Patients treated for claudication vs. critical limb ischemia (CLI) differed significantly in their initial cost of admission, readmission costs, length of stay (LOS), days to readmission, and mortality (during initial admission, as well as any admission), according to the results of a database analysis of more than 90,000 patients in the Nationwide Readmission Database.

©Andrei Malov/Thinkstock

Readmissions were influenced not only by the admission diagnosis and intervention performed “but more importantly and significantly by the patient’s characteristics such as age, sex, CCI [Charlson Comorbidity Index], and various other demographic factors,” wrote Rennier A. Martinez, MD, of JFK Medical Center, Atlantis, Fla., and his colleagues. The report was published in the October issue of Annals of Vascular Surgery.

The study used the International Classification of Diseases, Ninth Revision (ICD-9) codes and queried the Nationwide Readmission Database for 2013 and 2014 for all 92,769 adult patients admitted with the principal diagnosis of claudication (ICD-9 code 440.21; n = 33,055 patients) or CLI (ICD-9 code 440.22e440.24; n = 59,714 patients) who underwent percutaneous angioplasty (ICD-9 code 39.50, 39.90), peripheral bypass (ICD-9 code 39.29), or aortofemoral bypass (ICD-9 code 39.25).

The 30-day readmission rates were 9.0% for claudication and 19.3% for CLI. Similarly, the any readmission rates were 21.5% and 40.4% for claudication vs. CLI.

Significant differences were found for claudication and CLI, respectively, on initial cost of admission ($18,548 vs. $29,148), readmission costs ($14,726 vs. $17,681), LOS (4 days vs. 9 days), days to readmission (73 days vs. 59 days), mortality during initial admission (256 vs. 1,363), and mortality during any admission (538 vs. 3,838), all P less than .001.

Univariate and multivariate logistic regression analysis found that claudication, CLI, angioplasty, peripheral bypass, aortofemoral bypass, female sex, age younger than 65, Charlson Comorbidity Index, LOS, and primary expected payer status were all significant predictors of 30-day and overall readmissions at varying degrees.

The researchers also found that the five most common disease readmission groups were other vascular procedures (12.6%), amputation of lower limb except toes (6.3%), sepsis (5.4%), heart failure (4.9%), and postoperative or other device infections (4.8%) (Ann Vasc Surg. 2018;52:96-107).

The increased costs and higher levels of morbidity and mortality seen with CLI vs. claudication are not surprising given previous research showing that there are higher rates of complications in patients with CLI. A previous review showed there was a threefold higher risk of myocardial infarction, stroke, and vascular death in patients with CLI compared with patients with claudication, according Dr. Martinez and his colleagues.

“Readmissions after lower extremity procedures for patients admitted for claudication or CLI are influenced not only by the admission diagnosis and intervention performed but more importantly and significantly by the patient’s characteristics such as age, sex, CCI, and various other demographic factors,” the researchers wrote. “It is paramount to continue to perform this kind of study to better identify patients at risk for readmission and work toward prevention,” they concluded.

Dr. Martinez and his colleagues did not report disclosures, but indicated that the study did not receive any outside funding.

mlesney@mdedge.com

SOURCE: Martinez RA et al. Ann Vasc Surg. 2018;52:96-107.

Patients treated for claudication vs. critical limb ischemia (CLI) differed significantly in their initial cost of admission, readmission costs, length of stay (LOS), days to readmission, and mortality (during initial admission, as well as any admission), according to the results of a database analysis of more than 90,000 patients in the Nationwide Readmission Database.

©Andrei Malov/Thinkstock

Readmissions were influenced not only by the admission diagnosis and intervention performed “but more importantly and significantly by the patient’s characteristics such as age, sex, CCI [Charlson Comorbidity Index], and various other demographic factors,” wrote Rennier A. Martinez, MD, of JFK Medical Center, Atlantis, Fla., and his colleagues. The report was published in the October issue of Annals of Vascular Surgery.

The study used the International Classification of Diseases, Ninth Revision (ICD-9) codes and queried the Nationwide Readmission Database for 2013 and 2014 for all 92,769 adult patients admitted with the principal diagnosis of claudication (ICD-9 code 440.21; n = 33,055 patients) or CLI (ICD-9 code 440.22e440.24; n = 59,714 patients) who underwent percutaneous angioplasty (ICD-9 code 39.50, 39.90), peripheral bypass (ICD-9 code 39.29), or aortofemoral bypass (ICD-9 code 39.25).

The 30-day readmission rates were 9.0% for claudication and 19.3% for CLI. Similarly, the any readmission rates were 21.5% and 40.4% for claudication vs. CLI.

Significant differences were found for claudication and CLI, respectively, on initial cost of admission ($18,548 vs. $29,148), readmission costs ($14,726 vs. $17,681), LOS (4 days vs. 9 days), days to readmission (73 days vs. 59 days), mortality during initial admission (256 vs. 1,363), and mortality during any admission (538 vs. 3,838), all P less than .001.

Univariate and multivariate logistic regression analysis found that claudication, CLI, angioplasty, peripheral bypass, aortofemoral bypass, female sex, age younger than 65, Charlson Comorbidity Index, LOS, and primary expected payer status were all significant predictors of 30-day and overall readmissions at varying degrees.

The researchers also found that the five most common disease readmission groups were other vascular procedures (12.6%), amputation of lower limb except toes (6.3%), sepsis (5.4%), heart failure (4.9%), and postoperative or other device infections (4.8%) (Ann Vasc Surg. 2018;52:96-107).

The increased costs and higher levels of morbidity and mortality seen with CLI vs. claudication are not surprising given previous research showing that there are higher rates of complications in patients with CLI. A previous review showed there was a threefold higher risk of myocardial infarction, stroke, and vascular death in patients with CLI compared with patients with claudication, according Dr. Martinez and his colleagues.

“Readmissions after lower extremity procedures for patients admitted for claudication or CLI are influenced not only by the admission diagnosis and intervention performed but more importantly and significantly by the patient’s characteristics such as age, sex, CCI, and various other demographic factors,” the researchers wrote. “It is paramount to continue to perform this kind of study to better identify patients at risk for readmission and work toward prevention,” they concluded.

Dr. Martinez and his colleagues did not report disclosures, but indicated that the study did not receive any outside funding.

mlesney@mdedge.com

SOURCE: Martinez RA et al. Ann Vasc Surg. 2018;52:96-107.

Patients treated for claudication vs. critical limb ischemia (CLI) differed significantly in their initial cost of admission, readmission costs, length of stay (LOS), days to readmission, and mortality (during initial admission, as well as any admission), according to the results of a database analysis of more than 90,000 patients in the Nationwide Readmission Database.

©Andrei Malov/Thinkstock

Readmissions were influenced not only by the admission diagnosis and intervention performed “but more importantly and significantly by the patient’s characteristics such as age, sex, CCI [Charlson Comorbidity Index], and various other demographic factors,” wrote Rennier A. Martinez, MD, of JFK Medical Center, Atlantis, Fla., and his colleagues. The report was published in the October issue of Annals of Vascular Surgery.

The study used the International Classification of Diseases, Ninth Revision (ICD-9) codes and queried the Nationwide Readmission Database for 2013 and 2014 for all 92,769 adult patients admitted with the principal diagnosis of claudication (ICD-9 code 440.21; n = 33,055 patients) or CLI (ICD-9 code 440.22e440.24; n = 59,714 patients) who underwent percutaneous angioplasty (ICD-9 code 39.50, 39.90), peripheral bypass (ICD-9 code 39.29), or aortofemoral bypass (ICD-9 code 39.25).

The 30-day readmission rates were 9.0% for claudication and 19.3% for CLI. Similarly, the any readmission rates were 21.5% and 40.4% for claudication vs. CLI.

Significant differences were found for claudication and CLI, respectively, on initial cost of admission ($18,548 vs. $29,148), readmission costs ($14,726 vs. $17,681), LOS (4 days vs. 9 days), days to readmission (73 days vs. 59 days), mortality during initial admission (256 vs. 1,363), and mortality during any admission (538 vs. 3,838), all P less than .001.

Univariate and multivariate logistic regression analysis found that claudication, CLI, angioplasty, peripheral bypass, aortofemoral bypass, female sex, age younger than 65, Charlson Comorbidity Index, LOS, and primary expected payer status were all significant predictors of 30-day and overall readmissions at varying degrees.

The researchers also found that the five most common disease readmission groups were other vascular procedures (12.6%), amputation of lower limb except toes (6.3%), sepsis (5.4%), heart failure (4.9%), and postoperative or other device infections (4.8%) (Ann Vasc Surg. 2018;52:96-107).

The increased costs and higher levels of morbidity and mortality seen with CLI vs. claudication are not surprising given previous research showing that there are higher rates of complications in patients with CLI. A previous review showed there was a threefold higher risk of myocardial infarction, stroke, and vascular death in patients with CLI compared with patients with claudication, according Dr. Martinez and his colleagues.

“Readmissions after lower extremity procedures for patients admitted for claudication or CLI are influenced not only by the admission diagnosis and intervention performed but more importantly and significantly by the patient’s characteristics such as age, sex, CCI, and various other demographic factors,” the researchers wrote. “It is paramount to continue to perform this kind of study to better identify patients at risk for readmission and work toward prevention,” they concluded.

