsychotics
SAN DIEGO – Extra pounds are a perennial problem for schizophrenia patients who take antipsychotic medications with weight-boosting side effects. Now, a new randomized study finds that veterans who took part in a 12-month behavioral intervention program performed better on weight-loss measurements than those in a control group.
The difference between the two groups was far from large, with those undergoing the intervention losing an average of 1.04 centimeters in waist circumference over a year, compared with an average gain of 0.25 centimeters in the control group (P less than .001).
A recent meta-analysis found that weight gain is a potential side effect from prolonged use of “virtually all” antipsychotic medications, especially in those who have not taken the drugs previously (PLoS One. 2014 Apr 24;9[4]:e94112).
“Some of the most effective medications are associated with the highest weight-gain liability,” Dr. Ames said in an interview, “and patients with medication-resistant psychosis who don’t want to gain weight will resist taking these medications.”
As the meta-analysis notes, research suggests that the weight gain prompted by antipsychotics may boost mortality risk in patients with severe mental illness. The metabolic havoc linked to schizophrenia may be another factor: A 2010 summary of research notes that newer second-generation antipsychotics “generally tend to cause more problems relating to metabolic syndrome, such as obesity and type 2 diabetes mellitus,” compared with first-generation antipsychotics (FGA).
Weight gain “can be rapid and difficult to control,” the summary authors write,” adding that “the effect is worse with clozapine and olanzapine; minimal with aripiprazole and ziprasidone; and intermediate with other antipsychotics, including low-potency FGAs” (Am Fam Physician. 2010 Mar 1;81[5]:617-22).
For the new study, researchers randomly assigned 121 overweight or obese subjects with serious mental illness to either a “lifestyle balance” (LB) program (n = 62) or a usual care (UC) program (n = 59). All had become obese while taking an antipsychotic.
Subjects in the LB program met with registered dietitians for individual health coaching, weekly for 8 weeks and then monthly for up to 10 months. They also took part in 16 group nutrition and exercise classes over 2 months.
The UC group, meanwhile, met with case managers weekly for 8 weeks and then monthly for up to 10 months. They answered health questionnaires, underwent weight checks, and received self-help materials, Dr. Ames reported at the International Congress on Schizophrenia Research.
All of the participants lost weight, although waist circumference only declined in the intervention group. Body fat percentage declined in both groups, but by more (0.4% vs. 0.2%) in the intervention group, compared with UC (P = .038).
Judging by food diaries kept by 92% of the intervention group participants, their average daily caloric intake declined from 2,055 to 1,650 (P less than 0.001). The UC participants did not keep food diaries, so their caloric intake isn’t available.
Shouldn’t the intervention participants have lost more weight in light of such a large caloric decline? “Not necessarily,” Dr. Ames said. “Participants who were successful at making dietary changes began making these changes at different times throughout the study, some early and some well into the yearlong study. Decreases made in the latter part of the study would result in less weight lost. Also, exercise activity was variable, so decreased caloric intake could be offset by decreased physical activity.”
Other findings: Women did better than men at losing weight, and reducing waist circumference and body fat. There wasn’t a significant difference in the level of exercise between the groups. And researchers linked psychiatric illness insight in the LB group to greater weight loss but not in the UC group.
The study is supported by a $1.9 million VA grant for research from 2010 to 2017, Dr. Ames said.
In regard to cost-effectiveness, she said “a psychiatrist, nurse, or other mental health professional could easily weave these interventions into the care of patients in mental health settings. And the cost savings to patients by even losing just a few pounds could be enormous.”
The researchers hope to examine whether the intervention reduces the cost of medications, emergency department visits, and hospitalizations, she said.
Dr. Ames reports no relevant disclosures.
SAN DIEGO – Extra pounds are a perennial problem for schizophrenia patients who take antipsychotic medications with weight-boosting side effects. Now, a new randomized study finds that veterans who took part in a 12-month behavioral intervention program performed better on weight-loss measurements than those in a control group.
The difference between the two groups was far from large, with those undergoing the intervention losing an average of 1.04 centimeters in waist circumference over a year, compared with an average gain of 0.25 centimeters in the control group (P less than .001).
A recent meta-analysis found that weight gain is a potential side effect from prolonged use of “virtually all” antipsychotic medications, especially in those who have not taken the drugs previously (PLoS One. 2014 Apr 24;9[4]:e94112).
“Some of the most effective medications are associated with the highest weight-gain liability,” Dr. Ames said in an interview, “and patients with medication-resistant psychosis who don’t want to gain weight will resist taking these medications.”
As the meta-analysis notes, research suggests that the weight gain prompted by antipsychotics may boost mortality risk in patients with severe mental illness. The metabolic havoc linked to schizophrenia may be another factor: A 2010 summary of research notes that newer second-generation antipsychotics “generally tend to cause more problems relating to metabolic syndrome, such as obesity and type 2 diabetes mellitus,” compared with first-generation antipsychotics (FGA).
Weight gain “can be rapid and difficult to control,” the summary authors write,” adding that “the effect is worse with clozapine and olanzapine; minimal with aripiprazole and ziprasidone; and intermediate with other antipsychotics, including low-potency FGAs” (Am Fam Physician. 2010 Mar 1;81[5]:617-22).
For the new study, researchers randomly assigned 121 overweight or obese subjects with serious mental illness to either a “lifestyle balance” (LB) program (n = 62) or a usual care (UC) program (n = 59). All had become obese while taking an antipsychotic.
Subjects in the LB program met with registered dietitians for individual health coaching, weekly for 8 weeks and then monthly for up to 10 months. They also took part in 16 group nutrition and exercise classes over 2 months.
The UC group, meanwhile, met with case managers weekly for 8 weeks and then monthly for up to 10 months. They answered health questionnaires, underwent weight checks, and received self-help materials, Dr. Ames reported at the International Congress on Schizophrenia Research.
All of the participants lost weight, although waist circumference only declined in the intervention group. Body fat percentage declined in both groups, but by more (0.4% vs. 0.2%) in the intervention group, compared with UC (P = .038).
