LONDON – The risk for ST-elevation myocardial infarction (STEMI) increased in men when air quality dipped below acceptable levels as designated by the World Health Organization (WHO), based on the results of an observational study in Belgian.

The relative risk for a STEMI increased by 2.8% (1.026; 95% confidence interval, 1.005-1.048) for every 10 mcg/cm³ rise in fine particulate air pollution and by 5.1% (RR, 1.051; 95% CI, 1.018-1.084) for a comparable rise in nitric oxide air pollution. Ozone level was not associated with the risk for STEMI. Air pollution levels did not affect in-hospital mortality due to STEMI and had no clear effect on patients with coronary artery disease, diabetes or hypertension.

“Of course, it is very interesting that the results are only observed in men. This may be due to a statistical issue, because in our study population, the female group represents less than 25% of the population,” Dr. Jean-François Argacha, a study investigator, said during a press briefing at the annual congress of the European Society of Cardiology.

Subgroup analysis suggested that patients who were aged 75 years and older were more likely to develop STEMI in relation to exposure to particulate matter (RR, 1.046; 95% CI, 1.002-1.092, P = .041). Those aged 54 years and younger seemed more susceptible to nitric oxide levels (RR, 1.071; 95% CI, 1.010-1.136; P = .021).“The detrimental impact of nitric oxide exceeded that of fine particles and may be of particular concern in the younger population,” said Dr. Argacha, a cardiologist at University Hospital Brussels.

Previous research had shown that particulate matter is associated with an increased risk for acute myocardial infarction, but there had been no specific assessments on air pollution’s potential effects on STEMI, according to Dr. Argacha.

The study considered information on 11,428 patients in the Belgian Interdisciplinary Working Group on Acute Cardiology STEMI Registry between 2009 and 2013. Data on national air pollution parameters – particulate matter with an aerodynamic diameter of less than 10 (PM10) or 2.5 (PM2.5) mcm, nitric oxide and ozone – and air temperature were obtained from the Belgian Environment Agency database and adjusted for population density.

A case crossover analysis of STEMI risk was then performed, with risk being adjusted for ambient temperature, day of the week, and the season. The study’s case crossover design ensured that the effects were limited to air pollution and excluded other confounders including respiratory disease and air temperature.

Worldwide, WHO has estimated that poor urban air quality is responsible for around 1.3 million deaths per year, Dr. Argacha observed, noting that air pollution consists of fine (PM2.5) and larger (PM10) particles, nitric oxide, and ozone as well as sulfur dioxide and carbon monoxide.

During the observation period, the mean air pollution levels over the course of 1 year in Belgium were 23.9 mcg/cm³ for PM10, 16.1 mcg/cm³ for PM2.5, and 23.7 mcg/cm³ for nitric oxide. WHO guidelines set a daily limit of 25 mcg/cm³ for PM2.5. Dr. Argacha noted that this limit was exceeded in Belgium on 17.5% of days in the study.

Dr. Oscar Franco, professor of preventative medicine at the Erasmus University Medical Center in Rotterdam, the Netherlands, who cochaired the press conference noted that the European Society of Cardiology recently published a position paper on air pollution on cardiovascular disease (Eur Heart J. 2015;36:83-93) and has launched a major campaign to raise awareness of the detrimental effects that the environment can have on the heart.

The campaign notes that air and noise pollution are modifiable risk factors for the prevention and control of cardiovascular diseases, and advocated for acceptable limits that reflect WHO levels. Individuals “need to take action,” Dr. Franco urged. The decisions that people make every day – how they get to work for example – could have a potentially huge impact on the environment and health.

Dr. Argacha and Dr. Franco had no disclosures to report.

LONDON – The risk for ST-elevation myocardial infarction (STEMI) increased in men when air quality dipped below acceptable levels as designated by the World Health Organization (WHO), based on the results of an observational study in Belgian.

The relative risk for a STEMI increased by 2.8% (1.026; 95% confidence interval, 1.005-1.048) for every 10 mcg/cm³ rise in fine particulate air pollution and by 5.1% (RR, 1.051; 95% CI, 1.018-1.084) for a comparable rise in nitric oxide air pollution. Ozone level was not associated with the risk for STEMI. Air pollution levels did not affect in-hospital mortality due to STEMI and had no clear effect on patients with coronary artery disease, diabetes or hypertension.

“Of course, it is very interesting that the results are only observed in men. This may be due to a statistical issue, because in our study population, the female group represents less than 25% of the population,” Dr. Jean-François Argacha, a study investigator, said during a press briefing at the annual congress of the European Society of Cardiology.

Subgroup analysis suggested that patients who were aged 75 years and older were more likely to develop STEMI in relation to exposure to particulate matter (RR, 1.046; 95% CI, 1.002-1.092, P = .041). Those aged 54 years and younger seemed more susceptible to nitric oxide levels (RR, 1.071; 95% CI, 1.010-1.136; P = .021).“The detrimental impact of nitric oxide exceeded that of fine particles and may be of particular concern in the younger population,” said Dr. Argacha, a cardiologist at University Hospital Brussels.

Previous research had shown that particulate matter is associated with an increased risk for acute myocardial infarction, but there had been no specific assessments on air pollution’s potential effects on STEMI, according to Dr. Argacha.

The study considered information on 11,428 patients in the Belgian Interdisciplinary Working Group on Acute Cardiology STEMI Registry between 2009 and 2013. Data on national air pollution parameters – particulate matter with an aerodynamic diameter of less than 10 (PM10) or 2.5 (PM2.5) mcm, nitric oxide and ozone – and air temperature were obtained from the Belgian Environment Agency database and adjusted for population density.

A case crossover analysis of STEMI risk was then performed, with risk being adjusted for ambient temperature, day of the week, and the season. The study’s case crossover design ensured that the effects were limited to air pollution and excluded other confounders including respiratory disease and air temperature.

Worldwide, WHO has estimated that poor urban air quality is responsible for around 1.3 million deaths per year, Dr. Argacha observed, noting that air pollution consists of fine (PM2.5) and larger (PM10) particles, nitric oxide, and ozone as well as sulfur dioxide and carbon monoxide.

During the observation period, the mean air pollution levels over the course of 1 year in Belgium were 23.9 mcg/cm³ for PM10, 16.1 mcg/cm³ for PM2.5, and 23.7 mcg/cm³ for nitric oxide. WHO guidelines set a daily limit of 25 mcg/cm³ for PM2.5. Dr. Argacha noted that this limit was exceeded in Belgium on 17.5% of days in the study.

Dr. Oscar Franco, professor of preventative medicine at the Erasmus University Medical Center in Rotterdam, the Netherlands, who cochaired the press conference noted that the European Society of Cardiology recently published a position paper on air pollution on cardiovascular disease (Eur Heart J. 2015;36:83-93) and has launched a major campaign to raise awareness of the detrimental effects that the environment can have on the heart.

The campaign notes that air and noise pollution are modifiable risk factors for the prevention and control of cardiovascular diseases, and advocated for acceptable limits that reflect WHO levels. Individuals “need to take action,” Dr. Franco urged. The decisions that people make every day – how they get to work for example – could have a potentially huge impact on the environment and health.

Dr. Argacha and Dr. Franco had no disclosures to report.

LONDON – The risk for ST-elevation myocardial infarction (STEMI) increased in men when air quality dipped below acceptable levels as designated by the World Health Organization (WHO), based on the results of an observational study in Belgian.

The relative risk for a STEMI increased by 2.8% (1.026; 95% confidence interval, 1.005-1.048) for every 10 mcg/cm³ rise in fine particulate air pollution and by 5.1% (RR, 1.051; 95% CI, 1.018-1.084) for a comparable rise in nitric oxide air pollution. Ozone level was not associated with the risk for STEMI. Air pollution levels did not affect in-hospital mortality due to STEMI and had no clear effect on patients with coronary artery disease, diabetes or hypertension.

“Of course, it is very interesting that the results are only observed in men. This may be due to a statistical issue, because in our study population, the female group represents less than 25% of the population,” Dr. Jean-François Argacha, a study investigator, said during a press briefing at the annual congress of the European Society of Cardiology.

Subgroup analysis suggested that patients who were aged 75 years and older were more likely to develop STEMI in relation to exposure to particulate matter (RR, 1.046; 95% CI, 1.002-1.092, P = .041). Those aged 54 years and younger seemed more susceptible to nitric oxide levels (RR, 1.071; 95% CI, 1.010-1.136; P = .021).“The detrimental impact of nitric oxide exceeded that of fine particles and may be of particular concern in the younger population,” said Dr. Argacha, a cardiologist at University Hospital Brussels.

