Palliative care underutilized in dementia patients with acute abdomen

Not routine, but I always do it
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Despite high rates of in-hospital mortality and nonroutine discharge, palliative care is underutilized in patients with dementia and acute abdominal emergency, according to findings published in Surgery.

“Currently little is known about palliative care utilization among patients with dementia in possible need of surgical intervention. This raises the question of whether the acute surgical emergency represents an appropriate episode during which to introduce palliative care for patients with dementia,” wrote Ana Berlin, MD, FACS, of the department of surgery at New Jersey Medical School, Newark, N.J., and her coauthors (Surgery. 2017 Dec 4. doi: 10.1016/j.surg.2017.09.048).

Of 15,209 patients aged 50 years and older with dementia and acute abdomen, 7.5% received palliative care. Patients discharged nonroutinely and patients treated operatively were less likely to receive palliative care, the researchers reported.

Dr. Berlin and her colleagues used the National Inpatient Sample database to identify patients with dementia and acute abdomen who were admitted nonelectively between 2009 and 2013. They used ICD-9 primary and secondary codes to limit surgical diagnoses to gastrointestinal obstruction, ischemia, and perforation.

Overall, 50.9% of patients were admitted for gastrointestinal obstruction, 39.8% for perforation, 5.1% for bowel ischemia, and 4.3% for mixed pathology; 17.8% of patients were managed operatively.

Patients with intestinal ischemia had the highest rate of both operation and mortality, at 22.8% and 27.6%, respectively. These patients also had the lowest rate of routine discharge, at 15.9%, the authors said. In comparison, patients with obstruction had surgical intervention and in-hospital mortality rates of 17% and 10.1%, respectively, and a routine discharge rate of 20.9%. Patients with perforation had an operation rate of 13.8%, in-hospital mortality rate of 6.8%, and routine discharge rate of 26.9%.

The palliative care utilization rate overall was 7.5%. Patients with mixed pathology who did not have surgery were most likely to receive palliative care, at 21.1%, noted Dr. Berlin and her coauthors.

Patients who died postoperatively were less likely than were those who died without surgical intervention to have received palliative care (20.9% vs. 31.4%; odds ratio = 0.63, 95% confidence interval, 0.46-0.86; P = .0039), and those who were discharged nonroutinely after an operation were less likely than were patients who were discharged nonroutinely without an operation to receive palliative care (3.7% vs. 7.0%; OR = 0.44, 95% CI, 0.34-0.57; P less than .0001).

Lastly, patients who received palliative care had shorter median hospital stays than did those who did not receive palliative care (5 days vs. 6 days; P less than .0001). These patients also had lower median hospital charges ($29,500 vs. $31,600; P = .0403).

The results identify two subsets of patients with unmet palliative care needs: patients requiring operative intervention, and patients with a diagnosis of intestinal ischemia, the authors said. In addition, the findings suggest that “surgeons should consider initiating palliative care … early in the hospital course for patients with dementia presenting with acute surgical abdomen,” they wrote.

“Both hip fracture and intensive care unit admission in patients with dementia have been described as appropriate triggers for palliative care assessment. ... Acute abdominal emergency [may also represent] an appropriate episode during which to introduce palliative care for patients with dementia,” they concluded.

The study was funded by the Rutgers New Jersey Medical School department of surgery and the New Jersey Medical School Hispanic Center of Excellence, Health Resources, and Services Administration. No other disclosures were reported.

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Few surgeons would argue that a patient with dementia and an acute abdomen would be less appropriate for a palliative care consultation than demented patients with a hip fracture or ICU admission who have been shown to benefit from triggered palliative care consults. However, the dynamic interaction between patient, family, and surgeon, described by Thomas Miner as the “palliative triangle,” will likely prevent universal acceptance of triggered consults (Ann Surg Oncol. 2002;9[7]:696-709). Despite the current trend of increasingly algorithmic care, there is still a need for surgeon autonomy for treatment decisions even when the recommended triggered intervention is highly appropriate. A mentor of mine put it, “I never do things routinely, but there are some things I do all the time.” As the benefits of palliative care become more evident, the referrals for palliative care for this latest indication will become “some things I do all the time” just as pharmacokinetics referrals have become for antibiotics, anticoagulation, and total parenteral nutrition.

Dr. Geoffrey Dunn
Geoffrey P. Dunn, MD, FACS, is the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and vice chair of the ACS Committee on Surgical Palliative Care.

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Few surgeons would argue that a patient with dementia and an acute abdomen would be less appropriate for a palliative care consultation than demented patients with a hip fracture or ICU admission who have been shown to benefit from triggered palliative care consults. However, the dynamic interaction between patient, family, and surgeon, described by Thomas Miner as the “palliative triangle,” will likely prevent universal acceptance of triggered consults (Ann Surg Oncol. 2002;9[7]:696-709). Despite the current trend of increasingly algorithmic care, there is still a need for surgeon autonomy for treatment decisions even when the recommended triggered intervention is highly appropriate. A mentor of mine put it, “I never do things routinely, but there are some things I do all the time.” As the benefits of palliative care become more evident, the referrals for palliative care for this latest indication will become “some things I do all the time” just as pharmacokinetics referrals have become for antibiotics, anticoagulation, and total parenteral nutrition.

Dr. Geoffrey Dunn
Geoffrey P. Dunn, MD, FACS, is the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and vice chair of the ACS Committee on Surgical Palliative Care.

Body

 

Few surgeons would argue that a patient with dementia and an acute abdomen would be less appropriate for a palliative care consultation than demented patients with a hip fracture or ICU admission who have been shown to benefit from triggered palliative care consults. However, the dynamic interaction between patient, family, and surgeon, described by Thomas Miner as the “palliative triangle,” will likely prevent universal acceptance of triggered consults (Ann Surg Oncol. 2002;9[7]:696-709). Despite the current trend of increasingly algorithmic care, there is still a need for surgeon autonomy for treatment decisions even when the recommended triggered intervention is highly appropriate. A mentor of mine put it, “I never do things routinely, but there are some things I do all the time.” As the benefits of palliative care become more evident, the referrals for palliative care for this latest indication will become “some things I do all the time” just as pharmacokinetics referrals have become for antibiotics, anticoagulation, and total parenteral nutrition.

Dr. Geoffrey Dunn
Geoffrey P. Dunn, MD, FACS, is the medical director of the palliative care consultation service at the University of Pittsburgh Medical Center Hamot in Erie, Pa., and vice chair of the ACS Committee on Surgical Palliative Care.

Title
Not routine, but I always do it
Not routine, but I always do it

 

Despite high rates of in-hospital mortality and nonroutine discharge, palliative care is underutilized in patients with dementia and acute abdominal emergency, according to findings published in Surgery.

“Currently little is known about palliative care utilization among patients with dementia in possible need of surgical intervention. This raises the question of whether the acute surgical emergency represents an appropriate episode during which to introduce palliative care for patients with dementia,” wrote Ana Berlin, MD, FACS, of the department of surgery at New Jersey Medical School, Newark, N.J., and her coauthors (Surgery. 2017 Dec 4. doi: 10.1016/j.surg.2017.09.048).

Of 15,209 patients aged 50 years and older with dementia and acute abdomen, 7.5% received palliative care. Patients discharged nonroutinely and patients treated operatively were less likely to receive palliative care, the researchers reported.

Dr. Berlin and her colleagues used the National Inpatient Sample database to identify patients with dementia and acute abdomen who were admitted nonelectively between 2009 and 2013. They used ICD-9 primary and secondary codes to limit surgical diagnoses to gastrointestinal obstruction, ischemia, and perforation.

Overall, 50.9% of patients were admitted for gastrointestinal obstruction, 39.8% for perforation, 5.1% for bowel ischemia, and 4.3% for mixed pathology; 17.8% of patients were managed operatively.

Patients with intestinal ischemia had the highest rate of both operation and mortality, at 22.8% and 27.6%, respectively. These patients also had the lowest rate of routine discharge, at 15.9%, the authors said. In comparison, patients with obstruction had surgical intervention and in-hospital mortality rates of 17% and 10.1%, respectively, and a routine discharge rate of 20.9%. Patients with perforation had an operation rate of 13.8%, in-hospital mortality rate of 6.8%, and routine discharge rate of 26.9%.

The palliative care utilization rate overall was 7.5%. Patients with mixed pathology who did not have surgery were most likely to receive palliative care, at 21.1%, noted Dr. Berlin and her coauthors.

Patients who died postoperatively were less likely than were those who died without surgical intervention to have received palliative care (20.9% vs. 31.4%; odds ratio = 0.63, 95% confidence interval, 0.46-0.86; P = .0039), and those who were discharged nonroutinely after an operation were less likely than were patients who were discharged nonroutinely without an operation to receive palliative care (3.7% vs. 7.0%; OR = 0.44, 95% CI, 0.34-0.57; P less than .0001).

Lastly, patients who received palliative care had shorter median hospital stays than did those who did not receive palliative care (5 days vs. 6 days; P less than .0001). These patients also had lower median hospital charges ($29,500 vs. $31,600; P = .0403).

The results identify two subsets of patients with unmet palliative care needs: patients requiring operative intervention, and patients with a diagnosis of intestinal ischemia, the authors said. In addition, the findings suggest that “surgeons should consider initiating palliative care … early in the hospital course for patients with dementia presenting with acute surgical abdomen,” they wrote.

“Both hip fracture and intensive care unit admission in patients with dementia have been described as appropriate triggers for palliative care assessment. ... Acute abdominal emergency [may also represent] an appropriate episode during which to introduce palliative care for patients with dementia,” they concluded.

The study was funded by the Rutgers New Jersey Medical School department of surgery and the New Jersey Medical School Hispanic Center of Excellence, Health Resources, and Services Administration. No other disclosures were reported.

 

Despite high rates of in-hospital mortality and nonroutine discharge, palliative care is underutilized in patients with dementia and acute abdominal emergency, according to findings published in Surgery.

“Currently little is known about palliative care utilization among patients with dementia in possible need of surgical intervention. This raises the question of whether the acute surgical emergency represents an appropriate episode during which to introduce palliative care for patients with dementia,” wrote Ana Berlin, MD, FACS, of the department of surgery at New Jersey Medical School, Newark, N.J., and her coauthors (Surgery. 2017 Dec 4. doi: 10.1016/j.surg.2017.09.048).

Of 15,209 patients aged 50 years and older with dementia and acute abdomen, 7.5% received palliative care. Patients discharged nonroutinely and patients treated operatively were less likely to receive palliative care, the researchers reported.

Dr. Berlin and her colleagues used the National Inpatient Sample database to identify patients with dementia and acute abdomen who were admitted nonelectively between 2009 and 2013. They used ICD-9 primary and secondary codes to limit surgical diagnoses to gastrointestinal obstruction, ischemia, and perforation.

Overall, 50.9% of patients were admitted for gastrointestinal obstruction, 39.8% for perforation, 5.1% for bowel ischemia, and 4.3% for mixed pathology; 17.8% of patients were managed operatively.

Patients with intestinal ischemia had the highest rate of both operation and mortality, at 22.8% and 27.6%, respectively. These patients also had the lowest rate of routine discharge, at 15.9%, the authors said. In comparison, patients with obstruction had surgical intervention and in-hospital mortality rates of 17% and 10.1%, respectively, and a routine discharge rate of 20.9%. Patients with perforation had an operation rate of 13.8%, in-hospital mortality rate of 6.8%, and routine discharge rate of 26.9%.

The palliative care utilization rate overall was 7.5%. Patients with mixed pathology who did not have surgery were most likely to receive palliative care, at 21.1%, noted Dr. Berlin and her coauthors.

Patients who died postoperatively were less likely than were those who died without surgical intervention to have received palliative care (20.9% vs. 31.4%; odds ratio = 0.63, 95% confidence interval, 0.46-0.86; P = .0039), and those who were discharged nonroutinely after an operation were less likely than were patients who were discharged nonroutinely without an operation to receive palliative care (3.7% vs. 7.0%; OR = 0.44, 95% CI, 0.34-0.57; P less than .0001).

Lastly, patients who received palliative care had shorter median hospital stays than did those who did not receive palliative care (5 days vs. 6 days; P less than .0001). These patients also had lower median hospital charges ($29,500 vs. $31,600; P = .0403).

The results identify two subsets of patients with unmet palliative care needs: patients requiring operative intervention, and patients with a diagnosis of intestinal ischemia, the authors said. In addition, the findings suggest that “surgeons should consider initiating palliative care … early in the hospital course for patients with dementia presenting with acute surgical abdomen,” they wrote.

“Both hip fracture and intensive care unit admission in patients with dementia have been described as appropriate triggers for palliative care assessment. ... Acute abdominal emergency [may also represent] an appropriate episode during which to introduce palliative care for patients with dementia,” they concluded.

The study was funded by the Rutgers New Jersey Medical School department of surgery and the New Jersey Medical School Hispanic Center of Excellence, Health Resources, and Services Administration. No other disclosures were reported.

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Key clinical point: Despite high mortality and frequent nonroutine discharges, palliative care is underutilized in dementia patients with acute abdominal emergency.

Major finding: Among dementia patients with acute abdominal emergency, 7.5% received palliative care.

Data source: A retrospective analysis of 15,209 patients aged 50 years and older from the National Inpatient Sample, for the period of 2009-2013.

Disclosures: The study was funded by the Rutgers New Jersey Medical School Department of Surgery and the New Jersey Medical School Hispanic Center of Excellence, Health Resources, and Services Administration.

SOURCE: Surgery. 2017 Dec 4. doi: http://dx.doi.org/10.1016/j.surg.2017.09.048.

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Contraceptive use appears low in teen girls on teratogenic medications

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– A majority of U.S. teenage girls on Medicaid who were prescribed teratogenic medications for rheumatic diseases did not receive or fill prescriptions for contraception, and some became pregnant while taking the medication, a study showed.