Judging by food diaries kept by 92% of the intervention group participants, their average daily caloric intake declined from 2,055 to 1,650 (P less than 0.001). The UC participants did not keep food diaries, so their caloric intake isn’t available.
Shouldn’t the intervention participants have lost more weight in light of such a large caloric decline? “Not necessarily,” Dr. Ames said. “Participants who were successful at making dietary changes began making these changes at different times throughout the study, some early and some well into the yearlong study. Decreases made in the latter part of the study would result in less weight lost. Also, exercise activity was variable, so decreased caloric intake could be offset by decreased physical activity.”
Other findings: Women did better than men at losing weight, and reducing waist circumference and body fat. There wasn’t a significant difference in the level of exercise between the groups. And researchers linked psychiatric illness insight in the LB group to greater weight loss but not in the UC group.
The study is supported by a $1.9 million VA grant for research from 2010 to 2017, Dr. Ames said.
In regard to cost-effectiveness, she said “a psychiatrist, nurse, or other mental health professional could easily weave these interventions into the care of patients in mental health settings. And the cost savings to patients by even losing just a few pounds could be enormous.”
The researchers hope to examine whether the intervention reduces the cost of medications, emergency department visits, and hospitalizations, she said.
Dr. Ames reports no relevant disclosures.
SAN DIEGO – Extra pounds are a perennial problem for schizophrenia patients who take antipsychotic medications with weight-boosting side effects. Now, a new randomized study finds that veterans who took part in a 12-month behavioral intervention program performed better on weight-loss measurements than those in a control group.
The difference between the two groups was far from large, with those undergoing the intervention losing an average of 1.04 centimeters in waist circumference over a year, compared with an average gain of 0.25 centimeters in the control group (P less than .001).
A recent meta-analysis found that weight gain is a potential side effect from prolonged use of “virtually all” antipsychotic medications, especially in those who have not taken the drugs previously (PLoS One. 2014 Apr 24;9[4]:e94112).
“Some of the most effective medications are associated with the highest weight-gain liability,” Dr. Ames said in an interview, “and patients with medication-resistant psychosis who don’t want to gain weight will resist taking these medications.”
As the meta-analysis notes, research suggests that the weight gain prompted by antipsychotics may boost mortality risk in patients with severe mental illness. The metabolic havoc linked to schizophrenia may be another factor: A 2010 summary of research notes that newer second-generation antipsychotics “generally tend to cause more problems relating to metabolic syndrome, such as obesity and type 2 diabetes mellitus,” compared with first-generation antipsychotics (FGA).
Weight gain “can be rapid and difficult to control,” the summary authors write,” adding that “the effect is worse with clozapine and olanzapine; minimal with aripiprazole and ziprasidone; and intermediate with other antipsychotics, including low-potency FGAs” (Am Fam Physician. 2010 Mar 1;81[5]:617-22).
For the new study, researchers randomly assigned 121 overweight or obese subjects with serious mental illness to either a “lifestyle balance” (LB) program (n = 62) or a usual care (UC) program (n = 59). All had become obese while taking an antipsychotic.
Subjects in the LB program met with registered dietitians for individual health coaching, weekly for 8 weeks and then monthly for up to 10 months. They also took part in 16 group nutrition and exercise classes over 2 months.
The UC group, meanwhile, met with case managers weekly for 8 weeks and then monthly for up to 10 months. They answered health questionnaires, underwent weight checks, and received self-help materials, Dr. Ames reported at the International Congress on Schizophrenia Research.
All of the participants lost weight, although waist circumference only declined in the intervention group. Body fat percentage declined in both groups, but by more (0.4% vs. 0.2%) in the intervention group, compared with UC (P = .038).
Judging by food diaries kept by 92% of the intervention group participants, their average daily caloric intake declined from 2,055 to 1,650 (P less than 0.001). The UC participants did not keep food diaries, so their caloric intake isn’t available.
Shouldn’t the intervention participants have lost more weight in light of such a large caloric decline? “Not necessarily,” Dr. Ames said. “Participants who were successful at making dietary changes began making these changes at different times throughout the study, some early and some well into the yearlong study. Decreases made in the latter part of the study would result in less weight lost. Also, exercise activity was variable, so decreased caloric intake could be offset by decreased physical activity.”
Other findings: Women did better than men at losing weight, and reducing waist circumference and body fat. There wasn’t a significant difference in the level of exercise between the groups. And researchers linked psychiatric illness insight in the LB group to greater weight loss but not in the UC group.
The study is supported by a $1.9 million VA grant for research from 2010 to 2017, Dr. Ames said.
In regard to cost-effectiveness, she said “a psychiatrist, nurse, or other mental health professional could easily weave these interventions into the care of patients in mental health settings. And the cost savings to patients by even losing just a few pounds could be enormous.”
The researchers hope to examine whether the intervention reduces the cost of medications, emergency department visits, and hospitalizations, she said.
Dr. Ames reports no relevant disclosures.
AT THE ICSR BIENNIAL MEETING
Gotta catch ’em all: Is Pokémon Go an intervention for schizophrenia?
San Diego – A 22-year-old Minnesota patient with schizophrenia tried to “catch ’em all” during last year’s Pokémon Go craze, and he ended up landing something even more important: motivation to get outside and meet people.
That’s the word from clinicians who report that the game dramatically transformed the young man’s life, coaxing him to leave his house, chat with other players, and even stop worrying so much about his movement disorder.
Could Pokémon Go become a treatment for people with mental illness who need motivation to leave their homes? It’s not clear, and the decline of the Pokémon Go phenomenon may make it difficult for researchers to find out, at least until another version sweeps the nation.
The Minnesota clinicians want to study the idea; they also want to know why it seems – based on a tiny sample – that patients with schizophrenia may have trouble tolerating the “augmented reality” built into the game.
Dr. Elmaghraby and his coauthor Suzanne Geier Jasberg, MD, an attending psychiatrist with PrairieCare Medical Group in Minneapolis, described their findings in a poster at the International Congress on Schizophrenia Research.
