Nearly 3.5 million adherents to the religion of Islam (Muslims) live in the United States, and this number is projected to more than double to 8.1 million by 2050.¹ As of 2017, an estimated 58% of American Muslims were immigrants, but nearly 25% were born in the United States to parents who also were US-born, including many African American Muslims.¹ American Muslims face a rise of Islamophobia, hate crimes, and discrimination at school, work, and the communities in which they live.² This population may experience feelings of anger as well as rejection and abandonment by the country they call home. They may also wrestle with conforming to American social norms while maintaining their Muslim identity.

When providing psychiatric care to American Muslim patients, clinicians need to understand these patients’ specific stressors. American Muslim patients may experience a variety of mental health conditions, including posttraumatic stress disorder, major depressive disorder, generalized anxiety disorder, panic attacks, adjustment disorder, and somatization.² Unfortunately, American Muslims may be less likely to seek psychiatric help because the stigma of mental illness remains a barrier to care in this community.³ In addition, entrenched cultural beliefs about mental illness may discourage many from seeking treatment. Because of a paucity of data on the psychiatric care of American Muslim patients, there is a great need to understand how to treat this vulnerable, often marginalized population.

Suggestions for improving care

Based on my clinical experience, I recommend the following practices for clinicians to consider when caring for American Muslim patients:

• Ensure that your assessment accounts for religious and cultural factors to help understand your patient’s perception of his/her illness.⁴ Consider using the DSM-IV Outline for Culture Formulation,⁵ DSM-5 Cultural Formulation Interview,⁶ or the American Academy of Child and Adolescent Psychiatry Practice Parameter for Cultural Competence in Child and Adolescent Psychiatric Practice.⁷
• Be sensitive to your patient’s family hierarchy and history. Often, extended family members will accompany an American Muslim patient for input and support during a clinical visit.
• Provide appropriate psychoeducation, because some patients may shun medication, especially those who think that medication should be reserved for severe illness that requires long-term inpatient stays.
• Listen for somatic symptoms that may mask distress.⁸
• Be mindful of your patient’s preferences regarding gender roles. For example, a female patient may prefer to receive care from a female clinician.
• Align therapy with your patient’s religious and cultural beliefs. Some research shows that for Muslim patients, modified short-term psychodynamic therapy fares better than classic long-term psychoanalysis.⁹ Therapy should focus on family dynamics, conflicts, and relationships.⁹
• Consider employing cognitive-behavioral therapy, solution-focused therapy, modeling, and behavioral techniques such as behavioral modification, systemic desensitization, and flooding because these may be effective for Muslim patients.^9,10
• Suggest guided imagery and relaxation techniques because some Muslim patients may find that these could be a natural extension of prayer and meditation.⁹
• Work with local Imams (Muslim spiritual leaders) to recognize mental illness, overcome stigma in the community, dispel misinformation, and refer patients.¹¹
• If the patient has a “traditional healer,” such as a Sheikh or Imam, understand the extent of this individual’s involvement. Some healers may tell patients that mental illness is a problem of faith or being possessed by a spirit (ie, “jinn” or Satan-like spirits).
• Use an interpreter if English is not the patient’s primary language.
• Respect the patient’s religious practices. When possible, offer alternative treatments to medication formulations that include pork (most gelatins). Also, patients may want to adjust their medication schedule during Ramadan, when many Muslims fast from dawn to dusk.

Future goals: Increasing access, reducing stigma

More research on the mental health needs of American Muslim patients is needed, especially as discrimination and hate crimes against this population continue to rise. Clinicians should tailor their assessments and recommended treatments to these patients’ preferences, and address how religious and cultural connectedness may impact their patient’s mental health. Increasing access to services and reducing stigma associated with mental health care are critical for improving outcomes among Muslim patients.

Nearly 3.5 million adherents to the religion of Islam (Muslims) live in the United States, and this number is projected to more than double to 8.1 million by 2050.¹ As of 2017, an estimated 58% of American Muslims were immigrants, but nearly 25% were born in the United States to parents who also were US-born, including many African American Muslims.¹ American Muslims face a rise of Islamophobia, hate crimes, and discrimination at school, work, and the communities in which they live.² This population may experience feelings of anger as well as rejection and abandonment by the country they call home. They may also wrestle with conforming to American social norms while maintaining their Muslim identity.

When providing psychiatric care to American Muslim patients, clinicians need to understand these patients’ specific stressors. American Muslim patients may experience a variety of mental health conditions, including posttraumatic stress disorder, major depressive disorder, generalized anxiety disorder, panic attacks, adjustment disorder, and somatization.² Unfortunately, American Muslims may be less likely to seek psychiatric help because the stigma of mental illness remains a barrier to care in this community.³ In addition, entrenched cultural beliefs about mental illness may discourage many from seeking treatment. Because of a paucity of data on the psychiatric care of American Muslim patients, there is a great need to understand how to treat this vulnerable, often marginalized population.

Suggestions for improving care

Based on my clinical experience, I recommend the following practices for clinicians to consider when caring for American Muslim patients:

• Ensure that your assessment accounts for religious and cultural factors to help understand your patient’s perception of his/her illness.⁴ Consider using the DSM-IV Outline for Culture Formulation,⁵ DSM-5 Cultural Formulation Interview,⁶ or the American Academy of Child and Adolescent Psychiatry Practice Parameter for Cultural Competence in Child and Adolescent Psychiatric Practice.⁷
• Be sensitive to your patient’s family hierarchy and history. Often, extended family members will accompany an American Muslim patient for input and support during a clinical visit.
• Provide appropriate psychoeducation, because some patients may shun medication, especially those who think that medication should be reserved for severe illness that requires long-term inpatient stays.
• Listen for somatic symptoms that may mask distress.⁸
• Be mindful of your patient’s preferences regarding gender roles. For example, a female patient may prefer to receive care from a female clinician.
• Align therapy with your patient’s religious and cultural beliefs. Some research shows that for Muslim patients, modified short-term psychodynamic therapy fares better than classic long-term psychoanalysis.⁹ Therapy should focus on family dynamics, conflicts, and relationships.⁹
• Consider employing cognitive-behavioral therapy, solution-focused therapy, modeling, and behavioral techniques such as behavioral modification, systemic desensitization, and flooding because these may be effective for Muslim patients.^9,10
• Suggest guided imagery and relaxation techniques because some Muslim patients may find that these could be a natural extension of prayer and meditation.⁹
• Work with local Imams (Muslim spiritual leaders) to recognize mental illness, overcome stigma in the community, dispel misinformation, and refer patients.¹¹
• If the patient has a “traditional healer,” such as a Sheikh or Imam, understand the extent of this individual’s involvement. Some healers may tell patients that mental illness is a problem of faith or being possessed by a spirit (ie, “jinn” or Satan-like spirits).
• Use an interpreter if English is not the patient’s primary language.
• Respect the patient’s religious practices. When possible, offer alternative treatments to medication formulations that include pork (most gelatins). Also, patients may want to adjust their medication schedule during Ramadan, when many Muslims fast from dawn to dusk.

Future goals: Increasing access, reducing stigma

More research on the mental health needs of American Muslim patients is needed, especially as discrimination and hate crimes against this population continue to rise. Clinicians should tailor their assessments and recommended treatments to these patients’ preferences, and address how religious and cultural connectedness may impact their patient’s mental health. Increasing access to services and reducing stigma associated with mental health care are critical for improving outcomes among Muslim patients.

Nearly 3.5 million adherents to the religion of Islam (Muslims) live in the United States, and this number is projected to more than double to 8.1 million by 2050.¹ As of 2017, an estimated 58% of American Muslims were immigrants, but nearly 25% were born in the United States to parents who also were US-born, including many African American Muslims.¹ American Muslims face a rise of Islamophobia, hate crimes, and discrimination at school, work, and the communities in which they live.² This population may experience feelings of anger as well as rejection and abandonment by the country they call home. They may also wrestle with conforming to American social norms while maintaining their Muslim identity.

When providing psychiatric care to American Muslim patients, clinicians need to understand these patients’ specific stressors. American Muslim patients may experience a variety of mental health conditions, including posttraumatic stress disorder, major depressive disorder, generalized anxiety disorder, panic attacks, adjustment disorder, and somatization.² Unfortunately, American Muslims may be less likely to seek psychiatric help because the stigma of mental illness remains a barrier to care in this community.³ In addition, entrenched cultural beliefs about mental illness may discourage many from seeking treatment. Because of a paucity of data on the psychiatric care of American Muslim patients, there is a great need to understand how to treat this vulnerable, often marginalized population.

Suggestions for improving care

Based on my clinical experience, I recommend the following practices for clinicians to consider when caring for American Muslim patients:

• Ensure that your assessment accounts for religious and cultural factors to help understand your patient’s perception of his/her illness.⁴ Consider using the DSM-IV Outline for Culture Formulation,⁵ DSM-5 Cultural Formulation Interview,⁶ or the American Academy of Child and Adolescent Psychiatry Practice Parameter for Cultural Competence in Child and Adolescent Psychiatric Practice.⁷
• Be sensitive to your patient’s family hierarchy and history. Often, extended family members will accompany an American Muslim patient for input and support during a clinical visit.
• Provide appropriate psychoeducation, because some patients may shun medication, especially those who think that medication should be reserved for severe illness that requires long-term inpatient stays.
• Listen for somatic symptoms that may mask distress.⁸
• Be mindful of your patient’s preferences regarding gender roles. For example, a female patient may prefer to receive care from a female clinician.
• Align therapy with your patient’s religious and cultural beliefs. Some research shows that for Muslim patients, modified short-term psychodynamic therapy fares better than classic long-term psychoanalysis.⁹ Therapy should focus on family dynamics, conflicts, and relationships.⁹
• Consider employing cognitive-behavioral therapy, solution-focused therapy, modeling, and behavioral techniques such as behavioral modification, systemic desensitization, and flooding because these may be effective for Muslim patients.^9,10
• Suggest guided imagery and relaxation techniques because some Muslim patients may find that these could be a natural extension of prayer and meditation.⁹
• Work with local Imams (Muslim spiritual leaders) to recognize mental illness, overcome stigma in the community, dispel misinformation, and refer patients.¹¹
• If the patient has a “traditional healer,” such as a Sheikh or Imam, understand the extent of this individual’s involvement. Some healers may tell patients that mental illness is a problem of faith or being possessed by a spirit (ie, “jinn” or Satan-like spirits).
• Use an interpreter if English is not the patient’s primary language.
• Respect the patient’s religious practices. When possible, offer alternative treatments to medication formulations that include pork (most gelatins). Also, patients may want to adjust their medication schedule during Ramadan, when many Muslims fast from dawn to dusk.

Future goals: Increasing access, reducing stigma

More research on the mental health needs of American Muslim patients is needed, especially as discrimination and hate crimes against this population continue to rise. Clinicians should tailor their assessments and recommended treatments to these patients’ preferences, and address how religious and cultural connectedness may impact their patient’s mental health. Increasing access to services and reducing stigma associated with mental health care are critical for improving outcomes among Muslim patients.

