Ultrashort courses of antibiotics led to similar outcomes as longer durations of therapy among adults with suspected ventilator-associated pneumonia but minimal and stable ventilator settings, according to a large retrospective observational study.

­The duration of antibiotic therapy did not significantly affect the time to extubation alive (hazard ratio, 1.2; 95% CI, 1.0-1.4), time to hospital discharge (HR, 1.1; 95% CI, 0.9-1.3), rates of ventilator death (HR, 0.8; 95% CI, 0.6-1.2), or rates of hospital death (HR, 1.0; 95% CI, 0.8-1.31).), said Michael Klompas, MD, and his associates at Harvard Medical School in Boston. If confirmed, the findings would support surveillance of serial ventilator settings to “identify candidates for early antibiotic discontinuation,” the investigators reported (Clin Infect Dis. 2016 Dec 29. doi: 10.1093/cid/ciw870).

Suspected respiratory infections account for up to 70% of ICU antibiotic prescriptions, a “substantial fraction” of which may be unnecessary, the researchers said. “The predilection to overprescribe antibiotics for patients with possible ventilator-associated pneumonia (VAP) is not due to poor clinical skills per se, but rather the tension between practice guidelines that encourage early and aggressive prescribing [and] the difficulty [of] accurately diagnosing VAP,” they wrote. While withholding antibiotics in suspected VAP is “unrealistic” and can contribute to mortality, observing clinical trajectories and stopping antibiotics early when appropriate “may be more promising,” they added.

To test that idea, the researchers studied 1,290 cases of suspected VAP treated at Brigham and Women’s Hospital between 2006 and 2014. On the day antibiotics were started and during each of the next 2 days, all patients had a daily minimum positive end-expiratory pressure (PEEP) of no more than 5 cm H₂O and a daily minimum fraction of inspired oxygen (FiO₂) of no more than 40%.

A total of 259 patients received 1-3 days of antibiotics, while 1,031 patients received more than 3 days of therapy. These two groups were similar demographically, clinically, and in terms of comorbidities. Point estimates tended to favor ultrashort course antibiotics, but no association reached statistical significance in the overall analysis or in subgroups based on confirmed VAP diagnosis, confirmed pathogenic infection, or propensity-matched pairs.

The results suggest “that patients with suspected VAP but minimal and stable ventilator settings can be adequately managed with very short courses of antibiotics,” Dr. Klompas and his associates concluded. “If these findings are confirmed, assessing ventilator settings may prove to be a simple and objective strategy to identify potential candidates for early antibiotic discontinuation.”

The work was supported by the Centers for Disease Control and Prevention’s Prevention Epicenters Program. The investigators had no relevant financial disclosures.

chestphysician@frontlinemedcom.com
 

Ultrashort courses of antibiotics led to similar outcomes as longer durations of therapy among adults with suspected ventilator-associated pneumonia but minimal and stable ventilator settings, according to a large retrospective observational study.

­The duration of antibiotic therapy did not significantly affect the time to extubation alive (hazard ratio, 1.2; 95% CI, 1.0-1.4), time to hospital discharge (HR, 1.1; 95% CI, 0.9-1.3), rates of ventilator death (HR, 0.8; 95% CI, 0.6-1.2), or rates of hospital death (HR, 1.0; 95% CI, 0.8-1.31).), said Michael Klompas, MD, and his associates at Harvard Medical School in Boston. If confirmed, the findings would support surveillance of serial ventilator settings to “identify candidates for early antibiotic discontinuation,” the investigators reported (Clin Infect Dis. 2016 Dec 29. doi: 10.1093/cid/ciw870).

Suspected respiratory infections account for up to 70% of ICU antibiotic prescriptions, a “substantial fraction” of which may be unnecessary, the researchers said. “The predilection to overprescribe antibiotics for patients with possible ventilator-associated pneumonia (VAP) is not due to poor clinical skills per se, but rather the tension between practice guidelines that encourage early and aggressive prescribing [and] the difficulty [of] accurately diagnosing VAP,” they wrote. While withholding antibiotics in suspected VAP is “unrealistic” and can contribute to mortality, observing clinical trajectories and stopping antibiotics early when appropriate “may be more promising,” they added.

To test that idea, the researchers studied 1,290 cases of suspected VAP treated at Brigham and Women’s Hospital between 2006 and 2014. On the day antibiotics were started and during each of the next 2 days, all patients had a daily minimum positive end-expiratory pressure (PEEP) of no more than 5 cm H₂O and a daily minimum fraction of inspired oxygen (FiO₂) of no more than 40%.

A total of 259 patients received 1-3 days of antibiotics, while 1,031 patients received more than 3 days of therapy. These two groups were similar demographically, clinically, and in terms of comorbidities. Point estimates tended to favor ultrashort course antibiotics, but no association reached statistical significance in the overall analysis or in subgroups based on confirmed VAP diagnosis, confirmed pathogenic infection, or propensity-matched pairs.

The results suggest “that patients with suspected VAP but minimal and stable ventilator settings can be adequately managed with very short courses of antibiotics,” Dr. Klompas and his associates concluded. “If these findings are confirmed, assessing ventilator settings may prove to be a simple and objective strategy to identify potential candidates for early antibiotic discontinuation.”

The work was supported by the Centers for Disease Control and Prevention’s Prevention Epicenters Program. The investigators had no relevant financial disclosures.

chestphysician@frontlinemedcom.com
 

Ultrashort courses of antibiotics led to similar outcomes as longer durations of therapy among adults with suspected ventilator-associated pneumonia but minimal and stable ventilator settings, according to a large retrospective observational study.

­The duration of antibiotic therapy did not significantly affect the time to extubation alive (hazard ratio, 1.2; 95% CI, 1.0-1.4), time to hospital discharge (HR, 1.1; 95% CI, 0.9-1.3), rates of ventilator death (HR, 0.8; 95% CI, 0.6-1.2), or rates of hospital death (HR, 1.0; 95% CI, 0.8-1.31).), said Michael Klompas, MD, and his associates at Harvard Medical School in Boston. If confirmed, the findings would support surveillance of serial ventilator settings to “identify candidates for early antibiotic discontinuation,” the investigators reported (Clin Infect Dis. 2016 Dec 29. doi: 10.1093/cid/ciw870).

Suspected respiratory infections account for up to 70% of ICU antibiotic prescriptions, a “substantial fraction” of which may be unnecessary, the researchers said. “The predilection to overprescribe antibiotics for patients with possible ventilator-associated pneumonia (VAP) is not due to poor clinical skills per se, but rather the tension between practice guidelines that encourage early and aggressive prescribing [and] the difficulty [of] accurately diagnosing VAP,” they wrote. While withholding antibiotics in suspected VAP is “unrealistic” and can contribute to mortality, observing clinical trajectories and stopping antibiotics early when appropriate “may be more promising,” they added.

To test that idea, the researchers studied 1,290 cases of suspected VAP treated at Brigham and Women’s Hospital between 2006 and 2014. On the day antibiotics were started and during each of the next 2 days, all patients had a daily minimum positive end-expiratory pressure (PEEP) of no more than 5 cm H₂O and a daily minimum fraction of inspired oxygen (FiO₂) of no more than 40%.

A total of 259 patients received 1-3 days of antibiotics, while 1,031 patients received more than 3 days of therapy. These two groups were similar demographically, clinically, and in terms of comorbidities. Point estimates tended to favor ultrashort course antibiotics, but no association reached statistical significance in the overall analysis or in subgroups based on confirmed VAP diagnosis, confirmed pathogenic infection, or propensity-matched pairs.

The results suggest “that patients with suspected VAP but minimal and stable ventilator settings can be adequately managed with very short courses of antibiotics,” Dr. Klompas and his associates concluded. “If these findings are confirmed, assessing ventilator settings may prove to be a simple and objective strategy to identify potential candidates for early antibiotic discontinuation.”

The work was supported by the Centers for Disease Control and Prevention’s Prevention Epicenters Program. The investigators had no relevant financial disclosures.

chestphysician@frontlinemedcom.com
 

A risk-assessment tool that incorporates more data on patient and partner behavior is more specific than are the CDC criteria for initiating HIV preexposure prophylaxis and would allow more targeted treatment, according to a report published in the January issue of Sexually Transmitted Diseases.