The Pokémon Go game appeared in the summer of 2016, and during that time, many of the young patients attending a first-episode psychosis clinic began talking about playing it, Dr. Elmaghraby said in an interview.
“They have the negative symptoms – they’re socially isolated, withdrawing from friends and families, and don’t engage with society,” she said. But the game requires users to travel around the real world in search of Pokémon characters.
“People who hadn’t left the house in many days were getting multiple steps per day by going out in the environment and engaging with other people,” she said.
The poster focuses on the 22-year-old male, who had the disorganized type of schizophrenia with auditory and visual hallucinations. He also had residual dyskinetic movements related to a previous stint on risperidone.
His thought processes were improving, but he’d had trouble leaving the house for 6 months. Then, the game coaxed him into a new phase.
“He demonstrated remarkable improvement in his negative symptoms, most notably motivation,” the clinicians wrote. “The game seemed to have a unique ability to motivate this young person to engage more robustly in social interactions.”
They also noticed that several patients, including the young man, engaged in a peculiar behavior: They turned off the “augmented reality” in the game.
Normally, Pokémon Go players keep the augmented reality feature on, allowing them to see Pokémon characters as if they’re actually nearby. Smartphone screens create the illusion by blending their live camera view of the world with images of the characters. (Think about how Dick Van Dyke appears to dance with animated penguins in “Mary Poppins,” and you’ll get the idea.)
In this augmented reality, your smartphone screen may makes it appear as if a Pokémon character is on top of the coffee cup at your desk, said report coauthor Dr. Jasberg. This feature adds to the immediacy and fun of the game.
But players can turn off this feature, eliminating the view of the world through the smartphone camera. Instead of appearing as if they’re nearby in the real world, the characters simply show up on a green screen, Dr. Jasberg said. (Players still have to go places to find them.)
The patients couldn’t explain why they preferred to turn off the feature, which is easily done, Dr. Elmaghraby said. However, they indicated that it’s not in order to preserve battery life, she said.
Dr. Elmaghraby speculates that their choices may have something to do with their underlying sensory processing dysfunction.
The clinicians hope to study how the brains of patients with schizophrenia work when they play the game with the augmented reality turned off and on. And they’re intrigued by how such games as Pokémon Go might encourage people to move and become socially engaged.
There’s been fairly little published research into the effects of the Pokémon Go craze, possibly because it erupted so recently. Several studies have examined its effects on exercise, with one analysis of college students suggesting that it especially boosted activity levels in the formerly sedentary (Int J Health Geogr. 2017 Feb 22;16[1]:8). Another study of young adults found that the increase of activity in players was moderate and vanished after 6 weeks (BMJ. 2016 Dec 13;355:i6270).
For now, Dr. Jasberg encouraged clinicians to be aware of Pokémon Go and understand that it’s a low-risk intervention. The clinicians didn’t notice any negative impacts, although it’s possible that parents may have gotten zinged by a distinctly modern phenomenon – overtaxed smartphone data plans.
The authors reported no relevant disclosures.
San Diego – A 22-year-old Minnesota patient with schizophrenia tried to “catch ’em all” during last year’s Pokémon Go craze, and he ended up landing something even more important: motivation to get outside and meet people.
That’s the word from clinicians who report that the game dramatically transformed the young man’s life, coaxing him to leave his house, chat with other players, and even stop worrying so much about his movement disorder.
Could Pokémon Go become a treatment for people with mental illness who need motivation to leave their homes? It’s not clear, and the decline of the Pokémon Go phenomenon may make it difficult for researchers to find out, at least until another version sweeps the nation.
The Minnesota clinicians want to study the idea; they also want to know why it seems – based on a tiny sample – that patients with schizophrenia may have trouble tolerating the “augmented reality” built into the game.
Dr. Elmaghraby and his coauthor Suzanne Geier Jasberg, MD, an attending psychiatrist with PrairieCare Medical Group in Minneapolis, described their findings in a poster at the International Congress on Schizophrenia Research.
The Pokémon Go game appeared in the summer of 2016, and during that time, many of the young patients attending a first-episode psychosis clinic began talking about playing it, Dr. Elmaghraby said in an interview.
“They have the negative symptoms – they’re socially isolated, withdrawing from friends and families, and don’t engage with society,” she said. But the game requires users to travel around the real world in search of Pokémon characters.
“People who hadn’t left the house in many days were getting multiple steps per day by going out in the environment and engaging with other people,” she said.
The poster focuses on the 22-year-old male, who had the disorganized type of schizophrenia with auditory and visual hallucinations. He also had residual dyskinetic movements related to a previous stint on risperidone.
His thought processes were improving, but he’d had trouble leaving the house for 6 months. Then, the game coaxed him into a new phase.
“He demonstrated remarkable improvement in his negative symptoms, most notably motivation,” the clinicians wrote. “The game seemed to have a unique ability to motivate this young person to engage more robustly in social interactions.”
They also noticed that several patients, including the young man, engaged in a peculiar behavior: They turned off the “augmented reality” in the game.
Normally, Pokémon Go players keep the augmented reality feature on, allowing them to see Pokémon characters as if they’re actually nearby. Smartphone screens create the illusion by blending their live camera view of the world with images of the characters. (Think about how Dick Van Dyke appears to dance with animated penguins in “Mary Poppins,” and you’ll get the idea.)
In this augmented reality, your smartphone screen may makes it appear as if a Pokémon character is on top of the coffee cup at your desk, said report coauthor Dr. Jasberg. This feature adds to the immediacy and fun of the game.
But players can turn off this feature, eliminating the view of the world through the smartphone camera. Instead of appearing as if they’re nearby in the real world, the characters simply show up on a green screen, Dr. Jasberg said. (Players still have to go places to find them.)
The patients couldn’t explain why they preferred to turn off the feature, which is easily done, Dr. Elmaghraby said. However, they indicated that it’s not in order to preserve battery life, she said.