Previous research had shown that particulate matter is associated with an increased risk for acute myocardial infarction, but there had been no specific assessments on air pollution’s potential effects on STEMI, according to Dr. Argacha.

The study considered information on 11,428 patients in the Belgian Interdisciplinary Working Group on Acute Cardiology STEMI Registry between 2009 and 2013. Data on national air pollution parameters – particulate matter with an aerodynamic diameter of less than 10 (PM10) or 2.5 (PM2.5) mcm, nitric oxide and ozone – and air temperature were obtained from the Belgian Environment Agency database and adjusted for population density.

A case crossover analysis of STEMI risk was then performed, with risk being adjusted for ambient temperature, day of the week, and the season. The study’s case crossover design ensured that the effects were limited to air pollution and excluded other confounders including respiratory disease and air temperature.

Worldwide, WHO has estimated that poor urban air quality is responsible for around 1.3 million deaths per year, Dr. Argacha observed, noting that air pollution consists of fine (PM2.5) and larger (PM10) particles, nitric oxide, and ozone as well as sulfur dioxide and carbon monoxide.

During the observation period, the mean air pollution levels over the course of 1 year in Belgium were 23.9 mcg/cm³ for PM10, 16.1 mcg/cm³ for PM2.5, and 23.7 mcg/cm³ for nitric oxide. WHO guidelines set a daily limit of 25 mcg/cm³ for PM2.5. Dr. Argacha noted that this limit was exceeded in Belgium on 17.5% of days in the study.

Dr. Oscar Franco, professor of preventative medicine at the Erasmus University Medical Center in Rotterdam, the Netherlands, who cochaired the press conference noted that the European Society of Cardiology recently published a position paper on air pollution on cardiovascular disease (Eur Heart J. 2015;36:83-93) and has launched a major campaign to raise awareness of the detrimental effects that the environment can have on the heart.

The campaign notes that air and noise pollution are modifiable risk factors for the prevention and control of cardiovascular diseases, and advocated for acceptable limits that reflect WHO levels. Individuals “need to take action,” Dr. Franco urged. The decisions that people make every day – how they get to work for example – could have a potentially huge impact on the environment and health.

Dr. Argacha and Dr. Franco had no disclosures to report.

Bipolar disorder might include a distinct subphenotype characterized by externalizing symptoms and specific genetic variations, report Shanker Swaminathan, Ph.D., and his colleagues.

A study of 2,505 bipolar I disorder patients categorized participants into two groups: externalizing (those with comorbid externalizing disorders, plus a subgroup of patients with externalizing symptoms before 15 years of age) and nonexternalizing, wrote Dr. Swaminathan, formerly with the department of medical and molecular genetics at Indiana University, Indianapolis, and now with Baylor College of Medicine, Houston.

wildpixel/Thinkstock.com

Patients in the externalizing group showed significant differences in clinical features from the nonexternalizing group in multiple areas, including earlier age of onset of bipolar disorder, depression, and mania (P less than .001).

Additionally, those in the externalizing group had a higher frequency of self-harm incidents (P less than .001) and suicide attempts (P less than .008). These patients also were more likely to report a history of rapid switching and cycling (P less than .001), the authors reported.

Genetic analysis found numerous “nominally associated” SNPs, though none reached genome-wide significance, Dr. Swaminathan and his colleagues reported.

The findings “suggest the presence of an externalizing disorder subphenotype within [bipolar I disorder] warranting further investigation,” they concluded.

Read the full study here: J Affect Disord. 2015 Jun;178:206-14.

mrajaraman@frontlinemedcom.com

Bipolar disorder might include a distinct subphenotype characterized by externalizing symptoms and specific genetic variations, report Shanker Swaminathan, Ph.D., and his colleagues.

A study of 2,505 bipolar I disorder patients categorized participants into two groups: externalizing (those with comorbid externalizing disorders, plus a subgroup of patients with externalizing symptoms before 15 years of age) and nonexternalizing, wrote Dr. Swaminathan, formerly with the department of medical and molecular genetics at Indiana University, Indianapolis, and now with Baylor College of Medicine, Houston.

wildpixel/Thinkstock.com

Patients in the externalizing group showed significant differences in clinical features from the nonexternalizing group in multiple areas, including earlier age of onset of bipolar disorder, depression, and mania (P less than .001).

Additionally, those in the externalizing group had a higher frequency of self-harm incidents (P less than .001) and suicide attempts (P less than .008). These patients also were more likely to report a history of rapid switching and cycling (P less than .001), the authors reported.

Genetic analysis found numerous “nominally associated” SNPs, though none reached genome-wide significance, Dr. Swaminathan and his colleagues reported.

The findings “suggest the presence of an externalizing disorder subphenotype within [bipolar I disorder] warranting further investigation,” they concluded.

Read the full study here: J Affect Disord. 2015 Jun;178:206-14.

mrajaraman@frontlinemedcom.com

Bipolar disorder might include a distinct subphenotype characterized by externalizing symptoms and specific genetic variations, report Shanker Swaminathan, Ph.D., and his colleagues.

A study of 2,505 bipolar I disorder patients categorized participants into two groups: externalizing (those with comorbid externalizing disorders, plus a subgroup of patients with externalizing symptoms before 15 years of age) and nonexternalizing, wrote Dr. Swaminathan, formerly with the department of medical and molecular genetics at Indiana University, Indianapolis, and now with Baylor College of Medicine, Houston.

wildpixel/Thinkstock.com

Patients in the externalizing group showed significant differences in clinical features from the nonexternalizing group in multiple areas, including earlier age of onset of bipolar disorder, depression, and mania (P less than .001).

Additionally, those in the externalizing group had a higher frequency of self-harm incidents (P less than .001) and suicide attempts (P less than .008). These patients also were more likely to report a history of rapid switching and cycling (P less than .001), the authors reported.

Genetic analysis found numerous “nominally associated” SNPs, though none reached genome-wide significance, Dr. Swaminathan and his colleagues reported.

The findings “suggest the presence of an externalizing disorder subphenotype within [bipolar I disorder] warranting further investigation,” they concluded.

Read the full study here: J Affect Disord. 2015 Jun;178:206-14.

mrajaraman@frontlinemedcom.com

Several of the National Health Service’s mental health apps should be removed from the NHS Health Apps Library, because the apps lack evidence of their effectiveness, an article suggests.

The authors, researchers Simon Leigh of the Management School at the University of Liverpool, England, and Steve Flatt of the Liverpool Psychological Therapies Unit Community Interest Company, specifically fire shots at most of the NHS apps for the management of depression and anxiety. After assessing the metrics used to evaluate mental health apps currently in the library, they found that only four of the apps dedicated to the management of depression and anxiety “provide any evidence of patient-reported outcomes to substantiate claims of effectiveness” and only two apply validated metrics, including the generalized anxiety disorder 7-item scale (GAD-7) and 9-item patient health questionnaire (PHQ-9) to assess clinical performance.

©Milan_Zokic/thinkstockphotos.com

“As such, confidence in, and the validity of the claims made by apps that fail to apply such metrics must be considered as low at best, suggesting that the true clinical value of over 85% of NHS accredited mental health apps is at present impossible to determine,” they wrote.

The authors criticized many mental health apps sponsored by the NHS and other organizations, but they also advocate for the use of mental health apps that meet certain specifications, including those that “demonstrate evidence of real-world clinical effectiveness prior to receiving a seal of approval from a world-leading health care system and [be] recommended for patients in need of high-quality psychological interventions.”

Among the reasons the article’s authors list for supporting the idea of mental health apps is the possibility of such tools helping to decrease the wait time for receiving treatment, citing grim expected outcomes for patients currently waiting for mental health services in the United Kingdom. For example, 1 in 6 patients on waiting lists for mental health are expected to attempt suicide.

The writers also laud app-based psychological interventions’ potential to remove financial barriers to treatment and the fact that the use of some mental health apps has led to symptom improvement among patients with mental health issues.

“Given the ever increasing demands and limited supply of NHS mental health services, coupled with barriers to care, including a desire for anonymity, indirect financial costs, and impaired access to treatment centers, the use of apps may not only promote health service efficiency, but also support the NHS in returning to its seminal promise of equal access for equal need,” the authors wrote.