As clinicians, we increasingly communicate with each other via social media platforms to network, collaborate on research, find professional and personal support, refer patients, or hold academic conversations.^1,2 Although it is convenient, this form of online communication directly and indirectly breaks down barriers between our professional and personal lives, which can make it challenging to avoid behavior that could negatively affect one’s professional image.²

Although some medical organizations have offered guidelines on health care professionals’ use of social media,^2,3 these are subjective and not evidence-based. Here I offer some suggestions for appropriately interacting with your colleagues (ie, individuals who are not your personal friends) on social media.

Think before you post. Consider the potential professional ramifications of what you are about to post, and don’t post anything that may have adverse consequences on your image or that of psychiatry as a whole.

Don’t post derogatory or defamatory statements about colleagues. Such actions may violate professional codes of conduct. Disagreeing with colleagues on social media is common, but your posts should be respectful, friendly, and reflect positively on the profession.² Avoid making negative statements—even in jest—about your colleagues’ skills or professional experience, because such communication is not appropriate for public dissemination.²

If you notice colleagues posting unprofessional content that could negatively affect their careers or the public’s trust in psychiatry, tactfully express your concerns to them, and suggest that they take appropriate measures to rectify the situation.² Be aware of your state’s laws and regulations about mandated reporting if you discover a colleague’s online content violates the scope of clinical practice or ethical standards.¹ If the content is in violation of the law or medical board regulations, you may have a legal obligation to report that colleague to law enforcement, the licensing board, and/or his/her employer.^1,2

Avoid online snooping into the personal lives of colleagues. Respect their privacy when viewing their posts about personal activities that are not germane to their professional services.¹ If you find videos, images, or messages that reveal private, confidential, or sensitive information about a colleague, do not distribute that information without the colleague’s consent.¹

Be careful when accepting friend requests. Conflicts could arise if you accept friend requests from some but not all of your colleagues; this could be interpreted as favoritism and potentially create problematic work relationships.² Be consistent in accepting or rejecting colleagues’ friend requests. Consider using an employment-oriented social media platform to connect with colleagues outside of the workplace.²

As clinicians, we increasingly communicate with each other via social media platforms to network, collaborate on research, find professional and personal support, refer patients, or hold academic conversations.^1,2 Although it is convenient, this form of online communication directly and indirectly breaks down barriers between our professional and personal lives, which can make it challenging to avoid behavior that could negatively affect one’s professional image.²

Although some medical organizations have offered guidelines on health care professionals’ use of social media,^2,3 these are subjective and not evidence-based. Here I offer some suggestions for appropriately interacting with your colleagues (ie, individuals who are not your personal friends) on social media.

Think before you post. Consider the potential professional ramifications of what you are about to post, and don’t post anything that may have adverse consequences on your image or that of psychiatry as a whole.

Don’t post derogatory or defamatory statements about colleagues. Such actions may violate professional codes of conduct. Disagreeing with colleagues on social media is common, but your posts should be respectful, friendly, and reflect positively on the profession.² Avoid making negative statements—even in jest—about your colleagues’ skills or professional experience, because such communication is not appropriate for public dissemination.²

If you notice colleagues posting unprofessional content that could negatively affect their careers or the public’s trust in psychiatry, tactfully express your concerns to them, and suggest that they take appropriate measures to rectify the situation.² Be aware of your state’s laws and regulations about mandated reporting if you discover a colleague’s online content violates the scope of clinical practice or ethical standards.¹ If the content is in violation of the law or medical board regulations, you may have a legal obligation to report that colleague to law enforcement, the licensing board, and/or his/her employer.^1,2

Avoid online snooping into the personal lives of colleagues. Respect their privacy when viewing their posts about personal activities that are not germane to their professional services.¹ If you find videos, images, or messages that reveal private, confidential, or sensitive information about a colleague, do not distribute that information without the colleague’s consent.¹

Be careful when accepting friend requests. Conflicts could arise if you accept friend requests from some but not all of your colleagues; this could be interpreted as favoritism and potentially create problematic work relationships.² Be consistent in accepting or rejecting colleagues’ friend requests. Consider using an employment-oriented social media platform to connect with colleagues outside of the workplace.²

As clinicians, we increasingly communicate with each other via social media platforms to network, collaborate on research, find professional and personal support, refer patients, or hold academic conversations.^1,2 Although it is convenient, this form of online communication directly and indirectly breaks down barriers between our professional and personal lives, which can make it challenging to avoid behavior that could negatively affect one’s professional image.²

Although some medical organizations have offered guidelines on health care professionals’ use of social media,^2,3 these are subjective and not evidence-based. Here I offer some suggestions for appropriately interacting with your colleagues (ie, individuals who are not your personal friends) on social media.

Think before you post. Consider the potential professional ramifications of what you are about to post, and don’t post anything that may have adverse consequences on your image or that of psychiatry as a whole.

Don’t post derogatory or defamatory statements about colleagues. Such actions may violate professional codes of conduct. Disagreeing with colleagues on social media is common, but your posts should be respectful, friendly, and reflect positively on the profession.² Avoid making negative statements—even in jest—about your colleagues’ skills or professional experience, because such communication is not appropriate for public dissemination.²

If you notice colleagues posting unprofessional content that could negatively affect their careers or the public’s trust in psychiatry, tactfully express your concerns to them, and suggest that they take appropriate measures to rectify the situation.² Be aware of your state’s laws and regulations about mandated reporting if you discover a colleague’s online content violates the scope of clinical practice or ethical standards.¹ If the content is in violation of the law or medical board regulations, you may have a legal obligation to report that colleague to law enforcement, the licensing board, and/or his/her employer.^1,2

Avoid online snooping into the personal lives of colleagues. Respect their privacy when viewing their posts about personal activities that are not germane to their professional services.¹ If you find videos, images, or messages that reveal private, confidential, or sensitive information about a colleague, do not distribute that information without the colleague’s consent.¹

Be careful when accepting friend requests. Conflicts could arise if you accept friend requests from some but not all of your colleagues; this could be interpreted as favoritism and potentially create problematic work relationships.² Be consistent in accepting or rejecting colleagues’ friend requests. Consider using an employment-oriented social media platform to connect with colleagues outside of the workplace.²

GRAPEVINE, TEX. – Early postpartum glucose tolerance testing for women with gestational diabetes resulted in a 99% adherence rate, with similar sensitivity and specificity as the currently recommended 4- to 12-week postpartum testing schedule.

“Two-day postpartum glucose tolerance testing has similar diagnostic utility as the 4- to 12-week postpartum glucose tolerance test to identify impaired glucose metabolism and diabetes at 1 year postpartum,” said Erika Werner, MD, speaking at the meeting sponsored by the Society for Maternal-Fetal Medicine.

Overall, 29% of women studied had impaired glucose metabolism at 2 days postpartum, as did 25% in the 4- to 12-weeks postpartum window. At 1 year, that figure was 35%. The number of women meeting diagnostic criteria for diabetes held steady at 4% for all three time points.

The findings warrant “consideration for the 2-day postpartum glucose tolerance test (GTT) as the initial postpartum test for women who have gestational diabetes, with repeat testing at 1 year,” said Dr. Werner, a maternal-fetal medicine physician at Brown University, Providence, R.I.

Glucose testing for women with gestational diabetes mellitus (GDM) is recommended at 4-12 weeks postpartum by both the American Diabetes Association and the American College of Obstetricians and Gynecologists.

Testing can allow detection and treatment of impaired glucose metabolism, seen in 15%-40% of women with a history of GDM. Up to 1 in 20 women with GDM will receive a postpartum diagnosis of type 2 diabetes.

However, fewer than one in five women will actually have postpartum glucose testing, representing a large missed opportunity, said Dr. Werner.

Several factors likely contribute to those screening failures, she added. In addition to the potential for public insurance to lapse at 6 weeks postpartum, the logistical realities and time demands of parenting a newborn are themselves a significant barrier.

“What if we changed the timing?” and shifted glucose testing to the early postpartum days, before hospital discharge, asked Dr. Werner. Several pilot studies had already compared glucose screening in the first few days postpartum with the routine schedule, finding good correlation between the early and routine GTT schedule.

Importantly, the earlier studies achieved an adherence rate of more than 90% for early GTT. By contrast, fewer than half of the participants in the usual-care arms actually returned for postpartum GTT in the 4- to 12-week postpartum window, even under the optimized conditions associated with a medical study.

The single-center prospective cohort study conducted by Dr. Werner and collaborators enrolled 300 women with GDM. Women agreed to participate in glucose tolerance testing as inpatients, at 2 days postpartum, in addition to receiving a GTT between 4 and 12 weeks postpartum, and additional screening that included a glycosylated hemoglobin (HbA_1c) test at 1 year postpartum.

The investigators obtained postpartum day 2 GTTs for all but four of the patients. A total of 201 patients returned in the 4- to 12-week postpartum window, and 168 of those participants returned for HbA1c testing at 1 year. Of the 95 patients who didn’t come back for the 4- to 12-week test, 33 did return at 1 year for HbA_1c testing.

Dr. Werner and her coinvestigators included adult women who spoke either fluent Spanish or English and had GDM diagnosed by the Carpenter-Coustan criteria, or by having a blood glucose level of 200 mg/dL or more in a 1-hour glucose challenge test.

The early GTT results weren’t shared with patients or their health care providers. For outpatient visits, participants were offered financial incentives and received multiple reminder phone calls and the offer of free transportation.

For the purposes of the study, impaired glucose metabolism was defined as fasting blood glucose of 100 mg/dL or greater, a 2-hour GTT blood glucose level of 140 mg/dL or greater, or HbA_1c of 5.7% or greater.

Participants were diagnosed with diabetes if they had a fasting blood glucose of 126 mg/dL or greater, a 2-hour GTT blood glucose level of 200 mg/dL or greater, or HbA_1c of 6.5% or greater.

Dr. Werner and colleagues conducted two analyses of their results. In the first, they included only women in both arms who had complete data. In the second analysis, they looked at all women who had data for the 1-year postpartum mark, assuming that interval GTTs were negative for women who were missing these values.

The statistical analysis showed that, for women with complete data, both early and later postpartum GTTs were similar in predicting impaired glucose metabolism at 1 year postpartum (areas under the receiver operating curve [AUC], 0.63 and 0.60, respectively).

For identifying diabetes at 1 year, both early and late testing had high negative predictive value (98% and 99%, respectively), but the later testing strategy had higher sensitivity and specificity, yielding an AUC of 0.83, compared with 0.65 for early testing.

Turning to the second analysis that included all women who had 1-year postpartum HbA_1c values, negative predictive values for diabetes were similarly high (98%) for both the early and late testing strategies. For identifying impaired glucose metabolism at 1 year in this group, both the positive and negative predictive value of the early and late strategies were similar.

Patients were about 32 years old at baseline, with a mean body mass index of 31.7 kg/m². More than half of patients (52.3%) had private insurance, and 22% had GDM in a pregnancy prior to the index pregnancy. Black patients made up about 9% of the study population; 54% of participants were white, and 23% Hispanic. About one-third of patients were nulliparous, and two-thirds had education beyond high school.

During their pregnancies, about 44% of patients managed GDM by diet alone, 40% required insulin, with an additional 1% also requiring an oral agent. The remainder required oral agents alone. Patients delivered at a mean 38.3 weeks gestation, with about 40% receiving cesarean deliveries.