Dr. Kimberly Hays
In the sample, 53% received a prescription contraception at any time during the 3-year study period, but only 25% who became pregnant had received a contraception prescription prior to becoming pregnant, lead study author Kimberly Hays, MD, said at the annual meeting of the American College of Rheumatology.

The number of filled prescriptions for contraception was low despite the associated risk of the teratogenic medications, said Dr. Hays, a third-year pediatric rheumatology fellow at the Medical University of South Carolina in Charleston.

“Each teratogenic medication carries a different risk,” she said. “Certain teratogenic medications carry a greater risk than other teratogenic medications. The associated risk may vary based on the timing and duration of use.”

“The risks and benefits of using a teratogenic medication for treatment should be discussed with teens and women of reproductive age,” Dr. Hays said. “Disease activity should be low, and the teratogenic medication should be replaced with a safer medication prior to pregnancy if one is available. Highly effective forms of contraception should be offered to patients who are at risk for unintended pregnancy and those who are not trying to conceive.”

In addition to rheumatic diseases, the eight teratogenic medications cited in the study are used to treat other conditions such as inflammatory bowel disease, hypertension, kidney disease, and malignancy, Dr. Hays said.

The study population was made up of 45.0% whites, 36.6% blacks, 4.8% Hispanics, and 13.6% others.

About 10% were defined as having a specific rheumatic disease, mainly systemic lupus erythematosus (70%), Dr. Hays said. “However, more than 10% had a rheumatic condition of some kind. Generalizations in ICD-9 coding made it difficult to identify specific diseases in some cases.”

The study did not examine birth defect outcomes in the babies born to the females in the cohort, but Dr. Hays said researchers are considering whether to track these numbers via claims data. The study also was not able to capture the use of nonprescribed contraception, such as condoms.

Moving forward, Dr. Hays said the researchers “are planning to also look at pregnancy and contraception rates in age-matched teens not taking teratogenic medications using the same Medicaid claims database. We are also hoping to research patient and provider perspectives pertaining to teratogenic medication use/risk and contraception.”

In addition, researchers hope to examine how commonly the individual drugs were prescribed and link them to contraception use and pregnancy, she said.

The study authors had no relevant financial disclosures, and the study had no external funding. The Medical University of South Carolina provided funding for database access.

SOURCE: Hays K et al. ACR 2017 Abstract 1813.

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– A majority of U.S. teenage girls on Medicaid who were prescribed teratogenic medications for rheumatic diseases did not receive or fill prescriptions for contraception, and some became pregnant while taking the medication, a study showed.

Dr. Kimberly Hays
In the sample, 53% received a prescription contraception at any time during the 3-year study period, but only 25% who became pregnant had received a contraception prescription prior to becoming pregnant, lead study author Kimberly Hays, MD, said at the annual meeting of the American College of Rheumatology.

The number of filled prescriptions for contraception was low despite the associated risk of the teratogenic medications, said Dr. Hays, a third-year pediatric rheumatology fellow at the Medical University of South Carolina in Charleston.

“Each teratogenic medication carries a different risk,” she said. “Certain teratogenic medications carry a greater risk than other teratogenic medications. The associated risk may vary based on the timing and duration of use.”

“The risks and benefits of using a teratogenic medication for treatment should be discussed with teens and women of reproductive age,” Dr. Hays said. “Disease activity should be low, and the teratogenic medication should be replaced with a safer medication prior to pregnancy if one is available. Highly effective forms of contraception should be offered to patients who are at risk for unintended pregnancy and those who are not trying to conceive.”

In addition to rheumatic diseases, the eight teratogenic medications cited in the study are used to treat other conditions such as inflammatory bowel disease, hypertension, kidney disease, and malignancy, Dr. Hays said.

The study population was made up of 45.0% whites, 36.6% blacks, 4.8% Hispanics, and 13.6% others.

About 10% were defined as having a specific rheumatic disease, mainly systemic lupus erythematosus (70%), Dr. Hays said. “However, more than 10% had a rheumatic condition of some kind. Generalizations in ICD-9 coding made it difficult to identify specific diseases in some cases.”

The study did not examine birth defect outcomes in the babies born to the females in the cohort, but Dr. Hays said researchers are considering whether to track these numbers via claims data. The study also was not able to capture the use of nonprescribed contraception, such as condoms.

Moving forward, Dr. Hays said the researchers “are planning to also look at pregnancy and contraception rates in age-matched teens not taking teratogenic medications using the same Medicaid claims database. We are also hoping to research patient and provider perspectives pertaining to teratogenic medication use/risk and contraception.”

In addition, researchers hope to examine how commonly the individual drugs were prescribed and link them to contraception use and pregnancy, she said.

The study authors had no relevant financial disclosures, and the study had no external funding. The Medical University of South Carolina provided funding for database access.

SOURCE: Hays K et al. ACR 2017 Abstract 1813.

 

– A majority of U.S. teenage girls on Medicaid who were prescribed teratogenic medications for rheumatic diseases did not receive or fill prescriptions for contraception, and some became pregnant while taking the medication, a study showed.

Dr. Kimberly Hays
In the sample, 53% received a prescription contraception at any time during the 3-year study period, but only 25% who became pregnant had received a contraception prescription prior to becoming pregnant, lead study author Kimberly Hays, MD, said at the annual meeting of the American College of Rheumatology.

The number of filled prescriptions for contraception was low despite the associated risk of the teratogenic medications, said Dr. Hays, a third-year pediatric rheumatology fellow at the Medical University of South Carolina in Charleston.

“Each teratogenic medication carries a different risk,” she said. “Certain teratogenic medications carry a greater risk than other teratogenic medications. The associated risk may vary based on the timing and duration of use.”

“The risks and benefits of using a teratogenic medication for treatment should be discussed with teens and women of reproductive age,” Dr. Hays said. “Disease activity should be low, and the teratogenic medication should be replaced with a safer medication prior to pregnancy if one is available. Highly effective forms of contraception should be offered to patients who are at risk for unintended pregnancy and those who are not trying to conceive.”

In addition to rheumatic diseases, the eight teratogenic medications cited in the study are used to treat other conditions such as inflammatory bowel disease, hypertension, kidney disease, and malignancy, Dr. Hays said.

The study population was made up of 45.0% whites, 36.6% blacks, 4.8% Hispanics, and 13.6% others.

About 10% were defined as having a specific rheumatic disease, mainly systemic lupus erythematosus (70%), Dr. Hays said. “However, more than 10% had a rheumatic condition of some kind. Generalizations in ICD-9 coding made it difficult to identify specific diseases in some cases.”

The study did not examine birth defect outcomes in the babies born to the females in the cohort, but Dr. Hays said researchers are considering whether to track these numbers via claims data. The study also was not able to capture the use of nonprescribed contraception, such as condoms.

Moving forward, Dr. Hays said the researchers “are planning to also look at pregnancy and contraception rates in age-matched teens not taking teratogenic medications using the same Medicaid claims database. We are also hoping to research patient and provider perspectives pertaining to teratogenic medication use/risk and contraception.”

In addition, researchers hope to examine how commonly the individual drugs were prescribed and link them to contraception use and pregnancy, she said.

The study authors had no relevant financial disclosures, and the study had no external funding. The Medical University of South Carolina provided funding for database access.

SOURCE: Hays K et al. ACR 2017 Abstract 1813.

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Key clinical point: Many teen girls on teratogenic medications aren’t filling contraceptive prescriptions.

Major finding: A total of 7.6% of teen girls taking teratogenic medications became pregnant during a 3-year period.

Study details: An analysis of 4,853 females aged 15-19 on Medicaid who were taking teratogenic medications.

Disclosures: The study authors had no relevant financial disclosures. The study had no external funding. The Medical University of South Carolina provided funding for database access.

Source: Hays K et al. ACR 2017 Abstract 1813.

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Skin signs spotlight highest-risk SLE patients

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– Careful skin examination in patients known to have systemic lupus erythematosus (SLE) can reveal subtle findings indicative of systemic thrombotic vasculopathy warranting prompt initiation of long-term antiplatelet therapy, Dan Lipsker, MD, PhD, said in a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.
 

“Those patients are at very high risk. Those are the lupus patients with the poorest prognosis. Those are the lupus patients who still die today,” said Dr. Lipsker, professor of dermatology at the University of Strasbourg (France).

Dr. Dan Lipsker
He cited a classic observational study by the European Working Party on Systemic Lupus Erythematosus in which 1,000 SLE patients in seven European countries were prospectively followed for 10 years. During the first 5 years, the most common causes of death were infections and active, progressive, unstoppable SLE. In the second 5 years, however, thrombotic events – stroke, acute MI, pulmonary embolism – moved to the fore and became the most common causes of mortality (Medicine. 2003 Sep;82[5]:299-308).

Cutaneous clues suggestive of thrombosis in SLE patients include atrophie blanche, pseudo-Degos lesions, livedo racemosa, acral nonpalpable purpura or reticulate erythema, cutaneous necrosis, splinter hemorrhage, thrombophlebitis, and nailfold telangiectasias. These skin findings can occur simultaneously with or after potentially life-threatening thrombotic events, or in the best of all scenarios, beforehand.

Dr. Lipsker told his audience of dermatologists that, by demonstrating facility in identifying these cutaneous disorders, they can make themselves “indispensable” to the rheumatologists, nephrologists, internists, and/or pediatricians who often provide the bulk of specialized care for SLE patients.

Courtesy RegionalDerm.com
Atrophie blanche
Nondermatologists typically lack experience with these telltale skin lesions, and they cannot interpret a skin biopsy. Moreover, their practice guidelines often fail to recognize the diagnostic, therapeutic, and prognostic value of searching for these skin findings. For example, recent British Society for Rheumatology guidelines on the management of SLE go into extensive detail on the importance of regular laboratory monitoring of hematologic, renal, and biochemical parameters – every 3 months in patients who are clinically quiet but serologically active, and every 6 months in those with inactive disease and no previous organ damage – but the guidelines make no mention of the skin clues to thrombotic vasculopathy (Rheumatology. 2018 Jan 1;57[1]:e1-45. doi: 10.1093/rheumatology/kex286).

“We know today that, 5 years after initial diagnosis of SLE, the chief causes of morbidity and mortality are thrombotic events. And it can be extremely difficult to distinguish between an acute autoimmune lupus flare and a thrombotic event when, for example, the CNS or eyes are involved. But you will find direct evidence of thrombosis by carefully examining the skin,” the dermatologist maintained.

Some of these cutaneous signs constitute unequivocal evidence of thrombosis in SLE patients. Others are more ambiguous but should raise suspicion of an ongoing systemic thrombotic process unless another explanation is found.

One example of a skin finding that always indicates thrombosis is pseudo-Degos lesions: ivory-colored or white depressed atrophic papules with a raised border composed of telangiectasias. Biopsy shows evidence of a cone-shaped dermal arteriolar infarct.

Courtesy RegionalDerm.com
Livedo racemosa in a patient with SLE, showing the irregular, net-like mottling surrounding pale skin.
Another cutaneous finding that constitutes indisputable evidence of a thrombotic vasculopathy is acral noninfiltrated stellar purpura.

“We have biopsied dozens of patients with this presentation, and you always find occluded vessels without a single inflammatory cell. These lesions are usually painful, and when you put those patients on low-dose aspirin they do better,” Dr. Lipsker said.

Atrophie blanche in a patient with SLE is also strong evidence of thrombotic vasculopathy. Atrophie blanche is a porcelain-white atrophic white scar with surrounding hyperpigmentation on the lower leg that occurs after skin injury in an area with venous insufficiency.

Livedo racemosa in a patient with SLE is also highly suggestive of a systemic thrombotic process. Characteristic of this dermatologic disorder is an irregular, netlike mottling surrounding pale skin.

“All of these skin signs allow identification of patients who have very high risk of thrombotic events,” Dr. Lipsker stressed.

He reported having no financial conflicts of interest regarding his presentation.

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– Careful skin examination in patients known to have systemic lupus erythematosus (SLE) can reveal subtle findings indicative of systemic thrombotic vasculopathy warranting prompt initiation of long-term antiplatelet therapy, Dan Lipsker, MD, PhD, said in a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.
 

“Those patients are at very high risk. Those are the lupus patients with the poorest prognosis. Those are the lupus patients who still die today,” said Dr. Lipsker, professor of dermatology at the University of Strasbourg (France).

Dr. Dan Lipsker
He cited a classic observational study by the European Working Party on Systemic Lupus Erythematosus in which 1,000 SLE patients in seven European countries were prospectively followed for 10 years. During the first 5 years, the most common causes of death were infections and active, progressive, unstoppable SLE. In the second 5 years, however, thrombotic events – stroke, acute MI, pulmonary embolism – moved to the fore and became the most common causes of mortality (Medicine. 2003 Sep;82[5]:299-308).

Cutaneous clues suggestive of thrombosis in SLE patients include atrophie blanche, pseudo-Degos lesions, livedo racemosa, acral nonpalpable purpura or reticulate erythema, cutaneous necrosis, splinter hemorrhage, thrombophlebitis, and nailfold telangiectasias. These skin findings can occur simultaneously with or after potentially life-threatening thrombotic events, or in the best of all scenarios, beforehand.

Dr. Lipsker told his audience of dermatologists that, by demonstrating facility in identifying these cutaneous disorders, they can make themselves “indispensable” to the rheumatologists, nephrologists, internists, and/or pediatricians who often provide the bulk of specialized care for SLE patients.

Courtesy RegionalDerm.com
Atrophie blanche
Nondermatologists typically lack experience with these telltale skin lesions, and they cannot interpret a skin biopsy. Moreover, their practice guidelines often fail to recognize the diagnostic, therapeutic, and prognostic value of searching for these skin findings. For example, recent British Society for Rheumatology guidelines on the management of SLE go into extensive detail on the importance of regular laboratory monitoring of hematologic, renal, and biochemical parameters – every 3 months in patients who are clinically quiet but serologically active, and every 6 months in those with inactive disease and no previous organ damage – but the guidelines make no mention of the skin clues to thrombotic vasculopathy (Rheumatology. 2018 Jan 1;57[1]:e1-45. doi: 10.1093/rheumatology/kex286).