They added: “However, if this is to be an effective venture, this space clearly requires more stringent regulation, vetting, and quality control,”

Reacting to the article, a spokesperson for NHS England said: “This study illustrates that digital tools can act as powerful psychological interventions. It’s vital that patients know which apps to choose and that’s why we are working to upgrade the Health Apps Library, which launched as a pilot site in 2013 and reviews and recommends apps against a defined set of criteria. Earlier this year, we launched the Mental Health Apps Library, which features apps and digital tools that are compliant with IAPT [increasing access to psychological therapies] quality standards and offer National Institute of Health and Care Excellence approved treatments that can demonstrate effectiveness in treating mild and moderate depression and anxiety.”

Read the full article in Evidence-Based Mental Health (doi: 10.1136/eb-20150102203).

klennon@frontlinemedcom.com

Several of the National Health Service’s mental health apps should be removed from the NHS Health Apps Library, because the apps lack evidence of their effectiveness, an article suggests.

The authors, researchers Simon Leigh of the Management School at the University of Liverpool, England, and Steve Flatt of the Liverpool Psychological Therapies Unit Community Interest Company, specifically fire shots at most of the NHS apps for the management of depression and anxiety. After assessing the metrics used to evaluate mental health apps currently in the library, they found that only four of the apps dedicated to the management of depression and anxiety “provide any evidence of patient-reported outcomes to substantiate claims of effectiveness” and only two apply validated metrics, including the generalized anxiety disorder 7-item scale (GAD-7) and 9-item patient health questionnaire (PHQ-9) to assess clinical performance.

©Milan_Zokic/thinkstockphotos.com

“As such, confidence in, and the validity of the claims made by apps that fail to apply such metrics must be considered as low at best, suggesting that the true clinical value of over 85% of NHS accredited mental health apps is at present impossible to determine,” they wrote.

The authors criticized many mental health apps sponsored by the NHS and other organizations, but they also advocate for the use of mental health apps that meet certain specifications, including those that “demonstrate evidence of real-world clinical effectiveness prior to receiving a seal of approval from a world-leading health care system and [be] recommended for patients in need of high-quality psychological interventions.”

Among the reasons the article’s authors list for supporting the idea of mental health apps is the possibility of such tools helping to decrease the wait time for receiving treatment, citing grim expected outcomes for patients currently waiting for mental health services in the United Kingdom. For example, 1 in 6 patients on waiting lists for mental health are expected to attempt suicide.

The writers also laud app-based psychological interventions’ potential to remove financial barriers to treatment and the fact that the use of some mental health apps has led to symptom improvement among patients with mental health issues.

“Given the ever increasing demands and limited supply of NHS mental health services, coupled with barriers to care, including a desire for anonymity, indirect financial costs, and impaired access to treatment centers, the use of apps may not only promote health service efficiency, but also support the NHS in returning to its seminal promise of equal access for equal need,” the authors wrote.

They added: “However, if this is to be an effective venture, this space clearly requires more stringent regulation, vetting, and quality control,”

Reacting to the article, a spokesperson for NHS England said: “This study illustrates that digital tools can act as powerful psychological interventions. It’s vital that patients know which apps to choose and that’s why we are working to upgrade the Health Apps Library, which launched as a pilot site in 2013 and reviews and recommends apps against a defined set of criteria. Earlier this year, we launched the Mental Health Apps Library, which features apps and digital tools that are compliant with IAPT [increasing access to psychological therapies] quality standards and offer National Institute of Health and Care Excellence approved treatments that can demonstrate effectiveness in treating mild and moderate depression and anxiety.”

Read the full article in Evidence-Based Mental Health (doi: 10.1136/eb-20150102203).

klennon@frontlinemedcom.com

Several of the National Health Service’s mental health apps should be removed from the NHS Health Apps Library, because the apps lack evidence of their effectiveness, an article suggests.

The authors, researchers Simon Leigh of the Management School at the University of Liverpool, England, and Steve Flatt of the Liverpool Psychological Therapies Unit Community Interest Company, specifically fire shots at most of the NHS apps for the management of depression and anxiety. After assessing the metrics used to evaluate mental health apps currently in the library, they found that only four of the apps dedicated to the management of depression and anxiety “provide any evidence of patient-reported outcomes to substantiate claims of effectiveness” and only two apply validated metrics, including the generalized anxiety disorder 7-item scale (GAD-7) and 9-item patient health questionnaire (PHQ-9) to assess clinical performance.

©Milan_Zokic/thinkstockphotos.com

“As such, confidence in, and the validity of the claims made by apps that fail to apply such metrics must be considered as low at best, suggesting that the true clinical value of over 85% of NHS accredited mental health apps is at present impossible to determine,” they wrote.

The authors criticized many mental health apps sponsored by the NHS and other organizations, but they also advocate for the use of mental health apps that meet certain specifications, including those that “demonstrate evidence of real-world clinical effectiveness prior to receiving a seal of approval from a world-leading health care system and [be] recommended for patients in need of high-quality psychological interventions.”

Among the reasons the article’s authors list for supporting the idea of mental health apps is the possibility of such tools helping to decrease the wait time for receiving treatment, citing grim expected outcomes for patients currently waiting for mental health services in the United Kingdom. For example, 1 in 6 patients on waiting lists for mental health are expected to attempt suicide.

The writers also laud app-based psychological interventions’ potential to remove financial barriers to treatment and the fact that the use of some mental health apps has led to symptom improvement among patients with mental health issues.

“Given the ever increasing demands and limited supply of NHS mental health services, coupled with barriers to care, including a desire for anonymity, indirect financial costs, and impaired access to treatment centers, the use of apps may not only promote health service efficiency, but also support the NHS in returning to its seminal promise of equal access for equal need,” the authors wrote.

They added: “However, if this is to be an effective venture, this space clearly requires more stringent regulation, vetting, and quality control,”

Reacting to the article, a spokesperson for NHS England said: “This study illustrates that digital tools can act as powerful psychological interventions. It’s vital that patients know which apps to choose and that’s why we are working to upgrade the Health Apps Library, which launched as a pilot site in 2013 and reviews and recommends apps against a defined set of criteria. Earlier this year, we launched the Mental Health Apps Library, which features apps and digital tools that are compliant with IAPT [increasing access to psychological therapies] quality standards and offer National Institute of Health and Care Excellence approved treatments that can demonstrate effectiveness in treating mild and moderate depression and anxiety.”

Read the full article in Evidence-Based Mental Health (doi: 10.1136/eb-20150102203).

klennon@frontlinemedcom.com

An old joke about old jokes:

Three men have been friends for so long that to save time they tell jokes by number.

“38,” says one. Laughter.

“82,” says another. “That’s a good one!” say the others.

A puzzled onlooker decides to join in. “14!” he says. Stony silence. “What’s the matter?” he asks.

“You told it wrong,” they say.

Numbers are on my mind these days. ICD-10 is here. So many numbers. So little time.

As you recall, the ICD-10 rolled out on Oct. 1 after a year of postponement. Just before that date, a government spokesman sternly announced that doctors hoping for another reprieve were pipe-dreaming. “There will be no further delays,” he said. “Our ability to track Ebola and other epidemics depends on ICD-10.”

Ebola? Google helped me to understand. In the words of one health care consultant, ICD-9 has no specific code for Ebola, forcing doctors to use code 078.89: Other specified diseases due to viruses. This gave U.S. doctors no way to report and track Ebola. People were dying from inadequate classification.

I told this to a nonphysician friend, who asked, “Couldn’t they just make up a code for Ebola?” But that cannot be a good question, because no one of importance has asked it.

Now we have what we need: A98.4, Ebola virus disease, nestled between A98.1, Omsk hemorrhagic fever, and A98.8, Other specified viral hemorrhagic fevers. Note that these “Others” are specified. You must specify.

Now we can code for Ebola. And we have ICD-10, installed at a cost of untold billions of dollars spent by doctors, hospitals, billing services, and insurers. Armies of consultants stand ready to help all parties deal with the conversion. Things are bound to be better, though, for health care and for patients.

It is easy to make fun of ICD-10 by citing absurdities: V91.00XA, Burn due to merchant ship on fire, initial encounter. V97.33XD, Sucked into jet engine, subsequent encounter. (When will the silly fellow learn not to stand so close to jet engines?)

A truer flavor of dealing with the new classification system, however, comes from the degree of specificity – what the business-school types like to call granularity – that we now have to provide for the ordinary problems we clinicians encounter every day:

D23.10 Benign neoplasm, skin of eyelid.

D23.11 Other benign neoplasm of skin of right eyelid.

D23.12 Other benign neoplasm of skin of left eyelid.