Dr. Martinez and his colleagues did not report disclosures, but indicated that the study did not receive any outside funding.

mlesney@mdedge.com

SOURCE: Martinez RA et al. Ann Vasc Surg. 2018;52:96-107.

For hospitalists, burnout is a widespread and ongoing problem. In 2011, a Mayo Clinic study found that 45% of U.S. physicians had at least one symptom of professional burnout; by 2014, that number had risen to 54%.

shutteratakan/Thinkstock

“Burnout among physicians has been shown to be linked to quality of care, impacting medical errors, mortality ratios in hospitalized patients, and lower patient satisfaction,” said Ingrid T. Katz, MD, MHS, assistant professor of medicine at Harvard Medical School, Boston, and coauthor of a recent column on the subject published in the New England Journal of Medicine.

Widespread burnout is caused by systemic factors, not individual failures. “These systemic factors range from excessive clerical burden to ‘work beyond work,’ where people end up taking work home at night and are often found interfacing with the EHR well after their normal work day,” Dr. Katz said. “Many also express their disdain for the model of practice that no longer values autonomy, which was seen as inherent in the profession prior to the current model of care.”

Moving towards a better framework would require an inherent trust in physicians, limiting unnecessary intrusions into a physician’s practice that do not impact medical care. “It would remove the burden of excessive documentation and allow for physicians to get reinspired by the practice of medicine, an inherently altruistic profession,” Dr. Katz said.

Changes might include eliminating excessive clerical demands and improving EHRs to allow physicians to return to the bedside. Workloads would be geared towards quality in care and not focused on improving the bottom line of a health care system. One health system Dr. Katz wrote about instituted a team-based model; under this system medical assistants gather data and reconcile medications, allowing physicians to focus on performing physical exams and making medical decisions.

“Burnout will diminish when physicians are empowered to be part of the solution and hospital systems make changes that recognize the totality of the challenges that physicians face,” Dr. Katz said, adding that hospitalists are in a unique position to promote such changes on a systemic level. “Leadership needs to be willing to inform and engage their physicians, monitor well-being of physicians as closely as they monitor quality in care, and implement changes when needed.”

Reference

1. Katz IT et al. Beyond Burnout – Redesigning Care to Restore Meaning and Sanity for Physicians. N Engl J Med. 2018 Jan 25. doi: 10.1056/NEJMp1716845.

For hospitalists, burnout is a widespread and ongoing problem. In 2011, a Mayo Clinic study found that 45% of U.S. physicians had at least one symptom of professional burnout; by 2014, that number had risen to 54%.

shutteratakan/Thinkstock

“Burnout among physicians has been shown to be linked to quality of care, impacting medical errors, mortality ratios in hospitalized patients, and lower patient satisfaction,” said Ingrid T. Katz, MD, MHS, assistant professor of medicine at Harvard Medical School, Boston, and coauthor of a recent column on the subject published in the New England Journal of Medicine.

Widespread burnout is caused by systemic factors, not individual failures. “These systemic factors range from excessive clerical burden to ‘work beyond work,’ where people end up taking work home at night and are often found interfacing with the EHR well after their normal work day,” Dr. Katz said. “Many also express their disdain for the model of practice that no longer values autonomy, which was seen as inherent in the profession prior to the current model of care.”

Moving towards a better framework would require an inherent trust in physicians, limiting unnecessary intrusions into a physician’s practice that do not impact medical care. “It would remove the burden of excessive documentation and allow for physicians to get reinspired by the practice of medicine, an inherently altruistic profession,” Dr. Katz said.

Changes might include eliminating excessive clerical demands and improving EHRs to allow physicians to return to the bedside. Workloads would be geared towards quality in care and not focused on improving the bottom line of a health care system. One health system Dr. Katz wrote about instituted a team-based model; under this system medical assistants gather data and reconcile medications, allowing physicians to focus on performing physical exams and making medical decisions.

“Burnout will diminish when physicians are empowered to be part of the solution and hospital systems make changes that recognize the totality of the challenges that physicians face,” Dr. Katz said, adding that hospitalists are in a unique position to promote such changes on a systemic level. “Leadership needs to be willing to inform and engage their physicians, monitor well-being of physicians as closely as they monitor quality in care, and implement changes when needed.”

Reference

1. Katz IT et al. Beyond Burnout – Redesigning Care to Restore Meaning and Sanity for Physicians. N Engl J Med. 2018 Jan 25. doi: 10.1056/NEJMp1716845.

For hospitalists, burnout is a widespread and ongoing problem. In 2011, a Mayo Clinic study found that 45% of U.S. physicians had at least one symptom of professional burnout; by 2014, that number had risen to 54%.

shutteratakan/Thinkstock

“Burnout among physicians has been shown to be linked to quality of care, impacting medical errors, mortality ratios in hospitalized patients, and lower patient satisfaction,” said Ingrid T. Katz, MD, MHS, assistant professor of medicine at Harvard Medical School, Boston, and coauthor of a recent column on the subject published in the New England Journal of Medicine.

Widespread burnout is caused by systemic factors, not individual failures. “These systemic factors range from excessive clerical burden to ‘work beyond work,’ where people end up taking work home at night and are often found interfacing with the EHR well after their normal work day,” Dr. Katz said. “Many also express their disdain for the model of practice that no longer values autonomy, which was seen as inherent in the profession prior to the current model of care.”

Moving towards a better framework would require an inherent trust in physicians, limiting unnecessary intrusions into a physician’s practice that do not impact medical care. “It would remove the burden of excessive documentation and allow for physicians to get reinspired by the practice of medicine, an inherently altruistic profession,” Dr. Katz said.

Changes might include eliminating excessive clerical demands and improving EHRs to allow physicians to return to the bedside. Workloads would be geared towards quality in care and not focused on improving the bottom line of a health care system. One health system Dr. Katz wrote about instituted a team-based model; under this system medical assistants gather data and reconcile medications, allowing physicians to focus on performing physical exams and making medical decisions.

“Burnout will diminish when physicians are empowered to be part of the solution and hospital systems make changes that recognize the totality of the challenges that physicians face,” Dr. Katz said, adding that hospitalists are in a unique position to promote such changes on a systemic level. “Leadership needs to be willing to inform and engage their physicians, monitor well-being of physicians as closely as they monitor quality in care, and implement changes when needed.”

Reference

1. Katz IT et al. Beyond Burnout – Redesigning Care to Restore Meaning and Sanity for Physicians. N Engl J Med. 2018 Jan 25. doi: 10.1056/NEJMp1716845.

Homeless individuals aged 1 year and older should be vaccinated against hepatitis A, based on a unanimous vote at a meeting of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.

©vchal/Thinkstock

“It is important that we take a national approach to vaccinating homeless” people, Noele Nelson, MD, PhD, MPH, of the CDC’s Division of Viral Hepatitis, said in a presentation prior to the vote, in which all 11 committee members voted in favor of hepatitis A vaccination for the homeless population.

Even limited vaccination will increase the herd immunity of the homeless population over time, she said.

Dr. Nelson presented data on the pros and cons of routine hepatitis A vaccination for homeless individuals aged 1 year and older. The Hepatitis Vaccines Work Group convened four meetings in advance of the October ACIP meeting and reached a consensus that homelessness is an independent indication for hepatitis A vaccination, she said.

If the hepatitis A vaccine is included as an ACIP recommendation, “it is more likely to be considered by homeless service providers,” noted Dr. Nelson. She also cited a low quality of evidence for adverse events associated with hepatitis A vaccination.

The work group considerations in the wake of a nationwide hepatitis A outbreak earlier in 2018 included the challenges of controlling outbreaks, which can spread quickly among the homeless population because of poor personal hygiene, limited sanitation, and tight living quarters. These factors make the homeless population more reliant on a vaccine for protection. An outbreak in San Diego, Calif., in particular, occurred largely in the homeless population.

“Routine vaccination is a more feasible approach to reach the homeless over time through regular homeless care providers,” Dr. Nelson said. As for costs, integrating vaccination into routine care for the homeless is cheaper and much less disruptive than the cost of responding to an outbreak.

The “cons” of recommending routine hepatitis A vaccination for the homeless population included the challenges of administrative record keeping. However, during the public comment period, Mae Morgan, MD, an internist who is medical director of Mercy Care Decatur Street & City of Refuge in Atlanta, emphasized that local homeless care organizations have procedures to manage routine vaccination. “If anyone is concerned that there is not a network in place, there are health centers to do this [that] would implement the vaccine.”

The ACIP committee members had no financial conflicts to disclose.

Homeless individuals aged 1 year and older should be vaccinated against hepatitis A, based on a unanimous vote at a meeting of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.

©vchal/Thinkstock

“It is important that we take a national approach to vaccinating homeless” people, Noele Nelson, MD, PhD, MPH, of the CDC’s Division of Viral Hepatitis, said in a presentation prior to the vote, in which all 11 committee members voted in favor of hepatitis A vaccination for the homeless population.

Even limited vaccination will increase the herd immunity of the homeless population over time, she said.

Dr. Nelson presented data on the pros and cons of routine hepatitis A vaccination for homeless individuals aged 1 year and older. The Hepatitis Vaccines Work Group convened four meetings in advance of the October ACIP meeting and reached a consensus that homelessness is an independent indication for hepatitis A vaccination, she said.