To construct a risk-assessment tool that incorporated the most relevant information for predicting HIV acquisition, researchers collected data for all the men who have sex with men who underwent serial HIV testing at a single Los Angeles facility during a 4-year period. These 9,481 men were HIV negative at their baseline visit and were followed for a mean of 2 years (range, from less than 1 year to more than 4 years) for seroconversion, said Matthew R. Beymer, PhD, of the Los Angeles LGBT Center and the University of California, Los Angeles, and his associates.

A total of 370 of these men acquired HIV infection during 16,894 person-years of follow-up.

The investigators constructed a risk-assessment tool to guide the initiation of PrEP, which included seven factors that were the most predictive of HIV seroconversion: Hispanic or African-American ethnicity; a self-reported history of chlamydia, gonorrhea, and/or syphilis; not using a condom during their last occasion of receptive anal sex; having more than three sexual partners during the preceding month or more than five during the preceding 3 months; being of the same ethnicity as the last sexual partner; experiencing intimate partner violence; and using methamphetamines or inhaled nitrates during the preceding year.

“If all individuals in our population who had a risk score of greater than or equal to 5 (51%) had been given PrEP [at baseline], 75% of HIV infections would [have been] averted during follow-up, assuming adequate regimen adherence and near complete effectiveness,” Dr. Beymer and his associates said (Sex Transm Dis. 2017;44[1]:49-57).

In contrast, CDC criteria would have selected 69% of this cohort to begin PrEP. The additional behavioral data incorporated into the risk-assessment tool “allowed for more targeted PrEP. Physicians, their patients, and other interested individuals can obtain their own personalized risk score by visiting www.IsPrEPforMe.org,” the investigators said.

They recommend that men with a risk score of 5 or higher on this instrument begin PrEP, and strongly recommend that men with a risk score of 8 or higher do so. “For individuals whose risk score is less than 5 but who request PrEP, we believe the provider should consider it in light of their patient’s overall concerns.”

Using this tool instead of CDC criteria permits a more personalized recommendation, the authors wrote. Also, those at risk will be better informed about what actions and circumstances specifically lead to their increased HIV risk, which can aid in deciding “to initiate PrEP, reduce sexual risk, or make a plan that incorporates both PrEP initiation and sexual risk reduction,” Dr. Beymer and his associates said.

The Center for HIV Identification, Prevention, and Treatment; the National Institute of Mental Health; and the UCLA Center for AIDS Research supported the study. Dr. Beymer and his associates reported having no relevant disclosures.

A risk-assessment tool that incorporates more data on patient and partner behavior is more specific than are the CDC criteria for initiating HIV preexposure prophylaxis and would allow more targeted treatment, according to a report published in the January issue of Sexually Transmitted Diseases.

To construct a risk-assessment tool that incorporated the most relevant information for predicting HIV acquisition, researchers collected data for all the men who have sex with men who underwent serial HIV testing at a single Los Angeles facility during a 4-year period. These 9,481 men were HIV negative at their baseline visit and were followed for a mean of 2 years (range, from less than 1 year to more than 4 years) for seroconversion, said Matthew R. Beymer, PhD, of the Los Angeles LGBT Center and the University of California, Los Angeles, and his associates.

A total of 370 of these men acquired HIV infection during 16,894 person-years of follow-up.

The investigators constructed a risk-assessment tool to guide the initiation of PrEP, which included seven factors that were the most predictive of HIV seroconversion: Hispanic or African-American ethnicity; a self-reported history of chlamydia, gonorrhea, and/or syphilis; not using a condom during their last occasion of receptive anal sex; having more than three sexual partners during the preceding month or more than five during the preceding 3 months; being of the same ethnicity as the last sexual partner; experiencing intimate partner violence; and using methamphetamines or inhaled nitrates during the preceding year.

“If all individuals in our population who had a risk score of greater than or equal to 5 (51%) had been given PrEP [at baseline], 75% of HIV infections would [have been] averted during follow-up, assuming adequate regimen adherence and near complete effectiveness,” Dr. Beymer and his associates said (Sex Transm Dis. 2017;44[1]:49-57).

In contrast, CDC criteria would have selected 69% of this cohort to begin PrEP. The additional behavioral data incorporated into the risk-assessment tool “allowed for more targeted PrEP. Physicians, their patients, and other interested individuals can obtain their own personalized risk score by visiting www.IsPrEPforMe.org,” the investigators said.

They recommend that men with a risk score of 5 or higher on this instrument begin PrEP, and strongly recommend that men with a risk score of 8 or higher do so. “For individuals whose risk score is less than 5 but who request PrEP, we believe the provider should consider it in light of their patient’s overall concerns.”

Using this tool instead of CDC criteria permits a more personalized recommendation, the authors wrote. Also, those at risk will be better informed about what actions and circumstances specifically lead to their increased HIV risk, which can aid in deciding “to initiate PrEP, reduce sexual risk, or make a plan that incorporates both PrEP initiation and sexual risk reduction,” Dr. Beymer and his associates said.

The Center for HIV Identification, Prevention, and Treatment; the National Institute of Mental Health; and the UCLA Center for AIDS Research supported the study. Dr. Beymer and his associates reported having no relevant disclosures.

A risk-assessment tool that incorporates more data on patient and partner behavior is more specific than are the CDC criteria for initiating HIV preexposure prophylaxis and would allow more targeted treatment, according to a report published in the January issue of Sexually Transmitted Diseases.

To construct a risk-assessment tool that incorporated the most relevant information for predicting HIV acquisition, researchers collected data for all the men who have sex with men who underwent serial HIV testing at a single Los Angeles facility during a 4-year period. These 9,481 men were HIV negative at their baseline visit and were followed for a mean of 2 years (range, from less than 1 year to more than 4 years) for seroconversion, said Matthew R. Beymer, PhD, of the Los Angeles LGBT Center and the University of California, Los Angeles, and his associates.

A total of 370 of these men acquired HIV infection during 16,894 person-years of follow-up.

The investigators constructed a risk-assessment tool to guide the initiation of PrEP, which included seven factors that were the most predictive of HIV seroconversion: Hispanic or African-American ethnicity; a self-reported history of chlamydia, gonorrhea, and/or syphilis; not using a condom during their last occasion of receptive anal sex; having more than three sexual partners during the preceding month or more than five during the preceding 3 months; being of the same ethnicity as the last sexual partner; experiencing intimate partner violence; and using methamphetamines or inhaled nitrates during the preceding year.

“If all individuals in our population who had a risk score of greater than or equal to 5 (51%) had been given PrEP [at baseline], 75% of HIV infections would [have been] averted during follow-up, assuming adequate regimen adherence and near complete effectiveness,” Dr. Beymer and his associates said (Sex Transm Dis. 2017;44[1]:49-57).

In contrast, CDC criteria would have selected 69% of this cohort to begin PrEP. The additional behavioral data incorporated into the risk-assessment tool “allowed for more targeted PrEP. Physicians, their patients, and other interested individuals can obtain their own personalized risk score by visiting www.IsPrEPforMe.org,” the investigators said.

They recommend that men with a risk score of 5 or higher on this instrument begin PrEP, and strongly recommend that men with a risk score of 8 or higher do so. “For individuals whose risk score is less than 5 but who request PrEP, we believe the provider should consider it in light of their patient’s overall concerns.”

Using this tool instead of CDC criteria permits a more personalized recommendation, the authors wrote. Also, those at risk will be better informed about what actions and circumstances specifically lead to their increased HIV risk, which can aid in deciding “to initiate PrEP, reduce sexual risk, or make a plan that incorporates both PrEP initiation and sexual risk reduction,” Dr. Beymer and his associates said.

The Center for HIV Identification, Prevention, and Treatment; the National Institute of Mental Health; and the UCLA Center for AIDS Research supported the study. Dr. Beymer and his associates reported having no relevant disclosures.

VIENNA – A medical-grade topical honey product proved safe and effective for the treatment of rosacea in a randomized, placebo-controlled clinical trial, Brigitte Dreno, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

The product, known as Honevo, is a cream consisting of 90% New Zealand kanuka honey and 10% glycerine. It is applied twice daily as a face mask. Honevo is designed to wash off easily and is less sticky than honey.