Dr. Elmaghraby speculates that their choices may have something to do with their underlying sensory processing dysfunction.
The clinicians hope to study how the brains of patients with schizophrenia work when they play the game with the augmented reality turned off and on. And they’re intrigued by how such games as Pokémon Go might encourage people to move and become socially engaged.
There’s been fairly little published research into the effects of the Pokémon Go craze, possibly because it erupted so recently. Several studies have examined its effects on exercise, with one analysis of college students suggesting that it especially boosted activity levels in the formerly sedentary (Int J Health Geogr. 2017 Feb 22;16[1]:8). Another study of young adults found that the increase of activity in players was moderate and vanished after 6 weeks (BMJ. 2016 Dec 13;355:i6270).
For now, Dr. Jasberg encouraged clinicians to be aware of Pokémon Go and understand that it’s a low-risk intervention. The clinicians didn’t notice any negative impacts, although it’s possible that parents may have gotten zinged by a distinctly modern phenomenon – overtaxed smartphone data plans.
The authors reported no relevant disclosures.
San Diego – A 22-year-old Minnesota patient with schizophrenia tried to “catch ’em all” during last year’s Pokémon Go craze, and he ended up landing something even more important: motivation to get outside and meet people.
That’s the word from clinicians who report that the game dramatically transformed the young man’s life, coaxing him to leave his house, chat with other players, and even stop worrying so much about his movement disorder.
Could Pokémon Go become a treatment for people with mental illness who need motivation to leave their homes? It’s not clear, and the decline of the Pokémon Go phenomenon may make it difficult for researchers to find out, at least until another version sweeps the nation.
The Minnesota clinicians want to study the idea; they also want to know why it seems – based on a tiny sample – that patients with schizophrenia may have trouble tolerating the “augmented reality” built into the game.
Dr. Elmaghraby and his coauthor Suzanne Geier Jasberg, MD, an attending psychiatrist with PrairieCare Medical Group in Minneapolis, described their findings in a poster at the International Congress on Schizophrenia Research.
The Pokémon Go game appeared in the summer of 2016, and during that time, many of the young patients attending a first-episode psychosis clinic began talking about playing it, Dr. Elmaghraby said in an interview.
“They have the negative symptoms – they’re socially isolated, withdrawing from friends and families, and don’t engage with society,” she said. But the game requires users to travel around the real world in search of Pokémon characters.
“People who hadn’t left the house in many days were getting multiple steps per day by going out in the environment and engaging with other people,” she said.
The poster focuses on the 22-year-old male, who had the disorganized type of schizophrenia with auditory and visual hallucinations. He also had residual dyskinetic movements related to a previous stint on risperidone.
His thought processes were improving, but he’d had trouble leaving the house for 6 months. Then, the game coaxed him into a new phase.
“He demonstrated remarkable improvement in his negative symptoms, most notably motivation,” the clinicians wrote. “The game seemed to have a unique ability to motivate this young person to engage more robustly in social interactions.”
They also noticed that several patients, including the young man, engaged in a peculiar behavior: They turned off the “augmented reality” in the game.
Normally, Pokémon Go players keep the augmented reality feature on, allowing them to see Pokémon characters as if they’re actually nearby. Smartphone screens create the illusion by blending their live camera view of the world with images of the characters. (Think about how Dick Van Dyke appears to dance with animated penguins in “Mary Poppins,” and you’ll get the idea.)
In this augmented reality, your smartphone screen may makes it appear as if a Pokémon character is on top of the coffee cup at your desk, said report coauthor Dr. Jasberg. This feature adds to the immediacy and fun of the game.
But players can turn off this feature, eliminating the view of the world through the smartphone camera. Instead of appearing as if they’re nearby in the real world, the characters simply show up on a green screen, Dr. Jasberg said. (Players still have to go places to find them.)
The patients couldn’t explain why they preferred to turn off the feature, which is easily done, Dr. Elmaghraby said. However, they indicated that it’s not in order to preserve battery life, she said.
Dr. Elmaghraby speculates that their choices may have something to do with their underlying sensory processing dysfunction.
The clinicians hope to study how the brains of patients with schizophrenia work when they play the game with the augmented reality turned off and on. And they’re intrigued by how such games as Pokémon Go might encourage people to move and become socially engaged.
There’s been fairly little published research into the effects of the Pokémon Go craze, possibly because it erupted so recently. Several studies have examined its effects on exercise, with one analysis of college students suggesting that it especially boosted activity levels in the formerly sedentary (Int J Health Geogr. 2017 Feb 22;16[1]:8). Another study of young adults found that the increase of activity in players was moderate and vanished after 6 weeks (BMJ. 2016 Dec 13;355:i6270).
For now, Dr. Jasberg encouraged clinicians to be aware of Pokémon Go and understand that it’s a low-risk intervention. The clinicians didn’t notice any negative impacts, although it’s possible that parents may have gotten zinged by a distinctly modern phenomenon – overtaxed smartphone data plans.
The authors reported no relevant disclosures.
AT THE ICSR BIENNIAL MEETING
Calcium scores may assist cardiac screening in African Americans
A new study suggests calcium scores may help physicians as they navigate a wide cardiac screening guideline gap over recommendations about statin therapy in African Americans.
In a study sample of Mississippi residents, researchers found that the 2016 U.S. Preventive Services Task Force guidelines would reject statins for a quarter of the African Americans who’d be deemed statin eligible by the 2013 American College of Cardiology/American Heart Association (ACC/AHA) recommendations.
“ACC/AHA guidelines are more sensitive, but may lead to overtreatment of those who may not be at increased risk of cardiovascular disease,” said study coauthor Aferdita Spahillari, MD, a cardiology fellow at Tufts Medical Center and Beth Israel Deaconess Medical Center, Boston. In contrast, the task force guidelines “are more specific, yet they may miss individuals at higher risk who should be treated with statins,” she said.
Regardless of which screening guidelines are used, Dr. Spahillari said, “calcium scoring may aid decision making in those cases where guideline recommendations may be divergent.”