Ditto for the ear, including external auditory canal, right or left (D23.21 and D23.22), unspecified parts of the face (D23.30), scalp and neck (D23.4), trunk (D23.5), right and left upper limb including shoulder, (D23.61 and D23.62), right and left lower limb, including hip (D23.71 and D23.72.) If you don’t know what side the lesion is on, you can use D23.70, Other benign neoplasm of skin of unspecified lower limb, including hip. But don’t use an unspecified code. We will be paid less if we don’t specify. Or so they say. Who knows, really? Even the payers don’t seem to know yet. We will find out.

I have a pain in an unspecified upper limb. I won’t say which. You will have to guess.

The same goes not just for skin cancers but for furuncles, lipomas, and so on. Furuncle of foot: L02.629. Furuncle of neck: L02.12. Furuncle of perineum: L02.225. There is also L02.229, furuncle of trunk, unspecified. Don’t go there. Specify. It is vital that we collect data on precisely which body parts furunculize.

In a current film, Matt Damon plays a man on Mars. Were he to return, he might look at all of this coding granularity and think the world has gone mad.

But that cannot be true, since no one of importance thinks so. And then of course there is Ebola.

Jokes by the numbers. Diseases by the numbers. Patients by the numbers. That’s why we became doctors, isn’t it? I don’t recall. It’s been a long time.

I end with a reverie:

The three men who tell jokes by numbers are sitting at tables. Each faces a rectangular card covered with white squares bordered in black. Red counters fill some of the squares.

The interloper who can’t tell a joke stands before them. “Toenail fungus,” he says.

One of the men leaps up.

“B35.1!” he cries.

“BINGO!”

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. Write to him at dermnews@frontlinemedcom.com.

An old joke about old jokes:

Three men have been friends for so long that to save time they tell jokes by number.

“38,” says one. Laughter.

“82,” says another. “That’s a good one!” say the others.

A puzzled onlooker decides to join in. “14!” he says. Stony silence. “What’s the matter?” he asks.

“You told it wrong,” they say.

Numbers are on my mind these days. ICD-10 is here. So many numbers. So little time.

As you recall, the ICD-10 rolled out on Oct. 1 after a year of postponement. Just before that date, a government spokesman sternly announced that doctors hoping for another reprieve were pipe-dreaming. “There will be no further delays,” he said. “Our ability to track Ebola and other epidemics depends on ICD-10.”

Ebola? Google helped me to understand. In the words of one health care consultant, ICD-9 has no specific code for Ebola, forcing doctors to use code 078.89: Other specified diseases due to viruses. This gave U.S. doctors no way to report and track Ebola. People were dying from inadequate classification.

I told this to a nonphysician friend, who asked, “Couldn’t they just make up a code for Ebola?” But that cannot be a good question, because no one of importance has asked it.

Now we have what we need: A98.4, Ebola virus disease, nestled between A98.1, Omsk hemorrhagic fever, and A98.8, Other specified viral hemorrhagic fevers. Note that these “Others” are specified. You must specify.

Now we can code for Ebola. And we have ICD-10, installed at a cost of untold billions of dollars spent by doctors, hospitals, billing services, and insurers. Armies of consultants stand ready to help all parties deal with the conversion. Things are bound to be better, though, for health care and for patients.

It is easy to make fun of ICD-10 by citing absurdities: V91.00XA, Burn due to merchant ship on fire, initial encounter. V97.33XD, Sucked into jet engine, subsequent encounter. (When will the silly fellow learn not to stand so close to jet engines?)

A truer flavor of dealing with the new classification system, however, comes from the degree of specificity – what the business-school types like to call granularity – that we now have to provide for the ordinary problems we clinicians encounter every day:

D23.10 Benign neoplasm, skin of eyelid.

D23.11 Other benign neoplasm of skin of right eyelid.

D23.12 Other benign neoplasm of skin of left eyelid.

Ditto for the ear, including external auditory canal, right or left (D23.21 and D23.22), unspecified parts of the face (D23.30), scalp and neck (D23.4), trunk (D23.5), right and left upper limb including shoulder, (D23.61 and D23.62), right and left lower limb, including hip (D23.71 and D23.72.) If you don’t know what side the lesion is on, you can use D23.70, Other benign neoplasm of skin of unspecified lower limb, including hip. But don’t use an unspecified code. We will be paid less if we don’t specify. Or so they say. Who knows, really? Even the payers don’t seem to know yet. We will find out.

I have a pain in an unspecified upper limb. I won’t say which. You will have to guess.

The same goes not just for skin cancers but for furuncles, lipomas, and so on. Furuncle of foot: L02.629. Furuncle of neck: L02.12. Furuncle of perineum: L02.225. There is also L02.229, furuncle of trunk, unspecified. Don’t go there. Specify. It is vital that we collect data on precisely which body parts furunculize.

In a current film, Matt Damon plays a man on Mars. Were he to return, he might look at all of this coding granularity and think the world has gone mad.

But that cannot be true, since no one of importance thinks so. And then of course there is Ebola.

Jokes by the numbers. Diseases by the numbers. Patients by the numbers. That’s why we became doctors, isn’t it? I don’t recall. It’s been a long time.

I end with a reverie:

The three men who tell jokes by numbers are sitting at tables. Each faces a rectangular card covered with white squares bordered in black. Red counters fill some of the squares.

The interloper who can’t tell a joke stands before them. “Toenail fungus,” he says.

One of the men leaps up.

“B35.1!” he cries.

“BINGO!”

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. Write to him at dermnews@frontlinemedcom.com.

An old joke about old jokes:

Three men have been friends for so long that to save time they tell jokes by number.

“38,” says one. Laughter.

“82,” says another. “That’s a good one!” say the others.

A puzzled onlooker decides to join in. “14!” he says. Stony silence. “What’s the matter?” he asks.

“You told it wrong,” they say.

Numbers are on my mind these days. ICD-10 is here. So many numbers. So little time.

As you recall, the ICD-10 rolled out on Oct. 1 after a year of postponement. Just before that date, a government spokesman sternly announced that doctors hoping for another reprieve were pipe-dreaming. “There will be no further delays,” he said. “Our ability to track Ebola and other epidemics depends on ICD-10.”

Ebola? Google helped me to understand. In the words of one health care consultant, ICD-9 has no specific code for Ebola, forcing doctors to use code 078.89: Other specified diseases due to viruses. This gave U.S. doctors no way to report and track Ebola. People were dying from inadequate classification.

I told this to a nonphysician friend, who asked, “Couldn’t they just make up a code for Ebola?” But that cannot be a good question, because no one of importance has asked it.

Now we have what we need: A98.4, Ebola virus disease, nestled between A98.1, Omsk hemorrhagic fever, and A98.8, Other specified viral hemorrhagic fevers. Note that these “Others” are specified. You must specify.

Now we can code for Ebola. And we have ICD-10, installed at a cost of untold billions of dollars spent by doctors, hospitals, billing services, and insurers. Armies of consultants stand ready to help all parties deal with the conversion. Things are bound to be better, though, for health care and for patients.

It is easy to make fun of ICD-10 by citing absurdities: V91.00XA, Burn due to merchant ship on fire, initial encounter. V97.33XD, Sucked into jet engine, subsequent encounter. (When will the silly fellow learn not to stand so close to jet engines?)

A truer flavor of dealing with the new classification system, however, comes from the degree of specificity – what the business-school types like to call granularity – that we now have to provide for the ordinary problems we clinicians encounter every day:

D23.10 Benign neoplasm, skin of eyelid.

D23.11 Other benign neoplasm of skin of right eyelid.

D23.12 Other benign neoplasm of skin of left eyelid.

Ditto for the ear, including external auditory canal, right or left (D23.21 and D23.22), unspecified parts of the face (D23.30), scalp and neck (D23.4), trunk (D23.5), right and left upper limb including shoulder, (D23.61 and D23.62), right and left lower limb, including hip (D23.71 and D23.72.) If you don’t know what side the lesion is on, you can use D23.70, Other benign neoplasm of skin of unspecified lower limb, including hip. But don’t use an unspecified code. We will be paid less if we don’t specify. Or so they say. Who knows, really? Even the payers don’t seem to know yet. We will find out.

I have a pain in an unspecified upper limb. I won’t say which. You will have to guess.

The same goes not just for skin cancers but for furuncles, lipomas, and so on. Furuncle of foot: L02.629. Furuncle of neck: L02.12. Furuncle of perineum: L02.225. There is also L02.229, furuncle of trunk, unspecified. Don’t go there. Specify. It is vital that we collect data on precisely which body parts furunculize.

In a current film, Matt Damon plays a man on Mars. Were he to return, he might look at all of this coding granularity and think the world has gone mad.