Bruce Jancin/Frontline Medical News

bjancin@frontlinemedcom.com

VIENNA – A medical-grade topical honey product proved safe and effective for the treatment of rosacea in a randomized, placebo-controlled clinical trial, Brigitte Dreno, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

The product, known as Honevo, is a cream consisting of 90% New Zealand kanuka honey and 10% glycerine. It is applied twice daily as a face mask. Honevo is designed to wash off easily and is less sticky than honey.

Bruce Jancin/Frontline Medical News

bjancin@frontlinemedcom.com

VIENNA – A medical-grade topical honey product proved safe and effective for the treatment of rosacea in a randomized, placebo-controlled clinical trial, Brigitte Dreno, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

The product, known as Honevo, is a cream consisting of 90% New Zealand kanuka honey and 10% glycerine. It is applied twice daily as a face mask. Honevo is designed to wash off easily and is less sticky than honey.

Bruce Jancin/Frontline Medical News

bjancin@frontlinemedcom.com

Inpatient palliative care can help maintain quality of life (QoL) in patients undergoing hematopoietic stem cell transplantation (HCT), based on the results of a randomized clinical trial to assess the effect of inpatient palliative care on patient and caregiver-reported outcomes while hospitalized for HCT and for 3 months after transplantation.

During the 2-week period following their transplants, patients who received inpatient palliative care experienced a 14.72-point decrease in QoL, compared with a 21.54-point decrease in QoL for those assigned to standard transplant care alone. The difference was statistically significant (JAMA. 2016;316[20]:2094-2103. doi:10.1001/jama.2016.16786).

In addition to the QoL results, Areej El-Jawahri, MD, of Massachusetts General Hospital in Boston, and coauthors, noted that “exploratory secondary outcomes also showed that patients in the palliative care group benefited, with less increase in their depression symptoms, lower anxiety symptoms, and less increase in symptom burden compared with those receiving standard transplant care.

“Thus, palliative care may help to lessen the decline in QoL experienced by patients during hospitalization for HCT, which has long been perceived as a natural aspect of the transplantation process.”

The study cohort comprised 160 adults with hematologic malignancies undergoing autologous/allogeneic HCT, and 94 caregivers.

A total of 81 patients were assigned to the intervention, and were seen by palliative care clinicians at least twice a week while they were hospitalized. The palliative care intervention focused on managing both physical and psychological symptoms, and those who were assigned to the standard care arm (n = 79) could also request to be seen by the palliative care team.

Quality of life was measured based on mean FACT-BMT score. In the palliative care group, the FACT-BMT score was 110.26 at hospitalization and 95.46 at 2 weeks after transplant (mean change, −14.72). For the standard care group, FACT-BMT score was 106.83 at hospitalization and 85.42 at 2 weeks after transplant (mean change, −21.54) The −6.82 difference between the group groups was statistically significant (95% CI, −13.48 to −0.16; P = .045).

When looking at secondary outcomes, those in the intervention group had lower mean depression scores at 2 weeks based on the HADS-D measure. For the intervention group, the mean baseline score was 3.95 and the mean week 2 score was 6.39. For the control group, the baseline score was 4.94 and the week 2 score was 8.86. The difference between the groups was 1.49 (95% CI, 0.20-2.78; P = .02). Depression scores remained lower in the intervention group at 3 months.

The intervention group also reported a decrease in anxiety symptoms, but the control group reported an increase in anxiety symptoms from baseline to week 2 on the HADS-A measure. The mean difference in score between the two groups was 1.92; (95% CI, 0.83-3.01; P less than .001). However, there was no significant difference between the two groups at 3 months after transplant.

The study was supported by the National Palliative Care Research Foundation and grant K24 CA 181253 from the National Cancer Institute. Dr. El-Jawahri reported no disclosures.

Inpatient palliative care can help maintain quality of life (QoL) in patients undergoing hematopoietic stem cell transplantation (HCT), based on the results of a randomized clinical trial to assess the effect of inpatient palliative care on patient and caregiver-reported outcomes while hospitalized for HCT and for 3 months after transplantation.

During the 2-week period following their transplants, patients who received inpatient palliative care experienced a 14.72-point decrease in QoL, compared with a 21.54-point decrease in QoL for those assigned to standard transplant care alone. The difference was statistically significant (JAMA. 2016;316[20]:2094-2103. doi:10.1001/jama.2016.16786).

In addition to the QoL results, Areej El-Jawahri, MD, of Massachusetts General Hospital in Boston, and coauthors, noted that “exploratory secondary outcomes also showed that patients in the palliative care group benefited, with less increase in their depression symptoms, lower anxiety symptoms, and less increase in symptom burden compared with those receiving standard transplant care.

“Thus, palliative care may help to lessen the decline in QoL experienced by patients during hospitalization for HCT, which has long been perceived as a natural aspect of the transplantation process.”

The study cohort comprised 160 adults with hematologic malignancies undergoing autologous/allogeneic HCT, and 94 caregivers.

A total of 81 patients were assigned to the intervention, and were seen by palliative care clinicians at least twice a week while they were hospitalized. The palliative care intervention focused on managing both physical and psychological symptoms, and those who were assigned to the standard care arm (n = 79) could also request to be seen by the palliative care team.

Quality of life was measured based on mean FACT-BMT score. In the palliative care group, the FACT-BMT score was 110.26 at hospitalization and 95.46 at 2 weeks after transplant (mean change, −14.72). For the standard care group, FACT-BMT score was 106.83 at hospitalization and 85.42 at 2 weeks after transplant (mean change, −21.54) The −6.82 difference between the group groups was statistically significant (95% CI, −13.48 to −0.16; P = .045).

When looking at secondary outcomes, those in the intervention group had lower mean depression scores at 2 weeks based on the HADS-D measure. For the intervention group, the mean baseline score was 3.95 and the mean week 2 score was 6.39. For the control group, the baseline score was 4.94 and the week 2 score was 8.86. The difference between the groups was 1.49 (95% CI, 0.20-2.78; P = .02). Depression scores remained lower in the intervention group at 3 months.

The intervention group also reported a decrease in anxiety symptoms, but the control group reported an increase in anxiety symptoms from baseline to week 2 on the HADS-A measure. The mean difference in score between the two groups was 1.92; (95% CI, 0.83-3.01; P less than .001). However, there was no significant difference between the two groups at 3 months after transplant.

The study was supported by the National Palliative Care Research Foundation and grant K24 CA 181253 from the National Cancer Institute. Dr. El-Jawahri reported no disclosures.

Inpatient palliative care can help maintain quality of life (QoL) in patients undergoing hematopoietic stem cell transplantation (HCT), based on the results of a randomized clinical trial to assess the effect of inpatient palliative care on patient and caregiver-reported outcomes while hospitalized for HCT and for 3 months after transplantation.

During the 2-week period following their transplants, patients who received inpatient palliative care experienced a 14.72-point decrease in QoL, compared with a 21.54-point decrease in QoL for those assigned to standard transplant care alone. The difference was statistically significant (JAMA. 2016;316[20]:2094-2103. doi:10.1001/jama.2016.16786).

In addition to the QoL results, Areej El-Jawahri, MD, of Massachusetts General Hospital in Boston, and coauthors, noted that “exploratory secondary outcomes also showed that patients in the palliative care group benefited, with less increase in their depression symptoms, lower anxiety symptoms, and less increase in symptom burden compared with those receiving standard transplant care.

“Thus, palliative care may help to lessen the decline in QoL experienced by patients during hospitalization for HCT, which has long been perceived as a natural aspect of the transplantation process.”

The study cohort comprised 160 adults with hematologic malignancies undergoing autologous/allogeneic HCT, and 94 caregivers.

A total of 81 patients were assigned to the intervention, and were seen by palliative care clinicians at least twice a week while they were hospitalized. The palliative care intervention focused on managing both physical and psychological symptoms, and those who were assigned to the standard care arm (n = 79) could also request to be seen by the palliative care team.