Some of the study’s strengths included its prospective nature, the diverse population recruited, and the fact that participants and providers were both blinded to the 2-day GTT results. Although more than half of participants completed the study – besting the previous pilots – 44% of patients still had incomplete data, noted Dr. Werner.

The American Diabetes Association sponsored the study. Dr. Werner reported no other conflicts of interest.

koakes@mdedge.com

SOURCE: Werner E et al. SMFM 2020. Abstract 72.

GRAPEVINE, TEX. – Early postpartum glucose tolerance testing for women with gestational diabetes resulted in a 99% adherence rate, with similar sensitivity and specificity as the currently recommended 4- to 12-week postpartum testing schedule.

“Two-day postpartum glucose tolerance testing has similar diagnostic utility as the 4- to 12-week postpartum glucose tolerance test to identify impaired glucose metabolism and diabetes at 1 year postpartum,” said Erika Werner, MD, speaking at the meeting sponsored by the Society for Maternal-Fetal Medicine.

Overall, 29% of women studied had impaired glucose metabolism at 2 days postpartum, as did 25% in the 4- to 12-weeks postpartum window. At 1 year, that figure was 35%. The number of women meeting diagnostic criteria for diabetes held steady at 4% for all three time points.

The findings warrant “consideration for the 2-day postpartum glucose tolerance test (GTT) as the initial postpartum test for women who have gestational diabetes, with repeat testing at 1 year,” said Dr. Werner, a maternal-fetal medicine physician at Brown University, Providence, R.I.

Glucose testing for women with gestational diabetes mellitus (GDM) is recommended at 4-12 weeks postpartum by both the American Diabetes Association and the American College of Obstetricians and Gynecologists.

Testing can allow detection and treatment of impaired glucose metabolism, seen in 15%-40% of women with a history of GDM. Up to 1 in 20 women with GDM will receive a postpartum diagnosis of type 2 diabetes.

However, fewer than one in five women will actually have postpartum glucose testing, representing a large missed opportunity, said Dr. Werner.

Several factors likely contribute to those screening failures, she added. In addition to the potential for public insurance to lapse at 6 weeks postpartum, the logistical realities and time demands of parenting a newborn are themselves a significant barrier.

“What if we changed the timing?” and shifted glucose testing to the early postpartum days, before hospital discharge, asked Dr. Werner. Several pilot studies had already compared glucose screening in the first few days postpartum with the routine schedule, finding good correlation between the early and routine GTT schedule.

Importantly, the earlier studies achieved an adherence rate of more than 90% for early GTT. By contrast, fewer than half of the participants in the usual-care arms actually returned for postpartum GTT in the 4- to 12-week postpartum window, even under the optimized conditions associated with a medical study.

The single-center prospective cohort study conducted by Dr. Werner and collaborators enrolled 300 women with GDM. Women agreed to participate in glucose tolerance testing as inpatients, at 2 days postpartum, in addition to receiving a GTT between 4 and 12 weeks postpartum, and additional screening that included a glycosylated hemoglobin (HbA_1c) test at 1 year postpartum.

The investigators obtained postpartum day 2 GTTs for all but four of the patients. A total of 201 patients returned in the 4- to 12-week postpartum window, and 168 of those participants returned for HbA1c testing at 1 year. Of the 95 patients who didn’t come back for the 4- to 12-week test, 33 did return at 1 year for HbA_1c testing.

Dr. Werner and her coinvestigators included adult women who spoke either fluent Spanish or English and had GDM diagnosed by the Carpenter-Coustan criteria, or by having a blood glucose level of 200 mg/dL or more in a 1-hour glucose challenge test.

The early GTT results weren’t shared with patients or their health care providers. For outpatient visits, participants were offered financial incentives and received multiple reminder phone calls and the offer of free transportation.

For the purposes of the study, impaired glucose metabolism was defined as fasting blood glucose of 100 mg/dL or greater, a 2-hour GTT blood glucose level of 140 mg/dL or greater, or HbA_1c of 5.7% or greater.

Participants were diagnosed with diabetes if they had a fasting blood glucose of 126 mg/dL or greater, a 2-hour GTT blood glucose level of 200 mg/dL or greater, or HbA_1c of 6.5% or greater.

Dr. Werner and colleagues conducted two analyses of their results. In the first, they included only women in both arms who had complete data. In the second analysis, they looked at all women who had data for the 1-year postpartum mark, assuming that interval GTTs were negative for women who were missing these values.

The statistical analysis showed that, for women with complete data, both early and later postpartum GTTs were similar in predicting impaired glucose metabolism at 1 year postpartum (areas under the receiver operating curve [AUC], 0.63 and 0.60, respectively).

For identifying diabetes at 1 year, both early and late testing had high negative predictive value (98% and 99%, respectively), but the later testing strategy had higher sensitivity and specificity, yielding an AUC of 0.83, compared with 0.65 for early testing.

Turning to the second analysis that included all women who had 1-year postpartum HbA_1c values, negative predictive values for diabetes were similarly high (98%) for both the early and late testing strategies. For identifying impaired glucose metabolism at 1 year in this group, both the positive and negative predictive value of the early and late strategies were similar.

Patients were about 32 years old at baseline, with a mean body mass index of 31.7 kg/m². More than half of patients (52.3%) had private insurance, and 22% had GDM in a pregnancy prior to the index pregnancy. Black patients made up about 9% of the study population; 54% of participants were white, and 23% Hispanic. About one-third of patients were nulliparous, and two-thirds had education beyond high school.

During their pregnancies, about 44% of patients managed GDM by diet alone, 40% required insulin, with an additional 1% also requiring an oral agent. The remainder required oral agents alone. Patients delivered at a mean 38.3 weeks gestation, with about 40% receiving cesarean deliveries.

Some of the study’s strengths included its prospective nature, the diverse population recruited, and the fact that participants and providers were both blinded to the 2-day GTT results. Although more than half of participants completed the study – besting the previous pilots – 44% of patients still had incomplete data, noted Dr. Werner.

The American Diabetes Association sponsored the study. Dr. Werner reported no other conflicts of interest.

koakes@mdedge.com

SOURCE: Werner E et al. SMFM 2020. Abstract 72.

GRAPEVINE, TEX. – Early postpartum glucose tolerance testing for women with gestational diabetes resulted in a 99% adherence rate, with similar sensitivity and specificity as the currently recommended 4- to 12-week postpartum testing schedule.

“Two-day postpartum glucose tolerance testing has similar diagnostic utility as the 4- to 12-week postpartum glucose tolerance test to identify impaired glucose metabolism and diabetes at 1 year postpartum,” said Erika Werner, MD, speaking at the meeting sponsored by the Society for Maternal-Fetal Medicine.

Overall, 29% of women studied had impaired glucose metabolism at 2 days postpartum, as did 25% in the 4- to 12-weeks postpartum window. At 1 year, that figure was 35%. The number of women meeting diagnostic criteria for diabetes held steady at 4% for all three time points.

The findings warrant “consideration for the 2-day postpartum glucose tolerance test (GTT) as the initial postpartum test for women who have gestational diabetes, with repeat testing at 1 year,” said Dr. Werner, a maternal-fetal medicine physician at Brown University, Providence, R.I.

Glucose testing for women with gestational diabetes mellitus (GDM) is recommended at 4-12 weeks postpartum by both the American Diabetes Association and the American College of Obstetricians and Gynecologists.

Testing can allow detection and treatment of impaired glucose metabolism, seen in 15%-40% of women with a history of GDM. Up to 1 in 20 women with GDM will receive a postpartum diagnosis of type 2 diabetes.

However, fewer than one in five women will actually have postpartum glucose testing, representing a large missed opportunity, said Dr. Werner.

Several factors likely contribute to those screening failures, she added. In addition to the potential for public insurance to lapse at 6 weeks postpartum, the logistical realities and time demands of parenting a newborn are themselves a significant barrier.

“What if we changed the timing?” and shifted glucose testing to the early postpartum days, before hospital discharge, asked Dr. Werner. Several pilot studies had already compared glucose screening in the first few days postpartum with the routine schedule, finding good correlation between the early and routine GTT schedule.

Importantly, the earlier studies achieved an adherence rate of more than 90% for early GTT. By contrast, fewer than half of the participants in the usual-care arms actually returned for postpartum GTT in the 4- to 12-week postpartum window, even under the optimized conditions associated with a medical study.

The single-center prospective cohort study conducted by Dr. Werner and collaborators enrolled 300 women with GDM. Women agreed to participate in glucose tolerance testing as inpatients, at 2 days postpartum, in addition to receiving a GTT between 4 and 12 weeks postpartum, and additional screening that included a glycosylated hemoglobin (HbA_1c) test at 1 year postpartum.

The investigators obtained postpartum day 2 GTTs for all but four of the patients. A total of 201 patients returned in the 4- to 12-week postpartum window, and 168 of those participants returned for HbA1c testing at 1 year. Of the 95 patients who didn’t come back for the 4- to 12-week test, 33 did return at 1 year for HbA_1c testing.

Dr. Werner and her coinvestigators included adult women who spoke either fluent Spanish or English and had GDM diagnosed by the Carpenter-Coustan criteria, or by having a blood glucose level of 200 mg/dL or more in a 1-hour glucose challenge test.

The early GTT results weren’t shared with patients or their health care providers. For outpatient visits, participants were offered financial incentives and received multiple reminder phone calls and the offer of free transportation.

For the purposes of the study, impaired glucose metabolism was defined as fasting blood glucose of 100 mg/dL or greater, a 2-hour GTT blood glucose level of 140 mg/dL or greater, or HbA_1c of 5.7% or greater.

Participants were diagnosed with diabetes if they had a fasting blood glucose of 126 mg/dL or greater, a 2-hour GTT blood glucose level of 200 mg/dL or greater, or HbA_1c of 6.5% or greater.

Dr. Werner and colleagues conducted two analyses of their results. In the first, they included only women in both arms who had complete data. In the second analysis, they looked at all women who had data for the 1-year postpartum mark, assuming that interval GTTs were negative for women who were missing these values.

The statistical analysis showed that, for women with complete data, both early and later postpartum GTTs were similar in predicting impaired glucose metabolism at 1 year postpartum (areas under the receiver operating curve [AUC], 0.63 and 0.60, respectively).

For identifying diabetes at 1 year, both early and late testing had high negative predictive value (98% and 99%, respectively), but the later testing strategy had higher sensitivity and specificity, yielding an AUC of 0.83, compared with 0.65 for early testing.

Turning to the second analysis that included all women who had 1-year postpartum HbA_1c values, negative predictive values for diabetes were similarly high (98%) for both the early and late testing strategies. For identifying impaired glucose metabolism at 1 year in this group, both the positive and negative predictive value of the early and late strategies were similar.

Patients were about 32 years old at baseline, with a mean body mass index of 31.7 kg/m². More than half of patients (52.3%) had private insurance, and 22% had GDM in a pregnancy prior to the index pregnancy. Black patients made up about 9% of the study population; 54% of participants were white, and 23% Hispanic. About one-third of patients were nulliparous, and two-thirds had education beyond high school.