If the hepatitis A vaccine is included as an ACIP recommendation, “it is more likely to be considered by homeless service providers,” noted Dr. Nelson. She also cited a low quality of evidence for adverse events associated with hepatitis A vaccination.

The work group considerations in the wake of a nationwide hepatitis A outbreak earlier in 2018 included the challenges of controlling outbreaks, which can spread quickly among the homeless population because of poor personal hygiene, limited sanitation, and tight living quarters. These factors make the homeless population more reliant on a vaccine for protection. An outbreak in San Diego, Calif., in particular, occurred largely in the homeless population.

“Routine vaccination is a more feasible approach to reach the homeless over time through regular homeless care providers,” Dr. Nelson said. As for costs, integrating vaccination into routine care for the homeless is cheaper and much less disruptive than the cost of responding to an outbreak.

The “cons” of recommending routine hepatitis A vaccination for the homeless population included the challenges of administrative record keeping. However, during the public comment period, Mae Morgan, MD, an internist who is medical director of Mercy Care Decatur Street & City of Refuge in Atlanta, emphasized that local homeless care organizations have procedures to manage routine vaccination. “If anyone is concerned that there is not a network in place, there are health centers to do this [that] would implement the vaccine.”

The ACIP committee members had no financial conflicts to disclose.

Homeless individuals aged 1 year and older should be vaccinated against hepatitis A, based on a unanimous vote at a meeting of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.

©vchal/Thinkstock

“It is important that we take a national approach to vaccinating homeless” people, Noele Nelson, MD, PhD, MPH, of the CDC’s Division of Viral Hepatitis, said in a presentation prior to the vote, in which all 11 committee members voted in favor of hepatitis A vaccination for the homeless population.

Even limited vaccination will increase the herd immunity of the homeless population over time, she said.

Dr. Nelson presented data on the pros and cons of routine hepatitis A vaccination for homeless individuals aged 1 year and older. The Hepatitis Vaccines Work Group convened four meetings in advance of the October ACIP meeting and reached a consensus that homelessness is an independent indication for hepatitis A vaccination, she said.

If the hepatitis A vaccine is included as an ACIP recommendation, “it is more likely to be considered by homeless service providers,” noted Dr. Nelson. She also cited a low quality of evidence for adverse events associated with hepatitis A vaccination.

The work group considerations in the wake of a nationwide hepatitis A outbreak earlier in 2018 included the challenges of controlling outbreaks, which can spread quickly among the homeless population because of poor personal hygiene, limited sanitation, and tight living quarters. These factors make the homeless population more reliant on a vaccine for protection. An outbreak in San Diego, Calif., in particular, occurred largely in the homeless population.

“Routine vaccination is a more feasible approach to reach the homeless over time through regular homeless care providers,” Dr. Nelson said. As for costs, integrating vaccination into routine care for the homeless is cheaper and much less disruptive than the cost of responding to an outbreak.

The “cons” of recommending routine hepatitis A vaccination for the homeless population included the challenges of administrative record keeping. However, during the public comment period, Mae Morgan, MD, an internist who is medical director of Mercy Care Decatur Street & City of Refuge in Atlanta, emphasized that local homeless care organizations have procedures to manage routine vaccination. “If anyone is concerned that there is not a network in place, there are health centers to do this [that] would implement the vaccine.”

The ACIP committee members had no financial conflicts to disclose.

SAN FRANCISCO – There’s no need to wait for western blot results to differentiate Lyme arthritis from septic arthritis in children, as long as your lab, like many, uses the Liaison Borrelia burgdorferi assay, according to investigators at the University of Minnesota, Minneapolis.

M. Alexander Otto/MDedge News

Acute, isolated monoarthritis presents with a single swollen joint and pain whether it’s due to Lyme disease or infection, so it’s hard to tell them apart. Current guidelines recommend a two-tier approach to diagnose Lyme arthritis, an initial blood screen followed by western blot confirmation. Screening results come back in a few hours, but western blot confirmation can take days.

In the meantime, children are treated presumptively for the more concerning diagnosis – septic arthritis – which means hospitalization, surgical drainage, and IV antibiotics. Those who turn out to have Lyme are exposed to the risks and costs of unnecessary treatment and delays to proper diagnosis and doxycycline.

When “kids come in with a swollen knee, maybe 10% or 15% end up in the hospital being treated for septic arthritis that they never had. I wanted to see if we can diagnose Lyme arthritis more quickly,” said lead investigator Bazak Sharon, MD, a pediatric infectious disease specialist at the university’s Masonic Children’s Hospital.

Masonic and its affiliated health system use the Liaison Borrelia burgdorferi assay (DiaSorin) to screen for Lyme, and a careful parsing of the results seems to solve the problem.

Liaison is a chemiluminescence immunoassay that uses light to measure IgM and IgG antibodies to a B. burgdorferi surface protein in serum samples. Results are reported as relative light units (RLUs); below 0.9 RLUs is negative; 0.9-1.1 is equivocal, and over 1.1 is positive.

It’s where patients fall in the range of positivity that matters when it comes to differentiating Lyme from septic arthritis, Dr. Sharon said at ID Week, an annual scientific meeting on infectious diseases (Clin Vaccine Immunol. 2008 Dec;15[12]:1796-804).

He and his team reviewed 60 cases of acute, isolated monoarthritis culled from more than 700 children who presented with joint complaints from 2011 to 2016; 47 had Lyme arthritis confirmed by western blot; 13 had septic arthritis.

It turned out that “every single patient with a” Liaison value of 9 RLUs or higher was confirmed on western blot for Lyme. “Under 9, there was not a single case of Lyme arthritis,” Dr. Sharon said. Three other patients with acute arthritis also tested positive on the screen, but their RLU values were below 4; two turned out to be trauma related and one was ultimately diagnosed with juvenile idiopathic arthritis. Western blots were negative in all three.

The RLU number reported on the screening test “appears to correlate very well with Lyme arthritis. In an otherwise healthy child presenting with acute joint swelling, utilizing this screening test can confirm clinical suspicion of Lyme arthritis within hours, and prevent the potential harmful interventions accompanying a misdiagnosis of septic arthritis. Just do the screening. If it comes up above 9, you’ve got Lyme arthritis,” and don’t need to wait for western blot results to treat, Dr. Sharon said.

In other words, above 9, treat for Lyme.

The investigators plan to delve further into their results with sensitivity/specificity and other analyses before publishing. Ultimately, “my goal is to have a better diagnosis algorithm for kids who present with acute, isolated monoarthritis,” Dr. Sharon said.

There was no industry funding for the work, and the investigators didn’t have any disclosures.
 

aotto@mdedge.com

SOURCE: Sharon B et al. 2018 ID Week abstract 286.

SAN FRANCISCO – There’s no need to wait for western blot results to differentiate Lyme arthritis from septic arthritis in children, as long as your lab, like many, uses the Liaison Borrelia burgdorferi assay, according to investigators at the University of Minnesota, Minneapolis.

M. Alexander Otto/MDedge News

Acute, isolated monoarthritis presents with a single swollen joint and pain whether it’s due to Lyme disease or infection, so it’s hard to tell them apart. Current guidelines recommend a two-tier approach to diagnose Lyme arthritis, an initial blood screen followed by western blot confirmation. Screening results come back in a few hours, but western blot confirmation can take days.

In the meantime, children are treated presumptively for the more concerning diagnosis – septic arthritis – which means hospitalization, surgical drainage, and IV antibiotics. Those who turn out to have Lyme are exposed to the risks and costs of unnecessary treatment and delays to proper diagnosis and doxycycline.

When “kids come in with a swollen knee, maybe 10% or 15% end up in the hospital being treated for septic arthritis that they never had. I wanted to see if we can diagnose Lyme arthritis more quickly,” said lead investigator Bazak Sharon, MD, a pediatric infectious disease specialist at the university’s Masonic Children’s Hospital.

Masonic and its affiliated health system use the Liaison Borrelia burgdorferi assay (DiaSorin) to screen for Lyme, and a careful parsing of the results seems to solve the problem.

Liaison is a chemiluminescence immunoassay that uses light to measure IgM and IgG antibodies to a B. burgdorferi surface protein in serum samples. Results are reported as relative light units (RLUs); below 0.9 RLUs is negative; 0.9-1.1 is equivocal, and over 1.1 is positive.

It’s where patients fall in the range of positivity that matters when it comes to differentiating Lyme from septic arthritis, Dr. Sharon said at ID Week, an annual scientific meeting on infectious diseases (Clin Vaccine Immunol. 2008 Dec;15[12]:1796-804).

He and his team reviewed 60 cases of acute, isolated monoarthritis culled from more than 700 children who presented with joint complaints from 2011 to 2016; 47 had Lyme arthritis confirmed by western blot; 13 had septic arthritis.

It turned out that “every single patient with a” Liaison value of 9 RLUs or higher was confirmed on western blot for Lyme. “Under 9, there was not a single case of Lyme arthritis,” Dr. Sharon said. Three other patients with acute arthritis also tested positive on the screen, but their RLU values were below 4; two turned out to be trauma related and one was ultimately diagnosed with juvenile idiopathic arthritis. Western blots were negative in all three.

The RLU number reported on the screening test “appears to correlate very well with Lyme arthritis. In an otherwise healthy child presenting with acute joint swelling, utilizing this screening test can confirm clinical suspicion of Lyme arthritis within hours, and prevent the potential harmful interventions accompanying a misdiagnosis of septic arthritis. Just do the screening. If it comes up above 9, you’ve got Lyme arthritis,” and don’t need to wait for western blot results to treat, Dr. Sharon said.