The study was presented at the annual meeting of the American College of Cardiology and published simultaneously in the JAMA Cardiology (doi: 10.1001/jamacardio.2017.0944).
The researchers sought to answer these questions: How do the ACC/AHA and task force guidelines perform at identifying at-risk African Americans? And can calcium scores help refine decisions regarding statins? According to Dr. Spahillari, the latter issue has been studied in whites but not large African American populations.
Insight could help physicians better provide preventive treatment to African Americans, who face a higher risk of cardiac problems compared with whites. In addition, “studies have shown that racial disparities exist in prescription of cardioprotective medications,” Dr. Spahillari said, “and African Americans are prescribed statins less frequently than whites.”
For the new study, researchers tracked 2,812 African American individuals aged 40-75 years (mean age 55 [SD 9.4], 65.3% female, mean body mass index 31.6 kg/m2 [SD 7.0]) in the Jackson, Miss., area. They were examined in 2000-2004, 2005-2008, and 2009-2013 and included if they didn’t show signs of prevalent subclinical and clinical atherosclerotic cardiovascular disease and weren’t on statins at baseline.
If the task force guidelines regarding 10-year risk had been in existence, 1,072 (38.1%) of the participants would have been deemed eligible for treatment. A higher number – 1,404 (49.9%) – would have been eligible under ACC/AHA guidelines (risk difference, 11.8%; 95% CI, 10.5-13.1; P less than .001).
The two sets of guidelines diverged on the eligibility of 13.8% of the total subjects: 361 (12.8%) were deemed eligible for statins by the ACC/AHA guidelines alone. (They account for 25.7% of all the statin-eligible subjects under the ACC/AHA guidelines.)
In contrast, the task force guidelines alone deemed 29 (1%) to be eligible.
Those deemed eligible for statins under both guidelines had a cardiovascular event rate of 9.6 per 1,000 patient-years (95% CI, 7.8-11.8, P = .003) over a median 10-year follow-up. The event rate for those only statin-eligible under the ACC/AHA guidelines had an event rate of 4.1 events per 1,000 patient-years (95% CI, 2.4-6.9; P = .003), which Dr. Spahillari calls “a low to intermediate rate suggesting a decreased sensitivity of the task force recommendations in identifying participants at risk of atherosclerotic cardiovascular disease.”
And what about CAC levels? Task force guidelines identified 404 of 732 (55.2%) African Americans with coronary calcium; ACC/AHA guidelines identified 507 (69.3%).
“Participants eligible for statins under the ACC/AHA guidelines who had CAC were at higher risk than those without CAC,” Dr. Spahillari said. Specifically, among those deemed eligible for statins by the ACC/AHA recommendations, the 10-year event rate per 1,000 person-years was 8.1 (95% CI, 5.9-11.1) in those with CAC and 3.1 (95% CI, 1.6-5.9) in those without CAC (P = .02).
The situation was different under the task force guidelines. CAC didn’t significantly affect the risk in those deemed eligible for statins by the task force guidelines, but it did seem to boost risk in those who weren’t statin eligible, she said.
Among those deemed not statin eligible by the task force guidelines, the event rate per 1,000 person-years was 2.8 in those with CAC (95% CI, 1.5-5.4) and 0.8 in those without (95%, CI 0.3-1.7) (P = .03).
How could CAC levels be useful for physicians? “As the role of CAC measurement is evolving, our findings support that measurement of CAC in an African-American population with an intermediate risk score would be clinically useful,” Dr. Spahillari said.
When ACC/AHA guidelines are used, she said, “the absence of CAC may reduce the number of individuals indicated for treatment with statins by ACC/AHA recommendations and temper concerns for overtreatment.”
What if a physician uses the task force guidelines in this population? “The presence of CAC may push a recommendation for statin treatment in individuals who would otherwise not be indicated for statins,” she said.
The National Heart, Lung, and Blood Institute and the National Institute on Minority Health and Health Disparities funded the study. One author reported funding from a National Institutes of Health grant. The others had no disclosures.
A new study suggests calcium scores may help physicians as they navigate a wide cardiac screening guideline gap over recommendations about statin therapy in African Americans.
In a study sample of Mississippi residents, researchers found that the 2016 U.S. Preventive Services Task Force guidelines would reject statins for a quarter of the African Americans who’d be deemed statin eligible by the 2013 American College of Cardiology/American Heart Association (ACC/AHA) recommendations.
“ACC/AHA guidelines are more sensitive, but may lead to overtreatment of those who may not be at increased risk of cardiovascular disease,” said study coauthor Aferdita Spahillari, MD, a cardiology fellow at Tufts Medical Center and Beth Israel Deaconess Medical Center, Boston. In contrast, the task force guidelines “are more specific, yet they may miss individuals at higher risk who should be treated with statins,” she said.
Regardless of which screening guidelines are used, Dr. Spahillari said, “calcium scoring may aid decision making in those cases where guideline recommendations may be divergent.”
The study was presented at the annual meeting of the American College of Cardiology and published simultaneously in the JAMA Cardiology (doi: 10.1001/jamacardio.2017.0944).
The researchers sought to answer these questions: How do the ACC/AHA and task force guidelines perform at identifying at-risk African Americans? And can calcium scores help refine decisions regarding statins? According to Dr. Spahillari, the latter issue has been studied in whites but not large African American populations.
Insight could help physicians better provide preventive treatment to African Americans, who face a higher risk of cardiac problems compared with whites. In addition, “studies have shown that racial disparities exist in prescription of cardioprotective medications,” Dr. Spahillari said, “and African Americans are prescribed statins less frequently than whites.”
For the new study, researchers tracked 2,812 African American individuals aged 40-75 years (mean age 55 [SD 9.4], 65.3% female, mean body mass index 31.6 kg/m2 [SD 7.0]) in the Jackson, Miss., area. They were examined in 2000-2004, 2005-2008, and 2009-2013 and included if they didn’t show signs of prevalent subclinical and clinical atherosclerotic cardiovascular disease and weren’t on statins at baseline.