During their pregnancies, about 44% of patients managed GDM by diet alone, 40% required insulin, with an additional 1% also requiring an oral agent. The remainder required oral agents alone. Patients delivered at a mean 38.3 weeks gestation, with about 40% receiving cesarean deliveries.

Some of the study’s strengths included its prospective nature, the diverse population recruited, and the fact that participants and providers were both blinded to the 2-day GTT results. Although more than half of participants completed the study – besting the previous pilots – 44% of patients still had incomplete data, noted Dr. Werner.

The American Diabetes Association sponsored the study. Dr. Werner reported no other conflicts of interest.

koakes@mdedge.com

SOURCE: Werner E et al. SMFM 2020. Abstract 72.

LAS VEGAS – Between 2010 and 2017, the proportion of newly diagnosed cases of acute hepatitis C virus infection rose threefold, driven largely by the concomitant opioid epidemic.

Doug Brunk/MDedge News

That makes efforts to screen, diagnose, and cure high-risk populations more important than ever, Stevan A. Gonzalez, MD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association.

About 70% of HCV cases are related to injection drug use,” said Dr. Gonzalez, medical director of liver transplantation at the Baylor Simmons Transplant Institute at the Baylor Scott & White All Saints Medical Center in Fort Worth, Tex. “This is affecting whites as much as blacks and Hispanics, females as much as males, and in nonurban areas as much as in urban areas.”

Data from the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration indicate that during 2004-2014, the number of acute HCV cases among those aged 18-29 years increased 400%, and the use of injection opioids rose 600%.

At the same time, the number of HCV cases among those aged 30-39 years increased 325%, and the use of injection opioids rose 83%.

“We’re starting to see a pattern overlapping between HCV exposure and opioid injection,” Dr. Gonzalez said. Other high-risk populations include homeless and incarcerated individuals.

More than 70 million people worldwide have chronic HCV infection, Dr. Gonzalez noted, with possibly as many as 5 million cases in the United States. It remains the nation’s most common blood-borne infection.

Chronic disease develops in up to 85% of people who are exposed, infection is asymptomatic, and HCV remains one of the leading indications for liver transplantation and causes of liver cancer.

From a geographic standpoint, the prevalence of HCV in young adults is eclipsing that of Baby Boomers in several states in the Appalachian region and in Northeast, which have long been trouble spots for opioid use disorder (Gastroenterol. 2018 May;154[6]:1850-1).

Surprising exposure risk

The primary risk of transmission is through contaminated blood and the exposure through needles.

“It really doesn’t matter whether it’s a needle that has a small amount of dead space where a little bit of blood can remain or needles that have a larger amount of blood,” Dr. Gonzalez said.

“I’ve had patients who come to me and say, ‘I can’t believe I have HCV. It’s impossible. I always use my own needles. They’re always brand new; I’ve never shared with anybody,’” he continued.

“This is where education and awareness is so critical, because it’s not just the needles,” Dr. Gonzalez explained. “HCV can survive on inanimate objects. For example, on a tabletop surface or a water container, HCV can remain viable up to 3 weeks. In a syringe, 2 months. For that reason, HCV can also be transmitted through crack pipes and nasal drug use, where the prevalence can be up to 35%.”

The duration of a person’s HCV infection drives the transmission.

“That’s important to think about, because people who have chronic hepatitis C are infectious until they’re treated,” Dr. Gonzalez said. “If they don’t know that they have hepatitis C, they continue to transmit the virus to others.”

One study found that half of people living with HCV are unaware of their infection (PLoS One. 2014 Jul 2;9[7]:e101554). According to Dr. Gonzalez, forthcoming guidelines from the U.S. Preventive Services Task Force are expected to recommend a one-time screening for HCV infection in all adults aged 18-79 years, a Grade B recommendation. “That’s a big deal,” he said. (The draft recommendations are available here.)

HCV infection disproportionately affects individuals in correctional institutions. In fact, an estimated one in three inmates in the United States has chronic HCV.

“This is sort of a forgotten population with a lot of substance use and mental illness,” Dr. Gonzalez said. “Injection drug use in that setting is the most common risk factor: It’s about 60% in terms of the risk of transmission within correctional settings. HCV-associated liver disease has now surpassed HIV as a cause of death within correctional settings.”
 

Weighing treatment options

The most common oral regimens for chronic HCV include sofosbuvir/ledipasvir, sofosbuvir/velpatasvir, and glecaprevir/pibrentasvir. They achieve cure in 93%-100% of cases.

“HCV can be cured; it can be eradicated from the body long term,” Dr. Gonzalez said. “The choice of regimen, treatment duration, and use of ribavirin depends on the presence/absence of cirrhosis, prior treatment experience, and the genotype.”

All six forms of the HCV genotype can be treated with oral medication, he added, and methadone, bupropion, and naloxone are safe to use during therapy.

Reinfection following HCV treatment occurs infrequently. Dr. Gonzalez cited a randomized, controlled trial presented as an abstract at the 2018 annual meeting of the American Association for the Study of Liver Diseases. That study’s researchers found that – among 199 patients on opioid-replacement therapy who were receiving direct-acting antiviral therapy, in whom greater than 50% were actively using drugs – the rate of reinfection at 3 years was 1.8 reinfections/100 person-years.

“That’s lower than people expect,” Dr. Gonzalez said.
 

How to boost screening

Electronic health record systems can be used as an important tool to increase HCV screening in health care settings.

In 2017, researchers published an analysis of three randomized trials carried out at three separate primary care settings to improve screening for HCV: repeated mailings, an EHR best practice alert (BPA), and patient solicitation (Hepatology 2017 Jan;65[1]:44-53). They evaluated HCV antibody testing, diagnosis, and costs for each of the interventions, compared with standard-of-care testing.

The investigators found that the BPA intervention had the lowest incremental cost per completed test – $24 with fixed start-up costs, including technical design and development of the BPA system; $3 without fixed start-up costs. The BPA intervention also had the lowest incremental cost per new case identified.

Other efforts to expand access to screening and treatment are underway.

In 2019, Louisiana health officials negotiated a one-time fee for unlimited access for 5 years to sofosbuvir/velpatasvir (Epclusa) to treat the estimated 30,000 patients on Louisiana Medicaid and in that state’s department of corrections who have HCV.

“The goal is 90% cure; the burden is on the state health department to screen, diagnose, and dispense medication,” Dr. Gonzalez said.

Also in 2019, the state of Washington used an open bidding process to negotiate access to glecaprevir/pibrentasvir (Mavyret) for the state’s Medicaid population who have HCV.

“Those states are setting the pace,” Dr. Gonzalez said. “They are showing examples of how we can start implementing a process to treat these vulnerable populations.”

Meanwhile, the World Health Organization set a goal of eliminating viral hepatitis as a major public health threat by 2030.

“That sounds ambitious, but I think it’s possible,” Dr. Gonzalez said. “It’s important to address these high-risk populations: the incarcerated, people who use drugs, and the homeless, because those are the groups that have a high prevalence of HCV – mainly through injection drug use.

“If we don’t address that population, and we only target the general population, we’re going to have a continual source of transmission,” Dr. Gonzalez warned. “In that case, we would never be able to achieve elimination.”

Dr. Gonzalez disclosed that he is a member of the speakers bureau for AbbVie and Salix.

dbrunk@mdedge.com

LAS VEGAS – Between 2010 and 2017, the proportion of newly diagnosed cases of acute hepatitis C virus infection rose threefold, driven largely by the concomitant opioid epidemic.

Doug Brunk/MDedge News

That makes efforts to screen, diagnose, and cure high-risk populations more important than ever, Stevan A. Gonzalez, MD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association.

About 70% of HCV cases are related to injection drug use,” said Dr. Gonzalez, medical director of liver transplantation at the Baylor Simmons Transplant Institute at the Baylor Scott & White All Saints Medical Center in Fort Worth, Tex. “This is affecting whites as much as blacks and Hispanics, females as much as males, and in nonurban areas as much as in urban areas.”

Data from the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration indicate that during 2004-2014, the number of acute HCV cases among those aged 18-29 years increased 400%, and the use of injection opioids rose 600%.

At the same time, the number of HCV cases among those aged 30-39 years increased 325%, and the use of injection opioids rose 83%.

“We’re starting to see a pattern overlapping between HCV exposure and opioid injection,” Dr. Gonzalez said. Other high-risk populations include homeless and incarcerated individuals.

More than 70 million people worldwide have chronic HCV infection, Dr. Gonzalez noted, with possibly as many as 5 million cases in the United States. It remains the nation’s most common blood-borne infection.

Chronic disease develops in up to 85% of people who are exposed, infection is asymptomatic, and HCV remains one of the leading indications for liver transplantation and causes of liver cancer.

From a geographic standpoint, the prevalence of HCV in young adults is eclipsing that of Baby Boomers in several states in the Appalachian region and in Northeast, which have long been trouble spots for opioid use disorder (Gastroenterol. 2018 May;154[6]:1850-1).

Surprising exposure risk

The primary risk of transmission is through contaminated blood and the exposure through needles.

“It really doesn’t matter whether it’s a needle that has a small amount of dead space where a little bit of blood can remain or needles that have a larger amount of blood,” Dr. Gonzalez said.

“I’ve had patients who come to me and say, ‘I can’t believe I have HCV. It’s impossible. I always use my own needles. They’re always brand new; I’ve never shared with anybody,’” he continued.

“This is where education and awareness is so critical, because it’s not just the needles,” Dr. Gonzalez explained. “HCV can survive on inanimate objects. For example, on a tabletop surface or a water container, HCV can remain viable up to 3 weeks. In a syringe, 2 months. For that reason, HCV can also be transmitted through crack pipes and nasal drug use, where the prevalence can be up to 35%.”

The duration of a person’s HCV infection drives the transmission.

“That’s important to think about, because people who have chronic hepatitis C are infectious until they’re treated,” Dr. Gonzalez said. “If they don’t know that they have hepatitis C, they continue to transmit the virus to others.”

One study found that half of people living with HCV are unaware of their infection (PLoS One. 2014 Jul 2;9[7]:e101554). According to Dr. Gonzalez, forthcoming guidelines from the U.S. Preventive Services Task Force are expected to recommend a one-time screening for HCV infection in all adults aged 18-79 years, a Grade B recommendation. “That’s a big deal,” he said. (The draft recommendations are available here.)

HCV infection disproportionately affects individuals in correctional institutions. In fact, an estimated one in three inmates in the United States has chronic HCV.

“This is sort of a forgotten population with a lot of substance use and mental illness,” Dr. Gonzalez said. “Injection drug use in that setting is the most common risk factor: It’s about 60% in terms of the risk of transmission within correctional settings. HCV-associated liver disease has now surpassed HIV as a cause of death within correctional settings.”
 

Weighing treatment options

The most common oral regimens for chronic HCV include sofosbuvir/ledipasvir, sofosbuvir/velpatasvir, and glecaprevir/pibrentasvir. They achieve cure in 93%-100% of cases.

“HCV can be cured; it can be eradicated from the body long term,” Dr. Gonzalez said. “The choice of regimen, treatment duration, and use of ribavirin depends on the presence/absence of cirrhosis, prior treatment experience, and the genotype.”

All six forms of the HCV genotype can be treated with oral medication, he added, and methadone, bupropion, and naloxone are safe to use during therapy.