“We know today that, 5 years after initial diagnosis of SLE, the chief causes of morbidity and mortality are thrombotic events. And it can be extremely difficult to distinguish between an acute autoimmune lupus flare and a thrombotic event when, for example, the CNS or eyes are involved. But you will find direct evidence of thrombosis by carefully examining the skin,” the dermatologist maintained.

Some of these cutaneous signs constitute unequivocal evidence of thrombosis in SLE patients. Others are more ambiguous but should raise suspicion of an ongoing systemic thrombotic process unless another explanation is found.

One example of a skin finding that always indicates thrombosis is pseudo-Degos lesions: ivory-colored or white depressed atrophic papules with a raised border composed of telangiectasias. Biopsy shows evidence of a cone-shaped dermal arteriolar infarct.

Courtesy RegionalDerm.com
Livedo racemosa in a patient with SLE, showing the irregular, net-like mottling surrounding pale skin.
Another cutaneous finding that constitutes indisputable evidence of a thrombotic vasculopathy is acral noninfiltrated stellar purpura.

“We have biopsied dozens of patients with this presentation, and you always find occluded vessels without a single inflammatory cell. These lesions are usually painful, and when you put those patients on low-dose aspirin they do better,” Dr. Lipsker said.

Atrophie blanche in a patient with SLE is also strong evidence of thrombotic vasculopathy. Atrophie blanche is a porcelain-white atrophic white scar with surrounding hyperpigmentation on the lower leg that occurs after skin injury in an area with venous insufficiency.

Livedo racemosa in a patient with SLE is also highly suggestive of a systemic thrombotic process. Characteristic of this dermatologic disorder is an irregular, netlike mottling surrounding pale skin.

“All of these skin signs allow identification of patients who have very high risk of thrombotic events,” Dr. Lipsker stressed.

He reported having no financial conflicts of interest regarding his presentation.

 

– Careful skin examination in patients known to have systemic lupus erythematosus (SLE) can reveal subtle findings indicative of systemic thrombotic vasculopathy warranting prompt initiation of long-term antiplatelet therapy, Dan Lipsker, MD, PhD, said in a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.
 

“Those patients are at very high risk. Those are the lupus patients with the poorest prognosis. Those are the lupus patients who still die today,” said Dr. Lipsker, professor of dermatology at the University of Strasbourg (France).

Dr. Dan Lipsker
He cited a classic observational study by the European Working Party on Systemic Lupus Erythematosus in which 1,000 SLE patients in seven European countries were prospectively followed for 10 years. During the first 5 years, the most common causes of death were infections and active, progressive, unstoppable SLE. In the second 5 years, however, thrombotic events – stroke, acute MI, pulmonary embolism – moved to the fore and became the most common causes of mortality (Medicine. 2003 Sep;82[5]:299-308).

Cutaneous clues suggestive of thrombosis in SLE patients include atrophie blanche, pseudo-Degos lesions, livedo racemosa, acral nonpalpable purpura or reticulate erythema, cutaneous necrosis, splinter hemorrhage, thrombophlebitis, and nailfold telangiectasias. These skin findings can occur simultaneously with or after potentially life-threatening thrombotic events, or in the best of all scenarios, beforehand.

Dr. Lipsker told his audience of dermatologists that, by demonstrating facility in identifying these cutaneous disorders, they can make themselves “indispensable” to the rheumatologists, nephrologists, internists, and/or pediatricians who often provide the bulk of specialized care for SLE patients.

Courtesy RegionalDerm.com
Atrophie blanche
Nondermatologists typically lack experience with these telltale skin lesions, and they cannot interpret a skin biopsy. Moreover, their practice guidelines often fail to recognize the diagnostic, therapeutic, and prognostic value of searching for these skin findings. For example, recent British Society for Rheumatology guidelines on the management of SLE go into extensive detail on the importance of regular laboratory monitoring of hematologic, renal, and biochemical parameters – every 3 months in patients who are clinically quiet but serologically active, and every 6 months in those with inactive disease and no previous organ damage – but the guidelines make no mention of the skin clues to thrombotic vasculopathy (Rheumatology. 2018 Jan 1;57[1]:e1-45. doi: 10.1093/rheumatology/kex286).

“We know today that, 5 years after initial diagnosis of SLE, the chief causes of morbidity and mortality are thrombotic events. And it can be extremely difficult to distinguish between an acute autoimmune lupus flare and a thrombotic event when, for example, the CNS or eyes are involved. But you will find direct evidence of thrombosis by carefully examining the skin,” the dermatologist maintained.

Some of these cutaneous signs constitute unequivocal evidence of thrombosis in SLE patients. Others are more ambiguous but should raise suspicion of an ongoing systemic thrombotic process unless another explanation is found.

One example of a skin finding that always indicates thrombosis is pseudo-Degos lesions: ivory-colored or white depressed atrophic papules with a raised border composed of telangiectasias. Biopsy shows evidence of a cone-shaped dermal arteriolar infarct.

Courtesy RegionalDerm.com
Livedo racemosa in a patient with SLE, showing the irregular, net-like mottling surrounding pale skin.
Another cutaneous finding that constitutes indisputable evidence of a thrombotic vasculopathy is acral noninfiltrated stellar purpura.

“We have biopsied dozens of patients with this presentation, and you always find occluded vessels without a single inflammatory cell. These lesions are usually painful, and when you put those patients on low-dose aspirin they do better,” Dr. Lipsker said.

Atrophie blanche in a patient with SLE is also strong evidence of thrombotic vasculopathy. Atrophie blanche is a porcelain-white atrophic white scar with surrounding hyperpigmentation on the lower leg that occurs after skin injury in an area with venous insufficiency.

Livedo racemosa in a patient with SLE is also highly suggestive of a systemic thrombotic process. Characteristic of this dermatologic disorder is an irregular, netlike mottling surrounding pale skin.

“All of these skin signs allow identification of patients who have very high risk of thrombotic events,” Dr. Lipsker stressed.

He reported having no financial conflicts of interest regarding his presentation.

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Identity crisis

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Thu, 03/28/2019 - 14:43

 

The provider has received “advanced-level education in pharmacology, pathophysiology, and physical assessment, diagnosis, and management” and provides patient care in a medical home “in a holistic fashion including physical care, therapeutic treatments, education, and coordination of services.”

This quote comes from a recent story in Pediatric News about collaborative practice. Was the author offering a job description of a) a chiropractor, b) a nurse practitioner, c) a pediatric oncologist, or d) a primary care physician?

Dr. William G. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years.
Dr. William G. Wilkoff
I think the description could easily be applied to a nurse practitioner or a physician. However, the author Cathy Haut, DNP, CPNP-PC, a nurse practitioner herself, was describing the qualifications of a nurse practitioner in primary care practice (“Nurse practitioner/pediatrician collaboration: Try a pediatric health care/medical home model,” Pediatric News, November 2017). A major theme in Dr. Haut’s column is that the skills and training of a nurse practitioner can be complementary to those of a physician. She provides several examples of how such a complementary relationship can result in a collaboration that advances patient care, particularly in a medical home setting.

Based on my personal experience working with nurse practitioners, both in hospital and office settings, I wholeheartedly concur with Dr. Haut’s list of their qualifications and capabilities. My problem is that she doesn’t list, nor can I comfortably imagine, the additional skills that a physician should have in his or her toolbox to complete the complementary relationships in a primary care practice that Dr. Haut envisions.

From my perspective, nurse practitioners and primary care physicians share the same job description, the one I listed in the first paragraph of this column. They both provide face-to-face, usually hands-on, medical care. At that critical interface between patient and provider, how do their roles differ? What other skills does a physician need to complement those of a competent and already experienced nurse practitioner?

Does being a physician guarantee that he or she has more experience than a nurse practitioner? You know as well as I do that you finished your training pretty wet behind the ears, and the first 5 years or more of your practice career were when you really began to feel like a competent provider. If my child has an earache, I would probably be more comfortable, or at least as comfortable, with her seeing a nurse practitioner with 5 years of experience in a busy practice than a newly minted, board-eligible pediatrician.

Is the breadth of a physician’s training in medical school an asset? Does the 2-month rotation he or she did on the adult neurology service taking care of stroke victims give the physician an advantage when it comes to taking care of pediatric patients with asthma?

Actually, I can imagine a suite of skills that a physician might bring to a collaborative practice that a nurse practitioner may not have, or more likely may have chosen not to pursue. Those skills have little to do with direct patient care, but can be critical for survival in today’s medical care environment. Here I am thinking of things such as negotiating with third-party payers, and leading and/or administering the complexities of a medium-sized or larger medical group. Does having a degree from a medical school automatically mean that the graduate is a skilled leader or administrator?

I can envision that over time a physician and a nurse practitioner might create an arrangement in which one of them focuses on the patients with asthma and attention-deficit/hyperactivity disorder, and the other develops an expertise in breastfeeding management and picky eating. That kind of relationship fits my definition of complementary. However, a relationship in which the doctor is the boss and the nurse practitioner is not doesn’t feel complementary or collaborative to me.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

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The provider has received “advanced-level education in pharmacology, pathophysiology, and physical assessment, diagnosis, and management” and provides patient care in a medical home “in a holistic fashion including physical care, therapeutic treatments, education, and coordination of services.”

This quote comes from a recent story in Pediatric News about collaborative practice. Was the author offering a job description of a) a chiropractor, b) a nurse practitioner, c) a pediatric oncologist, or d) a primary care physician?

Dr. William G. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years.
Dr. William G. Wilkoff
I think the description could easily be applied to a nurse practitioner or a physician. However, the author Cathy Haut, DNP, CPNP-PC, a nurse practitioner herself, was describing the qualifications of a nurse practitioner in primary care practice (“Nurse practitioner/pediatrician collaboration: Try a pediatric health care/medical home model,” Pediatric News, November 2017). A major theme in Dr. Haut’s column is that the skills and training of a nurse practitioner can be complementary to those of a physician. She provides several examples of how such a complementary relationship can result in a collaboration that advances patient care, particularly in a medical home setting.

Based on my personal experience working with nurse practitioners, both in hospital and office settings, I wholeheartedly concur with Dr. Haut’s list of their qualifications and capabilities. My problem is that she doesn’t list, nor can I comfortably imagine, the additional skills that a physician should have in his or her toolbox to complete the complementary relationships in a primary care practice that Dr. Haut envisions.

From my perspective, nurse practitioners and primary care physicians share the same job description, the one I listed in the first paragraph of this column. They both provide face-to-face, usually hands-on, medical care. At that critical interface between patient and provider, how do their roles differ? What other skills does a physician need to complement those of a competent and already experienced nurse practitioner?

Does being a physician guarantee that he or she has more experience than a nurse practitioner? You know as well as I do that you finished your training pretty wet behind the ears, and the first 5 years or more of your practice career were when you really began to feel like a competent provider. If my child has an earache, I would probably be more comfortable, or at least as comfortable, with her seeing a nurse practitioner with 5 years of experience in a busy practice than a newly minted, board-eligible pediatrician.

Is the breadth of a physician’s training in medical school an asset? Does the 2-month rotation he or she did on the adult neurology service taking care of stroke victims give the physician an advantage when it comes to taking care of pediatric patients with asthma?

Actually, I can imagine a suite of skills that a physician might bring to a collaborative practice that a nurse practitioner may not have, or more likely may have chosen not to pursue. Those skills have little to do with direct patient care, but can be critical for survival in today’s medical care environment. Here I am thinking of things such as negotiating with third-party payers, and leading and/or administering the complexities of a medium-sized or larger medical group. Does having a degree from a medical school automatically mean that the graduate is a skilled leader or administrator?

I can envision that over time a physician and a nurse practitioner might create an arrangement in which one of them focuses on the patients with asthma and attention-deficit/hyperactivity disorder, and the other develops an expertise in breastfeeding management and picky eating. That kind of relationship fits my definition of complementary. However, a relationship in which the doctor is the boss and the nurse practitioner is not doesn’t feel complementary or collaborative to me.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

 

The provider has received “advanced-level education in pharmacology, pathophysiology, and physical assessment, diagnosis, and management” and provides patient care in a medical home “in a holistic fashion including physical care, therapeutic treatments, education, and coordination of services.”

This quote comes from a recent story in Pediatric News about collaborative practice. Was the author offering a job description of a) a chiropractor, b) a nurse practitioner, c) a pediatric oncologist, or d) a primary care physician?

Dr. William G. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years.
Dr. William G. Wilkoff
I think the description could easily be applied to a nurse practitioner or a physician. However, the author Cathy Haut, DNP, CPNP-PC, a nurse practitioner herself, was describing the qualifications of a nurse practitioner in primary care practice (“Nurse practitioner/pediatrician collaboration: Try a pediatric health care/medical home model,” Pediatric News, November 2017). A major theme in Dr. Haut’s column is that the skills and training of a nurse practitioner can be complementary to those of a physician. She provides several examples of how such a complementary relationship can result in a collaboration that advances patient care, particularly in a medical home setting.

Based on my personal experience working with nurse practitioners, both in hospital and office settings, I wholeheartedly concur with Dr. Haut’s list of their qualifications and capabilities. My problem is that she doesn’t list, nor can I comfortably imagine, the additional skills that a physician should have in his or her toolbox to complete the complementary relationships in a primary care practice that Dr. Haut envisions.

From my perspective, nurse practitioners and primary care physicians share the same job description, the one I listed in the first paragraph of this column. They both provide face-to-face, usually hands-on, medical care. At that critical interface between patient and provider, how do their roles differ? What other skills does a physician need to complement those of a competent and already experienced nurse practitioner?

Does being a physician guarantee that he or she has more experience than a nurse practitioner? You know as well as I do that you finished your training pretty wet behind the ears, and the first 5 years or more of your practice career were when you really began to feel like a competent provider. If my child has an earache, I would probably be more comfortable, or at least as comfortable, with her seeing a nurse practitioner with 5 years of experience in a busy practice than a newly minted, board-eligible pediatrician.