Quality of life was measured based on mean FACT-BMT score. In the palliative care group, the FACT-BMT score was 110.26 at hospitalization and 95.46 at 2 weeks after transplant (mean change, −14.72). For the standard care group, FACT-BMT score was 106.83 at hospitalization and 85.42 at 2 weeks after transplant (mean change, −21.54) The −6.82 difference between the group groups was statistically significant (95% CI, −13.48 to −0.16; P = .045).

When looking at secondary outcomes, those in the intervention group had lower mean depression scores at 2 weeks based on the HADS-D measure. For the intervention group, the mean baseline score was 3.95 and the mean week 2 score was 6.39. For the control group, the baseline score was 4.94 and the week 2 score was 8.86. The difference between the groups was 1.49 (95% CI, 0.20-2.78; P = .02). Depression scores remained lower in the intervention group at 3 months.

The intervention group also reported a decrease in anxiety symptoms, but the control group reported an increase in anxiety symptoms from baseline to week 2 on the HADS-A measure. The mean difference in score between the two groups was 1.92; (95% CI, 0.83-3.01; P less than .001). However, there was no significant difference between the two groups at 3 months after transplant.

The study was supported by the National Palliative Care Research Foundation and grant K24 CA 181253 from the National Cancer Institute. Dr. El-Jawahri reported no disclosures.

There are many topics within the child psychiatry community that are controversial. How many kids really deserve a diagnosis of bipolar disorder? Which type of therapy works best? Is cannabis a gateway drug? The existence of attention-deficit/hyperactivity disorder as a legitimate psychiatric entity, however, is not one of them.

Despite this fact, there remains considerable controversy in the public about how “real” ADHD actually is. Social media, blogs, and even entire books have been written that disparage the diagnosis and even suggest that ADHD was fabricated by the pharmaceutical industry to sell medications. Although these publications and posts generally ignore the scientific literature or at least twist it beyond recognition, there are several aspects of ADHD that legitimately cause more confusion and less confidence about the diagnosis, relative to other common pediatric problems. This column attempts to describe and contextualize these elements so that pediatricians can be more fully informed when they are called to respond to some of the allegations against ADHD that often are brought up by families.

Case summary

Hunter is a 6-year-old boy who presents with his mother and father for “behavioral concerns.” He always has been an energetic child, but the school has been having increasing difficulties with his behavior. Hunter struggles to stay in his seat and take part in quiet activities. His teacher needs to give multiple reminders per day about not interrupting others or speaking out in class. Without redirection, Hunter typically loses focus in class and does not complete his work. Because of these difficulties, the question of ADHD arose during a recent parent-teacher conference. While Hunter’s mother acknowledges these behaviors and notes similar ones at home, the father is resisting any further evaluation, claiming that Hunter “is just being a boy.” The father notes that he acted similarly as a child and “turned out okay.” When the mother tried to research ADHD online, she encountered several sites that claimed that the diagnosis of ADHD was “made up” by drug companies wanting “to turn kids into zombies.” At the appointment, the parents state that they want their son to succeed and be happy, but are concerned about some of the things they have read on the Internet.

Discussion

This example represents a common dilemma for parents who encounter so many mixed messages when doing background research on ADHD. Although the legitimacy of ADHD has been supported in literally hundreds of research studies that have examined areas such as genetics, neuropsychological testing, and brain imaging^1,2, some of the lingering doubts about ADHD validity are rooted in characteristics of the diagnosis that do differ from some nonpsychiatric diagnoses. At the same time, however, further inspection reveals that these qualities exist for many other entities that have received far less public criticism. Three of these main qualities include the following:

1. ADHD is a dimensional rather than binary entity. Despite the fact that the current nomenclature continues to frame ADHD as an all-or-nothing diagnosis, there is now overwhelming scientific evidence that it is much more accurately conceptualized as a dimension³. As such, there is no clear-cut boundary between what should be judged as “typical” levels of attention and activity and ADHD. As written in a previous column⁴, in some ways the label of ADHD is a lot like the label of someone being tall, with some individuals clearly falling into the category of “tall” or “not tall,” while many others could be considered in-between. However, many of the most common nonpsychiatric conditions such as hypertension and hypercholesterolemia also exist this way without high levels of public controversy.

2. ADHD lacks a specific known neurobiologic marker that can be measured by a lab or neuroimaging test. As mentioned, there is a vast literature supporting the idea that the brains of people with ADHD are different from those without ADHD, but these differences tend to describe quantitative differences in regional brain volume, cortical thickness, activity levels, or connectivity rather than a discrete “thing” that a radiologist can point to on a scan. Given the dimensional nature of ADHD and the broad brain processes required for complex functions such as attention and motor activity, the lack of a specific and universal “lesion” underlying ADHD is to be expected, yet it still remains easy ammunition for those who criticize the diagnosis. Again, very similar cases can be made for other entities such as autism or low intelligence, which few argue are not real but also have no reliable biomarker to support them.

3. Medications often are used to treat ADHD. The diagnosis of ADHD would probably be far less controversial if one of its primary treatments did not involve psychiatric medications. While it is probably fair to say that the many nonpharmacologic approaches to ADHD are quite underutilized, it seems a stretch to use potential overreliance on medication as a legitimate reason to question the validity of a diagnosis. Opiate abuse also is a problem in this country, but that doesn’t mean a person’s pain doesn’t exist. As a practical tip, it can be reassuring for families to hear explicitly from their physician that “zombification” is not considered an acceptable medical outcome and that the prescribing clinician will promptly deal with any side effects that might occur with treatment⁵.

Understanding these aspects about ADHD and how they are misinterpreted in the media can help families make more informed and comfortable decisions about their child’s care in collaboration with their pediatrician. It also is important for pediatricians to be proactive in distributing reliable and science-backed material to the public in this new age of information overload.

Case follow-up

The pediatrician hears the family’s concerns and discusses the evidence supporting the scientific legitimacy of ADHD, as well as some of the qualities of the diagnosis that have led to its controversy. The parents are reassured but would like to proceed carefully and cautiously with further work-up and treatment. The pediatrician sends the family home with some quantitative rating scales to be completed by Hunter’s parents and teacher. She also makes a plan to begin monitoring several health promotion areas that could be impacting Hunter’s behavior including sleep quality, physical activity, screen time, and nutrition.

References

1. Psychiatr Clin North Am. 2010 Mar;33(1):159-80.

2. Dev Neuropsychol. 2013;38(4):211-25.3. Can Fam Physician. 2016 Dec;62(12):979-82.

4. ADHD boundaries with normal behavior. Pediatric News; published online Aug. 27, 2014.

5. Zombification is not an acceptable medical outcome. Psychology Today, ABCs of Child Psychiatry blog; published online Oct. 18, 2013.
 

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine, Burlington. Follow him on Twitter @PediPsych.

There are many topics within the child psychiatry community that are controversial. How many kids really deserve a diagnosis of bipolar disorder? Which type of therapy works best? Is cannabis a gateway drug? The existence of attention-deficit/hyperactivity disorder as a legitimate psychiatric entity, however, is not one of them.

Despite this fact, there remains considerable controversy in the public about how “real” ADHD actually is. Social media, blogs, and even entire books have been written that disparage the diagnosis and even suggest that ADHD was fabricated by the pharmaceutical industry to sell medications. Although these publications and posts generally ignore the scientific literature or at least twist it beyond recognition, there are several aspects of ADHD that legitimately cause more confusion and less confidence about the diagnosis, relative to other common pediatric problems. This column attempts to describe and contextualize these elements so that pediatricians can be more fully informed when they are called to respond to some of the allegations against ADHD that often are brought up by families.

Case summary

Hunter is a 6-year-old boy who presents with his mother and father for “behavioral concerns.” He always has been an energetic child, but the school has been having increasing difficulties with his behavior. Hunter struggles to stay in his seat and take part in quiet activities. His teacher needs to give multiple reminders per day about not interrupting others or speaking out in class. Without redirection, Hunter typically loses focus in class and does not complete his work. Because of these difficulties, the question of ADHD arose during a recent parent-teacher conference. While Hunter’s mother acknowledges these behaviors and notes similar ones at home, the father is resisting any further evaluation, claiming that Hunter “is just being a boy.” The father notes that he acted similarly as a child and “turned out okay.” When the mother tried to research ADHD online, she encountered several sites that claimed that the diagnosis of ADHD was “made up” by drug companies wanting “to turn kids into zombies.” At the appointment, the parents state that they want their son to succeed and be happy, but are concerned about some of the things they have read on the Internet.