Reinfection following HCV treatment occurs infrequently. Dr. Gonzalez cited a randomized, controlled trial presented as an abstract at the 2018 annual meeting of the American Association for the Study of Liver Diseases. That study’s researchers found that – among 199 patients on opioid-replacement therapy who were receiving direct-acting antiviral therapy, in whom greater than 50% were actively using drugs – the rate of reinfection at 3 years was 1.8 reinfections/100 person-years.

“That’s lower than people expect,” Dr. Gonzalez said.
 

How to boost screening

Electronic health record systems can be used as an important tool to increase HCV screening in health care settings.

In 2017, researchers published an analysis of three randomized trials carried out at three separate primary care settings to improve screening for HCV: repeated mailings, an EHR best practice alert (BPA), and patient solicitation (Hepatology 2017 Jan;65[1]:44-53). They evaluated HCV antibody testing, diagnosis, and costs for each of the interventions, compared with standard-of-care testing.

The investigators found that the BPA intervention had the lowest incremental cost per completed test – $24 with fixed start-up costs, including technical design and development of the BPA system; $3 without fixed start-up costs. The BPA intervention also had the lowest incremental cost per new case identified.

Other efforts to expand access to screening and treatment are underway.

In 2019, Louisiana health officials negotiated a one-time fee for unlimited access for 5 years to sofosbuvir/velpatasvir (Epclusa) to treat the estimated 30,000 patients on Louisiana Medicaid and in that state’s department of corrections who have HCV.

“The goal is 90% cure; the burden is on the state health department to screen, diagnose, and dispense medication,” Dr. Gonzalez said.

Also in 2019, the state of Washington used an open bidding process to negotiate access to glecaprevir/pibrentasvir (Mavyret) for the state’s Medicaid population who have HCV.

“Those states are setting the pace,” Dr. Gonzalez said. “They are showing examples of how we can start implementing a process to treat these vulnerable populations.”

Meanwhile, the World Health Organization set a goal of eliminating viral hepatitis as a major public health threat by 2030.

“That sounds ambitious, but I think it’s possible,” Dr. Gonzalez said. “It’s important to address these high-risk populations: the incarcerated, people who use drugs, and the homeless, because those are the groups that have a high prevalence of HCV – mainly through injection drug use.

“If we don’t address that population, and we only target the general population, we’re going to have a continual source of transmission,” Dr. Gonzalez warned. “In that case, we would never be able to achieve elimination.”

Dr. Gonzalez disclosed that he is a member of the speakers bureau for AbbVie and Salix.

dbrunk@mdedge.com

LAS VEGAS – Between 2010 and 2017, the proportion of newly diagnosed cases of acute hepatitis C virus infection rose threefold, driven largely by the concomitant opioid epidemic.

Doug Brunk/MDedge News

That makes efforts to screen, diagnose, and cure high-risk populations more important than ever, Stevan A. Gonzalez, MD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association.

About 70% of HCV cases are related to injection drug use,” said Dr. Gonzalez, medical director of liver transplantation at the Baylor Simmons Transplant Institute at the Baylor Scott & White All Saints Medical Center in Fort Worth, Tex. “This is affecting whites as much as blacks and Hispanics, females as much as males, and in nonurban areas as much as in urban areas.”

Data from the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration indicate that during 2004-2014, the number of acute HCV cases among those aged 18-29 years increased 400%, and the use of injection opioids rose 600%.

At the same time, the number of HCV cases among those aged 30-39 years increased 325%, and the use of injection opioids rose 83%.

“We’re starting to see a pattern overlapping between HCV exposure and opioid injection,” Dr. Gonzalez said. Other high-risk populations include homeless and incarcerated individuals.

More than 70 million people worldwide have chronic HCV infection, Dr. Gonzalez noted, with possibly as many as 5 million cases in the United States. It remains the nation’s most common blood-borne infection.

Chronic disease develops in up to 85% of people who are exposed, infection is asymptomatic, and HCV remains one of the leading indications for liver transplantation and causes of liver cancer.

From a geographic standpoint, the prevalence of HCV in young adults is eclipsing that of Baby Boomers in several states in the Appalachian region and in Northeast, which have long been trouble spots for opioid use disorder (Gastroenterol. 2018 May;154[6]:1850-1).

Surprising exposure risk

The primary risk of transmission is through contaminated blood and the exposure through needles.

“It really doesn’t matter whether it’s a needle that has a small amount of dead space where a little bit of blood can remain or needles that have a larger amount of blood,” Dr. Gonzalez said.

“I’ve had patients who come to me and say, ‘I can’t believe I have HCV. It’s impossible. I always use my own needles. They’re always brand new; I’ve never shared with anybody,’” he continued.

“This is where education and awareness is so critical, because it’s not just the needles,” Dr. Gonzalez explained. “HCV can survive on inanimate objects. For example, on a tabletop surface or a water container, HCV can remain viable up to 3 weeks. In a syringe, 2 months. For that reason, HCV can also be transmitted through crack pipes and nasal drug use, where the prevalence can be up to 35%.”

The duration of a person’s HCV infection drives the transmission.

“That’s important to think about, because people who have chronic hepatitis C are infectious until they’re treated,” Dr. Gonzalez said. “If they don’t know that they have hepatitis C, they continue to transmit the virus to others.”

One study found that half of people living with HCV are unaware of their infection (PLoS One. 2014 Jul 2;9[7]:e101554). According to Dr. Gonzalez, forthcoming guidelines from the U.S. Preventive Services Task Force are expected to recommend a one-time screening for HCV infection in all adults aged 18-79 years, a Grade B recommendation. “That’s a big deal,” he said. (The draft recommendations are available here.)

HCV infection disproportionately affects individuals in correctional institutions. In fact, an estimated one in three inmates in the United States has chronic HCV.

“This is sort of a forgotten population with a lot of substance use and mental illness,” Dr. Gonzalez said. “Injection drug use in that setting is the most common risk factor: It’s about 60% in terms of the risk of transmission within correctional settings. HCV-associated liver disease has now surpassed HIV as a cause of death within correctional settings.”
 

Weighing treatment options

The most common oral regimens for chronic HCV include sofosbuvir/ledipasvir, sofosbuvir/velpatasvir, and glecaprevir/pibrentasvir. They achieve cure in 93%-100% of cases.

“HCV can be cured; it can be eradicated from the body long term,” Dr. Gonzalez said. “The choice of regimen, treatment duration, and use of ribavirin depends on the presence/absence of cirrhosis, prior treatment experience, and the genotype.”

All six forms of the HCV genotype can be treated with oral medication, he added, and methadone, bupropion, and naloxone are safe to use during therapy.

Reinfection following HCV treatment occurs infrequently. Dr. Gonzalez cited a randomized, controlled trial presented as an abstract at the 2018 annual meeting of the American Association for the Study of Liver Diseases. That study’s researchers found that – among 199 patients on opioid-replacement therapy who were receiving direct-acting antiviral therapy, in whom greater than 50% were actively using drugs – the rate of reinfection at 3 years was 1.8 reinfections/100 person-years.

“That’s lower than people expect,” Dr. Gonzalez said.
 

How to boost screening

Electronic health record systems can be used as an important tool to increase HCV screening in health care settings.

In 2017, researchers published an analysis of three randomized trials carried out at three separate primary care settings to improve screening for HCV: repeated mailings, an EHR best practice alert (BPA), and patient solicitation (Hepatology 2017 Jan;65[1]:44-53). They evaluated HCV antibody testing, diagnosis, and costs for each of the interventions, compared with standard-of-care testing.

The investigators found that the BPA intervention had the lowest incremental cost per completed test – $24 with fixed start-up costs, including technical design and development of the BPA system; $3 without fixed start-up costs. The BPA intervention also had the lowest incremental cost per new case identified.

Other efforts to expand access to screening and treatment are underway.

In 2019, Louisiana health officials negotiated a one-time fee for unlimited access for 5 years to sofosbuvir/velpatasvir (Epclusa) to treat the estimated 30,000 patients on Louisiana Medicaid and in that state’s department of corrections who have HCV.

“The goal is 90% cure; the burden is on the state health department to screen, diagnose, and dispense medication,” Dr. Gonzalez said.

Also in 2019, the state of Washington used an open bidding process to negotiate access to glecaprevir/pibrentasvir (Mavyret) for the state’s Medicaid population who have HCV.

“Those states are setting the pace,” Dr. Gonzalez said. “They are showing examples of how we can start implementing a process to treat these vulnerable populations.”

Meanwhile, the World Health Organization set a goal of eliminating viral hepatitis as a major public health threat by 2030.

“That sounds ambitious, but I think it’s possible,” Dr. Gonzalez said. “It’s important to address these high-risk populations: the incarcerated, people who use drugs, and the homeless, because those are the groups that have a high prevalence of HCV – mainly through injection drug use.

“If we don’t address that population, and we only target the general population, we’re going to have a continual source of transmission,” Dr. Gonzalez warned. “In that case, we would never be able to achieve elimination.”

Dr. Gonzalez disclosed that he is a member of the speakers bureau for AbbVie and Salix.

dbrunk@mdedge.com

Physicians in internal medicine struggle to find happiness both in and outside the workplace, according to Medscape’s 2020 Lifestyle, Happiness, and Burnout Report.

Only 22% of internists reported that they were very happy at work, with only neurologists reporting a worse at-work happiness rate, according to the Medscape report.

The news wasn’t much better when it came to happiness outside the office, as only 48% of internists reported they were very happy. Once again, neurologists had the lowest happiness rate outside the office, at 44%.

The rate of burnout among internists, at 43%, was similar to that of physicians overall at 41%; 14% of internists reported that they were both burned out and depressed. The most common contributing factors to burnout for internists were having too many bureaucratic tasks (62%), receiving a lack of respect from colleagues (34%), and spending too many hours at work (33%).

Internists dealt with burnout by isolating themselves from others (47%), talking with family/friends (45%), and exercising (41%). In addition, only 41% of internists took 3-4 weeks’ vacation, less than the 44% for physicians overall, and 43% took less than 3 weeks of vacation.

About 14% of internists said that they’d contemplated suicide, and 1% reported that they’d attempted it; 80% said they’d never thought about suicide. Only 16% said that they were seeking or planning to seek professional help for symptoms of burnout or depression, and 64% said they weren’t planning on seeking help and had never done so in the past.

The Medscape survey was conducted from June 25 to Sept. 19, 2019, and involved 15,181 physicians.

lfranki@mdedge.com

Physicians in internal medicine struggle to find happiness both in and outside the workplace, according to Medscape’s 2020 Lifestyle, Happiness, and Burnout Report.

Only 22% of internists reported that they were very happy at work, with only neurologists reporting a worse at-work happiness rate, according to the Medscape report.

The news wasn’t much better when it came to happiness outside the office, as only 48% of internists reported they were very happy. Once again, neurologists had the lowest happiness rate outside the office, at 44%.

The rate of burnout among internists, at 43%, was similar to that of physicians overall at 41%; 14% of internists reported that they were both burned out and depressed. The most common contributing factors to burnout for internists were having too many bureaucratic tasks (62%), receiving a lack of respect from colleagues (34%), and spending too many hours at work (33%).