Is the breadth of a physician’s training in medical school an asset? Does the 2-month rotation he or she did on the adult neurology service taking care of stroke victims give the physician an advantage when it comes to taking care of pediatric patients with asthma?

Actually, I can imagine a suite of skills that a physician might bring to a collaborative practice that a nurse practitioner may not have, or more likely may have chosen not to pursue. Those skills have little to do with direct patient care, but can be critical for survival in today’s medical care environment. Here I am thinking of things such as negotiating with third-party payers, and leading and/or administering the complexities of a medium-sized or larger medical group. Does having a degree from a medical school automatically mean that the graduate is a skilled leader or administrator?

I can envision that over time a physician and a nurse practitioner might create an arrangement in which one of them focuses on the patients with asthma and attention-deficit/hyperactivity disorder, and the other develops an expertise in breastfeeding management and picky eating. That kind of relationship fits my definition of complementary. However, a relationship in which the doctor is the boss and the nurse practitioner is not doesn’t feel complementary or collaborative to me.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”

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Long-acting naltrexone tied to fewer detox admissions, more treatment engagement

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– Persistence with long-acting naltrexone treatment was associated with significantly reduced detoxification admissions and concurrent engagement in treatment, a retrospective study of veterans found.

The Food and Drug Administration has approved long-acting naltrexone hydrochloride for the treatment of alcohol use disorder (AUD) and opioid use disorder (OUD), but little is known about the patients who initiate and continue this therapy, Grace Chang, MD, MPH, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. In an effort to evaluate the characteristics associated with long-term naltrexone treatment persistence, Dr. Chang, chief of consultation-liaison psychiatry at the VA Boston Healthcare System, and her associates studied 154 veterans who initiated long-acting naltrexone therapy for AUD or OUD between 2014 and 2015.

Doug Brunk/Frontline Medical News
Dr. Grace Chang
Compared with OUD patients, the AUD patients were older (a mean of 49 vs. 37 years, respectively; P less than .0001) and were more likely to be married (27% vs. 13%). The groups were similar in terms of gender (91% vs. 96% male), percentage employed (30% vs. 30%), percentage homeless (25% vs. 35%), presence of legal issues (39% vs. 40%), and the rate of death in the study year following the index shot (9% in each group). The OUD patients had a higher rate of percent service connected, which is a measure of disability (52% vs. 35%, P = .02).

Among those who died in the study year after the index shot, no difference in the average number of long-acting naltrexone injections was observed (5.3 in the OUD group vs. 6.8 in the AUD group, P = .62). There was a long interval between the last known injection of long-acting naltrexone and the date of death (381 days in the OUD group vs. 326 days in the AUD group, P = .67). The cause of death was unknown in 57% of cases, while 21% were from natural causes, and 21% were tied to overdose or self-inflicted injury.

The rates of posttraumatic stress disorder in the OUD and AUD groups were about the same, but the AUD patients had higher rates of mood disorder and anxiety disorder. The AUD patients had higher rates of cardiac disease and pulmonary disease, while the OUD patients had higher rates of musculoskeletal problems. Renal disease was relatively rare in both groups. “The AUD patients started using their drug of choice earlier, but the groups were comparable in being able to attain over 2 years of abstinence at some point,” said Dr. Chang, who is also professor of psychiatry at Harvard Medical School, Boston. “Both groups had about two detoxes in the year prior to the index shot.

In the year following the index shot, the number of detoxes dropped to one. We were also curious about what other drugs they were using prior to starting naltrexone. The OUD patients used more stimulants, more cocaine, and more sedative hypnotics. Smoking was endemic in both of these groups, as was marijuana use.”

The average interval from the time patients in both groups made the decision to start long-acting naltrexone to the time they received their first shot was about 2 months. “It’s safe to say that no one rushed into this,” Dr. Chang said. “The mean number of injections for the study year was about 5, which was very high, and the range was from 1 to 13, which suggests that some people got a shot every single month. Both of the groups had similar numbers of individual treatment sessions, which was about one. They had almost two residential admissions after the index shot and at least one other appointment with a prescribing psychiatrist.”

On Poisson regression analysis, factors associated with increased medication persistence included percent service connection and number of individual, group, residential, and other treatment modalities attended (P less than .05 for all associations). For each unit increase in the number of individual sessions, the number of long-acting naltrexone shots would go up by 7%, Dr. Chang said. For each unit increase in the number of group sessions, the number of long-acting naltrexone therapy shots would go up by 5%, while for each residential admission session, the number of long-acting naltrexone shots would go up by 14%.

“Keep in mind that our patients had an average of two residential admissions, so the number of shots went up by 28%,” she said. “For the number of other appointments with the addiction psychiatrist, the number of shots went up by 6%.”

Dr. Chang acknowledged certain limitations of the study, including its retrospective design and the relatively small sample size. “What was good to see is that the number of inpatient detox admissions was halved, when comparing the year before and the year after the shot,” she said. “This was highly statistically significant. Concurrent psychosocial treatment is highly important in the treatment persistence with this modality.”

Dr. Chang reported having no relevant financial disclosures.

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– Persistence with long-acting naltrexone treatment was associated with significantly reduced detoxification admissions and concurrent engagement in treatment, a retrospective study of veterans found.

The Food and Drug Administration has approved long-acting naltrexone hydrochloride for the treatment of alcohol use disorder (AUD) and opioid use disorder (OUD), but little is known about the patients who initiate and continue this therapy, Grace Chang, MD, MPH, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. In an effort to evaluate the characteristics associated with long-term naltrexone treatment persistence, Dr. Chang, chief of consultation-liaison psychiatry at the VA Boston Healthcare System, and her associates studied 154 veterans who initiated long-acting naltrexone therapy for AUD or OUD between 2014 and 2015.

Doug Brunk/Frontline Medical News
Dr. Grace Chang
Compared with OUD patients, the AUD patients were older (a mean of 49 vs. 37 years, respectively; P less than .0001) and were more likely to be married (27% vs. 13%). The groups were similar in terms of gender (91% vs. 96% male), percentage employed (30% vs. 30%), percentage homeless (25% vs. 35%), presence of legal issues (39% vs. 40%), and the rate of death in the study year following the index shot (9% in each group). The OUD patients had a higher rate of percent service connected, which is a measure of disability (52% vs. 35%, P = .02).

Among those who died in the study year after the index shot, no difference in the average number of long-acting naltrexone injections was observed (5.3 in the OUD group vs. 6.8 in the AUD group, P = .62). There was a long interval between the last known injection of long-acting naltrexone and the date of death (381 days in the OUD group vs. 326 days in the AUD group, P = .67). The cause of death was unknown in 57% of cases, while 21% were from natural causes, and 21% were tied to overdose or self-inflicted injury.

The rates of posttraumatic stress disorder in the OUD and AUD groups were about the same, but the AUD patients had higher rates of mood disorder and anxiety disorder. The AUD patients had higher rates of cardiac disease and pulmonary disease, while the OUD patients had higher rates of musculoskeletal problems. Renal disease was relatively rare in both groups. “The AUD patients started using their drug of choice earlier, but the groups were comparable in being able to attain over 2 years of abstinence at some point,” said Dr. Chang, who is also professor of psychiatry at Harvard Medical School, Boston. “Both groups had about two detoxes in the year prior to the index shot.

In the year following the index shot, the number of detoxes dropped to one. We were also curious about what other drugs they were using prior to starting naltrexone. The OUD patients used more stimulants, more cocaine, and more sedative hypnotics. Smoking was endemic in both of these groups, as was marijuana use.”

The average interval from the time patients in both groups made the decision to start long-acting naltrexone to the time they received their first shot was about 2 months. “It’s safe to say that no one rushed into this,” Dr. Chang said. “The mean number of injections for the study year was about 5, which was very high, and the range was from 1 to 13, which suggests that some people got a shot every single month. Both of the groups had similar numbers of individual treatment sessions, which was about one. They had almost two residential admissions after the index shot and at least one other appointment with a prescribing psychiatrist.”

On Poisson regression analysis, factors associated with increased medication persistence included percent service connection and number of individual, group, residential, and other treatment modalities attended (P less than .05 for all associations). For each unit increase in the number of individual sessions, the number of long-acting naltrexone shots would go up by 7%, Dr. Chang said. For each unit increase in the number of group sessions, the number of long-acting naltrexone therapy shots would go up by 5%, while for each residential admission session, the number of long-acting naltrexone shots would go up by 14%.

“Keep in mind that our patients had an average of two residential admissions, so the number of shots went up by 28%,” she said. “For the number of other appointments with the addiction psychiatrist, the number of shots went up by 6%.”

Dr. Chang acknowledged certain limitations of the study, including its retrospective design and the relatively small sample size. “What was good to see is that the number of inpatient detox admissions was halved, when comparing the year before and the year after the shot,” she said. “This was highly statistically significant. Concurrent psychosocial treatment is highly important in the treatment persistence with this modality.”

Dr. Chang reported having no relevant financial disclosures.

 

– Persistence with long-acting naltrexone treatment was associated with significantly reduced detoxification admissions and concurrent engagement in treatment, a retrospective study of veterans found.

The Food and Drug Administration has approved long-acting naltrexone hydrochloride for the treatment of alcohol use disorder (AUD) and opioid use disorder (OUD), but little is known about the patients who initiate and continue this therapy, Grace Chang, MD, MPH, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. In an effort to evaluate the characteristics associated with long-term naltrexone treatment persistence, Dr. Chang, chief of consultation-liaison psychiatry at the VA Boston Healthcare System, and her associates studied 154 veterans who initiated long-acting naltrexone therapy for AUD or OUD between 2014 and 2015.

Doug Brunk/Frontline Medical News
Dr. Grace Chang
Compared with OUD patients, the AUD patients were older (a mean of 49 vs. 37 years, respectively; P less than .0001) and were more likely to be married (27% vs. 13%). The groups were similar in terms of gender (91% vs. 96% male), percentage employed (30% vs. 30%), percentage homeless (25% vs. 35%), presence of legal issues (39% vs. 40%), and the rate of death in the study year following the index shot (9% in each group). The OUD patients had a higher rate of percent service connected, which is a measure of disability (52% vs. 35%, P = .02).

Among those who died in the study year after the index shot, no difference in the average number of long-acting naltrexone injections was observed (5.3 in the OUD group vs. 6.8 in the AUD group, P = .62). There was a long interval between the last known injection of long-acting naltrexone and the date of death (381 days in the OUD group vs. 326 days in the AUD group, P = .67). The cause of death was unknown in 57% of cases, while 21% were from natural causes, and 21% were tied to overdose or self-inflicted injury.

The rates of posttraumatic stress disorder in the OUD and AUD groups were about the same, but the AUD patients had higher rates of mood disorder and anxiety disorder. The AUD patients had higher rates of cardiac disease and pulmonary disease, while the OUD patients had higher rates of musculoskeletal problems. Renal disease was relatively rare in both groups. “The AUD patients started using their drug of choice earlier, but the groups were comparable in being able to attain over 2 years of abstinence at some point,” said Dr. Chang, who is also professor of psychiatry at Harvard Medical School, Boston. “Both groups had about two detoxes in the year prior to the index shot.

In the year following the index shot, the number of detoxes dropped to one. We were also curious about what other drugs they were using prior to starting naltrexone. The OUD patients used more stimulants, more cocaine, and more sedative hypnotics. Smoking was endemic in both of these groups, as was marijuana use.”

The average interval from the time patients in both groups made the decision to start long-acting naltrexone to the time they received their first shot was about 2 months. “It’s safe to say that no one rushed into this,” Dr. Chang said. “The mean number of injections for the study year was about 5, which was very high, and the range was from 1 to 13, which suggests that some people got a shot every single month. Both of the groups had similar numbers of individual treatment sessions, which was about one. They had almost two residential admissions after the index shot and at least one other appointment with a prescribing psychiatrist.”

On Poisson regression analysis, factors associated with increased medication persistence included percent service connection and number of individual, group, residential, and other treatment modalities attended (P less than .05 for all associations). For each unit increase in the number of individual sessions, the number of long-acting naltrexone shots would go up by 7%, Dr. Chang said. For each unit increase in the number of group sessions, the number of long-acting naltrexone therapy shots would go up by 5%, while for each residential admission session, the number of long-acting naltrexone shots would go up by 14%.

“Keep in mind that our patients had an average of two residential admissions, so the number of shots went up by 28%,” she said. “For the number of other appointments with the addiction psychiatrist, the number of shots went up by 6%.”

Dr. Chang acknowledged certain limitations of the study, including its retrospective design and the relatively small sample size. “What was good to see is that the number of inpatient detox admissions was halved, when comparing the year before and the year after the shot,” she said. “This was highly statistically significant. Concurrent psychosocial treatment is highly important in the treatment persistence with this modality.”

Dr. Chang reported having no relevant financial disclosures.

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Key clinical point: The number of inpatient detoxification admissions was halved when the year before and the year after the start of long-term naltrexone were compared.

Major finding: Factors associated with increased medication persistence included percent service connection and the number of individual, group, residential, and other treatment modalities attended (P less than .05 for all associations).

Study details: A retrospective analysis of 154 veterans who initiated long-acting naltrexone therapy between 2014 and 2015.

Disclosures: Dr. Chang reported having no relevant financial disclosures.

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Building a better SHM

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Fri, 09/14/2018 - 11:55
New HMX platform and website are highlights

 

As we enter the holiday season, the Society of Hospital Medicine is preparing to unwrap a refreshed experience for all members and partners.

Next month, SHM will launch its new association management system (AMS), its new online community platform for the Hospital Medicine Exchange (HMX), and a brand new website to better serve the needs of its constituents.

While many may be unaware of the systems and platforms SHM currently uses, an AMS is essentially SHM’s EHR for its members. It houses each member’s information, so the more information SHM has, the more SHM can customize the types of information you receive. All systems will be integrated so you can quickly access information on the chapter, interest group, or committee to which you belong.
 