If the task force guidelines regarding 10-year risk had been in existence, 1,072 (38.1%) of the participants would have been deemed eligible for treatment. A higher number – 1,404 (49.9%) – would have been eligible under ACC/AHA guidelines (risk difference, 11.8%; 95% CI, 10.5-13.1; P less than .001).
The two sets of guidelines diverged on the eligibility of 13.8% of the total subjects: 361 (12.8%) were deemed eligible for statins by the ACC/AHA guidelines alone. (They account for 25.7% of all the statin-eligible subjects under the ACC/AHA guidelines.)
In contrast, the task force guidelines alone deemed 29 (1%) to be eligible.
Those deemed eligible for statins under both guidelines had a cardiovascular event rate of 9.6 per 1,000 patient-years (95% CI, 7.8-11.8, P = .003) over a median 10-year follow-up. The event rate for those only statin-eligible under the ACC/AHA guidelines had an event rate of 4.1 events per 1,000 patient-years (95% CI, 2.4-6.9; P = .003), which Dr. Spahillari calls “a low to intermediate rate suggesting a decreased sensitivity of the task force recommendations in identifying participants at risk of atherosclerotic cardiovascular disease.”
And what about CAC levels? Task force guidelines identified 404 of 732 (55.2%) African Americans with coronary calcium; ACC/AHA guidelines identified 507 (69.3%).
“Participants eligible for statins under the ACC/AHA guidelines who had CAC were at higher risk than those without CAC,” Dr. Spahillari said. Specifically, among those deemed eligible for statins by the ACC/AHA recommendations, the 10-year event rate per 1,000 person-years was 8.1 (95% CI, 5.9-11.1) in those with CAC and 3.1 (95% CI, 1.6-5.9) in those without CAC (P = .02).
The situation was different under the task force guidelines. CAC didn’t significantly affect the risk in those deemed eligible for statins by the task force guidelines, but it did seem to boost risk in those who weren’t statin eligible, she said.
Among those deemed not statin eligible by the task force guidelines, the event rate per 1,000 person-years was 2.8 in those with CAC (95% CI, 1.5-5.4) and 0.8 in those without (95%, CI 0.3-1.7) (P = .03).
How could CAC levels be useful for physicians? “As the role of CAC measurement is evolving, our findings support that measurement of CAC in an African-American population with an intermediate risk score would be clinically useful,” Dr. Spahillari said.
When ACC/AHA guidelines are used, she said, “the absence of CAC may reduce the number of individuals indicated for treatment with statins by ACC/AHA recommendations and temper concerns for overtreatment.”
What if a physician uses the task force guidelines in this population? “The presence of CAC may push a recommendation for statin treatment in individuals who would otherwise not be indicated for statins,” she said.
The National Heart, Lung, and Blood Institute and the National Institute on Minority Health and Health Disparities funded the study. One author reported funding from a National Institutes of Health grant. The others had no disclosures.
A new study suggests calcium scores may help physicians as they navigate a wide cardiac screening guideline gap over recommendations about statin therapy in African Americans.
In a study sample of Mississippi residents, researchers found that the 2016 U.S. Preventive Services Task Force guidelines would reject statins for a quarter of the African Americans who’d be deemed statin eligible by the 2013 American College of Cardiology/American Heart Association (ACC/AHA) recommendations.
“ACC/AHA guidelines are more sensitive, but may lead to overtreatment of those who may not be at increased risk of cardiovascular disease,” said study coauthor Aferdita Spahillari, MD, a cardiology fellow at Tufts Medical Center and Beth Israel Deaconess Medical Center, Boston. In contrast, the task force guidelines “are more specific, yet they may miss individuals at higher risk who should be treated with statins,” she said.
Regardless of which screening guidelines are used, Dr. Spahillari said, “calcium scoring may aid decision making in those cases where guideline recommendations may be divergent.”
The study was presented at the annual meeting of the American College of Cardiology and published simultaneously in the JAMA Cardiology (doi: 10.1001/jamacardio.2017.0944).
The researchers sought to answer these questions: How do the ACC/AHA and task force guidelines perform at identifying at-risk African Americans? And can calcium scores help refine decisions regarding statins? According to Dr. Spahillari, the latter issue has been studied in whites but not large African American populations.
Insight could help physicians better provide preventive treatment to African Americans, who face a higher risk of cardiac problems compared with whites. In addition, “studies have shown that racial disparities exist in prescription of cardioprotective medications,” Dr. Spahillari said, “and African Americans are prescribed statins less frequently than whites.”
For the new study, researchers tracked 2,812 African American individuals aged 40-75 years (mean age 55 [SD 9.4], 65.3% female, mean body mass index 31.6 kg/m2 [SD 7.0]) in the Jackson, Miss., area. They were examined in 2000-2004, 2005-2008, and 2009-2013 and included if they didn’t show signs of prevalent subclinical and clinical atherosclerotic cardiovascular disease and weren’t on statins at baseline.
If the task force guidelines regarding 10-year risk had been in existence, 1,072 (38.1%) of the participants would have been deemed eligible for treatment. A higher number – 1,404 (49.9%) – would have been eligible under ACC/AHA guidelines (risk difference, 11.8%; 95% CI, 10.5-13.1; P less than .001).
The two sets of guidelines diverged on the eligibility of 13.8% of the total subjects: 361 (12.8%) were deemed eligible for statins by the ACC/AHA guidelines alone. (They account for 25.7% of all the statin-eligible subjects under the ACC/AHA guidelines.)
In contrast, the task force guidelines alone deemed 29 (1%) to be eligible.
Those deemed eligible for statins under both guidelines had a cardiovascular event rate of 9.6 per 1,000 patient-years (95% CI, 7.8-11.8, P = .003) over a median 10-year follow-up. The event rate for those only statin-eligible under the ACC/AHA guidelines had an event rate of 4.1 events per 1,000 patient-years (95% CI, 2.4-6.9; P = .003), which Dr. Spahillari calls “a low to intermediate rate suggesting a decreased sensitivity of the task force recommendations in identifying participants at risk of atherosclerotic cardiovascular disease.”