Internists dealt with burnout by isolating themselves from others (47%), talking with family/friends (45%), and exercising (41%). In addition, only 41% of internists took 3-4 weeks’ vacation, less than the 44% for physicians overall, and 43% took less than 3 weeks of vacation.

About 14% of internists said that they’d contemplated suicide, and 1% reported that they’d attempted it; 80% said they’d never thought about suicide. Only 16% said that they were seeking or planning to seek professional help for symptoms of burnout or depression, and 64% said they weren’t planning on seeking help and had never done so in the past.

The Medscape survey was conducted from June 25 to Sept. 19, 2019, and involved 15,181 physicians.

lfranki@mdedge.com

Physicians in internal medicine struggle to find happiness both in and outside the workplace, according to Medscape’s 2020 Lifestyle, Happiness, and Burnout Report.

Only 22% of internists reported that they were very happy at work, with only neurologists reporting a worse at-work happiness rate, according to the Medscape report.

The news wasn’t much better when it came to happiness outside the office, as only 48% of internists reported they were very happy. Once again, neurologists had the lowest happiness rate outside the office, at 44%.

The rate of burnout among internists, at 43%, was similar to that of physicians overall at 41%; 14% of internists reported that they were both burned out and depressed. The most common contributing factors to burnout for internists were having too many bureaucratic tasks (62%), receiving a lack of respect from colleagues (34%), and spending too many hours at work (33%).

Internists dealt with burnout by isolating themselves from others (47%), talking with family/friends (45%), and exercising (41%). In addition, only 41% of internists took 3-4 weeks’ vacation, less than the 44% for physicians overall, and 43% took less than 3 weeks of vacation.

About 14% of internists said that they’d contemplated suicide, and 1% reported that they’d attempted it; 80% said they’d never thought about suicide. Only 16% said that they were seeking or planning to seek professional help for symptoms of burnout or depression, and 64% said they weren’t planning on seeking help and had never done so in the past.

The Medscape survey was conducted from June 25 to Sept. 19, 2019, and involved 15,181 physicians.

lfranki@mdedge.com

Antibiotic resistance in strains of Streptococcus pneumoniae has been rising since 2013 because of changing susceptibility profiles, based on data from 1,201 isolates collected from 448 children in primary care settings.

“New strains expressing capsular serotypes not included in the 13-valent pneumococcal conjugate vaccine are emerging to cause disease, and strains that acquire antibiotic resistance are increasing in frequency due to their survival of the fittest advantage,” wrote Ravinder Kaur, PhD, of Rochester (N.Y.) General Hospital Research Institute, and colleagues.

Similar Darwinian principles occurred after the introduction of PCV-7, the study authors added.

In a prospective cohort study published in Clinical Infectious Diseases, the researchers reviewed 1,201 isolates collected from the nasopharynx during healthy periods, and from the nasopharynx and middle ear fluid (MEF) during episodes of acute otitis media, in children aged 6-36 months who were seen in primary care settings.

The isolates were collected during 2006-2016 to reflect the pre- and post-PCV13 era. Children received PCV-7 from 2006 until April 2010, and received PCV-13 after April 2010.

Overall, the number of acute otitis media (AOM) cases caused by S. pneumoniae was not significantly different between the PCV-7 and PCV-13 eras, nor was the frequency of pneumococci identified in the nasopharynx during healthy visits and visits at the start of an AOM infection.

The researchers examined susceptibility using minimum inhibitory concentrations (MIC). During healthy visits, the MIC₅₀ of isolated pneumococci was low (no greater than 0.06 mcg/mL) for all four beta-lactam drugs tested. And it didn’t change significantly over the study years.

In contrast, among the nasopharyngeal and MEF isolates during AOM, the MIC₅₀ to penicillin, amoxicillin, ceftriaxone, and meropenem during 2013-2016 rose significantly, the investigators said.

A change in antibiotic susceptibility within a subtype also contributed to the development of PCV-13 resistance.

The study authors identified three serotypes that affected the changes in susceptibility in their study population. Serotypes 35B and 35F increased their beta-lactam resistance during 2013-2016, and serotype 11A had a higher MIC to quinolones and became more prevalent during 2013-2016. Those three serotypes accounted for most of the change in antibiotic susceptibility, the researchers said.

In addition, “the frequency of strains resistant to penicillin and amoxicillin decreased with the introduction of PCV-13, but rebounded to levels similar to those before PCV-13 introduction by 2015-2016,” the investigators noted.

The study findings were limited by several factors, including the homogeneous study population and potential lack of generalizability to other settings. In addition, the researchers did not study antibiotic consumption or antibiotic treatment failure, and they could not account for potential AOM cases that may have been treated in settings other than primary care.

However, the investigators said the results support the need for additional studies and attention to the development of the next generation of PCVs, the PCV-15 and PCV-20. Both include serotypes 22F and 33F, but neither includes 35B or 35F. The PCV-20 also includes 11A and 15B.

The study was supported in part by the National Institutes of Health and Sanofi Pasteur. Some isolates collected during the 2010-2013 time period were part of a study supported by Pfizer. The researchers had no relevant financial conflicts to disclose.

SOURCE: Kaur R et al. Clin Inf Dis. 2020 Feb 18. doi: 10.1093/cid/ciaa157.

Antibiotic resistance in strains of Streptococcus pneumoniae has been rising since 2013 because of changing susceptibility profiles, based on data from 1,201 isolates collected from 448 children in primary care settings.

“New strains expressing capsular serotypes not included in the 13-valent pneumococcal conjugate vaccine are emerging to cause disease, and strains that acquire antibiotic resistance are increasing in frequency due to their survival of the fittest advantage,” wrote Ravinder Kaur, PhD, of Rochester (N.Y.) General Hospital Research Institute, and colleagues.

Similar Darwinian principles occurred after the introduction of PCV-7, the study authors added.

In a prospective cohort study published in Clinical Infectious Diseases, the researchers reviewed 1,201 isolates collected from the nasopharynx during healthy periods, and from the nasopharynx and middle ear fluid (MEF) during episodes of acute otitis media, in children aged 6-36 months who were seen in primary care settings.

The isolates were collected during 2006-2016 to reflect the pre- and post-PCV13 era. Children received PCV-7 from 2006 until April 2010, and received PCV-13 after April 2010.

Overall, the number of acute otitis media (AOM) cases caused by S. pneumoniae was not significantly different between the PCV-7 and PCV-13 eras, nor was the frequency of pneumococci identified in the nasopharynx during healthy visits and visits at the start of an AOM infection.

The researchers examined susceptibility using minimum inhibitory concentrations (MIC). During healthy visits, the MIC₅₀ of isolated pneumococci was low (no greater than 0.06 mcg/mL) for all four beta-lactam drugs tested. And it didn’t change significantly over the study years.

In contrast, among the nasopharyngeal and MEF isolates during AOM, the MIC₅₀ to penicillin, amoxicillin, ceftriaxone, and meropenem during 2013-2016 rose significantly, the investigators said.

A change in antibiotic susceptibility within a subtype also contributed to the development of PCV-13 resistance.

The study authors identified three serotypes that affected the changes in susceptibility in their study population. Serotypes 35B and 35F increased their beta-lactam resistance during 2013-2016, and serotype 11A had a higher MIC to quinolones and became more prevalent during 2013-2016. Those three serotypes accounted for most of the change in antibiotic susceptibility, the researchers said.

In addition, “the frequency of strains resistant to penicillin and amoxicillin decreased with the introduction of PCV-13, but rebounded to levels similar to those before PCV-13 introduction by 2015-2016,” the investigators noted.

The study findings were limited by several factors, including the homogeneous study population and potential lack of generalizability to other settings. In addition, the researchers did not study antibiotic consumption or antibiotic treatment failure, and they could not account for potential AOM cases that may have been treated in settings other than primary care.

However, the investigators said the results support the need for additional studies and attention to the development of the next generation of PCVs, the PCV-15 and PCV-20. Both include serotypes 22F and 33F, but neither includes 35B or 35F. The PCV-20 also includes 11A and 15B.

The study was supported in part by the National Institutes of Health and Sanofi Pasteur. Some isolates collected during the 2010-2013 time period were part of a study supported by Pfizer. The researchers had no relevant financial conflicts to disclose.

SOURCE: Kaur R et al. Clin Inf Dis. 2020 Feb 18. doi: 10.1093/cid/ciaa157.

Antibiotic resistance in strains of Streptococcus pneumoniae has been rising since 2013 because of changing susceptibility profiles, based on data from 1,201 isolates collected from 448 children in primary care settings.

“New strains expressing capsular serotypes not included in the 13-valent pneumococcal conjugate vaccine are emerging to cause disease, and strains that acquire antibiotic resistance are increasing in frequency due to their survival of the fittest advantage,” wrote Ravinder Kaur, PhD, of Rochester (N.Y.) General Hospital Research Institute, and colleagues.

Similar Darwinian principles occurred after the introduction of PCV-7, the study authors added.

In a prospective cohort study published in Clinical Infectious Diseases, the researchers reviewed 1,201 isolates collected from the nasopharynx during healthy periods, and from the nasopharynx and middle ear fluid (MEF) during episodes of acute otitis media, in children aged 6-36 months who were seen in primary care settings.

The isolates were collected during 2006-2016 to reflect the pre- and post-PCV13 era. Children received PCV-7 from 2006 until April 2010, and received PCV-13 after April 2010.

Overall, the number of acute otitis media (AOM) cases caused by S. pneumoniae was not significantly different between the PCV-7 and PCV-13 eras, nor was the frequency of pneumococci identified in the nasopharynx during healthy visits and visits at the start of an AOM infection.

The researchers examined susceptibility using minimum inhibitory concentrations (MIC). During healthy visits, the MIC₅₀ of isolated pneumococci was low (no greater than 0.06 mcg/mL) for all four beta-lactam drugs tested. And it didn’t change significantly over the study years.

In contrast, among the nasopharyngeal and MEF isolates during AOM, the MIC₅₀ to penicillin, amoxicillin, ceftriaxone, and meropenem during 2013-2016 rose significantly, the investigators said.

A change in antibiotic susceptibility within a subtype also contributed to the development of PCV-13 resistance.

The study authors identified three serotypes that affected the changes in susceptibility in their study population. Serotypes 35B and 35F increased their beta-lactam resistance during 2013-2016, and serotype 11A had a higher MIC to quinolones and became more prevalent during 2013-2016. Those three serotypes accounted for most of the change in antibiotic susceptibility, the researchers said.

In addition, “the frequency of strains resistant to penicillin and amoxicillin decreased with the introduction of PCV-13, but rebounded to levels similar to those before PCV-13 introduction by 2015-2016,” the investigators noted.

The study findings were limited by several factors, including the homogeneous study population and potential lack of generalizability to other settings. In addition, the researchers did not study antibiotic consumption or antibiotic treatment failure, and they could not account for potential AOM cases that may have been treated in settings other than primary care.

However, the investigators said the results support the need for additional studies and attention to the development of the next generation of PCVs, the PCV-15 and PCV-20. Both include serotypes 22F and 33F, but neither includes 35B or 35F. The PCV-20 also includes 11A and 15B.