What does this mean to you?

• You’ll be prompted to create a new password for your SHM account. When you set up your new password, we urge you to update your profile to make sure your information is current and that you are receiving content that is most relevant to you.

• As you update your profile, you will have an opportunity to edit your email preferences. If you have previously opted out of SHM emails, we urge you to opt back in to receive information on your local chapter meetings and more targeted messages about SHM offerings tailored specifically to your interests.

• The SHM website, www.hospitalmedicine.org, will be optimized for your smartphone and tablet and have a fresh look and feel on all devices, complete with new, intuitive navigation and streamlined content – making it easier for you to find the information that is the most relevant for you in even less time.

• The Hospital Medicine Exchange (HMX) will move to an intuitive new platform to enhance your online discussions and group collaborations, including chapters, interest groups, committees, and more.

In addition to these technological enhancements, watch for a refreshed design of The Hospitalist, the Journal of Hospital Medicine, and the overall SHM brand to bring a refined, sleek look to all SHM-related products, programs, and communications.

We look forward to better serving the needs of our members and partners with these improvements and encourage you to share your thoughts at feedback@hospitalmedicine.org.
 

Mr. Radler is marketing communications manager at the Society of Hospital Medicine.

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New HMX platform and website are highlights

 

As we enter the holiday season, the Society of Hospital Medicine is preparing to unwrap a refreshed experience for all members and partners.

Next month, SHM will launch its new association management system (AMS), its new online community platform for the Hospital Medicine Exchange (HMX), and a brand new website to better serve the needs of its constituents.

While many may be unaware of the systems and platforms SHM currently uses, an AMS is essentially SHM’s EHR for its members. It houses each member’s information, so the more information SHM has, the more SHM can customize the types of information you receive. All systems will be integrated so you can quickly access information on the chapter, interest group, or committee to which you belong.
 

What does this mean to you?

• You’ll be prompted to create a new password for your SHM account. When you set up your new password, we urge you to update your profile to make sure your information is current and that you are receiving content that is most relevant to you.

• As you update your profile, you will have an opportunity to edit your email preferences. If you have previously opted out of SHM emails, we urge you to opt back in to receive information on your local chapter meetings and more targeted messages about SHM offerings tailored specifically to your interests.

• The SHM website, www.hospitalmedicine.org, will be optimized for your smartphone and tablet and have a fresh look and feel on all devices, complete with new, intuitive navigation and streamlined content – making it easier for you to find the information that is the most relevant for you in even less time.

• The Hospital Medicine Exchange (HMX) will move to an intuitive new platform to enhance your online discussions and group collaborations, including chapters, interest groups, committees, and more.

In addition to these technological enhancements, watch for a refreshed design of The Hospitalist, the Journal of Hospital Medicine, and the overall SHM brand to bring a refined, sleek look to all SHM-related products, programs, and communications.

We look forward to better serving the needs of our members and partners with these improvements and encourage you to share your thoughts at feedback@hospitalmedicine.org.
 

Mr. Radler is marketing communications manager at the Society of Hospital Medicine.

 

As we enter the holiday season, the Society of Hospital Medicine is preparing to unwrap a refreshed experience for all members and partners.

Next month, SHM will launch its new association management system (AMS), its new online community platform for the Hospital Medicine Exchange (HMX), and a brand new website to better serve the needs of its constituents.

While many may be unaware of the systems and platforms SHM currently uses, an AMS is essentially SHM’s EHR for its members. It houses each member’s information, so the more information SHM has, the more SHM can customize the types of information you receive. All systems will be integrated so you can quickly access information on the chapter, interest group, or committee to which you belong.
 

What does this mean to you?

• You’ll be prompted to create a new password for your SHM account. When you set up your new password, we urge you to update your profile to make sure your information is current and that you are receiving content that is most relevant to you.

• As you update your profile, you will have an opportunity to edit your email preferences. If you have previously opted out of SHM emails, we urge you to opt back in to receive information on your local chapter meetings and more targeted messages about SHM offerings tailored specifically to your interests.

• The SHM website, www.hospitalmedicine.org, will be optimized for your smartphone and tablet and have a fresh look and feel on all devices, complete with new, intuitive navigation and streamlined content – making it easier for you to find the information that is the most relevant for you in even less time.

• The Hospital Medicine Exchange (HMX) will move to an intuitive new platform to enhance your online discussions and group collaborations, including chapters, interest groups, committees, and more.

In addition to these technological enhancements, watch for a refreshed design of The Hospitalist, the Journal of Hospital Medicine, and the overall SHM brand to bring a refined, sleek look to all SHM-related products, programs, and communications.

We look forward to better serving the needs of our members and partners with these improvements and encourage you to share your thoughts at feedback@hospitalmedicine.org.
 

Mr. Radler is marketing communications manager at the Society of Hospital Medicine.

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Chikungunya virus goes undetected despite chronic arthritis in 25% of patients after 20 months

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Up to a quarter of patients infected with chikungunya virus who reported joint pain as one of their initial symptoms continue to have joint pain after 20 months of follow-up, and evidence suggests that the persistent joint symptoms are not related to the continued presence of the virus in synovial fluid, according to two studies of patients infected during the 2014-2015 Colombian epidemic.

In the first large-scale, cross-sectional follow-up of a prospective cohort from the Colombian epidemic, Aileen Chang, MD, of George Washington University, Washington, and her colleagues at multiple other institutions reported persistent joint pain and multiple swollen and/or tender joints after 20 months in 123 of 485 Colombian patients who initially had joint pain with their Chikungunya virus infection (CHIKV) diagnosis. In their report in Arthritis & Rheumatology, they said that increased initial viral load and severe initial joint pain were predictors of persistent arthritis, which is consistent with the work of other researchers.

CDC/Cynthia Goldsmith
Shown is the Chikungunya virus.
In another study reported separately in Arthritis & Rheumatology from the same population of CHIKV patients with chronic arthritis, synovial fluid and blood plasma samples obtained from 38 patients at a median of 22 months of follow-up showed no signs of CHIKV RNA.

Dr. Chang worked with a variety of coinvestigators, some of whom were also involved in the larger symptom follow-up study, to conduct this Study of Chikungunya Arthritis Mechanisms in the Americas (CAMA). They collected synovial fluid and blood plasma from these 38 patients as well as 10 healthy controls who were serologically negative for CHIKV and never had arthritis, and analyzed the fluid and plasma for signs of CHIKV. They assessed viral RNA via quantitative reverse transcription polymerase chain reaction (qRT-PCR) testing, looked at viral proteins via mass spectrometry, and did viral cultures.

All samples from the 38 patients in the study were negative for CHIKV in two separate qRT-PCR assays. To determine if low-level viremia was present in synovial fluid samples, the samples were added to cell cultures to expand viral replication. No viral growth was found after three attempts and 10 days of culture. Conversely, controls with low quantities of virus (about 1 plaque-forming unit per well) yielded growth and detection of the virus.

Patients with CHIKV-associated arthritis also had no significant increase in rheumatoid arthritis markers or C-reactive protein. In fact, plasma markers for rheumatoid arthritis were found in only a fraction of patients with CHIKV arthritis: rheumatoid factor (RF) IgM antibody in 9%, RF IgG antibody in 12%, and anti–cyclic citrullinated peptide in 0%.

The more probable potential mechanisms through which CHIKV could cause persistent arthritis symptoms is through the presence of persistent CHIKV or viral antigens at low enough levels in the synovial tissue that it is undetectable in the synovial fluid, Dr. Chang and her associates suggested. There is also a possibility of epigenetic changes to the host DNA, altering host gene transcription. Other epigenetic changes, like epigenetic imprinting, could be possible in macrophages, leading to more aggressive cell behavior, they said. Unlikelier scenarios would be the presence of seronegative RA in these patients or, alternatively, the presence of seronegative RA indicating prior infection with CHIKV or other arthritogenic viruses.

Whatever mechanisms are causing CHIKV-associated arthritis, “these study findings may have important clinical relevance for CHIKV in the Americas. Since there is no current standard of care guidance for the treatment of CHIKV arthritis, some patients are currently being treated with immunosuppressant medications such as methotrexate, hydroxychloroquine, etanercept, adalimumab, sulfasalazine, fingolimod, abatacept, and tofacitinib,” Dr. Chang and her colleagues wrote. “This practice could be potentially harmful in the setting of replicating virus in the synovium as it could permit reemergence of a systemic viral infection.”

The CAMA study has several important limitations , the investigators said, the first being that during collection of synovial fluid, 0-20 mL of saline solution were used to flush the joints, which could have affected the ability to detect virus in the samples. In an attempt to mitigate this, the researchers cultured 0.5-1.5 mL of sampled synovial fluid to expand any replication-competent virus present in the sample, used two complementary PCR assays to detect nucleic acids, and a proteomic approach to look for viral proteins.

The researchers acknowledged that despite these measures, “proving the absence of a target is difficult, and we recognize that it is possible that our approach failed to detect low-level viral antigen; however, our orthogonal approach clearly demonstrates that if viral antigen exists in the synovial fluid, it is at extremely low levels.” They advised that future studies may want to use synovial biopsies rather than extracted fluid.

The investigators also did not include patients who had previously been infected by CHIKV without chronic arthritis. This issue was compounded by the lack of age- and sex-matched healthy controls.

All researchers involved in the studies reported no financial conflicts of interest. The studies were supported by various grants from the National Institutes of Health and the Rheumatology Research Foundation.

SOURCE: Chang A et al. Arthritis Rheumatol. 2017 Dec 20. doi: 10.1002/art.40383 and Chang A et al. Arthritis Rheumatol. 2017 Dec 20. doi: 10.1002/art.40384

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Up to a quarter of patients infected with chikungunya virus who reported joint pain as one of their initial symptoms continue to have joint pain after 20 months of follow-up, and evidence suggests that the persistent joint symptoms are not related to the continued presence of the virus in synovial fluid, according to two studies of patients infected during the 2014-2015 Colombian epidemic.

In the first large-scale, cross-sectional follow-up of a prospective cohort from the Colombian epidemic, Aileen Chang, MD, of George Washington University, Washington, and her colleagues at multiple other institutions reported persistent joint pain and multiple swollen and/or tender joints after 20 months in 123 of 485 Colombian patients who initially had joint pain with their Chikungunya virus infection (CHIKV) diagnosis. In their report in Arthritis & Rheumatology, they said that increased initial viral load and severe initial joint pain were predictors of persistent arthritis, which is consistent with the work of other researchers.

CDC/Cynthia Goldsmith
Shown is the Chikungunya virus.
In another study reported separately in Arthritis & Rheumatology from the same population of CHIKV patients with chronic arthritis, synovial fluid and blood plasma samples obtained from 38 patients at a median of 22 months of follow-up showed no signs of CHIKV RNA.

Dr. Chang worked with a variety of coinvestigators, some of whom were also involved in the larger symptom follow-up study, to conduct this Study of Chikungunya Arthritis Mechanisms in the Americas (CAMA). They collected synovial fluid and blood plasma from these 38 patients as well as 10 healthy controls who were serologically negative for CHIKV and never had arthritis, and analyzed the fluid and plasma for signs of CHIKV. They assessed viral RNA via quantitative reverse transcription polymerase chain reaction (qRT-PCR) testing, looked at viral proteins via mass spectrometry, and did viral cultures.

All samples from the 38 patients in the study were negative for CHIKV in two separate qRT-PCR assays. To determine if low-level viremia was present in synovial fluid samples, the samples were added to cell cultures to expand viral replication. No viral growth was found after three attempts and 10 days of culture. Conversely, controls with low quantities of virus (about 1 plaque-forming unit per well) yielded growth and detection of the virus.

Patients with CHIKV-associated arthritis also had no significant increase in rheumatoid arthritis markers or C-reactive protein. In fact, plasma markers for rheumatoid arthritis were found in only a fraction of patients with CHIKV arthritis: rheumatoid factor (RF) IgM antibody in 9%, RF IgG antibody in 12%, and anti–cyclic citrullinated peptide in 0%.

The more probable potential mechanisms through which CHIKV could cause persistent arthritis symptoms is through the presence of persistent CHIKV or viral antigens at low enough levels in the synovial tissue that it is undetectable in the synovial fluid, Dr. Chang and her associates suggested. There is also a possibility of epigenetic changes to the host DNA, altering host gene transcription. Other epigenetic changes, like epigenetic imprinting, could be possible in macrophages, leading to more aggressive cell behavior, they said. Unlikelier scenarios would be the presence of seronegative RA in these patients or, alternatively, the presence of seronegative RA indicating prior infection with CHIKV or other arthritogenic viruses.

Whatever mechanisms are causing CHIKV-associated arthritis, “these study findings may have important clinical relevance for CHIKV in the Americas. Since there is no current standard of care guidance for the treatment of CHIKV arthritis, some patients are currently being treated with immunosuppressant medications such as methotrexate, hydroxychloroquine, etanercept, adalimumab, sulfasalazine, fingolimod, abatacept, and tofacitinib,” Dr. Chang and her colleagues wrote. “This practice could be potentially harmful in the setting of replicating virus in the synovium as it could permit reemergence of a systemic viral infection.”

The CAMA study has several important limitations , the investigators said, the first being that during collection of synovial fluid, 0-20 mL of saline solution were used to flush the joints, which could have affected the ability to detect virus in the samples. In an attempt to mitigate this, the researchers cultured 0.5-1.5 mL of sampled synovial fluid to expand any replication-competent virus present in the sample, used two complementary PCR assays to detect nucleic acids, and a proteomic approach to look for viral proteins.

The researchers acknowledged that despite these measures, “proving the absence of a target is difficult, and we recognize that it is possible that our approach failed to detect low-level viral antigen; however, our orthogonal approach clearly demonstrates that if viral antigen exists in the synovial fluid, it is at extremely low levels.” They advised that future studies may want to use synovial biopsies rather than extracted fluid.