Discussion

This example represents a common dilemma for parents who encounter so many mixed messages when doing background research on ADHD. Although the legitimacy of ADHD has been supported in literally hundreds of research studies that have examined areas such as genetics, neuropsychological testing, and brain imaging^1,2, some of the lingering doubts about ADHD validity are rooted in characteristics of the diagnosis that do differ from some nonpsychiatric diagnoses. At the same time, however, further inspection reveals that these qualities exist for many other entities that have received far less public criticism. Three of these main qualities include the following:

1. ADHD is a dimensional rather than binary entity. Despite the fact that the current nomenclature continues to frame ADHD as an all-or-nothing diagnosis, there is now overwhelming scientific evidence that it is much more accurately conceptualized as a dimension³. As such, there is no clear-cut boundary between what should be judged as “typical” levels of attention and activity and ADHD. As written in a previous column⁴, in some ways the label of ADHD is a lot like the label of someone being tall, with some individuals clearly falling into the category of “tall” or “not tall,” while many others could be considered in-between. However, many of the most common nonpsychiatric conditions such as hypertension and hypercholesterolemia also exist this way without high levels of public controversy.

2. ADHD lacks a specific known neurobiologic marker that can be measured by a lab or neuroimaging test. As mentioned, there is a vast literature supporting the idea that the brains of people with ADHD are different from those without ADHD, but these differences tend to describe quantitative differences in regional brain volume, cortical thickness, activity levels, or connectivity rather than a discrete “thing” that a radiologist can point to on a scan. Given the dimensional nature of ADHD and the broad brain processes required for complex functions such as attention and motor activity, the lack of a specific and universal “lesion” underlying ADHD is to be expected, yet it still remains easy ammunition for those who criticize the diagnosis. Again, very similar cases can be made for other entities such as autism or low intelligence, which few argue are not real but also have no reliable biomarker to support them.

3. Medications often are used to treat ADHD. The diagnosis of ADHD would probably be far less controversial if one of its primary treatments did not involve psychiatric medications. While it is probably fair to say that the many nonpharmacologic approaches to ADHD are quite underutilized, it seems a stretch to use potential overreliance on medication as a legitimate reason to question the validity of a diagnosis. Opiate abuse also is a problem in this country, but that doesn’t mean a person’s pain doesn’t exist. As a practical tip, it can be reassuring for families to hear explicitly from their physician that “zombification” is not considered an acceptable medical outcome and that the prescribing clinician will promptly deal with any side effects that might occur with treatment⁵.

Understanding these aspects about ADHD and how they are misinterpreted in the media can help families make more informed and comfortable decisions about their child’s care in collaboration with their pediatrician. It also is important for pediatricians to be proactive in distributing reliable and science-backed material to the public in this new age of information overload.

Case follow-up

The pediatrician hears the family’s concerns and discusses the evidence supporting the scientific legitimacy of ADHD, as well as some of the qualities of the diagnosis that have led to its controversy. The parents are reassured but would like to proceed carefully and cautiously with further work-up and treatment. The pediatrician sends the family home with some quantitative rating scales to be completed by Hunter’s parents and teacher. She also makes a plan to begin monitoring several health promotion areas that could be impacting Hunter’s behavior including sleep quality, physical activity, screen time, and nutrition.

References

1. Psychiatr Clin North Am. 2010 Mar;33(1):159-80.

2. Dev Neuropsychol. 2013;38(4):211-25.3. Can Fam Physician. 2016 Dec;62(12):979-82.

4. ADHD boundaries with normal behavior. Pediatric News; published online Aug. 27, 2014.

5. Zombification is not an acceptable medical outcome. Psychology Today, ABCs of Child Psychiatry blog; published online Oct. 18, 2013.
 

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine, Burlington. Follow him on Twitter @PediPsych.

There are many topics within the child psychiatry community that are controversial. How many kids really deserve a diagnosis of bipolar disorder? Which type of therapy works best? Is cannabis a gateway drug? The existence of attention-deficit/hyperactivity disorder as a legitimate psychiatric entity, however, is not one of them.

Despite this fact, there remains considerable controversy in the public about how “real” ADHD actually is. Social media, blogs, and even entire books have been written that disparage the diagnosis and even suggest that ADHD was fabricated by the pharmaceutical industry to sell medications. Although these publications and posts generally ignore the scientific literature or at least twist it beyond recognition, there are several aspects of ADHD that legitimately cause more confusion and less confidence about the diagnosis, relative to other common pediatric problems. This column attempts to describe and contextualize these elements so that pediatricians can be more fully informed when they are called to respond to some of the allegations against ADHD that often are brought up by families.

Case summary

Hunter is a 6-year-old boy who presents with his mother and father for “behavioral concerns.” He always has been an energetic child, but the school has been having increasing difficulties with his behavior. Hunter struggles to stay in his seat and take part in quiet activities. His teacher needs to give multiple reminders per day about not interrupting others or speaking out in class. Without redirection, Hunter typically loses focus in class and does not complete his work. Because of these difficulties, the question of ADHD arose during a recent parent-teacher conference. While Hunter’s mother acknowledges these behaviors and notes similar ones at home, the father is resisting any further evaluation, claiming that Hunter “is just being a boy.” The father notes that he acted similarly as a child and “turned out okay.” When the mother tried to research ADHD online, she encountered several sites that claimed that the diagnosis of ADHD was “made up” by drug companies wanting “to turn kids into zombies.” At the appointment, the parents state that they want their son to succeed and be happy, but are concerned about some of the things they have read on the Internet.

Discussion

This example represents a common dilemma for parents who encounter so many mixed messages when doing background research on ADHD. Although the legitimacy of ADHD has been supported in literally hundreds of research studies that have examined areas such as genetics, neuropsychological testing, and brain imaging^1,2, some of the lingering doubts about ADHD validity are rooted in characteristics of the diagnosis that do differ from some nonpsychiatric diagnoses. At the same time, however, further inspection reveals that these qualities exist for many other entities that have received far less public criticism. Three of these main qualities include the following:

1. ADHD is a dimensional rather than binary entity. Despite the fact that the current nomenclature continues to frame ADHD as an all-or-nothing diagnosis, there is now overwhelming scientific evidence that it is much more accurately conceptualized as a dimension³. As such, there is no clear-cut boundary between what should be judged as “typical” levels of attention and activity and ADHD. As written in a previous column⁴, in some ways the label of ADHD is a lot like the label of someone being tall, with some individuals clearly falling into the category of “tall” or “not tall,” while many others could be considered in-between. However, many of the most common nonpsychiatric conditions such as hypertension and hypercholesterolemia also exist this way without high levels of public controversy.

2. ADHD lacks a specific known neurobiologic marker that can be measured by a lab or neuroimaging test. As mentioned, there is a vast literature supporting the idea that the brains of people with ADHD are different from those without ADHD, but these differences tend to describe quantitative differences in regional brain volume, cortical thickness, activity levels, or connectivity rather than a discrete “thing” that a radiologist can point to on a scan. Given the dimensional nature of ADHD and the broad brain processes required for complex functions such as attention and motor activity, the lack of a specific and universal “lesion” underlying ADHD is to be expected, yet it still remains easy ammunition for those who criticize the diagnosis. Again, very similar cases can be made for other entities such as autism or low intelligence, which few argue are not real but also have no reliable biomarker to support them.

3. Medications often are used to treat ADHD. The diagnosis of ADHD would probably be far less controversial if one of its primary treatments did not involve psychiatric medications. While it is probably fair to say that the many nonpharmacologic approaches to ADHD are quite underutilized, it seems a stretch to use potential overreliance on medication as a legitimate reason to question the validity of a diagnosis. Opiate abuse also is a problem in this country, but that doesn’t mean a person’s pain doesn’t exist. As a practical tip, it can be reassuring for families to hear explicitly from their physician that “zombification” is not considered an acceptable medical outcome and that the prescribing clinician will promptly deal with any side effects that might occur with treatment⁵.