The study was supported in part by the National Institutes of Health and Sanofi Pasteur. Some isolates collected during the 2010-2013 time period were part of a study supported by Pfizer. The researchers had no relevant financial conflicts to disclose.

SOURCE: Kaur R et al. Clin Inf Dis. 2020 Feb 18. doi: 10.1093/cid/ciaa157.

WEST PALM BEACH, FLA. – Failure to recover completely from early relapses in multiple sclerosis (MS) is significantly associated with higher long-term disability, according to research presented at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

Incomplete recovery thus should be given more consideration when evaluating research and clinical practice outcomes, the study investigators cautioned.

“We found that the recovery from early relapses is an important predictor of future disability,” first author Marinos G. Sotiropoulos, MD, of the department of neurology, Brigham and Women’s Hospital, Boston, said in an interview. “It should be incorporated in future predictive models of disease severity and clinical trials, [and] it could be useful in clinical decision making as well.”

Incomplete recovery from relapses is known to be linked to disability progression and to the likelihood of transitioning to secondary progressive MS. Research on its role in longer-term outcomes is lacking, however.

To investigate the effect of incomplete relapse recovery in the first 3 years of MS on rates of disability at 10 years, Dr. Sotiropoulos and colleagues evaluated data on 360 patients enrolled in the CLIMB (Comprehensive Longitudinal Investigation in Multiple Sclerosis at Brigham and Women’s Hospital) study. CLIMB is a natural history study spanning 20 years, with more than 2,000 patients.

Patients were included if at least 8.5 years had passed since their first documented symptom, if they were at least 18 years at their first visit to the Partners MS Center, if that visit occurred within 1 year of their first symptom, and if they had a diagnosis of relapsing-remitting MS or secondary progressive MS.

Among the 308 patients included in the study, 74% were female and 89% were white, with a mean age at the first symptom of 35.9 years.

A total of 403 early attacks from those 308 patients were included in the study. Half of the attacks (50.4%) were followed by incomplete recovery after 6 months, defined specifically as an increase in the Expanded Disability Status Scale (EDSS) scores from baseline to at least 6 months after the onset of the attack.

As of their 10-year visit, 27.3% of patients had a normal examination, defined as EDSS 0, and 64.1% had no significant disability (EDSS less than 2). The mean EDSS at 10 years was 1.52.

Patients’ recovery index, defined as the percentage of early attacks that recovered completely, was significantly associated with 10-year EDSS scores (P less than .001).

Patient age at first symptom was also a significant predictor of 10-year disability (P less than .004). Factors that were significantly associated with incomplete relapse recovery were the duration of time from first symptom (P less than .001) and moderate severity of the relapse (P = .029).

With the type of drug treatment likely representing an important factor in whether a patient has incomplete relapse recovery, the issue should be the subject of further research, Dr. Sotiropoulos said.

“This is something that is important to look at because none of the clinical trials for the drugs we currently have looked at relapse recovery as an outcome,” he explained.

“There have been some post hoc analyses [that] have shown that some of the new medications can improve recovery from relapses, but there is a lot to look into now that we know relapse recovery is an important clinical parameter,” he said. “We have to factor in the treatment effect in preventing residual disability after relapses.”

The findings suggest that “patients with incomplete early recovery might be considered for highly effective disease-modifying therapy,” added senior author Tanuja Chitnis, MD, also of the department of neurology at Brigham and Women’s Hospital. “We are now analyzing the biological mechanisms associated with relapse recovery.”

The authors of a recent study that echoes the importance of relapse recovery call it “the forgotten variable in multiple sclerosis clinical trials.” In that study, the researchers found an increased likelihood of a benign disease course among patients who received immediate disease-modifying therapy (DMT) initiation after failing to have a good recovery from an initial relapse (Neurol Neuroimmunol Neuroinflamm. 2019 Dec 17;7[2]).

“Some clinicians may choose to hold off DMTs because the patient may not have high disease activity levels,” Burcu Zeydan, MD, a coauthor of that study and an assistant professor of radiology in the Center of MS and Autoimmune Neurology at the Mayo Clinic, Rochester, Minn., said in an interview.

“What these studies add is that, if a patient is a poor recoverer despite not having highly active disease, that patient should be considered for immediate treatment initiation,” she said. “Otherwise, there is the possibility of a next relapse, which may not happen often. But when it happens, it may lead to more residual deficit with additional disability burden.”

The CLIMB study received funding from Mallinckrodt and the National MS Society Nancy Davis Center Without Walls. Dr. Sotiropoulos has received research support from Mallinckrodt. Dr. Chitnis has served on advisory boards for Biogen, Novartis, and Sanofi-Genzyme, and she has received research support from the Department of Defense, National MS Society, Guthy-Jackson Charitable Foundation, Novartis, Octave, Serono, and Verily. Dr. Zeydan had no disclosures to report.

SOURCE: Sotiropoulos MG et al. ACTRIMS Forum 2020. Abstract LB 317.

WEST PALM BEACH, FLA. – Failure to recover completely from early relapses in multiple sclerosis (MS) is significantly associated with higher long-term disability, according to research presented at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

Incomplete recovery thus should be given more consideration when evaluating research and clinical practice outcomes, the study investigators cautioned.

“We found that the recovery from early relapses is an important predictor of future disability,” first author Marinos G. Sotiropoulos, MD, of the department of neurology, Brigham and Women’s Hospital, Boston, said in an interview. “It should be incorporated in future predictive models of disease severity and clinical trials, [and] it could be useful in clinical decision making as well.”

Incomplete recovery from relapses is known to be linked to disability progression and to the likelihood of transitioning to secondary progressive MS. Research on its role in longer-term outcomes is lacking, however.

To investigate the effect of incomplete relapse recovery in the first 3 years of MS on rates of disability at 10 years, Dr. Sotiropoulos and colleagues evaluated data on 360 patients enrolled in the CLIMB (Comprehensive Longitudinal Investigation in Multiple Sclerosis at Brigham and Women’s Hospital) study. CLIMB is a natural history study spanning 20 years, with more than 2,000 patients.

Patients were included if at least 8.5 years had passed since their first documented symptom, if they were at least 18 years at their first visit to the Partners MS Center, if that visit occurred within 1 year of their first symptom, and if they had a diagnosis of relapsing-remitting MS or secondary progressive MS.

Among the 308 patients included in the study, 74% were female and 89% were white, with a mean age at the first symptom of 35.9 years.

A total of 403 early attacks from those 308 patients were included in the study. Half of the attacks (50.4%) were followed by incomplete recovery after 6 months, defined specifically as an increase in the Expanded Disability Status Scale (EDSS) scores from baseline to at least 6 months after the onset of the attack.

As of their 10-year visit, 27.3% of patients had a normal examination, defined as EDSS 0, and 64.1% had no significant disability (EDSS less than 2). The mean EDSS at 10 years was 1.52.

Patients’ recovery index, defined as the percentage of early attacks that recovered completely, was significantly associated with 10-year EDSS scores (P less than .001).

Patient age at first symptom was also a significant predictor of 10-year disability (P less than .004). Factors that were significantly associated with incomplete relapse recovery were the duration of time from first symptom (P less than .001) and moderate severity of the relapse (P = .029).

With the type of drug treatment likely representing an important factor in whether a patient has incomplete relapse recovery, the issue should be the subject of further research, Dr. Sotiropoulos said.

“This is something that is important to look at because none of the clinical trials for the drugs we currently have looked at relapse recovery as an outcome,” he explained.

“There have been some post hoc analyses [that] have shown that some of the new medications can improve recovery from relapses, but there is a lot to look into now that we know relapse recovery is an important clinical parameter,” he said. “We have to factor in the treatment effect in preventing residual disability after relapses.”

The findings suggest that “patients with incomplete early recovery might be considered for highly effective disease-modifying therapy,” added senior author Tanuja Chitnis, MD, also of the department of neurology at Brigham and Women’s Hospital. “We are now analyzing the biological mechanisms associated with relapse recovery.”

The authors of a recent study that echoes the importance of relapse recovery call it “the forgotten variable in multiple sclerosis clinical trials.” In that study, the researchers found an increased likelihood of a benign disease course among patients who received immediate disease-modifying therapy (DMT) initiation after failing to have a good recovery from an initial relapse (Neurol Neuroimmunol Neuroinflamm. 2019 Dec 17;7[2]).

“Some clinicians may choose to hold off DMTs because the patient may not have high disease activity levels,” Burcu Zeydan, MD, a coauthor of that study and an assistant professor of radiology in the Center of MS and Autoimmune Neurology at the Mayo Clinic, Rochester, Minn., said in an interview.

“What these studies add is that, if a patient is a poor recoverer despite not having highly active disease, that patient should be considered for immediate treatment initiation,” she said. “Otherwise, there is the possibility of a next relapse, which may not happen often. But when it happens, it may lead to more residual deficit with additional disability burden.”

The CLIMB study received funding from Mallinckrodt and the National MS Society Nancy Davis Center Without Walls. Dr. Sotiropoulos has received research support from Mallinckrodt. Dr. Chitnis has served on advisory boards for Biogen, Novartis, and Sanofi-Genzyme, and she has received research support from the Department of Defense, National MS Society, Guthy-Jackson Charitable Foundation, Novartis, Octave, Serono, and Verily. Dr. Zeydan had no disclosures to report.

SOURCE: Sotiropoulos MG et al. ACTRIMS Forum 2020. Abstract LB 317.

WEST PALM BEACH, FLA. – Failure to recover completely from early relapses in multiple sclerosis (MS) is significantly associated with higher long-term disability, according to research presented at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis.

Incomplete recovery thus should be given more consideration when evaluating research and clinical practice outcomes, the study investigators cautioned.

“We found that the recovery from early relapses is an important predictor of future disability,” first author Marinos G. Sotiropoulos, MD, of the department of neurology, Brigham and Women’s Hospital, Boston, said in an interview. “It should be incorporated in future predictive models of disease severity and clinical trials, [and] it could be useful in clinical decision making as well.”

Incomplete recovery from relapses is known to be linked to disability progression and to the likelihood of transitioning to secondary progressive MS. Research on its role in longer-term outcomes is lacking, however.

To investigate the effect of incomplete relapse recovery in the first 3 years of MS on rates of disability at 10 years, Dr. Sotiropoulos and colleagues evaluated data on 360 patients enrolled in the CLIMB (Comprehensive Longitudinal Investigation in Multiple Sclerosis at Brigham and Women’s Hospital) study. CLIMB is a natural history study spanning 20 years, with more than 2,000 patients.

Patients were included if at least 8.5 years had passed since their first documented symptom, if they were at least 18 years at their first visit to the Partners MS Center, if that visit occurred within 1 year of their first symptom, and if they had a diagnosis of relapsing-remitting MS or secondary progressive MS.

Among the 308 patients included in the study, 74% were female and 89% were white, with a mean age at the first symptom of 35.9 years.

A total of 403 early attacks from those 308 patients were included in the study. Half of the attacks (50.4%) were followed by incomplete recovery after 6 months, defined specifically as an increase in the Expanded Disability Status Scale (EDSS) scores from baseline to at least 6 months after the onset of the attack.