In other words, above 9, treat for Lyme.

The investigators plan to delve further into their results with sensitivity/specificity and other analyses before publishing. Ultimately, “my goal is to have a better diagnosis algorithm for kids who present with acute, isolated monoarthritis,” Dr. Sharon said.

There was no industry funding for the work, and the investigators didn’t have any disclosures.
 

aotto@mdedge.com

SOURCE: Sharon B et al. 2018 ID Week abstract 286.

SAN FRANCISCO – There’s no need to wait for western blot results to differentiate Lyme arthritis from septic arthritis in children, as long as your lab, like many, uses the Liaison Borrelia burgdorferi assay, according to investigators at the University of Minnesota, Minneapolis.

M. Alexander Otto/MDedge News

Acute, isolated monoarthritis presents with a single swollen joint and pain whether it’s due to Lyme disease or infection, so it’s hard to tell them apart. Current guidelines recommend a two-tier approach to diagnose Lyme arthritis, an initial blood screen followed by western blot confirmation. Screening results come back in a few hours, but western blot confirmation can take days.

In the meantime, children are treated presumptively for the more concerning diagnosis – septic arthritis – which means hospitalization, surgical drainage, and IV antibiotics. Those who turn out to have Lyme are exposed to the risks and costs of unnecessary treatment and delays to proper diagnosis and doxycycline.

When “kids come in with a swollen knee, maybe 10% or 15% end up in the hospital being treated for septic arthritis that they never had. I wanted to see if we can diagnose Lyme arthritis more quickly,” said lead investigator Bazak Sharon, MD, a pediatric infectious disease specialist at the university’s Masonic Children’s Hospital.

Masonic and its affiliated health system use the Liaison Borrelia burgdorferi assay (DiaSorin) to screen for Lyme, and a careful parsing of the results seems to solve the problem.

Liaison is a chemiluminescence immunoassay that uses light to measure IgM and IgG antibodies to a B. burgdorferi surface protein in serum samples. Results are reported as relative light units (RLUs); below 0.9 RLUs is negative; 0.9-1.1 is equivocal, and over 1.1 is positive.

It’s where patients fall in the range of positivity that matters when it comes to differentiating Lyme from septic arthritis, Dr. Sharon said at ID Week, an annual scientific meeting on infectious diseases (Clin Vaccine Immunol. 2008 Dec;15[12]:1796-804).

He and his team reviewed 60 cases of acute, isolated monoarthritis culled from more than 700 children who presented with joint complaints from 2011 to 2016; 47 had Lyme arthritis confirmed by western blot; 13 had septic arthritis.

It turned out that “every single patient with a” Liaison value of 9 RLUs or higher was confirmed on western blot for Lyme. “Under 9, there was not a single case of Lyme arthritis,” Dr. Sharon said. Three other patients with acute arthritis also tested positive on the screen, but their RLU values were below 4; two turned out to be trauma related and one was ultimately diagnosed with juvenile idiopathic arthritis. Western blots were negative in all three.

The RLU number reported on the screening test “appears to correlate very well with Lyme arthritis. In an otherwise healthy child presenting with acute joint swelling, utilizing this screening test can confirm clinical suspicion of Lyme arthritis within hours, and prevent the potential harmful interventions accompanying a misdiagnosis of septic arthritis. Just do the screening. If it comes up above 9, you’ve got Lyme arthritis,” and don’t need to wait for western blot results to treat, Dr. Sharon said.

In other words, above 9, treat for Lyme.

The investigators plan to delve further into their results with sensitivity/specificity and other analyses before publishing. Ultimately, “my goal is to have a better diagnosis algorithm for kids who present with acute, isolated monoarthritis,” Dr. Sharon said.

There was no industry funding for the work, and the investigators didn’t have any disclosures.
 

aotto@mdedge.com

SOURCE: Sharon B et al. 2018 ID Week abstract 286.

The Food and Drug Administration has approved Xofluza (baloxavir marboxil) for the treatment of acute uncomplicated influenza in people aged 12 years or older who have been symptomatic for 48 hours or less.

The FDA approval is based on results from two randomized, clinical trials. In both trials, patients who received Xofluza experienced a shorter duration until alleviation of symptoms, compared with patients who received a placebo. In the second trial, patients who received Xofluza and patients who received another approved antiviral influenza medication experienced similar durations until symptom alleviation.

“When treatment is started within 48 hours of becoming sick with flu symptoms, antiviral drugs can lessen symptoms and shorten the time patients feel sick. Having more treatment options that work in different ways to attack the virus is important because flu viruses can become resistant to antiviral drugs,” Debra Birnkrant, MD, director of the Division of Antiviral Products in the FDA’s Center for Drug Evaluation and Research, said in a press release.

The most common adverse events associated with Xofluza were diarrhea and bronchitis.

“This is the first new antiviral flu treatment with a novel mechanism of action approved by the FDA in nearly 20 years,” FDA Commissioner Scott Gottlieb, MD, added. “With thousands of people getting the flu every year, and many people becoming seriously ill, having safe and effective treatment alternatives is critical. This novel drug provides an important, additional treatment option.”

Find the full press release on the FDA website.

lfranki@mdedge.com

The Food and Drug Administration has approved Xofluza (baloxavir marboxil) for the treatment of acute uncomplicated influenza in people aged 12 years or older who have been symptomatic for 48 hours or less.

The FDA approval is based on results from two randomized, clinical trials. In both trials, patients who received Xofluza experienced a shorter duration until alleviation of symptoms, compared with patients who received a placebo. In the second trial, patients who received Xofluza and patients who received another approved antiviral influenza medication experienced similar durations until symptom alleviation.

“When treatment is started within 48 hours of becoming sick with flu symptoms, antiviral drugs can lessen symptoms and shorten the time patients feel sick. Having more treatment options that work in different ways to attack the virus is important because flu viruses can become resistant to antiviral drugs,” Debra Birnkrant, MD, director of the Division of Antiviral Products in the FDA’s Center for Drug Evaluation and Research, said in a press release.

The most common adverse events associated with Xofluza were diarrhea and bronchitis.

“This is the first new antiviral flu treatment with a novel mechanism of action approved by the FDA in nearly 20 years,” FDA Commissioner Scott Gottlieb, MD, added. “With thousands of people getting the flu every year, and many people becoming seriously ill, having safe and effective treatment alternatives is critical. This novel drug provides an important, additional treatment option.”

Find the full press release on the FDA website.

lfranki@mdedge.com

The Food and Drug Administration has approved Xofluza (baloxavir marboxil) for the treatment of acute uncomplicated influenza in people aged 12 years or older who have been symptomatic for 48 hours or less.

The FDA approval is based on results from two randomized, clinical trials. In both trials, patients who received Xofluza experienced a shorter duration until alleviation of symptoms, compared with patients who received a placebo. In the second trial, patients who received Xofluza and patients who received another approved antiviral influenza medication experienced similar durations until symptom alleviation.

“When treatment is started within 48 hours of becoming sick with flu symptoms, antiviral drugs can lessen symptoms and shorten the time patients feel sick. Having more treatment options that work in different ways to attack the virus is important because flu viruses can become resistant to antiviral drugs,” Debra Birnkrant, MD, director of the Division of Antiviral Products in the FDA’s Center for Drug Evaluation and Research, said in a press release.

The most common adverse events associated with Xofluza were diarrhea and bronchitis.

“This is the first new antiviral flu treatment with a novel mechanism of action approved by the FDA in nearly 20 years,” FDA Commissioner Scott Gottlieb, MD, added. “With thousands of people getting the flu every year, and many people becoming seriously ill, having safe and effective treatment alternatives is critical. This novel drug provides an important, additional treatment option.”

Find the full press release on the FDA website.

lfranki@mdedge.com

Elderly patients with non-Hodgkin lymphoma (NHL) are more likely to die, but not relapse, within 1 year of allogeneic hematopoietic cell transplantation (alloHCT), compared with younger or middle-age patients, according to investigators.

copyright claudiobaba/iStockPhoto.com

Comorbidities also increased risks of nonrelapse mortality (NRM) at 1 year, but to a lesser extent than that of elderly status, reported lead author Charalampia Kyriakou, MD, PhD, of the department of haematology at University College London Hospital and London North West University Healthcare NHS Trust, and her colleagues.

“Although alloHCT is feasible and effective in very old patients, the increased NRM risk must be taken into account when assessing the indication for alloHCT for NHL in this age group,” the investigators wrote in Biology of Blood and Marrow Transplantation.

This decision is becoming more common, they noted. “With the advent of reduced-intensity conditioning (RIC) strategies and other improvements in transplantation technology, alloHCT is being increasingly considered in elderly patients with [relapsed and refractory] NHL.”

The retrospective study analyzed 3,919 patients with NHL who underwent alloHCT between 2003 and 2013. Patients were sorted into three age groups: young (18-50 years), middle age (51-65 years), or elderly (66-77 years).

Disease types also were reported: 1,461 patients had follicular lymphoma (FL; 37%), 1,192 had diffuse large B cell lymphoma (DLBCL; 30%), 823 had mantle cell lymphoma (MCL; 21%), and 443 had peripheral T cell lymphoma (PTCL; 11%).