The investigators also did not include patients who had previously been infected by CHIKV without chronic arthritis. This issue was compounded by the lack of age- and sex-matched healthy controls.

All researchers involved in the studies reported no financial conflicts of interest. The studies were supported by various grants from the National Institutes of Health and the Rheumatology Research Foundation.

SOURCE: Chang A et al. Arthritis Rheumatol. 2017 Dec 20. doi: 10.1002/art.40383 and Chang A et al. Arthritis Rheumatol. 2017 Dec 20. doi: 10.1002/art.40384

 

Up to a quarter of patients infected with chikungunya virus who reported joint pain as one of their initial symptoms continue to have joint pain after 20 months of follow-up, and evidence suggests that the persistent joint symptoms are not related to the continued presence of the virus in synovial fluid, according to two studies of patients infected during the 2014-2015 Colombian epidemic.

In the first large-scale, cross-sectional follow-up of a prospective cohort from the Colombian epidemic, Aileen Chang, MD, of George Washington University, Washington, and her colleagues at multiple other institutions reported persistent joint pain and multiple swollen and/or tender joints after 20 months in 123 of 485 Colombian patients who initially had joint pain with their Chikungunya virus infection (CHIKV) diagnosis. In their report in Arthritis & Rheumatology, they said that increased initial viral load and severe initial joint pain were predictors of persistent arthritis, which is consistent with the work of other researchers.

CDC/Cynthia Goldsmith
Shown is the Chikungunya virus.
In another study reported separately in Arthritis & Rheumatology from the same population of CHIKV patients with chronic arthritis, synovial fluid and blood plasma samples obtained from 38 patients at a median of 22 months of follow-up showed no signs of CHIKV RNA.

Dr. Chang worked with a variety of coinvestigators, some of whom were also involved in the larger symptom follow-up study, to conduct this Study of Chikungunya Arthritis Mechanisms in the Americas (CAMA). They collected synovial fluid and blood plasma from these 38 patients as well as 10 healthy controls who were serologically negative for CHIKV and never had arthritis, and analyzed the fluid and plasma for signs of CHIKV. They assessed viral RNA via quantitative reverse transcription polymerase chain reaction (qRT-PCR) testing, looked at viral proteins via mass spectrometry, and did viral cultures.

All samples from the 38 patients in the study were negative for CHIKV in two separate qRT-PCR assays. To determine if low-level viremia was present in synovial fluid samples, the samples were added to cell cultures to expand viral replication. No viral growth was found after three attempts and 10 days of culture. Conversely, controls with low quantities of virus (about 1 plaque-forming unit per well) yielded growth and detection of the virus.

Patients with CHIKV-associated arthritis also had no significant increase in rheumatoid arthritis markers or C-reactive protein. In fact, plasma markers for rheumatoid arthritis were found in only a fraction of patients with CHIKV arthritis: rheumatoid factor (RF) IgM antibody in 9%, RF IgG antibody in 12%, and anti–cyclic citrullinated peptide in 0%.

The more probable potential mechanisms through which CHIKV could cause persistent arthritis symptoms is through the presence of persistent CHIKV or viral antigens at low enough levels in the synovial tissue that it is undetectable in the synovial fluid, Dr. Chang and her associates suggested. There is also a possibility of epigenetic changes to the host DNA, altering host gene transcription. Other epigenetic changes, like epigenetic imprinting, could be possible in macrophages, leading to more aggressive cell behavior, they said. Unlikelier scenarios would be the presence of seronegative RA in these patients or, alternatively, the presence of seronegative RA indicating prior infection with CHIKV or other arthritogenic viruses.

Whatever mechanisms are causing CHIKV-associated arthritis, “these study findings may have important clinical relevance for CHIKV in the Americas. Since there is no current standard of care guidance for the treatment of CHIKV arthritis, some patients are currently being treated with immunosuppressant medications such as methotrexate, hydroxychloroquine, etanercept, adalimumab, sulfasalazine, fingolimod, abatacept, and tofacitinib,” Dr. Chang and her colleagues wrote. “This practice could be potentially harmful in the setting of replicating virus in the synovium as it could permit reemergence of a systemic viral infection.”

The CAMA study has several important limitations , the investigators said, the first being that during collection of synovial fluid, 0-20 mL of saline solution were used to flush the joints, which could have affected the ability to detect virus in the samples. In an attempt to mitigate this, the researchers cultured 0.5-1.5 mL of sampled synovial fluid to expand any replication-competent virus present in the sample, used two complementary PCR assays to detect nucleic acids, and a proteomic approach to look for viral proteins.

The researchers acknowledged that despite these measures, “proving the absence of a target is difficult, and we recognize that it is possible that our approach failed to detect low-level viral antigen; however, our orthogonal approach clearly demonstrates that if viral antigen exists in the synovial fluid, it is at extremely low levels.” They advised that future studies may want to use synovial biopsies rather than extracted fluid.

The investigators also did not include patients who had previously been infected by CHIKV without chronic arthritis. This issue was compounded by the lack of age- and sex-matched healthy controls.

All researchers involved in the studies reported no financial conflicts of interest. The studies were supported by various grants from the National Institutes of Health and the Rheumatology Research Foundation.

SOURCE: Chang A et al. Arthritis Rheumatol. 2017 Dec 20. doi: 10.1002/art.40383 and Chang A et al. Arthritis Rheumatol. 2017 Dec 20. doi: 10.1002/art.40384

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Key clinical point: Arthritis persists at 20 months in 25% with CHIKV-associated arthritis, but these patients appear to test negative for persistent CHIKV viral RNA.

Major finding: No signs of persistent CHIKV infection can be found in synovial fluid or blood plasma from patients with chronic arthritis after CHIKV.

Study details: Cross-sectional studies of 485 Colombian patients who had clinical CHIKV and associated arthritis symptoms in 2014-2015 and another 38 patients who underwent further synovial fluid and blood plasma testing after a median of 22 months.

Disclosures: All researchers involved in the studies reported no financial conflicts of interest. The studies were supported by various grants from the National Institutes of Health and the Rheumatology Research Foundation.

Source: Chang A et al. Arthritis Rheumatol. 2017 Dec 20. doi: 10.1002/art.40383 and Chang A et al. Arthritis Rheumatol. 2017 Dec 20. doi: 10.1002/art.40384.

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DCIS risk signature is validated in SweDCIS population

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– A biological risk signature can help guide decisions about use of adjuvant radiation therapy in patients with ductal carcinoma in situ (DCIS), suggests a validation study reported at the San Antonio Breast Cancer Symposium.

Radiation therapy reduces the 10-year risk of any ipsilateral recurrence in this population by about 50% as established in a large overview of trials (J Natl Cancer Inst Monogr. 2010;2010:162-77), noted lead investigator Fredrik Wärnberg, MD, PhD, of Uppsala Academic Hospital, Uppsala University, Sweden. But factors such as tumor size, grade, and margins have not been helpful in identifying patients most likely to benefit.

Dr. Fredrik Wärnberg
He and his colleagues validated a biological risk signature (DCISionRT; PreludeDx) among 584 patients with pure primary DCIS treated on the SweDCIS trial. The trial randomized patients who had undergone breast-conserving surgery to receive radiation therapy or not, and then followed them for 20 years.

The risk signature incorporates four clinicopathologic factors and seven immunohistochemically assessed biomarkers of hormone receptor status, HER2 status, stress response, and proliferation. Possible scores range from 0 to 10, and are split into categories of low risk (0 to 3) and elevated risk (greater than 3). “To me, the magic of this signature is that it is nonlinear. Each factor can be dependent on the value of other factors in the model,” Dr. Wärnberg said.

Results of the validation study showed that among the 506 patients who had clear margins after surgery, radiation therapy significantly reduced the 10-year risk of invasive recurrence in those with an elevated risk score by more than three-fourths, but not in those with a low risk score.

“The biologic risk signature … correlated to risk. It’s prognostic, that’s nothing new,” he summarized. “More interestingly, it was also predictive for radiotherapy benefit. Not all patient groups had the same benefit from radiation therapy. In the low-risk group, there wasn’t any significant benefit from radiation therapy for invasive recurrences. But in the elevated risk group, the radiation therapy benefit was twice as high as expected – about a 76% relative risk reduction with radiotherapy for invasive recurrences.”

Study details

Main results from the SweDCIS trial, previously reported (J Clin Oncol. 2014;32:3613-8), showed that adjuvant radiation therapy reduced recurrences, yielding a 12% absolute reduction in risk of ipsilateral recurrence (10% for in situ recurrences and 2% for invasive recurrences).

For the validation study, Dr. Wärnberg and his colleagues were able to obtain tissue and biological signature results, blinded to patient outcome, for 56% of the original trial population. About half of patients each were determined to have low risk scores and elevated risk scores.

Among the 506 patients with clear margins, the score, analyzed as a continuous variable, was associated with risk of any (in situ or invasive) ipsilateral recurrence during follow-up (hazard ratio, 1.49 per 5-unit increase; P = .038).

In a multivariate model, receipt of radiation therapy was associated with a 52% relative reduction in 10-year risk of any ipsilateral recurrence for those with a low-risk score (HR, 0.48; P = .04) and a greater 69% relative reduction for those with an elevated risk score (HR, 0.31; P less than .001).

Radiation therapy did not significantly reduce the risk of ipsilateral invasive recurrence in the low risk group (HR, 0.84; P = .70), but it did in the elevated risk group (HR, 0.24; P = .012).

These findings essentially mirrored those of a 2015 validation study in a separate cohort of 526 patients from Uppsala University Hospital and the University of Massachusetts, according to Dr. Wärnberg. “We found highly consistent data with these two different sets,” he said.

Analyses additionally showed that radiation therapy reduced the 10-year risk of an invasive breast cancer recurrence by an absolute 1% for patients with low risk scores (not significant) but by an absolute 9% for patients with elevated risk scores (P = .012).

Dr. Wärnberg disclosed that he had no relevant conflicts of interest. The study was funded in part by PreludeDx.

SOURCE: Warnberg et al., SABCS Abstract GS5-08

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– A biological risk signature can help guide decisions about use of adjuvant radiation therapy in patients with ductal carcinoma in situ (DCIS), suggests a validation study reported at the San Antonio Breast Cancer Symposium.

Radiation therapy reduces the 10-year risk of any ipsilateral recurrence in this population by about 50% as established in a large overview of trials (J Natl Cancer Inst Monogr. 2010;2010:162-77), noted lead investigator Fredrik Wärnberg, MD, PhD, of Uppsala Academic Hospital, Uppsala University, Sweden. But factors such as tumor size, grade, and margins have not been helpful in identifying patients most likely to benefit.

Dr. Fredrik Wärnberg
He and his colleagues validated a biological risk signature (DCISionRT; PreludeDx) among 584 patients with pure primary DCIS treated on the SweDCIS trial. The trial randomized patients who had undergone breast-conserving surgery to receive radiation therapy or not, and then followed them for 20 years.

The risk signature incorporates four clinicopathologic factors and seven immunohistochemically assessed biomarkers of hormone receptor status, HER2 status, stress response, and proliferation. Possible scores range from 0 to 10, and are split into categories of low risk (0 to 3) and elevated risk (greater than 3). “To me, the magic of this signature is that it is nonlinear. Each factor can be dependent on the value of other factors in the model,” Dr. Wärnberg said.

Results of the validation study showed that among the 506 patients who had clear margins after surgery, radiation therapy significantly reduced the 10-year risk of invasive recurrence in those with an elevated risk score by more than three-fourths, but not in those with a low risk score.

“The biologic risk signature … correlated to risk. It’s prognostic, that’s nothing new,” he summarized. “More interestingly, it was also predictive for radiotherapy benefit. Not all patient groups had the same benefit from radiation therapy. In the low-risk group, there wasn’t any significant benefit from radiation therapy for invasive recurrences. But in the elevated risk group, the radiation therapy benefit was twice as high as expected – about a 76% relative risk reduction with radiotherapy for invasive recurrences.”

Study details

Main results from the SweDCIS trial, previously reported (J Clin Oncol. 2014;32:3613-8), showed that adjuvant radiation therapy reduced recurrences, yielding a 12% absolute reduction in risk of ipsilateral recurrence (10% for in situ recurrences and 2% for invasive recurrences).

For the validation study, Dr. Wärnberg and his colleagues were able to obtain tissue and biological signature results, blinded to patient outcome, for 56% of the original trial population. About half of patients each were determined to have low risk scores and elevated risk scores.

Among the 506 patients with clear margins, the score, analyzed as a continuous variable, was associated with risk of any (in situ or invasive) ipsilateral recurrence during follow-up (hazard ratio, 1.49 per 5-unit increase; P = .038).

In a multivariate model, receipt of radiation therapy was associated with a 52% relative reduction in 10-year risk of any ipsilateral recurrence for those with a low-risk score (HR, 0.48; P = .04) and a greater 69% relative reduction for those with an elevated risk score (HR, 0.31; P less than .001).

Radiation therapy did not significantly reduce the risk of ipsilateral invasive recurrence in the low risk group (HR, 0.84; P = .70), but it did in the elevated risk group (HR, 0.24; P = .012).

These findings essentially mirrored those of a 2015 validation study in a separate cohort of 526 patients from Uppsala University Hospital and the University of Massachusetts, according to Dr. Wärnberg. “We found highly consistent data with these two different sets,” he said.

Analyses additionally showed that radiation therapy reduced the 10-year risk of an invasive breast cancer recurrence by an absolute 1% for patients with low risk scores (not significant) but by an absolute 9% for patients with elevated risk scores (P = .012).

Dr. Wärnberg disclosed that he had no relevant conflicts of interest. The study was funded in part by PreludeDx.

SOURCE: Warnberg et al., SABCS Abstract GS5-08

 

– A biological risk signature can help guide decisions about use of adjuvant radiation therapy in patients with ductal carcinoma in situ (DCIS), suggests a validation study reported at the San Antonio Breast Cancer Symposium.