As of their 10-year visit, 27.3% of patients had a normal examination, defined as EDSS 0, and 64.1% had no significant disability (EDSS less than 2). The mean EDSS at 10 years was 1.52.

Patients’ recovery index, defined as the percentage of early attacks that recovered completely, was significantly associated with 10-year EDSS scores (P less than .001).

Patient age at first symptom was also a significant predictor of 10-year disability (P less than .004). Factors that were significantly associated with incomplete relapse recovery were the duration of time from first symptom (P less than .001) and moderate severity of the relapse (P = .029).

With the type of drug treatment likely representing an important factor in whether a patient has incomplete relapse recovery, the issue should be the subject of further research, Dr. Sotiropoulos said.

“This is something that is important to look at because none of the clinical trials for the drugs we currently have looked at relapse recovery as an outcome,” he explained.

“There have been some post hoc analyses [that] have shown that some of the new medications can improve recovery from relapses, but there is a lot to look into now that we know relapse recovery is an important clinical parameter,” he said. “We have to factor in the treatment effect in preventing residual disability after relapses.”

The findings suggest that “patients with incomplete early recovery might be considered for highly effective disease-modifying therapy,” added senior author Tanuja Chitnis, MD, also of the department of neurology at Brigham and Women’s Hospital. “We are now analyzing the biological mechanisms associated with relapse recovery.”

The authors of a recent study that echoes the importance of relapse recovery call it “the forgotten variable in multiple sclerosis clinical trials.” In that study, the researchers found an increased likelihood of a benign disease course among patients who received immediate disease-modifying therapy (DMT) initiation after failing to have a good recovery from an initial relapse (Neurol Neuroimmunol Neuroinflamm. 2019 Dec 17;7[2]).

“Some clinicians may choose to hold off DMTs because the patient may not have high disease activity levels,” Burcu Zeydan, MD, a coauthor of that study and an assistant professor of radiology in the Center of MS and Autoimmune Neurology at the Mayo Clinic, Rochester, Minn., said in an interview.

“What these studies add is that, if a patient is a poor recoverer despite not having highly active disease, that patient should be considered for immediate treatment initiation,” she said. “Otherwise, there is the possibility of a next relapse, which may not happen often. But when it happens, it may lead to more residual deficit with additional disability burden.”

The CLIMB study received funding from Mallinckrodt and the National MS Society Nancy Davis Center Without Walls. Dr. Sotiropoulos has received research support from Mallinckrodt. Dr. Chitnis has served on advisory boards for Biogen, Novartis, and Sanofi-Genzyme, and she has received research support from the Department of Defense, National MS Society, Guthy-Jackson Charitable Foundation, Novartis, Octave, Serono, and Verily. Dr. Zeydan had no disclosures to report.

SOURCE: Sotiropoulos MG et al. ACTRIMS Forum 2020. Abstract LB 317.

“We are what we repeatedly do. Excellence, then, is not an act, but a habit.”
—Will Durant

We are a collection of our habits—the routine, repetitive, subconscious behaviors we perform on a daily basis. Some of these behaviors are positive, others less so. Habits allow us to perform tasks automatically, without the need for active decision making. Amidst a constantly changing clinical environment, cultivating consistent habits can improve our adherence to best practices and free cognitive effort toward more challenging diagnostic or therapeutic tasks.

Establishing habits requires practice and intentionality. First, identify those habits that are desirable in your personal and professional life. Next, find a method to develop the habit. Then, hold yourself accountable as you work to embed the habit. Simple? Not quite.

In “The Power of Habit,” author Charles Duhigg introduces habit loops as a way to successfully develop this practice.¹ Habit loops—sequences comprising a cue, routine, and reward—are integral to developing routines that support professional and personal aspects of hospitalist life. Consider a hospitalist seeking to develop a prerounds routine to increase efficiency and limit missed patient information. First, the clinician should identify a cue to start the routine, such as sitting down to log in at a specific workstation. Second, a sequence of actions is “chunked” into a consistent order, such as a review of vital signs, clinical notes, and patient labs. After the routine is completed, the clinician should finish with a reward, such as a cup of coffee after rounds. Want to set up a habit for ensuring learning goals are set with trainees at the beginning of every block? Set a calendar reminder for this on the first day, standardize how you communicate goals, and reward yourself with a team lunch at the end of the rotation. What if it’s a busy first day on service? Doesn’t matter. As Clay Christensen notes in “How Will You Measure Your Life?,” making one commitment to a habit is easier than deciding whether or not to engage in the routine every time new circumstances arise.² The intentionality that comes with this act ensures consistency in the practice.

As a busy hospitalist, establishing habits for personal and professional development requires cues and rewards. For example, do you want to cement a habit of reading the latest journal articles or carving out time each day to reflect on your work? Then cultivate the routine by creating a cue, such as a dashboard on a wall to visualize how many articles you’ve read this week or whether you’ve paused to reflect on your rotation. Reinforce the routine by creating a reward: a walk outside, time with family, or another activity you enjoy. Pair the same reward with the same routine to strengthen the habit loop.

A few additional tips for cultivating habits: it is useful to pair an existing reliable habit, or “anchor habit,” with a new one, such as a short meditation after brushing your teeth.³ Doing so reinforces behaviors in a positive way. You may use the same principles to lose unwanted habits (eg, checking e-mail excessively) by removing cues, such as turning off notifications or using airplane mode and rewarding yourself when you see the behavior through.

Habits are larger than behaviors; they can impact your personal and professional life in important ways. By actively creating habits that align with your long-term priorities, you can create a safety net if and when change arrives. Understanding the psychology of habits and employing cues and rewards effectively can lead hospitalists to create positive routines that improve their clinical practice and personal lives.

“We are what we repeatedly do. Excellence, then, is not an act, but a habit.”
—Will Durant

We are a collection of our habits—the routine, repetitive, subconscious behaviors we perform on a daily basis. Some of these behaviors are positive, others less so. Habits allow us to perform tasks automatically, without the need for active decision making. Amidst a constantly changing clinical environment, cultivating consistent habits can improve our adherence to best practices and free cognitive effort toward more challenging diagnostic or therapeutic tasks.

Establishing habits requires practice and intentionality. First, identify those habits that are desirable in your personal and professional life. Next, find a method to develop the habit. Then, hold yourself accountable as you work to embed the habit. Simple? Not quite.

In “The Power of Habit,” author Charles Duhigg introduces habit loops as a way to successfully develop this practice.¹ Habit loops—sequences comprising a cue, routine, and reward—are integral to developing routines that support professional and personal aspects of hospitalist life. Consider a hospitalist seeking to develop a prerounds routine to increase efficiency and limit missed patient information. First, the clinician should identify a cue to start the routine, such as sitting down to log in at a specific workstation. Second, a sequence of actions is “chunked” into a consistent order, such as a review of vital signs, clinical notes, and patient labs. After the routine is completed, the clinician should finish with a reward, such as a cup of coffee after rounds. Want to set up a habit for ensuring learning goals are set with trainees at the beginning of every block? Set a calendar reminder for this on the first day, standardize how you communicate goals, and reward yourself with a team lunch at the end of the rotation. What if it’s a busy first day on service? Doesn’t matter. As Clay Christensen notes in “How Will You Measure Your Life?,” making one commitment to a habit is easier than deciding whether or not to engage in the routine every time new circumstances arise.² The intentionality that comes with this act ensures consistency in the practice.

As a busy hospitalist, establishing habits for personal and professional development requires cues and rewards. For example, do you want to cement a habit of reading the latest journal articles or carving out time each day to reflect on your work? Then cultivate the routine by creating a cue, such as a dashboard on a wall to visualize how many articles you’ve read this week or whether you’ve paused to reflect on your rotation. Reinforce the routine by creating a reward: a walk outside, time with family, or another activity you enjoy. Pair the same reward with the same routine to strengthen the habit loop.

A few additional tips for cultivating habits: it is useful to pair an existing reliable habit, or “anchor habit,” with a new one, such as a short meditation after brushing your teeth.³ Doing so reinforces behaviors in a positive way. You may use the same principles to lose unwanted habits (eg, checking e-mail excessively) by removing cues, such as turning off notifications or using airplane mode and rewarding yourself when you see the behavior through.

Habits are larger than behaviors; they can impact your personal and professional life in important ways. By actively creating habits that align with your long-term priorities, you can create a safety net if and when change arrives. Understanding the psychology of habits and employing cues and rewards effectively can lead hospitalists to create positive routines that improve their clinical practice and personal lives.

“We are what we repeatedly do. Excellence, then, is not an act, but a habit.”
—Will Durant

We are a collection of our habits—the routine, repetitive, subconscious behaviors we perform on a daily basis. Some of these behaviors are positive, others less so. Habits allow us to perform tasks automatically, without the need for active decision making. Amidst a constantly changing clinical environment, cultivating consistent habits can improve our adherence to best practices and free cognitive effort toward more challenging diagnostic or therapeutic tasks.

Establishing habits requires practice and intentionality. First, identify those habits that are desirable in your personal and professional life. Next, find a method to develop the habit. Then, hold yourself accountable as you work to embed the habit. Simple? Not quite.

In “The Power of Habit,” author Charles Duhigg introduces habit loops as a way to successfully develop this practice.¹ Habit loops—sequences comprising a cue, routine, and reward—are integral to developing routines that support professional and personal aspects of hospitalist life. Consider a hospitalist seeking to develop a prerounds routine to increase efficiency and limit missed patient information. First, the clinician should identify a cue to start the routine, such as sitting down to log in at a specific workstation. Second, a sequence of actions is “chunked” into a consistent order, such as a review of vital signs, clinical notes, and patient labs. After the routine is completed, the clinician should finish with a reward, such as a cup of coffee after rounds. Want to set up a habit for ensuring learning goals are set with trainees at the beginning of every block? Set a calendar reminder for this on the first day, standardize how you communicate goals, and reward yourself with a team lunch at the end of the rotation. What if it’s a busy first day on service? Doesn’t matter. As Clay Christensen notes in “How Will You Measure Your Life?,” making one commitment to a habit is easier than deciding whether or not to engage in the routine every time new circumstances arise.² The intentionality that comes with this act ensures consistency in the practice.

As a busy hospitalist, establishing habits for personal and professional development requires cues and rewards. For example, do you want to cement a habit of reading the latest journal articles or carving out time each day to reflect on your work? Then cultivate the routine by creating a cue, such as a dashboard on a wall to visualize how many articles you’ve read this week or whether you’ve paused to reflect on your rotation. Reinforce the routine by creating a reward: a walk outside, time with family, or another activity you enjoy. Pair the same reward with the same routine to strengthen the habit loop.

A few additional tips for cultivating habits: it is useful to pair an existing reliable habit, or “anchor habit,” with a new one, such as a short meditation after brushing your teeth.³ Doing so reinforces behaviors in a positive way. You may use the same principles to lose unwanted habits (eg, checking e-mail excessively) by removing cues, such as turning off notifications or using airplane mode and rewarding yourself when you see the behavior through.

Habits are larger than behaviors; they can impact your personal and professional life in important ways. By actively creating habits that align with your long-term priorities, you can create a safety net if and when change arrives. Understanding the psychology of habits and employing cues and rewards effectively can lead hospitalists to create positive routines that improve their clinical practice and personal lives.