But that cannot be true, since no one of importance thinks so. And then of course there is Ebola.

Jokes by the numbers. Diseases by the numbers. Patients by the numbers. That’s why we became doctors, isn’t it? I don’t recall. It’s been a long time.

I end with a reverie:

The three men who tell jokes by numbers are sitting at tables. Each faces a rectangular card covered with white squares bordered in black. Red counters fill some of the squares.

The interloper who can’t tell a joke stands before them. “Toenail fungus,” he says.

One of the men leaps up.

“B35.1!” he cries.

“BINGO!”

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. Write to him at dermnews@frontlinemedcom.com.

The addition of thrombectomy to percutaneous coronary intervention didn’t improve cardiac flow or clinical endpoints any more than PCI alone in patients with a subacute ST-elevation myocardial infarction.

Thrombosis aspiration decreased microvascular obstruction less than 1% more than did PCI alone – 2.5% vs. 3% of the left ventricular mass, Dr. Steffan Desch said at the Transcatheter Cardiovascular Therapeutics annual meeting. There were also no significant differences in infarct size, myocardial salvage, or left ventricular ejection fraction, he said at the meeting sponsored by the Cardiovascular Research Foundation.

“Routine manual thrombectomy and aspiration didn’t show any significant reduction in microvascular obstruction on imaging,” said Dr. Desch of University Heart Center, Lübeck, Germany. “This finding was supported by a variety of secondary endpoints, none of them significantly beneficial.”

The study, which was simultaneously published online (JACC Cardiovasc Interv. 2015. doi: 10.1016/j.jcin.2015.09.010), gives the first firm evidence that clot removal is not particularly helpful to patients who present late after symptom onset. With a mean development time of 28 hours, thrombi in this cohort were more mature, with higher fibrin content than the typically soft material seen in patients with acute ST-elevation myocardial infarction (STEMI). When the clot becomes denser and more organized, it is likely less suitable for aspiration, he said.

The cohort comprised 152 patients who presented in a 12- to 48-hour window after onset of symptoms. They were randomized to either standard PCI or to clot aspiration followed by PCI. The primary outcome was the extent of major vessel occlusion on magnetic resonance imaging conducted 1-4 days after the intervention. Secondary outcomes included infarct size, myocardial salvage, and left ventricular volume and ejection fraction.

Patients were a mean of 66 years old, with typical baseline characteristics. Most were men; hypertension was common (about 70%). About half had signs of ongoing ischemia at admission. The door-to-balloon time was 78 minutes in the combination therapy group and 62 minutes in the PCI-only group. Most (62.5%) had a complete occlusion of the culprit vessel.

In addition to providing no benefit in microvascular occlusion, aspiration did not significantly improve TIMI flow grade above that achieved with PCI only. After the intervention, 78% of those in the thrombectomy group and 69% of those in the PCI group achieved a TIMI flow grade 3. Nor was there a significant difference in myocardial blush grade (70% vs. 65%). When troponin T values were used to assess enzymatic infarct size, they were similar in both groups at 24 and 48 hours.

Clinical outcomes were similar as well. All-cause mortality was 3% in the aspiration group and 5% in the PCI-only group; cardiovascular death occurred in 3% and 4%, respectively. There were no reinfarctions and no stent thromboses. One stroke occurred in a patient who underwent PCI alone.

Dr. Desch noted in the published article that the study took all comers, rather than selecting for specific patient characteristics. Therefore, he said “it is possible that thrombus aspiration might only be advantageous in specific subsets of patients such as those with large thrombus burden, total occlusion or reduced flow.”

The study was funded by a research grant from Medtronic. Dr. Desch reported grant/research support from Medtronic.

msullivan@frontlinemedcom.com

The addition of thrombectomy to percutaneous coronary intervention didn’t improve cardiac flow or clinical endpoints any more than PCI alone in patients with a subacute ST-elevation myocardial infarction.

Thrombosis aspiration decreased microvascular obstruction less than 1% more than did PCI alone – 2.5% vs. 3% of the left ventricular mass, Dr. Steffan Desch said at the Transcatheter Cardiovascular Therapeutics annual meeting. There were also no significant differences in infarct size, myocardial salvage, or left ventricular ejection fraction, he said at the meeting sponsored by the Cardiovascular Research Foundation.

“Routine manual thrombectomy and aspiration didn’t show any significant reduction in microvascular obstruction on imaging,” said Dr. Desch of University Heart Center, Lübeck, Germany. “This finding was supported by a variety of secondary endpoints, none of them significantly beneficial.”

The study, which was simultaneously published online (JACC Cardiovasc Interv. 2015. doi: 10.1016/j.jcin.2015.09.010), gives the first firm evidence that clot removal is not particularly helpful to patients who present late after symptom onset. With a mean development time of 28 hours, thrombi in this cohort were more mature, with higher fibrin content than the typically soft material seen in patients with acute ST-elevation myocardial infarction (STEMI). When the clot becomes denser and more organized, it is likely less suitable for aspiration, he said.

The cohort comprised 152 patients who presented in a 12- to 48-hour window after onset of symptoms. They were randomized to either standard PCI or to clot aspiration followed by PCI. The primary outcome was the extent of major vessel occlusion on magnetic resonance imaging conducted 1-4 days after the intervention. Secondary outcomes included infarct size, myocardial salvage, and left ventricular volume and ejection fraction.

Patients were a mean of 66 years old, with typical baseline characteristics. Most were men; hypertension was common (about 70%). About half had signs of ongoing ischemia at admission. The door-to-balloon time was 78 minutes in the combination therapy group and 62 minutes in the PCI-only group. Most (62.5%) had a complete occlusion of the culprit vessel.

In addition to providing no benefit in microvascular occlusion, aspiration did not significantly improve TIMI flow grade above that achieved with PCI only. After the intervention, 78% of those in the thrombectomy group and 69% of those in the PCI group achieved a TIMI flow grade 3. Nor was there a significant difference in myocardial blush grade (70% vs. 65%). When troponin T values were used to assess enzymatic infarct size, they were similar in both groups at 24 and 48 hours.

Clinical outcomes were similar as well. All-cause mortality was 3% in the aspiration group and 5% in the PCI-only group; cardiovascular death occurred in 3% and 4%, respectively. There were no reinfarctions and no stent thromboses. One stroke occurred in a patient who underwent PCI alone.

Dr. Desch noted in the published article that the study took all comers, rather than selecting for specific patient characteristics. Therefore, he said “it is possible that thrombus aspiration might only be advantageous in specific subsets of patients such as those with large thrombus burden, total occlusion or reduced flow.”

The study was funded by a research grant from Medtronic. Dr. Desch reported grant/research support from Medtronic.

msullivan@frontlinemedcom.com

The addition of thrombectomy to percutaneous coronary intervention didn’t improve cardiac flow or clinical endpoints any more than PCI alone in patients with a subacute ST-elevation myocardial infarction.

Thrombosis aspiration decreased microvascular obstruction less than 1% more than did PCI alone – 2.5% vs. 3% of the left ventricular mass, Dr. Steffan Desch said at the Transcatheter Cardiovascular Therapeutics annual meeting. There were also no significant differences in infarct size, myocardial salvage, or left ventricular ejection fraction, he said at the meeting sponsored by the Cardiovascular Research Foundation.

“Routine manual thrombectomy and aspiration didn’t show any significant reduction in microvascular obstruction on imaging,” said Dr. Desch of University Heart Center, Lübeck, Germany. “This finding was supported by a variety of secondary endpoints, none of them significantly beneficial.”

The study, which was simultaneously published online (JACC Cardiovasc Interv. 2015. doi: 10.1016/j.jcin.2015.09.010), gives the first firm evidence that clot removal is not particularly helpful to patients who present late after symptom onset. With a mean development time of 28 hours, thrombi in this cohort were more mature, with higher fibrin content than the typically soft material seen in patients with acute ST-elevation myocardial infarction (STEMI). When the clot becomes denser and more organized, it is likely less suitable for aspiration, he said.

The cohort comprised 152 patients who presented in a 12- to 48-hour window after onset of symptoms. They were randomized to either standard PCI or to clot aspiration followed by PCI. The primary outcome was the extent of major vessel occlusion on magnetic resonance imaging conducted 1-4 days after the intervention. Secondary outcomes included infarct size, myocardial salvage, and left ventricular volume and ejection fraction.