Understanding these aspects about ADHD and how they are misinterpreted in the media can help families make more informed and comfortable decisions about their child’s care in collaboration with their pediatrician. It also is important for pediatricians to be proactive in distributing reliable and science-backed material to the public in this new age of information overload.

Case follow-up

The pediatrician hears the family’s concerns and discusses the evidence supporting the scientific legitimacy of ADHD, as well as some of the qualities of the diagnosis that have led to its controversy. The parents are reassured but would like to proceed carefully and cautiously with further work-up and treatment. The pediatrician sends the family home with some quantitative rating scales to be completed by Hunter’s parents and teacher. She also makes a plan to begin monitoring several health promotion areas that could be impacting Hunter’s behavior including sleep quality, physical activity, screen time, and nutrition.

References

1. Psychiatr Clin North Am. 2010 Mar;33(1):159-80.

2. Dev Neuropsychol. 2013;38(4):211-25.3. Can Fam Physician. 2016 Dec;62(12):979-82.

4. ADHD boundaries with normal behavior. Pediatric News; published online Aug. 27, 2014.

5. Zombification is not an acceptable medical outcome. Psychology Today, ABCs of Child Psychiatry blog; published online Oct. 18, 2013.
 

Dr. Rettew is a child and adolescent psychiatrist and associate professor of psychiatry and pediatrics at the University of Vermont Larner College of Medicine, Burlington. Follow him on Twitter @PediPsych.

SAN DIEGO – Aggressive, refractory non-Hodgkin lymphomas responded to anti-CD19 chimeric antigen receptor T cells in ZUMA-1, the first multicenter trial of the cellular immunotherapy, based on early data reported at the annual meeting of the American Society of Hematology.

In an interim analysis of 51 patients with diffuse large B-cell lymphomas, 47% had complete remissions and 29% had partial remissions. But the remission rate declined to 33% complete remissions and 6% partial remissions after 3 months.

There have really been no new treatments in the last 20 years for patients with non-Hodgkin lymphoma that does not respond to chemotherapy or recurs after autologous stem cell transplant. With median overall survival of 6 months, and about 8% complete remissions with existing therapies, CAR T cells might be a solution for these patients, said ZUMA-1 investigator Sattva S. Neelapu, MD, of the University of Texas MD Anderson Cancer Center in Houston.

In our video interview at the meeting, Dr. Neelapu discussed initial results in the real-world setting of 22 participating centers, most of which had no previous experience with CAR T-cell therapy. With an efficient production and logistics plan, 91% of 110 patients were able to receive the investigational product, known as KTE-C19.

ZUMA-1 is funded by Kite, which makes KTE-C19, and the Leukemia & Lymphoma Society Therapy Acceleration Program. Dr. Neelapu receives research support from and is an advisor to Kite.

mdales@frontlinemedcom.com

On Twitter @maryjodales

SAN DIEGO – Aggressive, refractory non-Hodgkin lymphomas responded to anti-CD19 chimeric antigen receptor T cells in ZUMA-1, the first multicenter trial of the cellular immunotherapy, based on early data reported at the annual meeting of the American Society of Hematology.

In an interim analysis of 51 patients with diffuse large B-cell lymphomas, 47% had complete remissions and 29% had partial remissions. But the remission rate declined to 33% complete remissions and 6% partial remissions after 3 months.

There have really been no new treatments in the last 20 years for patients with non-Hodgkin lymphoma that does not respond to chemotherapy or recurs after autologous stem cell transplant. With median overall survival of 6 months, and about 8% complete remissions with existing therapies, CAR T cells might be a solution for these patients, said ZUMA-1 investigator Sattva S. Neelapu, MD, of the University of Texas MD Anderson Cancer Center in Houston.

In our video interview at the meeting, Dr. Neelapu discussed initial results in the real-world setting of 22 participating centers, most of which had no previous experience with CAR T-cell therapy. With an efficient production and logistics plan, 91% of 110 patients were able to receive the investigational product, known as KTE-C19.

ZUMA-1 is funded by Kite, which makes KTE-C19, and the Leukemia & Lymphoma Society Therapy Acceleration Program. Dr. Neelapu receives research support from and is an advisor to Kite.

mdales@frontlinemedcom.com

On Twitter @maryjodales

SAN DIEGO – Aggressive, refractory non-Hodgkin lymphomas responded to anti-CD19 chimeric antigen receptor T cells in ZUMA-1, the first multicenter trial of the cellular immunotherapy, based on early data reported at the annual meeting of the American Society of Hematology.

In an interim analysis of 51 patients with diffuse large B-cell lymphomas, 47% had complete remissions and 29% had partial remissions. But the remission rate declined to 33% complete remissions and 6% partial remissions after 3 months.

There have really been no new treatments in the last 20 years for patients with non-Hodgkin lymphoma that does not respond to chemotherapy or recurs after autologous stem cell transplant. With median overall survival of 6 months, and about 8% complete remissions with existing therapies, CAR T cells might be a solution for these patients, said ZUMA-1 investigator Sattva S. Neelapu, MD, of the University of Texas MD Anderson Cancer Center in Houston.

In our video interview at the meeting, Dr. Neelapu discussed initial results in the real-world setting of 22 participating centers, most of which had no previous experience with CAR T-cell therapy. With an efficient production and logistics plan, 91% of 110 patients were able to receive the investigational product, known as KTE-C19.

ZUMA-1 is funded by Kite, which makes KTE-C19, and the Leukemia & Lymphoma Society Therapy Acceleration Program. Dr. Neelapu receives research support from and is an advisor to Kite.

mdales@frontlinemedcom.com

On Twitter @maryjodales

SAN FRANCISCO – Are electronic medical records wreaking havoc for you? Herschel R. Lessin, MD, vice president of the Children’s Medical Group in Poughkeepsie, N.Y., had some EMR recommendations.

In his presentation entitled “Help! My EMR Threw Me Under the Bus!” at the annual meeting of the American Academy of Pediatrics, Dr. Lessin offered the following recommendations for troubleshooting or preventing EMR problems, starting with customizing your EMR right away to reduce alert fatigue.

kokouu/iStockphoto.com

• Document the specifics of a particular condition, treatment, history, or other note when checking boxes.

• Document your thinking in terms of differential diagnoses.

• Document a follow-up plan beyond just checking the box of a patient’s return date.

• Be wary of cutting and pasting too quickly or relying on the template as a standard of care instead of thoughtful application of the evidence.

• Learn the entry fields for diagnosis codes and for medications and their route of administration.

• Double check that you’re clicking the correct patient, medication, and date of service.

• To prevent data breaches, including HIPAA violations, set up different levels of employee access to EMRs and never share your password.

• Narrative notes should be customized and included, even if the records ask many yes/no questions.

• Keep consistent records. Inconsistency in record keeping is one of the fastest ways to end up in litigation, Dr. Lessin warned. Separation of staff duties in filling out different parts of the EMR, failure to review templates, and “hybrid” charts for which the paper and electronic records don’t match are among the biggest risks for inconsistencies.

• Devise a method for tracking and following up with nonresponsive specialists and with patients, checking on their compliance and unique health care needs. “If a patient with diabetes comes in three times between October and February and you don’t give them a flu shot, then when they get the flu, whose fault is that?” he said. “You need some way to track high-risk patients who need immunizations.”

• Enter notes in a timely fashion – knowing that audits will show time and date of entries – and only use addenda to modify notes.

“If you’re going to make any changes in the medical record, you need to do it as an addendum,” Dr. Lessin said. And, of course, never try to erase a record. Even accidental alterations of records that aren’t following the rules can look very bad, he said.

Dr. Lessin is a principal with Physician Integration Consultants in Atlanta.

SAN FRANCISCO – Are electronic medical records wreaking havoc for you? Herschel R. Lessin, MD, vice president of the Children’s Medical Group in Poughkeepsie, N.Y., had some EMR recommendations.

In his presentation entitled “Help! My EMR Threw Me Under the Bus!” at the annual meeting of the American Academy of Pediatrics, Dr. Lessin offered the following recommendations for troubleshooting or preventing EMR problems, starting with customizing your EMR right away to reduce alert fatigue.

kokouu/iStockphoto.com

• Document the specifics of a particular condition, treatment, history, or other note when checking boxes.