Radiation therapy reduces the 10-year risk of any ipsilateral recurrence in this population by about 50% as established in a large overview of trials (J Natl Cancer Inst Monogr. 2010;2010:162-77), noted lead investigator Fredrik Wärnberg, MD, PhD, of Uppsala Academic Hospital, Uppsala University, Sweden. But factors such as tumor size, grade, and margins have not been helpful in identifying patients most likely to benefit.

Dr. Fredrik Wärnberg
He and his colleagues validated a biological risk signature (DCISionRT; PreludeDx) among 584 patients with pure primary DCIS treated on the SweDCIS trial. The trial randomized patients who had undergone breast-conserving surgery to receive radiation therapy or not, and then followed them for 20 years.

The risk signature incorporates four clinicopathologic factors and seven immunohistochemically assessed biomarkers of hormone receptor status, HER2 status, stress response, and proliferation. Possible scores range from 0 to 10, and are split into categories of low risk (0 to 3) and elevated risk (greater than 3). “To me, the magic of this signature is that it is nonlinear. Each factor can be dependent on the value of other factors in the model,” Dr. Wärnberg said.

Results of the validation study showed that among the 506 patients who had clear margins after surgery, radiation therapy significantly reduced the 10-year risk of invasive recurrence in those with an elevated risk score by more than three-fourths, but not in those with a low risk score.

“The biologic risk signature … correlated to risk. It’s prognostic, that’s nothing new,” he summarized. “More interestingly, it was also predictive for radiotherapy benefit. Not all patient groups had the same benefit from radiation therapy. In the low-risk group, there wasn’t any significant benefit from radiation therapy for invasive recurrences. But in the elevated risk group, the radiation therapy benefit was twice as high as expected – about a 76% relative risk reduction with radiotherapy for invasive recurrences.”

Study details

Main results from the SweDCIS trial, previously reported (J Clin Oncol. 2014;32:3613-8), showed that adjuvant radiation therapy reduced recurrences, yielding a 12% absolute reduction in risk of ipsilateral recurrence (10% for in situ recurrences and 2% for invasive recurrences).

For the validation study, Dr. Wärnberg and his colleagues were able to obtain tissue and biological signature results, blinded to patient outcome, for 56% of the original trial population. About half of patients each were determined to have low risk scores and elevated risk scores.

Among the 506 patients with clear margins, the score, analyzed as a continuous variable, was associated with risk of any (in situ or invasive) ipsilateral recurrence during follow-up (hazard ratio, 1.49 per 5-unit increase; P = .038).

In a multivariate model, receipt of radiation therapy was associated with a 52% relative reduction in 10-year risk of any ipsilateral recurrence for those with a low-risk score (HR, 0.48; P = .04) and a greater 69% relative reduction for those with an elevated risk score (HR, 0.31; P less than .001).

Radiation therapy did not significantly reduce the risk of ipsilateral invasive recurrence in the low risk group (HR, 0.84; P = .70), but it did in the elevated risk group (HR, 0.24; P = .012).

These findings essentially mirrored those of a 2015 validation study in a separate cohort of 526 patients from Uppsala University Hospital and the University of Massachusetts, according to Dr. Wärnberg. “We found highly consistent data with these two different sets,” he said.

Analyses additionally showed that radiation therapy reduced the 10-year risk of an invasive breast cancer recurrence by an absolute 1% for patients with low risk scores (not significant) but by an absolute 9% for patients with elevated risk scores (P = .012).

Dr. Wärnberg disclosed that he had no relevant conflicts of interest. The study was funded in part by PreludeDx.

SOURCE: Warnberg et al., SABCS Abstract GS5-08

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Key clinical point: The biologic risk signature was both prognostic and predictive of radiation therapy benefit.

Major finding: Among patients with clear margins, radiation therapy significantly reduced 10-year risk of invasive recurrence in those with an elevated risk score (hazard ratio, 0.24; P = .012) but not in those with a low risk score (HR, 0.84; P = .70).

Data source: A validation study in 584 patients with DCIS from a randomized trial of radiation therapy (SweDCIS).

Disclosures: Dr. Wärnberg disclosed that he had no relevant conflicts of interest. The study was funded in part by PreludeDx.

Source: Warnberg et al., SABCS Abstract GS5-08

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Typhoid isn’t covered??!!

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Fri, 01/18/2019 - 17:17

 

My wife and I decided to visit Morocco, to test the maxim that my fellow columnist Joe Eastern often cites: The words you won’t say on your deathbed are, “If only I had spent more time at the office.”

Though I’m not convinced he’s right about that – he’s never even seen my office – I thought I’d give being away a try. My office manager comes from near Marrakesh. While bound for Morocco, we could check out her hometown, even if there is no obvious tax angle.

VanderWolf-Images


As I contemplated exotic travel, the first things that came to mind of course were what rare diseases I might catch, which vaccines could prevent them, and how to get insurance to pay for getting immunized. Alexa helped me find CDC recommendations for immunizations for travel to Morocco, which included:

• Typhoid ... contaminated food or water.

• Hepatitis A ... contaminated food or water.

• Hepatitis B ... contaminated body fluids (sex, needles, etc.).

• Cholera ... contaminated food or water.

• Rabies ... infected animals.

• Influenza ... airborne droplets.

This trip was indeed starting to sound like an awful lot of fun.

My PCP called in several of the relevant vaccines to my local pharmacy, who informed me that typhoid vaccine is not covered by my health insurance. This spurred the following (somewhat embellished) dialogue with my insurer:

“Why is typhoid not covered?”

“Contractual exclusion. We don’t cover anything starting with “typ-,” including typhoid, typhus, typical, and typographic.”

“Do you cover bubonic plague?”

“Only for high-risk travel.”

“Such as?”

“Such as if you travel to Europe during the 14th century.”

“How about Hepatitis B and rabies?”

“That would depend.”

“On what?”

“On whether you plan to have sex with rabid bats, or rabid sex with placid bats.”

“I wouldn’t say I have plans. But, you know, in the moment ...”

“Sorry, not covered.”

“How about cholera?”

“Have you ever been threatened by cholera?

“Not exactly. But I did have a cranky uncle. When he was irritated, he often said, ‘May cholera grab you!’ ”

“You’re not covered. Your uncle might be.”

“We’ve decided on a side trip to Tanzania. As long as we’re already in Africa ...”

“Do you suffer from Sleeping Sickness?”

“Only at Grand Rounds.”

“We do cover eflornithine, but there is a problem ...”

“What problem?”

“Our only eflornithine manufacturing facility is in Bangladesh, where it takes up two floors of a factory that also makes designer jeans. That factory is closed for safety and child-labor violations.”

“For how long?”

“Indefinitely”

“Then what can I do?”

“You can apply eflornithine cream for your Sleeping Sickness and hope for the best.”

“Eflornithine cream?”

“Vaniqa. It may not help your sleeping symptoms, but you’ll need fewer haircuts.”

“Oh, thanks. What about River Blindness? Do you cover ivermectin?”

“Only if the preferred formulary alternatives have been exhausted.”

“What are those?”

“Metronidazole and azelaic acid.”

“Hold on! Are you looking at the page for onchocerciasis or the one for rosacea?”

Dr. Alan Rockoff
“You may be right ... I’ll have to get back to you on that. Any other questions?”

“Yes. Did Montezuma ever make it to Morocco?”

“I don’t have that information. You’ll have to ask Alexa. Anything else?”

“No, I’m all set. Just remind me what you said about bats?”

In the end a family situation came up, and we had to cancel our trip. Instead, we watched the movie “Casablanca.” That is an excellent movie, with many pungent and memorable lines. Not only that but watching it does not cause jet lag.

As for the typhoid vaccine, in the end, it was not covered by insurance. Nevertheless, I haven’t had a bit of typhoid, so the vaccine seems to be working very well.
 

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.

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My wife and I decided to visit Morocco, to test the maxim that my fellow columnist Joe Eastern often cites: The words you won’t say on your deathbed are, “If only I had spent more time at the office.”

Though I’m not convinced he’s right about that – he’s never even seen my office – I thought I’d give being away a try. My office manager comes from near Marrakesh. While bound for Morocco, we could check out her hometown, even if there is no obvious tax angle.

VanderWolf-Images


As I contemplated exotic travel, the first things that came to mind of course were what rare diseases I might catch, which vaccines could prevent them, and how to get insurance to pay for getting immunized. Alexa helped me find CDC recommendations for immunizations for travel to Morocco, which included:

• Typhoid ... contaminated food or water.

• Hepatitis A ... contaminated food or water.

• Hepatitis B ... contaminated body fluids (sex, needles, etc.).

• Cholera ... contaminated food or water.

• Rabies ... infected animals.

• Influenza ... airborne droplets.

This trip was indeed starting to sound like an awful lot of fun.

My PCP called in several of the relevant vaccines to my local pharmacy, who informed me that typhoid vaccine is not covered by my health insurance. This spurred the following (somewhat embellished) dialogue with my insurer:

“Why is typhoid not covered?”

“Contractual exclusion. We don’t cover anything starting with “typ-,” including typhoid, typhus, typical, and typographic.”

“Do you cover bubonic plague?”

“Only for high-risk travel.”

“Such as?”

“Such as if you travel to Europe during the 14th century.”

“How about Hepatitis B and rabies?”

“That would depend.”

“On what?”

“On whether you plan to have sex with rabid bats, or rabid sex with placid bats.”

“I wouldn’t say I have plans. But, you know, in the moment ...”

“Sorry, not covered.”

“How about cholera?”

“Have you ever been threatened by cholera?

“Not exactly. But I did have a cranky uncle. When he was irritated, he often said, ‘May cholera grab you!’ ”

“You’re not covered. Your uncle might be.”

“We’ve decided on a side trip to Tanzania. As long as we’re already in Africa ...”

“Do you suffer from Sleeping Sickness?”

“Only at Grand Rounds.”

“We do cover eflornithine, but there is a problem ...”

“What problem?”

“Our only eflornithine manufacturing facility is in Bangladesh, where it takes up two floors of a factory that also makes designer jeans. That factory is closed for safety and child-labor violations.”

“For how long?”

“Indefinitely”

“Then what can I do?”

“You can apply eflornithine cream for your Sleeping Sickness and hope for the best.”

“Eflornithine cream?”

“Vaniqa. It may not help your sleeping symptoms, but you’ll need fewer haircuts.”

“Oh, thanks. What about River Blindness? Do you cover ivermectin?”

“Only if the preferred formulary alternatives have been exhausted.”

“What are those?”

“Metronidazole and azelaic acid.”

“Hold on! Are you looking at the page for onchocerciasis or the one for rosacea?”

Dr. Alan Rockoff
“You may be right ... I’ll have to get back to you on that. Any other questions?”

“Yes. Did Montezuma ever make it to Morocco?”

“I don’t have that information. You’ll have to ask Alexa. Anything else?”

“No, I’m all set. Just remind me what you said about bats?”

In the end a family situation came up, and we had to cancel our trip. Instead, we watched the movie “Casablanca.” That is an excellent movie, with many pungent and memorable lines. Not only that but watching it does not cause jet lag.

As for the typhoid vaccine, in the end, it was not covered by insurance. Nevertheless, I haven’t had a bit of typhoid, so the vaccine seems to be working very well.
 

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.

 

My wife and I decided to visit Morocco, to test the maxim that my fellow columnist Joe Eastern often cites: The words you won’t say on your deathbed are, “If only I had spent more time at the office.”

Though I’m not convinced he’s right about that – he’s never even seen my office – I thought I’d give being away a try. My office manager comes from near Marrakesh. While bound for Morocco, we could check out her hometown, even if there is no obvious tax angle.

VanderWolf-Images


As I contemplated exotic travel, the first things that came to mind of course were what rare diseases I might catch, which vaccines could prevent them, and how to get insurance to pay for getting immunized. Alexa helped me find CDC recommendations for immunizations for travel to Morocco, which included:

• Typhoid ... contaminated food or water.

• Hepatitis A ... contaminated food or water.

• Hepatitis B ... contaminated body fluids (sex, needles, etc.).

• Cholera ... contaminated food or water.

• Rabies ... infected animals.

• Influenza ... airborne droplets.

This trip was indeed starting to sound like an awful lot of fun.

My PCP called in several of the relevant vaccines to my local pharmacy, who informed me that typhoid vaccine is not covered by my health insurance. This spurred the following (somewhat embellished) dialogue with my insurer:

“Why is typhoid not covered?”

“Contractual exclusion. We don’t cover anything starting with “typ-,” including typhoid, typhus, typical, and typographic.”

“Do you cover bubonic plague?”

“Only for high-risk travel.”

“Such as?”

“Such as if you travel to Europe during the 14th century.”

“How about Hepatitis B and rabies?”

“That would depend.”

“On what?”

“On whether you plan to have sex with rabid bats, or rabid sex with placid bats.”

“I wouldn’t say I have plans. But, you know, in the moment ...”

“Sorry, not covered.”

“How about cholera?”

“Have you ever been threatened by cholera?

“Not exactly. But I did have a cranky uncle. When he was irritated, he often said, ‘May cholera grab you!’ ”

“You’re not covered. Your uncle might be.”

“We’ve decided on a side trip to Tanzania. As long as we’re already in Africa ...”

“Do you suffer from Sleeping Sickness?”

“Only at Grand Rounds.”

“We do cover eflornithine, but there is a problem ...”

“What problem?”

“Our only eflornithine manufacturing facility is in Bangladesh, where it takes up two floors of a factory that also makes designer jeans. That factory is closed for safety and child-labor violations.”

“For how long?”

“Indefinitely”

“Then what can I do?”

“You can apply eflornithine cream for your Sleeping Sickness and hope for the best.”

“Eflornithine cream?”

“Vaniqa. It may not help your sleeping symptoms, but you’ll need fewer haircuts.”

“Oh, thanks. What about River Blindness? Do you cover ivermectin?”

“Only if the preferred formulary alternatives have been exhausted.”

“What are those?”