At the time of alloHCT, about 85% of patients were chemosensitive, with the remainder being chemorefractory. The age groups had similar patient characteristics, with exceptions noted for unrelated donors, MCL, and RIC, which became increasingly overrepresented with age.

The results showed that NRM at 1 year was 13% for young patients, 20% for middle-age patients, and 33% for elderly patients (P less than .001). Overall survival at 3 years followed an inverse trend, decreasing with age from 60% in young patients to 54% in middle-age patients, before dropping more dramatically to 38% in the elderly (P less than .001).

In contrast to these significant associations between age and survival, relapse risk at 3 years remained relatively consistent, with young patients at 30%, middle-age patients at 31%, and elderly patients at 28% (P = .355).

The investigators noted that the risk of NRM increased most dramatically between middle age and old age, with less significant differences between the middle-age and young groups. They suggested that “age per se should have a limited impact on the indication for alloHCT for NHL in patients up to age 65 years.”

The increased risk with elderly status could not be fully explained by comorbidities, although these were more common in elderly patients. After analyzing information from a subset of patients, the investigators concluded that “the presence of comorbidities is a significant risk factor for NRM and survival, but this does not fully explain the outcome disadvantages in our [elderly] group.” Therefore, age remains an independent risk factor.

“The information provided in this cohort of patients with NHL, the largest reported to date, is useful and relevant, especially in the era of evolving therapies,” the investigators wrote. They added that the information is “even more relevant now with the availability of treatment with ... chimeric antigen receptor (CAR) T cells ... after relapse post-alloHCT.”

The investigators reported having no financial disclosures.

SOURCE: Kyriakou C et al. Biol Blood Marrow Transplant. 2018 Sep 13. doi: 10.1016/j.bbmt.2018.08.025.

Elderly patients with non-Hodgkin lymphoma (NHL) are more likely to die, but not relapse, within 1 year of allogeneic hematopoietic cell transplantation (alloHCT), compared with younger or middle-age patients, according to investigators.

copyright claudiobaba/iStockPhoto.com

Comorbidities also increased risks of nonrelapse mortality (NRM) at 1 year, but to a lesser extent than that of elderly status, reported lead author Charalampia Kyriakou, MD, PhD, of the department of haematology at University College London Hospital and London North West University Healthcare NHS Trust, and her colleagues.

“Although alloHCT is feasible and effective in very old patients, the increased NRM risk must be taken into account when assessing the indication for alloHCT for NHL in this age group,” the investigators wrote in Biology of Blood and Marrow Transplantation.

This decision is becoming more common, they noted. “With the advent of reduced-intensity conditioning (RIC) strategies and other improvements in transplantation technology, alloHCT is being increasingly considered in elderly patients with [relapsed and refractory] NHL.”

The retrospective study analyzed 3,919 patients with NHL who underwent alloHCT between 2003 and 2013. Patients were sorted into three age groups: young (18-50 years), middle age (51-65 years), or elderly (66-77 years).

Disease types also were reported: 1,461 patients had follicular lymphoma (FL; 37%), 1,192 had diffuse large B cell lymphoma (DLBCL; 30%), 823 had mantle cell lymphoma (MCL; 21%), and 443 had peripheral T cell lymphoma (PTCL; 11%).

At the time of alloHCT, about 85% of patients were chemosensitive, with the remainder being chemorefractory. The age groups had similar patient characteristics, with exceptions noted for unrelated donors, MCL, and RIC, which became increasingly overrepresented with age.

The results showed that NRM at 1 year was 13% for young patients, 20% for middle-age patients, and 33% for elderly patients (P less than .001). Overall survival at 3 years followed an inverse trend, decreasing with age from 60% in young patients to 54% in middle-age patients, before dropping more dramatically to 38% in the elderly (P less than .001).

In contrast to these significant associations between age and survival, relapse risk at 3 years remained relatively consistent, with young patients at 30%, middle-age patients at 31%, and elderly patients at 28% (P = .355).

The investigators noted that the risk of NRM increased most dramatically between middle age and old age, with less significant differences between the middle-age and young groups. They suggested that “age per se should have a limited impact on the indication for alloHCT for NHL in patients up to age 65 years.”

The increased risk with elderly status could not be fully explained by comorbidities, although these were more common in elderly patients. After analyzing information from a subset of patients, the investigators concluded that “the presence of comorbidities is a significant risk factor for NRM and survival, but this does not fully explain the outcome disadvantages in our [elderly] group.” Therefore, age remains an independent risk factor.

“The information provided in this cohort of patients with NHL, the largest reported to date, is useful and relevant, especially in the era of evolving therapies,” the investigators wrote. They added that the information is “even more relevant now with the availability of treatment with ... chimeric antigen receptor (CAR) T cells ... after relapse post-alloHCT.”

The investigators reported having no financial disclosures.

SOURCE: Kyriakou C et al. Biol Blood Marrow Transplant. 2018 Sep 13. doi: 10.1016/j.bbmt.2018.08.025.

Elderly patients with non-Hodgkin lymphoma (NHL) are more likely to die, but not relapse, within 1 year of allogeneic hematopoietic cell transplantation (alloHCT), compared with younger or middle-age patients, according to investigators.

copyright claudiobaba/iStockPhoto.com

Comorbidities also increased risks of nonrelapse mortality (NRM) at 1 year, but to a lesser extent than that of elderly status, reported lead author Charalampia Kyriakou, MD, PhD, of the department of haematology at University College London Hospital and London North West University Healthcare NHS Trust, and her colleagues.

“Although alloHCT is feasible and effective in very old patients, the increased NRM risk must be taken into account when assessing the indication for alloHCT for NHL in this age group,” the investigators wrote in Biology of Blood and Marrow Transplantation.

This decision is becoming more common, they noted. “With the advent of reduced-intensity conditioning (RIC) strategies and other improvements in transplantation technology, alloHCT is being increasingly considered in elderly patients with [relapsed and refractory] NHL.”

The retrospective study analyzed 3,919 patients with NHL who underwent alloHCT between 2003 and 2013. Patients were sorted into three age groups: young (18-50 years), middle age (51-65 years), or elderly (66-77 years).

Disease types also were reported: 1,461 patients had follicular lymphoma (FL; 37%), 1,192 had diffuse large B cell lymphoma (DLBCL; 30%), 823 had mantle cell lymphoma (MCL; 21%), and 443 had peripheral T cell lymphoma (PTCL; 11%).

At the time of alloHCT, about 85% of patients were chemosensitive, with the remainder being chemorefractory. The age groups had similar patient characteristics, with exceptions noted for unrelated donors, MCL, and RIC, which became increasingly overrepresented with age.

The results showed that NRM at 1 year was 13% for young patients, 20% for middle-age patients, and 33% for elderly patients (P less than .001). Overall survival at 3 years followed an inverse trend, decreasing with age from 60% in young patients to 54% in middle-age patients, before dropping more dramatically to 38% in the elderly (P less than .001).

In contrast to these significant associations between age and survival, relapse risk at 3 years remained relatively consistent, with young patients at 30%, middle-age patients at 31%, and elderly patients at 28% (P = .355).

The investigators noted that the risk of NRM increased most dramatically between middle age and old age, with less significant differences between the middle-age and young groups. They suggested that “age per se should have a limited impact on the indication for alloHCT for NHL in patients up to age 65 years.”

The increased risk with elderly status could not be fully explained by comorbidities, although these were more common in elderly patients. After analyzing information from a subset of patients, the investigators concluded that “the presence of comorbidities is a significant risk factor for NRM and survival, but this does not fully explain the outcome disadvantages in our [elderly] group.” Therefore, age remains an independent risk factor.

“The information provided in this cohort of patients with NHL, the largest reported to date, is useful and relevant, especially in the era of evolving therapies,” the investigators wrote. They added that the information is “even more relevant now with the availability of treatment with ... chimeric antigen receptor (CAR) T cells ... after relapse post-alloHCT.”

The investigators reported having no financial disclosures.

SOURCE: Kyriakou C et al. Biol Blood Marrow Transplant. 2018 Sep 13. doi: 10.1016/j.bbmt.2018.08.025.

EXPERT COMMENTARY

Because of women’s personal preference and aversion, for various reasons, to LARC methods, the current estimated use rate of 17% for LARC methods would increase only to 24% to 29% even if major barriers, such as cost and availability, were removed.¹ To gain more insight into this issue, Hubacher and colleagues sought to determine if LARC methods would meet the contraceptive needs and be acceptable to a population of women who were not seeking these methods actively and who might have some reservation about using them.

Details of the study

The authors approached women actively seeking 1 of the 2 SARC methods but not a LARC method for contraception. They enrolled 524 women into a cohort study in which they received their desired SARC method. In addition, 392 women agreed to be enrolled in a randomized clinical trial comparing women beginning a LARC method for the first time with a group receiving 1 of the 2 SARC methods.

Importance of covered costs. Of note, the women in the randomized trial had the costs of the insertion or removal of the LARC method covered; those randomly assigned to the comparative SARC arm had the costs of their oral contraceptives (OCs) or depot medroxyprogesterone acetate (DMPA) covered for the first year of use. Underwriting the costs in the randomized study was likely important for study recruitment, since 47% of participants who were randomized to the LARC group cited cost as one of the reasons they did not try a LARC method previously.