And what about CAC levels? Task force guidelines identified 404 of 732 (55.2%) African Americans with coronary calcium; ACC/AHA guidelines identified 507 (69.3%).
“Participants eligible for statins under the ACC/AHA guidelines who had CAC were at higher risk than those without CAC,” Dr. Spahillari said. Specifically, among those deemed eligible for statins by the ACC/AHA recommendations, the 10-year event rate per 1,000 person-years was 8.1 (95% CI, 5.9-11.1) in those with CAC and 3.1 (95% CI, 1.6-5.9) in those without CAC (P = .02).
The situation was different under the task force guidelines. CAC didn’t significantly affect the risk in those deemed eligible for statins by the task force guidelines, but it did seem to boost risk in those who weren’t statin eligible, she said.
Among those deemed not statin eligible by the task force guidelines, the event rate per 1,000 person-years was 2.8 in those with CAC (95% CI, 1.5-5.4) and 0.8 in those without (95%, CI 0.3-1.7) (P = .03).
How could CAC levels be useful for physicians? “As the role of CAC measurement is evolving, our findings support that measurement of CAC in an African-American population with an intermediate risk score would be clinically useful,” Dr. Spahillari said.
When ACC/AHA guidelines are used, she said, “the absence of CAC may reduce the number of individuals indicated for treatment with statins by ACC/AHA recommendations and temper concerns for overtreatment.”
What if a physician uses the task force guidelines in this population? “The presence of CAC may push a recommendation for statin treatment in individuals who would otherwise not be indicated for statins,” she said.
The National Heart, Lung, and Blood Institute and the National Institute on Minority Health and Health Disparities funded the study. One author reported funding from a National Institutes of Health grant. The others had no disclosures.
FROM ACC 17
Key clinical point: Cardiac screening guidelines diverge on statin-eligible African Americans, but calcium levels can provide treatment insight.
Major finding: U.S. Preventive Services Task Force guidelines did not recommend statins in 25.7% of 1,404 African Americans who were deemed statin eligible by American College of Cardiology/American Heart Association guidelines.
Data source: Prospective, community-based study of 2,812 African American subjects in Mississippi – aged 40-75 years, mean age 55, 65.3% female, mean body mass index 31.6 kg/m2 – tracked for median of 10 years; 1,743 underwent computed tomography.
Disclosures: The National Heart, Lung, and Blood Institute and the National Institute on Minority Health and Health Disparities funded the study. One author reported funding from a National Institutes of Health grant. The others had no disclosures.
No benefit found for routine inpatient rehab after knee replacement
A new randomized study from Australia suggests that for many patients, brief inpatient rehabilitation after knee replacement provides no benefits in several measures, compared with rehab at home.
However, “we are not concluding that there is no role for inpatient rehabilitation after knee arthroplasty,” said study coauthor Justine Naylor, PhD, of the University of New South Wales, Liverpool, Australia. “We are simply saying that for people who are otherwise well enough to be discharged directly home, inpatient rehabilitation does not provide more superior recovery across a range of outcomes.”
For the new study, conducted at two Australian hospitals during 2012-2015, researchers recruited patients aged 40 years or older with a primary diagnosis of osteoarthritis who were undergoing a primary unilateral knee arthroplasty and did not have complications such as a need for inpatient care in recovery beyond an initial 5 days after surgery.
The researchers randomly assigned 165 knee arthroplasty patients with uncomplicated cases to undergo either inpatient rehabilitation for 10 days and then recover at home for 6 weeks or a monitored 6-week home rehab program that began 2 weeks after surgery (JAMA. 2017;317[10]:1037-46).
A third group of 112 patients, 87 of whom were included in the primary analysis, were observed as they entered the home rehab protocol. They were in an initial group of 215 who declined to be randomized, mostly because they wanted to get home quickly after surgery.
The average age of all participants was 67 years, and just over two-thirds were women.
At 26 weeks, the researchers found that there was no significant difference in how the patients in the three groups fared on a 6-minute walk test (mean difference, −1.01 meters; 95% confidence interval, −25.56 to 23.55). They also found no significant difference in measurements of patient-reported pain and function (knee score mean difference, 2.06; 95% CI, −0.59 to 4.71), and quality of life (EQ-5D visual analog scale mean difference, 1.41; 95% CI, −6.42 to 3.60).
However, the patients did seem to have a preference. “Satisfaction with rehabilitation was significantly higher with inpatient rehab, average 92% vs. 83%, though both modes were well received overall,” Dr. Naylor said in an interview.
“Many patients who went to inpatient rehabilitation really enjoyed it,” she added. “We have observed that patients and carers like the convenience of inpatient rehab – a one-stop shop where patients get access to multiple clinicians, gyms, and other patients and do not have to prepare meals.”
However, she said, while “we have no doubt the inpatient rehabilitation environment is nurturing, there must also be advantages to being discharged directly home, otherwise we would have seen differences between the groups. It is possible that monitored home programs like the one provided in this study help people gain independence quickly and empower patients in their recovery.”
Dr. Naylor cautioned that inpatient rehabilitation does have potential benefits for certain patients, such as those who are the most impaired and those without someone available to care for them at home. “Future research could focus on what is best in those situations or, at least, design community-based programs [that] offer some of the perceived benefits of inpatient therapy,” she said. “In addition, we also need to know what the best rehabilitation approach is after hip arthroplasty.”
The study was funded by various sources, including a foundation grant. The study authors reported no relevant disclosures.
A new randomized study from Australia suggests that for many patients, brief inpatient rehabilitation after knee replacement provides no benefits in several measures, compared with rehab at home.
However, “we are not concluding that there is no role for inpatient rehabilitation after knee arthroplasty,” said study coauthor Justine Naylor, PhD, of the University of New South Wales, Liverpool, Australia. “We are simply saying that for people who are otherwise well enough to be discharged directly home, inpatient rehabilitation does not provide more superior recovery across a range of outcomes.”