“Metronidazole and azelaic acid.”

“Hold on! Are you looking at the page for onchocerciasis or the one for rosacea?”

Dr. Alan Rockoff
“You may be right ... I’ll have to get back to you on that. Any other questions?”

“Yes. Did Montezuma ever make it to Morocco?”

“I don’t have that information. You’ll have to ask Alexa. Anything else?”

“No, I’m all set. Just remind me what you said about bats?”

In the end a family situation came up, and we had to cancel our trip. Instead, we watched the movie “Casablanca.” That is an excellent movie, with many pungent and memorable lines. Not only that but watching it does not cause jet lag.

As for the typhoid vaccine, in the end, it was not covered by insurance. Nevertheless, I haven’t had a bit of typhoid, so the vaccine seems to be working very well.
 

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.

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Tau imaging predicts looming cognitive decline in cognitively normal elderly

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– Progressive tau accumulation in the temporal lobe of cognitively normal older adults was associated with cognitive decline over time in a prospective, longitudinal study presented at the Clinical Trials on Alzheimer’s Disease conference.

This track of cognitive impairment following tau pathology in a preclinical Alzheimer’s disease (AD) population suggests two roles for serial positron emission tomography (PET) scans with a tau binding agent, Bernard Hanseeuw, MD, PhD, said at the meeting. In the near future, they could be used to track therapeutic response in clinical trials. Farther out, if future validation studies confirm these preliminary results, they might be a useful clinical tool for predicting how fast an individual Alzheimer’s patient will progress, he said in an interview.

Dr. Bernard Hanseeuw
“Tau imaging will be a very important way to track disease progression,” said Dr. Hanseeuw of the Gordon Center for Medical Imaging at Massachusetts General Hospital, Boston. “Amyloid imaging is excellent to detect AD pathology, but it’s not the perfect way to track the progression of disease, because it changes little over 2-3 years. So repeating an amyloid PET will not add much information, compared to baseline, to predict future cognitive decline.”

Serial tau scans, however, would, he said.

“Every patient with Alzheimer’s disease is different, with a different disease course. Amyloid scans can tell us if someone is on the wrong path, but tau scans could tell us how fast they are going. If you have Alzheimer’s, it’s important to know if you may not be able to live in your own home in a year. With tau PET, we could track the disease and predict how fast it might evolve. That is very clinically relevant,” said Dr. Hanseeuw.

Tau imaging remains investigational only. Several tau imaging agents are being developed, but none has yet been approved in the United States or in Europe.

To investigate the correlation of tau and cognitive decline in preclinical Alzheimer’s, Dr. Hanseeuw examined serial tau and amyloid PET scans conducted on 60 clinically normal older adults with a mean age of 75 years. About one-third of the cohort was positive for the APOE4 allele. All of them had a baseline Clinical Dementia Rating (CDR) score of 0 and a mean Mini-Mental State Exam score of at least 27. They also scored in the normal range on the Preclinical Alzheimer’s Cognitive Composite (PACC) test. This relatively new cognitive scale is an increasingly popular item in clinical trials. The PACC is a composite of the WAIS-R Digit Symbol Substitution Test, Mini-Mental State Exam, Free and Cued Selective Reminding Test, and Logical Memory IIA Delayed Recall, and correlates well with amyloid accumulation in the brain.

The study included up to 4 years of data on cognition and amyloid PET imaging, and up to 3 years of tau PET imaging data. The investigators assessed amyloid as a whole-brain aggregate and tau in the bilateral inferior temporal neocortex. “This is where the change is most happening in patients, and it’s a place where relatively few normal elderly would have tau,” Dr. Hanseeuw said. All of the analyses controlled for age, sex, and years of education.

Baseline amyloid levels were low in 36 participants and high in 24. At least some tau was present in all of the subjects. This is not an unexpected finding, since tau accumulates with age, Dr. Hanseeuw said. Over the study period, six subjects progressed to a CDR of 0.5 – a rating consistent with mild cognitive impairment. At baseline, high tau and high amyloid levels were both associated with a progressive decline in PACC scores in the following years. However, the rate of change in tau predicted change in cognition better than did the baseline measurements. In contrast, the rate of change in amyloid was not associated with cognitive decline.

Courtesy of Dr. Bernard Hanseeuw
PET imaging with a tau radioligand shows tau accumulation in the temporal lobe (red).
When looking at the overall changes in each outcome (amyloid, cognition, and tau), Dr. Hanseeuw found that tau levels changed the fastest and the most consistently – significantly faster than either amyloid or cognition. In fact, tau changed about twice as fast as cognition changed, suggesting that increasing tau accumulation is a powerful predictor of looming cognitive decline.

“What is interesting here is that tau changed four times faster than amyloid,” Dr. Hanseeuw said. “The average subject needed 5 years to change 1 standard deviation in tau, but would have needed 20 years to change 1 standard deviation in amyloid.”

Fast-changing outcomes are important to accelerate drug assessment in clinical trials. Currently, it takes 3-5 years to conduct most anti-AD trials, he added.

Dr. Hanseeuw had no relevant financial disclosures.

SOURCE: Hanseeuw B et al. CTAD 2017 Abstract OC2.

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– Progressive tau accumulation in the temporal lobe of cognitively normal older adults was associated with cognitive decline over time in a prospective, longitudinal study presented at the Clinical Trials on Alzheimer’s Disease conference.

This track of cognitive impairment following tau pathology in a preclinical Alzheimer’s disease (AD) population suggests two roles for serial positron emission tomography (PET) scans with a tau binding agent, Bernard Hanseeuw, MD, PhD, said at the meeting. In the near future, they could be used to track therapeutic response in clinical trials. Farther out, if future validation studies confirm these preliminary results, they might be a useful clinical tool for predicting how fast an individual Alzheimer’s patient will progress, he said in an interview.

Dr. Bernard Hanseeuw
“Tau imaging will be a very important way to track disease progression,” said Dr. Hanseeuw of the Gordon Center for Medical Imaging at Massachusetts General Hospital, Boston. “Amyloid imaging is excellent to detect AD pathology, but it’s not the perfect way to track the progression of disease, because it changes little over 2-3 years. So repeating an amyloid PET will not add much information, compared to baseline, to predict future cognitive decline.”

Serial tau scans, however, would, he said.

“Every patient with Alzheimer’s disease is different, with a different disease course. Amyloid scans can tell us if someone is on the wrong path, but tau scans could tell us how fast they are going. If you have Alzheimer’s, it’s important to know if you may not be able to live in your own home in a year. With tau PET, we could track the disease and predict how fast it might evolve. That is very clinically relevant,” said Dr. Hanseeuw.

Tau imaging remains investigational only. Several tau imaging agents are being developed, but none has yet been approved in the United States or in Europe.

To investigate the correlation of tau and cognitive decline in preclinical Alzheimer’s, Dr. Hanseeuw examined serial tau and amyloid PET scans conducted on 60 clinically normal older adults with a mean age of 75 years. About one-third of the cohort was positive for the APOE4 allele. All of them had a baseline Clinical Dementia Rating (CDR) score of 0 and a mean Mini-Mental State Exam score of at least 27. They also scored in the normal range on the Preclinical Alzheimer’s Cognitive Composite (PACC) test. This relatively new cognitive scale is an increasingly popular item in clinical trials. The PACC is a composite of the WAIS-R Digit Symbol Substitution Test, Mini-Mental State Exam, Free and Cued Selective Reminding Test, and Logical Memory IIA Delayed Recall, and correlates well with amyloid accumulation in the brain.

The study included up to 4 years of data on cognition and amyloid PET imaging, and up to 3 years of tau PET imaging data. The investigators assessed amyloid as a whole-brain aggregate and tau in the bilateral inferior temporal neocortex. “This is where the change is most happening in patients, and it’s a place where relatively few normal elderly would have tau,” Dr. Hanseeuw said. All of the analyses controlled for age, sex, and years of education.

Baseline amyloid levels were low in 36 participants and high in 24. At least some tau was present in all of the subjects. This is not an unexpected finding, since tau accumulates with age, Dr. Hanseeuw said. Over the study period, six subjects progressed to a CDR of 0.5 – a rating consistent with mild cognitive impairment. At baseline, high tau and high amyloid levels were both associated with a progressive decline in PACC scores in the following years. However, the rate of change in tau predicted change in cognition better than did the baseline measurements. In contrast, the rate of change in amyloid was not associated with cognitive decline.

Courtesy of Dr. Bernard Hanseeuw
PET imaging with a tau radioligand shows tau accumulation in the temporal lobe (red).
When looking at the overall changes in each outcome (amyloid, cognition, and tau), Dr. Hanseeuw found that tau levels changed the fastest and the most consistently – significantly faster than either amyloid or cognition. In fact, tau changed about twice as fast as cognition changed, suggesting that increasing tau accumulation is a powerful predictor of looming cognitive decline.

“What is interesting here is that tau changed four times faster than amyloid,” Dr. Hanseeuw said. “The average subject needed 5 years to change 1 standard deviation in tau, but would have needed 20 years to change 1 standard deviation in amyloid.”

Fast-changing outcomes are important to accelerate drug assessment in clinical trials. Currently, it takes 3-5 years to conduct most anti-AD trials, he added.

Dr. Hanseeuw had no relevant financial disclosures.

SOURCE: Hanseeuw B et al. CTAD 2017 Abstract OC2.

 

– Progressive tau accumulation in the temporal lobe of cognitively normal older adults was associated with cognitive decline over time in a prospective, longitudinal study presented at the Clinical Trials on Alzheimer’s Disease conference.

This track of cognitive impairment following tau pathology in a preclinical Alzheimer’s disease (AD) population suggests two roles for serial positron emission tomography (PET) scans with a tau binding agent, Bernard Hanseeuw, MD, PhD, said at the meeting. In the near future, they could be used to track therapeutic response in clinical trials. Farther out, if future validation studies confirm these preliminary results, they might be a useful clinical tool for predicting how fast an individual Alzheimer’s patient will progress, he said in an interview.

Dr. Bernard Hanseeuw
“Tau imaging will be a very important way to track disease progression,” said Dr. Hanseeuw of the Gordon Center for Medical Imaging at Massachusetts General Hospital, Boston. “Amyloid imaging is excellent to detect AD pathology, but it’s not the perfect way to track the progression of disease, because it changes little over 2-3 years. So repeating an amyloid PET will not add much information, compared to baseline, to predict future cognitive decline.”

Serial tau scans, however, would, he said.

“Every patient with Alzheimer’s disease is different, with a different disease course. Amyloid scans can tell us if someone is on the wrong path, but tau scans could tell us how fast they are going. If you have Alzheimer’s, it’s important to know if you may not be able to live in your own home in a year. With tau PET, we could track the disease and predict how fast it might evolve. That is very clinically relevant,” said Dr. Hanseeuw.

Tau imaging remains investigational only. Several tau imaging agents are being developed, but none has yet been approved in the United States or in Europe.

To investigate the correlation of tau and cognitive decline in preclinical Alzheimer’s, Dr. Hanseeuw examined serial tau and amyloid PET scans conducted on 60 clinically normal older adults with a mean age of 75 years. About one-third of the cohort was positive for the APOE4 allele. All of them had a baseline Clinical Dementia Rating (CDR) score of 0 and a mean Mini-Mental State Exam score of at least 27. They also scored in the normal range on the Preclinical Alzheimer’s Cognitive Composite (PACC) test. This relatively new cognitive scale is an increasingly popular item in clinical trials. The PACC is a composite of the WAIS-R Digit Symbol Substitution Test, Mini-Mental State Exam, Free and Cued Selective Reminding Test, and Logical Memory IIA Delayed Recall, and correlates well with amyloid accumulation in the brain.

The study included up to 4 years of data on cognition and amyloid PET imaging, and up to 3 years of tau PET imaging data. The investigators assessed amyloid as a whole-brain aggregate and tau in the bilateral inferior temporal neocortex. “This is where the change is most happening in patients, and it’s a place where relatively few normal elderly would have tau,” Dr. Hanseeuw said. All of the analyses controlled for age, sex, and years of education.

Baseline amyloid levels were low in 36 participants and high in 24. At least some tau was present in all of the subjects. This is not an unexpected finding, since tau accumulates with age, Dr. Hanseeuw said. Over the study period, six subjects progressed to a CDR of 0.5 – a rating consistent with mild cognitive impairment. At baseline, high tau and high amyloid levels were both associated with a progressive decline in PACC scores in the following years. However, the rate of change in tau predicted change in cognition better than did the baseline measurements. In contrast, the rate of change in amyloid was not associated with cognitive decline.

Courtesy of Dr. Bernard Hanseeuw
PET imaging with a tau radioligand shows tau accumulation in the temporal lobe (red).
When looking at the overall changes in each outcome (amyloid, cognition, and tau), Dr. Hanseeuw found that tau levels changed the fastest and the most consistently – significantly faster than either amyloid or cognition. In fact, tau changed about twice as fast as cognition changed, suggesting that increasing tau accumulation is a powerful predictor of looming cognitive decline.

“What is interesting here is that tau changed four times faster than amyloid,” Dr. Hanseeuw said. “The average subject needed 5 years to change 1 standard deviation in tau, but would have needed 20 years to change 1 standard deviation in amyloid.”

Fast-changing outcomes are important to accelerate drug assessment in clinical trials. Currently, it takes 3-5 years to conduct most anti-AD trials, he added.

Dr. Hanseeuw had no relevant financial disclosures.

SOURCE: Hanseeuw B et al. CTAD 2017 Abstract OC2.

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Key clinical point: Among cognitively normal elderly, early tau aggregation predicts oncoming cognitive decline.

Major finding: Tau levels changed twice as fast as cognition, suggesting that the protein is a significant marker of future cognitive change.

Data source: A prospective, longitudinal study of 60 cognitively normal subjects.

Disclosures: Dr. Hanseeuw had no relevant financial disclosures.

Source: Hanseeuw B et al. CTAD 2017 Abstract OC2.

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