Satisfaction with contraceptive method. In addition to the differences in continuation rates and pregnancy rates noted, it is interesting that, among women who tried a LARC method and who had some persistent negative feelings about the method, 65.9% would try the method again.

Satisfaction levels were estimated using 3 choices, with “happiness” being the highest level of satisfaction, followed by “neutral” and “unhappy.” At 24 months, the number of women indicating happiness was similar among the 3 study groups: 71.4% for the LARC randomized group, 75.0% for the randomized SARC group, and 77.6% for the preferred SARC cohort group.

Among women who discontinued their LARC method, occurrence of adverse effects was the reason given 74.2% of the time, while among SARC method users in both groups there was no dominant reason for discontinuation. Also, among women who discontinued their method, the percentage indicating happiness was 32.2% for the LARC randomized group compared with 69.9% and 68.2% for the randomized and preference cohort SARC groups, respectively.
 

Study strengths and weaknesses

This study had several strengths. The population from which the study groups were obtained was demographically diverse and was appropriate for determining if women with reservations about LARC methods could have satisfactory outcomes similar to women who self-select LARC methods. Further, the 24 months of observations indicate that, for the most part, satisfaction persisted.

One of the study’s shortcomings is the limited data on the subsets, that is, the specific method chosen, within each of the study groups.

Share your thoughts! Send your Letter to the Editor to rbarbieri@mdedge.com. Please include your name and the city and state in which you practice.

EXPERT COMMENTARY

Because of women’s personal preference and aversion, for various reasons, to LARC methods, the current estimated use rate of 17% for LARC methods would increase only to 24% to 29% even if major barriers, such as cost and availability, were removed.¹ To gain more insight into this issue, Hubacher and colleagues sought to determine if LARC methods would meet the contraceptive needs and be acceptable to a population of women who were not seeking these methods actively and who might have some reservation about using them.

Details of the study

The authors approached women actively seeking 1 of the 2 SARC methods but not a LARC method for contraception. They enrolled 524 women into a cohort study in which they received their desired SARC method. In addition, 392 women agreed to be enrolled in a randomized clinical trial comparing women beginning a LARC method for the first time with a group receiving 1 of the 2 SARC methods.

Importance of covered costs. Of note, the women in the randomized trial had the costs of the insertion or removal of the LARC method covered; those randomly assigned to the comparative SARC arm had the costs of their oral contraceptives (OCs) or depot medroxyprogesterone acetate (DMPA) covered for the first year of use. Underwriting the costs in the randomized study was likely important for study recruitment, since 47% of participants who were randomized to the LARC group cited cost as one of the reasons they did not try a LARC method previously.

Satisfaction with contraceptive method. In addition to the differences in continuation rates and pregnancy rates noted, it is interesting that, among women who tried a LARC method and who had some persistent negative feelings about the method, 65.9% would try the method again.

Satisfaction levels were estimated using 3 choices, with “happiness” being the highest level of satisfaction, followed by “neutral” and “unhappy.” At 24 months, the number of women indicating happiness was similar among the 3 study groups: 71.4% for the LARC randomized group, 75.0% for the randomized SARC group, and 77.6% for the preferred SARC cohort group.

Among women who discontinued their LARC method, occurrence of adverse effects was the reason given 74.2% of the time, while among SARC method users in both groups there was no dominant reason for discontinuation. Also, among women who discontinued their method, the percentage indicating happiness was 32.2% for the LARC randomized group compared with 69.9% and 68.2% for the randomized and preference cohort SARC groups, respectively.
 

Study strengths and weaknesses

This study had several strengths. The population from which the study groups were obtained was demographically diverse and was appropriate for determining if women with reservations about LARC methods could have satisfactory outcomes similar to women who self-select LARC methods. Further, the 24 months of observations indicate that, for the most part, satisfaction persisted.

One of the study’s shortcomings is the limited data on the subsets, that is, the specific method chosen, within each of the study groups.

Share your thoughts! Send your Letter to the Editor to rbarbieri@mdedge.com. Please include your name and the city and state in which you practice.

EXPERT COMMENTARY

Because of women’s personal preference and aversion, for various reasons, to LARC methods, the current estimated use rate of 17% for LARC methods would increase only to 24% to 29% even if major barriers, such as cost and availability, were removed.¹ To gain more insight into this issue, Hubacher and colleagues sought to determine if LARC methods would meet the contraceptive needs and be acceptable to a population of women who were not seeking these methods actively and who might have some reservation about using them.

Details of the study

The authors approached women actively seeking 1 of the 2 SARC methods but not a LARC method for contraception. They enrolled 524 women into a cohort study in which they received their desired SARC method. In addition, 392 women agreed to be enrolled in a randomized clinical trial comparing women beginning a LARC method for the first time with a group receiving 1 of the 2 SARC methods.

Importance of covered costs. Of note, the women in the randomized trial had the costs of the insertion or removal of the LARC method covered; those randomly assigned to the comparative SARC arm had the costs of their oral contraceptives (OCs) or depot medroxyprogesterone acetate (DMPA) covered for the first year of use. Underwriting the costs in the randomized study was likely important for study recruitment, since 47% of participants who were randomized to the LARC group cited cost as one of the reasons they did not try a LARC method previously.

Satisfaction with contraceptive method. In addition to the differences in continuation rates and pregnancy rates noted, it is interesting that, among women who tried a LARC method and who had some persistent negative feelings about the method, 65.9% would try the method again.

Satisfaction levels were estimated using 3 choices, with “happiness” being the highest level of satisfaction, followed by “neutral” and “unhappy.” At 24 months, the number of women indicating happiness was similar among the 3 study groups: 71.4% for the LARC randomized group, 75.0% for the randomized SARC group, and 77.6% for the preferred SARC cohort group.

Among women who discontinued their LARC method, occurrence of adverse effects was the reason given 74.2% of the time, while among SARC method users in both groups there was no dominant reason for discontinuation. Also, among women who discontinued their method, the percentage indicating happiness was 32.2% for the LARC randomized group compared with 69.9% and 68.2% for the randomized and preference cohort SARC groups, respectively.
 

Study strengths and weaknesses

This study had several strengths. The population from which the study groups were obtained was demographically diverse and was appropriate for determining if women with reservations about LARC methods could have satisfactory outcomes similar to women who self-select LARC methods. Further, the 24 months of observations indicate that, for the most part, satisfaction persisted.

One of the study’s shortcomings is the limited data on the subsets, that is, the specific method chosen, within each of the study groups.

Share your thoughts! Send your Letter to the Editor to rbarbieri@mdedge.com. Please include your name and the city and state in which you practice.

SAN DIEGO – Angiograms can be deceiving, so it’s best to measure fractional flow reserve (FFR) across coronary obstructions to gauge patients’ true need for intervention. That’s hardly news to cardiologists, but FFR is not often done. The problem is that traditional measurement requires threading wires down coronary arteries; the technique is a bit risky and takes time and training. It also has to be repeated for each lesion.
 

But now, several companies are developing noninvasive ways to measure FFR.

Findings from one of them, CathWorks, were presented at the Transcatheter Cardiovascular Therapeutics annual meeting sponsored by the Cardiovascular Research Foundation. Its FFRangio system uses high-quality angiograms and an algorithm to estimate resistance and flow across stenoses. After a few cases, the process takes less than 5 minutes (Circulation. 2018 Sep 24. doi: 10.1161/CIRCULATIONAHA.118.037350).

“I think this is a big breakthrough. ... Ultimately, it should lead to better patient outcomes,” said lead investigator William Fearon, MD, professor of cardiology at Stanford University, Calif.

In an interview at TCT 2018, Dr. Fearon explained the importance of FFR, the data for FFRangio, and what’s coming down the pike from other companies. He disclosed institutional research grants from the company.

aotto@mdedge.com

SAN DIEGO – Angiograms can be deceiving, so it’s best to measure fractional flow reserve (FFR) across coronary obstructions to gauge patients’ true need for intervention. That’s hardly news to cardiologists, but FFR is not often done. The problem is that traditional measurement requires threading wires down coronary arteries; the technique is a bit risky and takes time and training. It also has to be repeated for each lesion.
 

But now, several companies are developing noninvasive ways to measure FFR.

Findings from one of them, CathWorks, were presented at the Transcatheter Cardiovascular Therapeutics annual meeting sponsored by the Cardiovascular Research Foundation. Its FFRangio system uses high-quality angiograms and an algorithm to estimate resistance and flow across stenoses. After a few cases, the process takes less than 5 minutes (Circulation. 2018 Sep 24. doi: 10.1161/CIRCULATIONAHA.118.037350).

“I think this is a big breakthrough. ... Ultimately, it should lead to better patient outcomes,” said lead investigator William Fearon, MD, professor of cardiology at Stanford University, Calif.

In an interview at TCT 2018, Dr. Fearon explained the importance of FFR, the data for FFRangio, and what’s coming down the pike from other companies. He disclosed institutional research grants from the company.

aotto@mdedge.com

SAN DIEGO – Angiograms can be deceiving, so it’s best to measure fractional flow reserve (FFR) across coronary obstructions to gauge patients’ true need for intervention. That’s hardly news to cardiologists, but FFR is not often done. The problem is that traditional measurement requires threading wires down coronary arteries; the technique is a bit risky and takes time and training. It also has to be repeated for each lesion.
 

But now, several companies are developing noninvasive ways to measure FFR.