For the new study, conducted at two Australian hospitals during 2012-2015, researchers recruited patients aged 40 years or older with a primary diagnosis of osteoarthritis who were undergoing a primary unilateral knee arthroplasty and did not have complications such as a need for inpatient care in recovery beyond an initial 5 days after surgery.
The researchers randomly assigned 165 knee arthroplasty patients with uncomplicated cases to undergo either inpatient rehabilitation for 10 days and then recover at home for 6 weeks or a monitored 6-week home rehab program that began 2 weeks after surgery (JAMA. 2017;317[10]:1037-46).
A third group of 112 patients, 87 of whom were included in the primary analysis, were observed as they entered the home rehab protocol. They were in an initial group of 215 who declined to be randomized, mostly because they wanted to get home quickly after surgery.
The average age of all participants was 67 years, and just over two-thirds were women.
At 26 weeks, the researchers found that there was no significant difference in how the patients in the three groups fared on a 6-minute walk test (mean difference, −1.01 meters; 95% confidence interval, −25.56 to 23.55). They also found no significant difference in measurements of patient-reported pain and function (knee score mean difference, 2.06; 95% CI, −0.59 to 4.71), and quality of life (EQ-5D visual analog scale mean difference, 1.41; 95% CI, −6.42 to 3.60).
However, the patients did seem to have a preference. “Satisfaction with rehabilitation was significantly higher with inpatient rehab, average 92% vs. 83%, though both modes were well received overall,” Dr. Naylor said in an interview.
“Many patients who went to inpatient rehabilitation really enjoyed it,” she added. “We have observed that patients and carers like the convenience of inpatient rehab – a one-stop shop where patients get access to multiple clinicians, gyms, and other patients and do not have to prepare meals.”
However, she said, while “we have no doubt the inpatient rehabilitation environment is nurturing, there must also be advantages to being discharged directly home, otherwise we would have seen differences between the groups. It is possible that monitored home programs like the one provided in this study help people gain independence quickly and empower patients in their recovery.”
Dr. Naylor cautioned that inpatient rehabilitation does have potential benefits for certain patients, such as those who are the most impaired and those without someone available to care for them at home. “Future research could focus on what is best in those situations or, at least, design community-based programs [that] offer some of the perceived benefits of inpatient therapy,” she said. “In addition, we also need to know what the best rehabilitation approach is after hip arthroplasty.”
The study was funded by various sources, including a foundation grant. The study authors reported no relevant disclosures.
A new randomized study from Australia suggests that for many patients, brief inpatient rehabilitation after knee replacement provides no benefits in several measures, compared with rehab at home.
However, “we are not concluding that there is no role for inpatient rehabilitation after knee arthroplasty,” said study coauthor Justine Naylor, PhD, of the University of New South Wales, Liverpool, Australia. “We are simply saying that for people who are otherwise well enough to be discharged directly home, inpatient rehabilitation does not provide more superior recovery across a range of outcomes.”
For the new study, conducted at two Australian hospitals during 2012-2015, researchers recruited patients aged 40 years or older with a primary diagnosis of osteoarthritis who were undergoing a primary unilateral knee arthroplasty and did not have complications such as a need for inpatient care in recovery beyond an initial 5 days after surgery.
The researchers randomly assigned 165 knee arthroplasty patients with uncomplicated cases to undergo either inpatient rehabilitation for 10 days and then recover at home for 6 weeks or a monitored 6-week home rehab program that began 2 weeks after surgery (JAMA. 2017;317[10]:1037-46).
A third group of 112 patients, 87 of whom were included in the primary analysis, were observed as they entered the home rehab protocol. They were in an initial group of 215 who declined to be randomized, mostly because they wanted to get home quickly after surgery.
The average age of all participants was 67 years, and just over two-thirds were women.
At 26 weeks, the researchers found that there was no significant difference in how the patients in the three groups fared on a 6-minute walk test (mean difference, −1.01 meters; 95% confidence interval, −25.56 to 23.55). They also found no significant difference in measurements of patient-reported pain and function (knee score mean difference, 2.06; 95% CI, −0.59 to 4.71), and quality of life (EQ-5D visual analog scale mean difference, 1.41; 95% CI, −6.42 to 3.60).
However, the patients did seem to have a preference. “Satisfaction with rehabilitation was significantly higher with inpatient rehab, average 92% vs. 83%, though both modes were well received overall,” Dr. Naylor said in an interview.
“Many patients who went to inpatient rehabilitation really enjoyed it,” she added. “We have observed that patients and carers like the convenience of inpatient rehab – a one-stop shop where patients get access to multiple clinicians, gyms, and other patients and do not have to prepare meals.”
However, she said, while “we have no doubt the inpatient rehabilitation environment is nurturing, there must also be advantages to being discharged directly home, otherwise we would have seen differences between the groups. It is possible that monitored home programs like the one provided in this study help people gain independence quickly and empower patients in their recovery.”
Dr. Naylor cautioned that inpatient rehabilitation does have potential benefits for certain patients, such as those who are the most impaired and those without someone available to care for them at home. “Future research could focus on what is best in those situations or, at least, design community-based programs [that] offer some of the perceived benefits of inpatient therapy,” she said. “In addition, we also need to know what the best rehabilitation approach is after hip arthroplasty.”
The study was funded by various sources, including a foundation grant. The study authors reported no relevant disclosures.
FROM JAMA
Key clinical point:
Major finding: There were no significant differences in the primary outcome of a 6-minute walk test at 26 weeks or in pain, function, and quality of life measures between patients randomized to inpatient or at-home rehab protocols.
Data source: A parallel, randomized controlled trial of 165 uncomplicated knee arthroplasty patients assigned to undergo either inpatient rehab for 10 days then in-home monitored rehab for 6 weeks or to a monitored 6-week home rehab 2 weeks after surgery. The study also included a third observational group of 112 patients (87 included in analysis) who underwent at-home rehab.
Disclosures: The study was funded by various sources, including a foundation grant. The study authors reported no relevant disclosures.