• Document your thinking in terms of differential diagnoses.

• Document a follow-up plan beyond just checking the box of a patient’s return date.

• Be wary of cutting and pasting too quickly or relying on the template as a standard of care instead of thoughtful application of the evidence.

• Learn the entry fields for diagnosis codes and for medications and their route of administration.

• Double check that you’re clicking the correct patient, medication, and date of service.

• To prevent data breaches, including HIPAA violations, set up different levels of employee access to EMRs and never share your password.

• Narrative notes should be customized and included, even if the records ask many yes/no questions.

• Keep consistent records. Inconsistency in record keeping is one of the fastest ways to end up in litigation, Dr. Lessin warned. Separation of staff duties in filling out different parts of the EMR, failure to review templates, and “hybrid” charts for which the paper and electronic records don’t match are among the biggest risks for inconsistencies.

• Devise a method for tracking and following up with nonresponsive specialists and with patients, checking on their compliance and unique health care needs. “If a patient with diabetes comes in three times between October and February and you don’t give them a flu shot, then when they get the flu, whose fault is that?” he said. “You need some way to track high-risk patients who need immunizations.”

• Enter notes in a timely fashion – knowing that audits will show time and date of entries – and only use addenda to modify notes.

“If you’re going to make any changes in the medical record, you need to do it as an addendum,” Dr. Lessin said. And, of course, never try to erase a record. Even accidental alterations of records that aren’t following the rules can look very bad, he said.

Dr. Lessin is a principal with Physician Integration Consultants in Atlanta.

SAN FRANCISCO – Are electronic medical records wreaking havoc for you? Herschel R. Lessin, MD, vice president of the Children’s Medical Group in Poughkeepsie, N.Y., had some EMR recommendations.

In his presentation entitled “Help! My EMR Threw Me Under the Bus!” at the annual meeting of the American Academy of Pediatrics, Dr. Lessin offered the following recommendations for troubleshooting or preventing EMR problems, starting with customizing your EMR right away to reduce alert fatigue.

kokouu/iStockphoto.com

• Document the specifics of a particular condition, treatment, history, or other note when checking boxes.

• Document your thinking in terms of differential diagnoses.

• Document a follow-up plan beyond just checking the box of a patient’s return date.

• Be wary of cutting and pasting too quickly or relying on the template as a standard of care instead of thoughtful application of the evidence.

• Learn the entry fields for diagnosis codes and for medications and their route of administration.

• Double check that you’re clicking the correct patient, medication, and date of service.

• To prevent data breaches, including HIPAA violations, set up different levels of employee access to EMRs and never share your password.

• Narrative notes should be customized and included, even if the records ask many yes/no questions.

• Keep consistent records. Inconsistency in record keeping is one of the fastest ways to end up in litigation, Dr. Lessin warned. Separation of staff duties in filling out different parts of the EMR, failure to review templates, and “hybrid” charts for which the paper and electronic records don’t match are among the biggest risks for inconsistencies.

• Devise a method for tracking and following up with nonresponsive specialists and with patients, checking on their compliance and unique health care needs. “If a patient with diabetes comes in three times between October and February and you don’t give them a flu shot, then when they get the flu, whose fault is that?” he said. “You need some way to track high-risk patients who need immunizations.”

• Enter notes in a timely fashion – knowing that audits will show time and date of entries – and only use addenda to modify notes.

“If you’re going to make any changes in the medical record, you need to do it as an addendum,” Dr. Lessin said. And, of course, never try to erase a record. Even accidental alterations of records that aren’t following the rules can look very bad, he said.

Dr. Lessin is a principal with Physician Integration Consultants in Atlanta.

Parents of children with psoriasis experience significant negative quality-of-life issues, according to Dr. Megha Tollefson and her associates.

In interviews with 31 parents of children with psoriasis, four themes impacting quality of life emerged. Parental health and self-care were negatively affected, with 52% reporting affected sleep patterns and 35% reporting difficulty in maintaining self-care. Mental health issues were common as well, with 65% of parents reporting concern over their child’s condition and nearly half of parents reporting excess stress and sadness, anxiety, or depression.

Lori Farmer/Frontline Medical News

lfranki@frontlinemedcom.com

Parents of children with psoriasis experience significant negative quality-of-life issues, according to Dr. Megha Tollefson and her associates.

In interviews with 31 parents of children with psoriasis, four themes impacting quality of life emerged. Parental health and self-care were negatively affected, with 52% reporting affected sleep patterns and 35% reporting difficulty in maintaining self-care. Mental health issues were common as well, with 65% of parents reporting concern over their child’s condition and nearly half of parents reporting excess stress and sadness, anxiety, or depression.

Lori Farmer/Frontline Medical News

lfranki@frontlinemedcom.com

Parents of children with psoriasis experience significant negative quality-of-life issues, according to Dr. Megha Tollefson and her associates.

In interviews with 31 parents of children with psoriasis, four themes impacting quality of life emerged. Parental health and self-care were negatively affected, with 52% reporting affected sleep patterns and 35% reporting difficulty in maintaining self-care. Mental health issues were common as well, with 65% of parents reporting concern over their child’s condition and nearly half of parents reporting excess stress and sadness, anxiety, or depression.

Lori Farmer/Frontline Medical News

lfranki@frontlinemedcom.com

Hospitals that frequently treat acute COPD exacerbations using noninvasive ventilation – a practice known to reduce mortality, length of stay, and the need for more invasive treatment – did not have better patient outcomes than did hospitals that used noninvasive ventilation less frequently, according to a report published in Annals of the American Thoracic Society.

Acute COPD exacerbations are “one of the few conditions with high-level evidence demonstrating the benefits of noninvasive ventilation in patients with respiratory distress,” and the treatment has been widely adopted for this patient population. However, for noninvasive ventilation to succeed, patients must be carefully selected and closely monitored, and a multidisciplinary team of nurses, respiratory therapists, and physicians must coordinate the treatment, often across multiple hospital settings, said Anuj B. Mehta, MD, of The Pulmonary Center, Boston University, and his associates.

Until now, it was not known whether hospitals with a high volume of noninvasive ventilation develop specialized expertise and thus deliver superior patient outcomes, or whether a high volume results from suboptimal patient selection or otherwise puts a strain on a hospital’s staff and thus produces poor outcomes. To examine this question, Dr. Mehta and his associates analyzed information in a database enrolling adults treated at 252 California hospitals for acute COPD exacerbation. They focused on 37,516 hospitalizations that occurred during a single year.

Overall, 9.3% of these patients received noninvasive ventilation. The median annual case volume of noninvasive ventilation for any indication was 64 per hospital. But rates of noninvasive ventilation varied widely across hospitals, with 40% of facilities significantly deviating from this median rate.

“Contrary to our hypothesis, we did not observe significantly lower COPD mortality” in hospitals with high volumes of noninvasive ventilation. For individual patients, admission to a hospital with a high volume of noninvasive ventilation was associated with significantly higher odds of treatment failure (adjusted OR, 1.95), and such failure was associated with significantly higher odds of death (adjusted OR, 1.81). In addition, at the hospital level, a high volume of noninvasive ventilation was associated with a significantly higher risk of treatment failure, which in turn was associated with higher patient mortality.

“Hospitals with higher total noninvasive ventilation case volume tended to use [it] in patients with more comorbidities and acute organ failures, suggesting potential overuse among patients at higher risk of treatment failure. ... [This] may partially explain why hospitals with high rates of using an evidence-based intervention did not achieve significant mortality benefits,” Dr. Mehta and his associates said (Ann Am Thorac Soc. 2016;13[10]:1752-9).

They added that the wide variation between hospitals in failure rates for noninvasive ventilation were likely attributable to unmeasured hospital factors, speculating that the site of treatment (regular ward vs. ICU); staffing ratios for nurses, respiratory therapists, and physicians; and the intensity of patient monitoring, such as the frequency of blood-gas measurement, may contribute.

“High rates of treatment failure at some hospitals suggest that further work is needed to maximize the real-world effectiveness of noninvasive ventilation, even for an indication [backed by] strong evidence,” the investigators said.