Findings from one of them, CathWorks, were presented at the Transcatheter Cardiovascular Therapeutics annual meeting sponsored by the Cardiovascular Research Foundation. Its FFRangio system uses high-quality angiograms and an algorithm to estimate resistance and flow across stenoses. After a few cases, the process takes less than 5 minutes (Circulation. 2018 Sep 24. doi: 10.1161/CIRCULATIONAHA.118.037350).

“I think this is a big breakthrough. ... Ultimately, it should lead to better patient outcomes,” said lead investigator William Fearon, MD, professor of cardiology at Stanford University, Calif.

In an interview at TCT 2018, Dr. Fearon explained the importance of FFR, the data for FFRangio, and what’s coming down the pike from other companies. He disclosed institutional research grants from the company.

aotto@mdedge.com

Secondary prevention of cardiovascular disease could significantly reduce cardiac mortality among patients with schizophrenia, yet is underused, a study published Oct. 24 has found.

The retrospective study, which included a Danish nationwide cohort of 105,018 patients with myocardial infarction, including 684 patients with schizophrenia, showed that individuals with schizophrenia who did not receive secondary cardioprotective treatment had a more than eight times higher mortality, compared with people in the general population who did receive treatment (hazard ratio, 8.78; 95% confidence interval, 4.37-17.64), Pirathiv Kugathasan and his associates reported in JAMA Psychiatry.

In contrast, the investigators found, patients with schizophrenia who received cardioprotective treatment had a 97% higher mortality (HR, 1.97; 95% CI, 1.25-310), compared with the treated general population, which was not statistically different from individuals in the general population who did not receive treatment (HR, 2.95; 95% CI, 2.62-3.32) after adjustment for baseline characteristics.

“Given the increased cardiovascular risk among patients with schizophrenia, we believe that the current findings support the use of intensive cardioprotective treatments in patients with schizophrenia,” reported Mr. Kugathasan, a PhD candidate in the department of psychiatry at Aalborg University Hospital in Denmark.

However, 7.8% of patients diagnosed with schizophrenia received no prescriptions for cardioprotective medications after a myocardial infarction, compared with 3.3% of the general population. They were significantly less likely than were individuals from the general population to receive a prescription for antiplatelets (84.9% vs. 91.8%), vitamin K antagonists (15.9% vs. 24.2%), beta-blockers (74.1% vs. 84.9%), ACE inhibitors (70.9% vs. 86.6%), and statins (72.2% vs. 87.3%).

The mortality rates were not significantly different between untreated patients with schizophrenia and untreated participants from the general population.

When the researchers examined the effects of different treatment types, they found that mortality rates were still higher in treated patients with schizophrenia, compared with treated patients from the general population – with the exception of those treated with antiplatelets and statins. For ACE inhibitors, treated patients with schizophrenia had a twofold higher mortality than that of treated patients from the general population, while the mortality was more than twofold higher in the case of vitamin K antagonists.

“Previous studies have found that patients with schizophrenia have increased cardiovascular mortality and a lower prescription rate for cardioprotective treatment compared with the general population,” the authors wrote.

They noted that patients with schizophrenia might have more problems with medication adherence, and pointed to another study showing this in patients with schizophrenia and diabetes. Other studies also showed that patients with schizophrenia were less likely to talk to a cardiologist after a cardiac event.

“Together, we believe that these results could point toward a deficit in establishing an appropriate cardiac treatment plan in patients with schizophrenia that causes failure in initiation and maintenance of cardioprotective treatment,” they wrote. “This hypothesis could explain the results of a generally increased mortality rate among patients with schizophrenia, especially when the results suggest that these patients die of cardiovascular causes that might be treatable.”

They called for patients with schizophrenia to be followed up during treatment, and to increase treatment intensity after cardiac events, “because a diagnosis of schizophrenia may be associated with an increased cardiac risk, which potentially can be countered by secondary preventive cardiac treatment.”

In patients who received triple therapy, the mortality rates were similar for those with schizophrenia and the general population. However, there were much higher mortality rate differences between patients with schizophrenia and the general population for those receiving dual or monotherapy.

Significantly more patients from the general population were readmitted with myocardial infarction and more underwent percutaneous coronary intervention than from the group of patients with schizophrenia.

The prevalence of hypertension was similar between the two populations, but more patients with schizophrenia had diabetes and substance abuse, compared with the general population.

The authors noted that they did not have information on the severity of myocardial infarction or the effect of other lifestyle factors.

“Future research should attempt to assess the degree to which these factors contribute to the increased mortality in patients with schizophrenia,” they wrote.

One author declared grants, speaking fees and advisory roles with the pharmaceutical industry. No other conflicts of interest were declared.

SOURCE: Kugathasan P et al. JAMA Psychiatry 2018. Oct 24. doi: 10.1001/jamapsychiatry.2018.2742.

Secondary prevention of cardiovascular disease could significantly reduce cardiac mortality among patients with schizophrenia, yet is underused, a study published Oct. 24 has found.

The retrospective study, which included a Danish nationwide cohort of 105,018 patients with myocardial infarction, including 684 patients with schizophrenia, showed that individuals with schizophrenia who did not receive secondary cardioprotective treatment had a more than eight times higher mortality, compared with people in the general population who did receive treatment (hazard ratio, 8.78; 95% confidence interval, 4.37-17.64), Pirathiv Kugathasan and his associates reported in JAMA Psychiatry.

In contrast, the investigators found, patients with schizophrenia who received cardioprotective treatment had a 97% higher mortality (HR, 1.97; 95% CI, 1.25-310), compared with the treated general population, which was not statistically different from individuals in the general population who did not receive treatment (HR, 2.95; 95% CI, 2.62-3.32) after adjustment for baseline characteristics.

“Given the increased cardiovascular risk among patients with schizophrenia, we believe that the current findings support the use of intensive cardioprotective treatments in patients with schizophrenia,” reported Mr. Kugathasan, a PhD candidate in the department of psychiatry at Aalborg University Hospital in Denmark.

However, 7.8% of patients diagnosed with schizophrenia received no prescriptions for cardioprotective medications after a myocardial infarction, compared with 3.3% of the general population. They were significantly less likely than were individuals from the general population to receive a prescription for antiplatelets (84.9% vs. 91.8%), vitamin K antagonists (15.9% vs. 24.2%), beta-blockers (74.1% vs. 84.9%), ACE inhibitors (70.9% vs. 86.6%), and statins (72.2% vs. 87.3%).

The mortality rates were not significantly different between untreated patients with schizophrenia and untreated participants from the general population.

When the researchers examined the effects of different treatment types, they found that mortality rates were still higher in treated patients with schizophrenia, compared with treated patients from the general population – with the exception of those treated with antiplatelets and statins. For ACE inhibitors, treated patients with schizophrenia had a twofold higher mortality than that of treated patients from the general population, while the mortality was more than twofold higher in the case of vitamin K antagonists.

“Previous studies have found that patients with schizophrenia have increased cardiovascular mortality and a lower prescription rate for cardioprotective treatment compared with the general population,” the authors wrote.

They noted that patients with schizophrenia might have more problems with medication adherence, and pointed to another study showing this in patients with schizophrenia and diabetes. Other studies also showed that patients with schizophrenia were less likely to talk to a cardiologist after a cardiac event.

“Together, we believe that these results could point toward a deficit in establishing an appropriate cardiac treatment plan in patients with schizophrenia that causes failure in initiation and maintenance of cardioprotective treatment,” they wrote. “This hypothesis could explain the results of a generally increased mortality rate among patients with schizophrenia, especially when the results suggest that these patients die of cardiovascular causes that might be treatable.”

They called for patients with schizophrenia to be followed up during treatment, and to increase treatment intensity after cardiac events, “because a diagnosis of schizophrenia may be associated with an increased cardiac risk, which potentially can be countered by secondary preventive cardiac treatment.”

In patients who received triple therapy, the mortality rates were similar for those with schizophrenia and the general population. However, there were much higher mortality rate differences between patients with schizophrenia and the general population for those receiving dual or monotherapy.

Significantly more patients from the general population were readmitted with myocardial infarction and more underwent percutaneous coronary intervention than from the group of patients with schizophrenia.

The prevalence of hypertension was similar between the two populations, but more patients with schizophrenia had diabetes and substance abuse, compared with the general population.

The authors noted that they did not have information on the severity of myocardial infarction or the effect of other lifestyle factors.

“Future research should attempt to assess the degree to which these factors contribute to the increased mortality in patients with schizophrenia,” they wrote.

One author declared grants, speaking fees and advisory roles with the pharmaceutical industry. No other conflicts of interest were declared.

SOURCE: Kugathasan P et al. JAMA Psychiatry 2018. Oct 24. doi: 10.1001/jamapsychiatry.2018.2742.

Secondary prevention of cardiovascular disease could significantly reduce cardiac mortality among patients with schizophrenia, yet is underused, a study published Oct. 24 has found.

The retrospective study, which included a Danish nationwide cohort of 105,018 patients with myocardial infarction, including 684 patients with schizophrenia, showed that individuals with schizophrenia who did not receive secondary cardioprotective treatment had a more than eight times higher mortality, compared with people in the general population who did receive treatment (hazard ratio, 8.78; 95% confidence interval, 4.37-17.64), Pirathiv Kugathasan and his associates reported in JAMA Psychiatry.