Patients were a mean of 66 years old, with typical baseline characteristics. Most were men; hypertension was common (about 70%). About half had signs of ongoing ischemia at admission. The door-to-balloon time was 78 minutes in the combination therapy group and 62 minutes in the PCI-only group. Most (62.5%) had a complete occlusion of the culprit vessel.

In addition to providing no benefit in microvascular occlusion, aspiration did not significantly improve TIMI flow grade above that achieved with PCI only. After the intervention, 78% of those in the thrombectomy group and 69% of those in the PCI group achieved a TIMI flow grade 3. Nor was there a significant difference in myocardial blush grade (70% vs. 65%). When troponin T values were used to assess enzymatic infarct size, they were similar in both groups at 24 and 48 hours.

Clinical outcomes were similar as well. All-cause mortality was 3% in the aspiration group and 5% in the PCI-only group; cardiovascular death occurred in 3% and 4%, respectively. There were no reinfarctions and no stent thromboses. One stroke occurred in a patient who underwent PCI alone.

Dr. Desch noted in the published article that the study took all comers, rather than selecting for specific patient characteristics. Therefore, he said “it is possible that thrombus aspiration might only be advantageous in specific subsets of patients such as those with large thrombus burden, total occlusion or reduced flow.”

The study was funded by a research grant from Medtronic. Dr. Desch reported grant/research support from Medtronic.

msullivan@frontlinemedcom.com

You probably first heard the acronym EDC in medical school, and it replaced what you had been referring to as a “due date.” Of course, you remember the “C” is the first letter of “confinement.” Or is it? You would be forgiven if you thought EDC stood for Estimated Date of Cesarean.

While the practice of keeping new mothers cooped up in their homes for month and placed on dietary, activity, and even hygienic restrictions has all but disappeared in this country, the tradition persists in China. Believing that the process of even a normal delivery renders a woman vulnerable to all sorts of maladies, for 2,000 years Chinese grandmothers have been confining their daughters at home for the first month post partum.

In a recent article in the New York Times, I learned that while confinement continues post partum in China, it has changed among some affluent families so that it is more like spending a month in a high-end spa (“A Tradition for New Mothers in China, Now $27,000 a month” By Dan Levin, Oct. 1, 2015). The new confinement includes breastfeeding instruction, and dietary and activity choices that purport to be more scientifically based than the traditional restrictions. It has become popular with women who can afford it, while in the past confinement could be a month filled with tension between grandmothers and their daughters taking care of their new babies.

I can’t see the new Chinese version of confinement catching on here in North America, but the New York Times article did get me thinking about how we could do a better job helping mothers navigate the choppy waters of those first 30 days post partum. The Chinese are correct that a delivery is an assault on the body of even a previously healthy young woman. Even as one who hasn’t had the experience, I can only imagine it is like pulling an all-nighter (or two) and then running a marathon. Oh, and along the way losing a pint or two of blood.

There are a few families in North America who can afford to hire trained personnel (doulas), but for the most part we aren’t doing a very good job of helping women transition into motherhood. Of course, universal and more liberal family leave policies could make things easier. But simply lessening some of the tension associated with the inevitable return to the workplace isn’t enough. It is unlikely that we have the political will to make the changes to see those policies enacted.

However, there are things that we as pediatricians can do to make the postpartum period safer, healthier, and more comfortable for struggling families. First, we can encourage expectant mothers to make prenatal visits in our offices. While these visits are often little more than doctor shopping, we can ask the families who have committed to our practices to make a second appointment with more educational content. Would we get paid for it? Maybe not, but these second visits could pay for themselves in fewer after-hours calls.

We should do a better job of getting to know a new mother before she goes home from the hospital. What is her discharge hemoglobin? Does she have a history of depression and/or anxiety? Anemia and psychiatric issues can dramatically increase the risk that breastfeeding won’t go well and that post partum depression is more likely to ensue.

Are our offices and lactation consultants really available 24/7? Are we all on the same page when it comes to post partum advice? Do we return calls promptly and make follow-up calls? Are our offices and schedules truly new-mother friendly? Have we made use of all the available home health services that might be required?

The first postpartum month is critical, and new mothers need to be treated as our highest priority, but not confined.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.” Email him at pdnews@frontlinemedcom.com.

You probably first heard the acronym EDC in medical school, and it replaced what you had been referring to as a “due date.” Of course, you remember the “C” is the first letter of “confinement.” Or is it? You would be forgiven if you thought EDC stood for Estimated Date of Cesarean.

While the practice of keeping new mothers cooped up in their homes for month and placed on dietary, activity, and even hygienic restrictions has all but disappeared in this country, the tradition persists in China. Believing that the process of even a normal delivery renders a woman vulnerable to all sorts of maladies, for 2,000 years Chinese grandmothers have been confining their daughters at home for the first month post partum.

In a recent article in the New York Times, I learned that while confinement continues post partum in China, it has changed among some affluent families so that it is more like spending a month in a high-end spa (“A Tradition for New Mothers in China, Now $27,000 a month” By Dan Levin, Oct. 1, 2015). The new confinement includes breastfeeding instruction, and dietary and activity choices that purport to be more scientifically based than the traditional restrictions. It has become popular with women who can afford it, while in the past confinement could be a month filled with tension between grandmothers and their daughters taking care of their new babies.

I can’t see the new Chinese version of confinement catching on here in North America, but the New York Times article did get me thinking about how we could do a better job helping mothers navigate the choppy waters of those first 30 days post partum. The Chinese are correct that a delivery is an assault on the body of even a previously healthy young woman. Even as one who hasn’t had the experience, I can only imagine it is like pulling an all-nighter (or two) and then running a marathon. Oh, and along the way losing a pint or two of blood.

There are a few families in North America who can afford to hire trained personnel (doulas), but for the most part we aren’t doing a very good job of helping women transition into motherhood. Of course, universal and more liberal family leave policies could make things easier. But simply lessening some of the tension associated with the inevitable return to the workplace isn’t enough. It is unlikely that we have the political will to make the changes to see those policies enacted.

However, there are things that we as pediatricians can do to make the postpartum period safer, healthier, and more comfortable for struggling families. First, we can encourage expectant mothers to make prenatal visits in our offices. While these visits are often little more than doctor shopping, we can ask the families who have committed to our practices to make a second appointment with more educational content. Would we get paid for it? Maybe not, but these second visits could pay for themselves in fewer after-hours calls.

We should do a better job of getting to know a new mother before she goes home from the hospital. What is her discharge hemoglobin? Does she have a history of depression and/or anxiety? Anemia and psychiatric issues can dramatically increase the risk that breastfeeding won’t go well and that post partum depression is more likely to ensue.

Are our offices and lactation consultants really available 24/7? Are we all on the same page when it comes to post partum advice? Do we return calls promptly and make follow-up calls? Are our offices and schedules truly new-mother friendly? Have we made use of all the available home health services that might be required?

The first postpartum month is critical, and new mothers need to be treated as our highest priority, but not confined.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.” Email him at pdnews@frontlinemedcom.com.

You probably first heard the acronym EDC in medical school, and it replaced what you had been referring to as a “due date.” Of course, you remember the “C” is the first letter of “confinement.” Or is it? You would be forgiven if you thought EDC stood for Estimated Date of Cesarean.

While the practice of keeping new mothers cooped up in their homes for month and placed on dietary, activity, and even hygienic restrictions has all but disappeared in this country, the tradition persists in China. Believing that the process of even a normal delivery renders a woman vulnerable to all sorts of maladies, for 2,000 years Chinese grandmothers have been confining their daughters at home for the first month post partum.

In a recent article in the New York Times, I learned that while confinement continues post partum in China, it has changed among some affluent families so that it is more like spending a month in a high-end spa (“A Tradition for New Mothers in China, Now $27,000 a month” By Dan Levin, Oct. 1, 2015). The new confinement includes breastfeeding instruction, and dietary and activity choices that purport to be more scientifically based than the traditional restrictions. It has become popular with women who can afford it, while in the past confinement could be a month filled with tension between grandmothers and their daughters taking care of their new babies.

I can’t see the new Chinese version of confinement catching on here in North America, but the New York Times article did get me thinking about how we could do a better job helping mothers navigate the choppy waters of those first 30 days post partum. The Chinese are correct that a delivery is an assault on the body of even a previously healthy young woman. Even as one who hasn’t had the experience, I can only imagine it is like pulling an all-nighter (or two) and then running a marathon. Oh, and along the way losing a pint or two of blood.

There are a few families in North America who can afford to hire trained personnel (doulas), but for the most part we aren’t doing a very good job of helping women transition into motherhood. Of course, universal and more liberal family leave policies could make things easier. But simply lessening some of the tension associated with the inevitable return to the workplace isn’t enough. It is unlikely that we have the political will to make the changes to see those policies enacted.