The National Institutes of Health; the National Heart, Lung, and Blood Institute; and Boston University supported the study. The investigators’ financial disclosures are available at www.atsjournals.org.

Hospitals that frequently treat acute COPD exacerbations using noninvasive ventilation – a practice known to reduce mortality, length of stay, and the need for more invasive treatment – did not have better patient outcomes than did hospitals that used noninvasive ventilation less frequently, according to a report published in Annals of the American Thoracic Society.

Acute COPD exacerbations are “one of the few conditions with high-level evidence demonstrating the benefits of noninvasive ventilation in patients with respiratory distress,” and the treatment has been widely adopted for this patient population. However, for noninvasive ventilation to succeed, patients must be carefully selected and closely monitored, and a multidisciplinary team of nurses, respiratory therapists, and physicians must coordinate the treatment, often across multiple hospital settings, said Anuj B. Mehta, MD, of The Pulmonary Center, Boston University, and his associates.

Until now, it was not known whether hospitals with a high volume of noninvasive ventilation develop specialized expertise and thus deliver superior patient outcomes, or whether a high volume results from suboptimal patient selection or otherwise puts a strain on a hospital’s staff and thus produces poor outcomes. To examine this question, Dr. Mehta and his associates analyzed information in a database enrolling adults treated at 252 California hospitals for acute COPD exacerbation. They focused on 37,516 hospitalizations that occurred during a single year.

Overall, 9.3% of these patients received noninvasive ventilation. The median annual case volume of noninvasive ventilation for any indication was 64 per hospital. But rates of noninvasive ventilation varied widely across hospitals, with 40% of facilities significantly deviating from this median rate.

“Contrary to our hypothesis, we did not observe significantly lower COPD mortality” in hospitals with high volumes of noninvasive ventilation. For individual patients, admission to a hospital with a high volume of noninvasive ventilation was associated with significantly higher odds of treatment failure (adjusted OR, 1.95), and such failure was associated with significantly higher odds of death (adjusted OR, 1.81). In addition, at the hospital level, a high volume of noninvasive ventilation was associated with a significantly higher risk of treatment failure, which in turn was associated with higher patient mortality.

“Hospitals with higher total noninvasive ventilation case volume tended to use [it] in patients with more comorbidities and acute organ failures, suggesting potential overuse among patients at higher risk of treatment failure. ... [This] may partially explain why hospitals with high rates of using an evidence-based intervention did not achieve significant mortality benefits,” Dr. Mehta and his associates said (Ann Am Thorac Soc. 2016;13[10]:1752-9).

They added that the wide variation between hospitals in failure rates for noninvasive ventilation were likely attributable to unmeasured hospital factors, speculating that the site of treatment (regular ward vs. ICU); staffing ratios for nurses, respiratory therapists, and physicians; and the intensity of patient monitoring, such as the frequency of blood-gas measurement, may contribute.

“High rates of treatment failure at some hospitals suggest that further work is needed to maximize the real-world effectiveness of noninvasive ventilation, even for an indication [backed by] strong evidence,” the investigators said.

The National Institutes of Health; the National Heart, Lung, and Blood Institute; and Boston University supported the study. The investigators’ financial disclosures are available at www.atsjournals.org.

Hospitals that frequently treat acute COPD exacerbations using noninvasive ventilation – a practice known to reduce mortality, length of stay, and the need for more invasive treatment – did not have better patient outcomes than did hospitals that used noninvasive ventilation less frequently, according to a report published in Annals of the American Thoracic Society.

Acute COPD exacerbations are “one of the few conditions with high-level evidence demonstrating the benefits of noninvasive ventilation in patients with respiratory distress,” and the treatment has been widely adopted for this patient population. However, for noninvasive ventilation to succeed, patients must be carefully selected and closely monitored, and a multidisciplinary team of nurses, respiratory therapists, and physicians must coordinate the treatment, often across multiple hospital settings, said Anuj B. Mehta, MD, of The Pulmonary Center, Boston University, and his associates.

Until now, it was not known whether hospitals with a high volume of noninvasive ventilation develop specialized expertise and thus deliver superior patient outcomes, or whether a high volume results from suboptimal patient selection or otherwise puts a strain on a hospital’s staff and thus produces poor outcomes. To examine this question, Dr. Mehta and his associates analyzed information in a database enrolling adults treated at 252 California hospitals for acute COPD exacerbation. They focused on 37,516 hospitalizations that occurred during a single year.

Overall, 9.3% of these patients received noninvasive ventilation. The median annual case volume of noninvasive ventilation for any indication was 64 per hospital. But rates of noninvasive ventilation varied widely across hospitals, with 40% of facilities significantly deviating from this median rate.

“Contrary to our hypothesis, we did not observe significantly lower COPD mortality” in hospitals with high volumes of noninvasive ventilation. For individual patients, admission to a hospital with a high volume of noninvasive ventilation was associated with significantly higher odds of treatment failure (adjusted OR, 1.95), and such failure was associated with significantly higher odds of death (adjusted OR, 1.81). In addition, at the hospital level, a high volume of noninvasive ventilation was associated with a significantly higher risk of treatment failure, which in turn was associated with higher patient mortality.

“Hospitals with higher total noninvasive ventilation case volume tended to use [it] in patients with more comorbidities and acute organ failures, suggesting potential overuse among patients at higher risk of treatment failure. ... [This] may partially explain why hospitals with high rates of using an evidence-based intervention did not achieve significant mortality benefits,” Dr. Mehta and his associates said (Ann Am Thorac Soc. 2016;13[10]:1752-9).

They added that the wide variation between hospitals in failure rates for noninvasive ventilation were likely attributable to unmeasured hospital factors, speculating that the site of treatment (regular ward vs. ICU); staffing ratios for nurses, respiratory therapists, and physicians; and the intensity of patient monitoring, such as the frequency of blood-gas measurement, may contribute.

“High rates of treatment failure at some hospitals suggest that further work is needed to maximize the real-world effectiveness of noninvasive ventilation, even for an indication [backed by] strong evidence,” the investigators said.

The National Institutes of Health; the National Heart, Lung, and Blood Institute; and Boston University supported the study. The investigators’ financial disclosures are available at www.atsjournals.org.

The Food and Drug Administration and the Environmental Protection Agency have issued updated guidance about fish consumption for pregnant women and young children, clarifying which types of fish are recommended and what types of fish to avoid.

In guidance issued Jan. 18, the agencies sort 62 types of fish into three categories based on mercury level: best choices, good choices, and fish to avoid. They recommend that women who are pregnant, women who may become pregnant, breastfeeding mothers, and young children eat two to three servings of fish in the “best choices” category per week. Women and young children are advised to eat one serving per week of fish in the “good choices” category, according to the announcement. Fish in the “best choices” category make up nearly 90% of fish eaten in the United States, according to the FDA.

agallegos@frontlinemedcom.com

On Twitter @legal_med

The Food and Drug Administration and the Environmental Protection Agency have issued updated guidance about fish consumption for pregnant women and young children, clarifying which types of fish are recommended and what types of fish to avoid.

In guidance issued Jan. 18, the agencies sort 62 types of fish into three categories based on mercury level: best choices, good choices, and fish to avoid. They recommend that women who are pregnant, women who may become pregnant, breastfeeding mothers, and young children eat two to three servings of fish in the “best choices” category per week. Women and young children are advised to eat one serving per week of fish in the “good choices” category, according to the announcement. Fish in the “best choices” category make up nearly 90% of fish eaten in the United States, according to the FDA.

agallegos@frontlinemedcom.com

On Twitter @legal_med

The Food and Drug Administration and the Environmental Protection Agency have issued updated guidance about fish consumption for pregnant women and young children, clarifying which types of fish are recommended and what types of fish to avoid.

In guidance issued Jan. 18, the agencies sort 62 types of fish into three categories based on mercury level: best choices, good choices, and fish to avoid. They recommend that women who are pregnant, women who may become pregnant, breastfeeding mothers, and young children eat two to three servings of fish in the “best choices” category per week. Women and young children are advised to eat one serving per week of fish in the “good choices” category, according to the announcement. Fish in the “best choices” category make up nearly 90% of fish eaten in the United States, according to the FDA.

agallegos@frontlinemedcom.com

On Twitter @legal_med