In contrast, the investigators found, patients with schizophrenia who received cardioprotective treatment had a 97% higher mortality (HR, 1.97; 95% CI, 1.25-310), compared with the treated general population, which was not statistically different from individuals in the general population who did not receive treatment (HR, 2.95; 95% CI, 2.62-3.32) after adjustment for baseline characteristics.

“Given the increased cardiovascular risk among patients with schizophrenia, we believe that the current findings support the use of intensive cardioprotective treatments in patients with schizophrenia,” reported Mr. Kugathasan, a PhD candidate in the department of psychiatry at Aalborg University Hospital in Denmark.

However, 7.8% of patients diagnosed with schizophrenia received no prescriptions for cardioprotective medications after a myocardial infarction, compared with 3.3% of the general population. They were significantly less likely than were individuals from the general population to receive a prescription for antiplatelets (84.9% vs. 91.8%), vitamin K antagonists (15.9% vs. 24.2%), beta-blockers (74.1% vs. 84.9%), ACE inhibitors (70.9% vs. 86.6%), and statins (72.2% vs. 87.3%).

The mortality rates were not significantly different between untreated patients with schizophrenia and untreated participants from the general population.

When the researchers examined the effects of different treatment types, they found that mortality rates were still higher in treated patients with schizophrenia, compared with treated patients from the general population – with the exception of those treated with antiplatelets and statins. For ACE inhibitors, treated patients with schizophrenia had a twofold higher mortality than that of treated patients from the general population, while the mortality was more than twofold higher in the case of vitamin K antagonists.

“Previous studies have found that patients with schizophrenia have increased cardiovascular mortality and a lower prescription rate for cardioprotective treatment compared with the general population,” the authors wrote.

They noted that patients with schizophrenia might have more problems with medication adherence, and pointed to another study showing this in patients with schizophrenia and diabetes. Other studies also showed that patients with schizophrenia were less likely to talk to a cardiologist after a cardiac event.

“Together, we believe that these results could point toward a deficit in establishing an appropriate cardiac treatment plan in patients with schizophrenia that causes failure in initiation and maintenance of cardioprotective treatment,” they wrote. “This hypothesis could explain the results of a generally increased mortality rate among patients with schizophrenia, especially when the results suggest that these patients die of cardiovascular causes that might be treatable.”

They called for patients with schizophrenia to be followed up during treatment, and to increase treatment intensity after cardiac events, “because a diagnosis of schizophrenia may be associated with an increased cardiac risk, which potentially can be countered by secondary preventive cardiac treatment.”

In patients who received triple therapy, the mortality rates were similar for those with schizophrenia and the general population. However, there were much higher mortality rate differences between patients with schizophrenia and the general population for those receiving dual or monotherapy.

Significantly more patients from the general population were readmitted with myocardial infarction and more underwent percutaneous coronary intervention than from the group of patients with schizophrenia.

The prevalence of hypertension was similar between the two populations, but more patients with schizophrenia had diabetes and substance abuse, compared with the general population.

The authors noted that they did not have information on the severity of myocardial infarction or the effect of other lifestyle factors.

“Future research should attempt to assess the degree to which these factors contribute to the increased mortality in patients with schizophrenia,” they wrote.

One author declared grants, speaking fees and advisory roles with the pharmaceutical industry. No other conflicts of interest were declared.

SOURCE: Kugathasan P et al. JAMA Psychiatry 2018. Oct 24. doi: 10.1001/jamapsychiatry.2018.2742.

CHICAGO – Rheumatology advocates have been working to get a variety of bills passed in Congress, including efforts on creating exemptions to step therapy or “fail first” insurer policies, increasing osteoporosis screening payment, and raising research dollars for arthritis in the Department of Defense, Dr. Angus Worthing said at the annual meeting of the American College of Rheumatology.

Visits by rheumatologist advocates to receptive members of the House and Senate have been fruitful for these issues, said Dr. Worthing, who is chair of the ACR’s Government Affairs Committee and a practicing rheumatologist in the Washington area.

“There’s a bill in the House [H.R. 2077, Restoring the Patient’s Voice Act], reforming step therapy that would institute appropriate exemptions if a doctor can predict that a drug that’s the first step in a step therapy will cause side effects, will be ineffective, or has already been used by a patient, as well as other appropriate guardrails,” so that the policy can be circumvented and the patient can get the prescription that the doctor ordered, he said.


The ACR is working with coalition partners such as the National Psoriasis Foundation and other patient organizations to get a companion bill to H.R. 2077 introduced in the Senate, Dr. Worthing noted.

The ACR is also working to advance separate bills in the House (H.R. 1898) and Senate (S. 3160) to increase payment levels for dual x-ray absorptiometry scans, which were cut by 60%-70% about 10 years ago.

The two bills have broad bipartisan support in both the House and Senate. “Watch for that to hopefully become law,” Dr. Worthing said.

The ACR has been advocating for the last 4 years to increase research dollars specifically for arthritis and rheumatology at the Department of Defense. After years of trying, rheumatologist advocates were able to get funding for studying trauma-related osteoarthritis and military serology data banks added as an amendment in the most recent appropriations bill. However, it was pulled at the last minute because of a lack of support.

“But with that advancement we’ll be able to go into the next Congress in January and either get it into the bill or hopefully have the amendment voted on next year,” he said.

Dr. Worthing called for those interested in advocating for rheumatology to visit the ACR’s Legislative Action Center.

jevans@mdedge.com

CHICAGO – Rheumatology advocates have been working to get a variety of bills passed in Congress, including efforts on creating exemptions to step therapy or “fail first” insurer policies, increasing osteoporosis screening payment, and raising research dollars for arthritis in the Department of Defense, Dr. Angus Worthing said at the annual meeting of the American College of Rheumatology.

Visits by rheumatologist advocates to receptive members of the House and Senate have been fruitful for these issues, said Dr. Worthing, who is chair of the ACR’s Government Affairs Committee and a practicing rheumatologist in the Washington area.

“There’s a bill in the House [H.R. 2077, Restoring the Patient’s Voice Act], reforming step therapy that would institute appropriate exemptions if a doctor can predict that a drug that’s the first step in a step therapy will cause side effects, will be ineffective, or has already been used by a patient, as well as other appropriate guardrails,” so that the policy can be circumvented and the patient can get the prescription that the doctor ordered, he said.


The ACR is working with coalition partners such as the National Psoriasis Foundation and other patient organizations to get a companion bill to H.R. 2077 introduced in the Senate, Dr. Worthing noted.

The ACR is also working to advance separate bills in the House (H.R. 1898) and Senate (S. 3160) to increase payment levels for dual x-ray absorptiometry scans, which were cut by 60%-70% about 10 years ago.

The two bills have broad bipartisan support in both the House and Senate. “Watch for that to hopefully become law,” Dr. Worthing said.

The ACR has been advocating for the last 4 years to increase research dollars specifically for arthritis and rheumatology at the Department of Defense. After years of trying, rheumatologist advocates were able to get funding for studying trauma-related osteoarthritis and military serology data banks added as an amendment in the most recent appropriations bill. However, it was pulled at the last minute because of a lack of support.

“But with that advancement we’ll be able to go into the next Congress in January and either get it into the bill or hopefully have the amendment voted on next year,” he said.

Dr. Worthing called for those interested in advocating for rheumatology to visit the ACR’s Legislative Action Center.

jevans@mdedge.com

CHICAGO – Rheumatology advocates have been working to get a variety of bills passed in Congress, including efforts on creating exemptions to step therapy or “fail first” insurer policies, increasing osteoporosis screening payment, and raising research dollars for arthritis in the Department of Defense, Dr. Angus Worthing said at the annual meeting of the American College of Rheumatology.

Visits by rheumatologist advocates to receptive members of the House and Senate have been fruitful for these issues, said Dr. Worthing, who is chair of the ACR’s Government Affairs Committee and a practicing rheumatologist in the Washington area.

“There’s a bill in the House [H.R. 2077, Restoring the Patient’s Voice Act], reforming step therapy that would institute appropriate exemptions if a doctor can predict that a drug that’s the first step in a step therapy will cause side effects, will be ineffective, or has already been used by a patient, as well as other appropriate guardrails,” so that the policy can be circumvented and the patient can get the prescription that the doctor ordered, he said.


The ACR is working with coalition partners such as the National Psoriasis Foundation and other patient organizations to get a companion bill to H.R. 2077 introduced in the Senate, Dr. Worthing noted.

The ACR is also working to advance separate bills in the House (H.R. 1898) and Senate (S. 3160) to increase payment levels for dual x-ray absorptiometry scans, which were cut by 60%-70% about 10 years ago.

The two bills have broad bipartisan support in both the House and Senate. “Watch for that to hopefully become law,” Dr. Worthing said.

The ACR has been advocating for the last 4 years to increase research dollars specifically for arthritis and rheumatology at the Department of Defense. After years of trying, rheumatologist advocates were able to get funding for studying trauma-related osteoarthritis and military serology data banks added as an amendment in the most recent appropriations bill. However, it was pulled at the last minute because of a lack of support.

“But with that advancement we’ll be able to go into the next Congress in January and either get it into the bill or hopefully have the amendment voted on next year,” he said.

Dr. Worthing called for those interested in advocating for rheumatology to visit the ACR’s Legislative Action Center.

jevans@mdedge.com