However, there are things that we as pediatricians can do to make the postpartum period safer, healthier, and more comfortable for struggling families. First, we can encourage expectant mothers to make prenatal visits in our offices. While these visits are often little more than doctor shopping, we can ask the families who have committed to our practices to make a second appointment with more educational content. Would we get paid for it? Maybe not, but these second visits could pay for themselves in fewer after-hours calls.

We should do a better job of getting to know a new mother before she goes home from the hospital. What is her discharge hemoglobin? Does she have a history of depression and/or anxiety? Anemia and psychiatric issues can dramatically increase the risk that breastfeeding won’t go well and that post partum depression is more likely to ensue.

Are our offices and lactation consultants really available 24/7? Are we all on the same page when it comes to post partum advice? Do we return calls promptly and make follow-up calls? Are our offices and schedules truly new-mother friendly? Have we made use of all the available home health services that might be required?

The first postpartum month is critical, and new mothers need to be treated as our highest priority, but not confined.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping With a Picky Eater.” Email him at pdnews@frontlinemedcom.com.

CHICAGO – Major molecular response rates at 12 months were better among chronic myeloid leukemia patients treated with dasatinib/nilotinib vs. imatinib for first-line therapy, and among patients enrolled vs. not enrolled in clinical trials, in a retrospective review of patients treated with first-line tyrosine kinase inhibitors between 2002 and 2014.

The overall rates of major molecular response (MMR) at 12 and 24 months in the 51 patients in the study were 23.5% (12 patients) and 44.9% (22 patients), which was comparable to historical data, Dr. Isabelle Phuong Le reported in a poster at the American Society of Hematology Meeting on Hematologic Malignancies.

The MMR rate among those treated with dasatinib/nilotinib first line was 53%, compared with 10% for those treated with imatinib, said Dr. Le of the University of Texas Health Science Center, San Antonio.

Further the MMR rates at 12 and 24 months among those enrolled vs. not enrolled in clinical trials were 83% vs 15% and 100% vs. 45%, respectively, she noted.

Patients in the analysis were adults with a mean age of 44.6 years who had chronic phase chronic myeloid leukemia (CML). Almost half (49%) were Hispanic, and 56.9% were women. Two-thirds (66.7%) received imatinib first line, and 33.3% received dasatinib/nilotinib first line. More than a third (37.2%) were younger than age 40 years, 15% had a language barrier, and 11.7% were enrolled in clinical trials.

No differences in the MMR rates at 12 and 24 months were seen between Hispanics and non-Hispanics, those with and without language barrier, or men and women, nor were any differences seen between those with more than three lines of therapy and those with three or fewer lines of therapy, or between patients older vs. younger than 40 years, although there was a trend toward improved response rates in older patients, she noted.

“Our patients have similar MMR rates at 12 months and 24 months compared to historical data,” Dr. Le wrote, noting that the findings regarding improved MMR rates with dasatinib/nilotinib were expected.

The findings regarding improved MMR rates among those enrolled in clinical trials could be due to “selective patients as clinical trial patients, more controlled and monitored treatment, frequent follow-ups, and better education regarding disease and treatment,” she said, concluding that “ we can improve treatment response rates in our patients with better disease education.”

Dr. Le reported having no disclosures.

sworcester@frontlinemedcom.com

CHICAGO – Major molecular response rates at 12 months were better among chronic myeloid leukemia patients treated with dasatinib/nilotinib vs. imatinib for first-line therapy, and among patients enrolled vs. not enrolled in clinical trials, in a retrospective review of patients treated with first-line tyrosine kinase inhibitors between 2002 and 2014.

The overall rates of major molecular response (MMR) at 12 and 24 months in the 51 patients in the study were 23.5% (12 patients) and 44.9% (22 patients), which was comparable to historical data, Dr. Isabelle Phuong Le reported in a poster at the American Society of Hematology Meeting on Hematologic Malignancies.

The MMR rate among those treated with dasatinib/nilotinib first line was 53%, compared with 10% for those treated with imatinib, said Dr. Le of the University of Texas Health Science Center, San Antonio.

Further the MMR rates at 12 and 24 months among those enrolled vs. not enrolled in clinical trials were 83% vs 15% and 100% vs. 45%, respectively, she noted.

Patients in the analysis were adults with a mean age of 44.6 years who had chronic phase chronic myeloid leukemia (CML). Almost half (49%) were Hispanic, and 56.9% were women. Two-thirds (66.7%) received imatinib first line, and 33.3% received dasatinib/nilotinib first line. More than a third (37.2%) were younger than age 40 years, 15% had a language barrier, and 11.7% were enrolled in clinical trials.

No differences in the MMR rates at 12 and 24 months were seen between Hispanics and non-Hispanics, those with and without language barrier, or men and women, nor were any differences seen between those with more than three lines of therapy and those with three or fewer lines of therapy, or between patients older vs. younger than 40 years, although there was a trend toward improved response rates in older patients, she noted.

“Our patients have similar MMR rates at 12 months and 24 months compared to historical data,” Dr. Le wrote, noting that the findings regarding improved MMR rates with dasatinib/nilotinib were expected.

The findings regarding improved MMR rates among those enrolled in clinical trials could be due to “selective patients as clinical trial patients, more controlled and monitored treatment, frequent follow-ups, and better education regarding disease and treatment,” she said, concluding that “ we can improve treatment response rates in our patients with better disease education.”

Dr. Le reported having no disclosures.

sworcester@frontlinemedcom.com

CHICAGO – Major molecular response rates at 12 months were better among chronic myeloid leukemia patients treated with dasatinib/nilotinib vs. imatinib for first-line therapy, and among patients enrolled vs. not enrolled in clinical trials, in a retrospective review of patients treated with first-line tyrosine kinase inhibitors between 2002 and 2014.

The overall rates of major molecular response (MMR) at 12 and 24 months in the 51 patients in the study were 23.5% (12 patients) and 44.9% (22 patients), which was comparable to historical data, Dr. Isabelle Phuong Le reported in a poster at the American Society of Hematology Meeting on Hematologic Malignancies.

The MMR rate among those treated with dasatinib/nilotinib first line was 53%, compared with 10% for those treated with imatinib, said Dr. Le of the University of Texas Health Science Center, San Antonio.

Further the MMR rates at 12 and 24 months among those enrolled vs. not enrolled in clinical trials were 83% vs 15% and 100% vs. 45%, respectively, she noted.

Patients in the analysis were adults with a mean age of 44.6 years who had chronic phase chronic myeloid leukemia (CML). Almost half (49%) were Hispanic, and 56.9% were women. Two-thirds (66.7%) received imatinib first line, and 33.3% received dasatinib/nilotinib first line. More than a third (37.2%) were younger than age 40 years, 15% had a language barrier, and 11.7% were enrolled in clinical trials.

No differences in the MMR rates at 12 and 24 months were seen between Hispanics and non-Hispanics, those with and without language barrier, or men and women, nor were any differences seen between those with more than three lines of therapy and those with three or fewer lines of therapy, or between patients older vs. younger than 40 years, although there was a trend toward improved response rates in older patients, she noted.

“Our patients have similar MMR rates at 12 months and 24 months compared to historical data,” Dr. Le wrote, noting that the findings regarding improved MMR rates with dasatinib/nilotinib were expected.

The findings regarding improved MMR rates among those enrolled in clinical trials could be due to “selective patients as clinical trial patients, more controlled and monitored treatment, frequent follow-ups, and better education regarding disease and treatment,” she said, concluding that “ we can improve treatment response rates in our patients with better disease education.”

Dr. Le reported having no disclosures.

sworcester@frontlinemedcom.com

New guidelines on cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) set upper limits on chest compression rate and depth, add naloxone to the care of suspected opioid abusers, and remove vasopressin from the advanced cardiac life support (ACLS) algorithm.

The American Heart Association published its revised guidelines Oct. 15 in Circulation. The AHA released its previous guidelines in 2010.

©Stockbyte/thinkstockphotos.com

“Everyone has a role to play in the chain of survival – from bystanders to dispatchers, emergency responders to health care providers,” Dr. Mark Creager said in a statement. “When everyone knows their role, knows CPR, and works together, we can dramatically improve cardiac arrest victims’ chances of survival,” said Dr. Creager, AHA president and director of the Heart and Vascular Center at Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

The 2015 guidelines’ new recommendations include the following:

• Resuscitation pathways. The guidelines note that the resuscitation pathways are very different for patients who experience cardiac arrest present in either a hospital setting (IHCA) or out-of-hospital setting (OHCA). In OHCA, the patient depends on lay rescuers to not only recognize the situation but also call for help, initiate CPR, and, if available, administer defibrillation until emergency medical personnel arrive. However, IHCA involves prevention of cardiac arrest and smooth delivery of care in a multidisciplinary setting.

• Layperson CPR. Untrained lay rescuers should provide compression-only CPR for OHCA. Trained lay rescuers who are able to provide rescue breaths should begin CPR with compressions followed by breaths at a ratio of 30 compressions to two breaths. Compression-only CPR is easier to perform for untrained lay rescuers, the guidelines note, and survival rates are similar using CPR with or without rescue breaths in adult cardiac arrest with a cardiac etiology.

• Compression rate and depth. The new guidelines set upper limits on chest compression depth and heart rate, recommending a compression rate of 100-120 compressions per minute with a depth of at least 2 inches, not to exceed 2.4 inches in adults.

• Social media dispatching. Despite limited evidence, the guideline authors said that it may be reasonable for communities to use social media technologies to alert lay rescuers with mobile phones about nearby OHCA cases.

• Naloxone and opioid addiction. Also new to the guidelines is the recommended use of naloxone for patients with suspected or known opioid addiction by appropriately trained lay rescuers or basic life support (BLS) providers.

• CPR training. The guidelines highlight several changes to simplify health care provider training in CPR. For example, trained rescuers can simultaneously perform some tasks to reduce the time to initiate chest compressions. Likewise, in a team of trained rescuers, multiple steps such as activating the emergency response system, chest compression, ventilation, and defibrillator retrieval can be accomplished simultaneously.

• High-quality CPR. Finally, the guidelines focus on emphasizing high-quality CPR with adequate compression rate and depth, complete chest recoil, few interruptions to compressions, and appropriate ventilation.

The guidelines offer several changes to advanced cardiac life support (ACLS). The algorithm was simplified by removing vasopressin, because the authors note that “the combined use of vasopressin and epinephrine offers no advantage to using standard-dose epinephrine in cardiac arrest.”

Likewise, the guidelines note conflicting studies to support the use of lidocaine after return of spontaneous circulation (ROSC). “However, the initiation or continuation of lidocaine may be considered immediately after ROSC from VF/pulseless ventricular tachycardia cardiac arrest,” the guideline authors wrote. Finally, the guidelines highlight updates in post–cardiac arrest care, including a wider range of target temperatures, between 32° C and 36° C, to be maintained for at least 24 hours in comatose adults with ROSC after cardiac arrest. In comparison, the 2010 guidelines called for a target temperature range of 32° C to 34° C for 12-24 hours. The guidelines also detail new updates for acute coronary syndrome, pediatric BLS, pediatric ACLS, and neonatal resuscitation.

As the AHA updates its CPR guidelines, it’s also important for lay rescuers and health providers to update their own training, noted Dr. Clifton Callaway, chair of the AHA’s Emergency Cardiovascular Care (ECC) committee.

“Research shows resuscitation skills can decline within a few months after training – far before the 2-year period in which basic and advanced life support skills are currently evaluated,” cautioned Dr. Callaway, professor of emergency medicine at the University of Pittsburgh. “Frequent training with shorter intervals of basic and advanced cardiovascular life support skills may be helpful for providers who are likely to encounter a cardiac arrest to ensure the patient receives high-quality CPR,” he added.

New guidelines on cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) set upper limits on chest compression rate and depth, add naloxone to the care of suspected opioid abusers, and remove vasopressin from the advanced cardiac life support (ACLS) algorithm.

The American Heart Association published its revised guidelines Oct. 15 in Circulation. The AHA released its previous guidelines in 2010.

©Stockbyte/thinkstockphotos.com

“Everyone has a role to play in the chain of survival – from bystanders to dispatchers, emergency responders to health care providers,” Dr. Mark Creager said in a statement. “When everyone knows their role, knows CPR, and works together, we can dramatically improve cardiac arrest victims’ chances of survival,” said Dr. Creager, AHA president and director of the Heart and Vascular Center at Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

The 2015 guidelines’ new recommendations include the following:

• Resuscitation pathways. The guidelines note that the resuscitation pathways are very different for patients who experience cardiac arrest present in either a hospital setting (IHCA) or out-of-hospital setting (OHCA). In OHCA, the patient depends on lay rescuers to not only recognize the situation but also call for help, initiate CPR, and, if available, administer defibrillation until emergency medical personnel arrive. However, IHCA involves prevention of cardiac arrest and smooth delivery of care in a multidisciplinary setting.

• Layperson CPR. Untrained lay rescuers should provide compression-only CPR for OHCA. Trained lay rescuers who are able to provide rescue breaths should begin CPR with compressions followed by breaths at a ratio of 30 compressions to two breaths. Compression-only CPR is easier to perform for untrained lay rescuers, the guidelines note, and survival rates are similar using CPR with or without rescue breaths in adult cardiac arrest with a cardiac etiology.

• Compression rate and depth. The new guidelines set upper limits on chest compression depth and heart rate, recommending a compression rate of 100-120 compressions per minute with a depth of at least 2 inches, not to exceed 2.4 inches in adults.

• Social media dispatching. Despite limited evidence, the guideline authors said that it may be reasonable for communities to use social media technologies to alert lay rescuers with mobile phones about nearby OHCA cases.

• Naloxone and opioid addiction. Also new to the guidelines is the recommended use of naloxone for patients with suspected or known opioid addiction by appropriately trained lay rescuers or basic life support (BLS) providers.

• CPR training. The guidelines highlight several changes to simplify health care provider training in CPR. For example, trained rescuers can simultaneously perform some tasks to reduce the time to initiate chest compressions. Likewise, in a team of trained rescuers, multiple steps such as activating the emergency response system, chest compression, ventilation, and defibrillator retrieval can be accomplished simultaneously.

• High-quality CPR. Finally, the guidelines focus on emphasizing high-quality CPR with adequate compression rate and depth, complete chest recoil, few interruptions to compressions, and appropriate ventilation.

The guidelines offer several changes to advanced cardiac life support (ACLS). The algorithm was simplified by removing vasopressin, because the authors note that “the combined use of vasopressin and epinephrine offers no advantage to using standard-dose epinephrine in cardiac arrest.”

Likewise, the guidelines note conflicting studies to support the use of lidocaine after return of spontaneous circulation (ROSC). “However, the initiation or continuation of lidocaine may be considered immediately after ROSC from VF/pulseless ventricular tachycardia cardiac arrest,” the guideline authors wrote. Finally, the guidelines highlight updates in post–cardiac arrest care, including a wider range of target temperatures, between 32° C and 36° C, to be maintained for at least 24 hours in comatose adults with ROSC after cardiac arrest. In comparison, the 2010 guidelines called for a target temperature range of 32° C to 34° C for 12-24 hours. The guidelines also detail new updates for acute coronary syndrome, pediatric BLS, pediatric ACLS, and neonatal resuscitation.

As the AHA updates its CPR guidelines, it’s also important for lay rescuers and health providers to update their own training, noted Dr. Clifton Callaway, chair of the AHA’s Emergency Cardiovascular Care (ECC) committee.

“Research shows resuscitation skills can decline within a few months after training – far before the 2-year period in which basic and advanced life support skills are currently evaluated,” cautioned Dr. Callaway, professor of emergency medicine at the University of Pittsburgh. “Frequent training with shorter intervals of basic and advanced cardiovascular life support skills may be helpful for providers who are likely to encounter a cardiac arrest to ensure the patient receives high-quality CPR,” he added.

New guidelines on cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) set upper limits on chest compression rate and depth, add naloxone to the care of suspected opioid abusers, and remove vasopressin from the advanced cardiac life support (ACLS) algorithm.

The American Heart Association published its revised guidelines Oct. 15 in Circulation. The AHA released its previous guidelines in 2010.

©Stockbyte/thinkstockphotos.com

“Everyone has a role to play in the chain of survival – from bystanders to dispatchers, emergency responders to health care providers,” Dr. Mark Creager said in a statement. “When everyone knows their role, knows CPR, and works together, we can dramatically improve cardiac arrest victims’ chances of survival,” said Dr. Creager, AHA president and director of the Heart and Vascular Center at Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

The 2015 guidelines’ new recommendations include the following:

• Resuscitation pathways. The guidelines note that the resuscitation pathways are very different for patients who experience cardiac arrest present in either a hospital setting (IHCA) or out-of-hospital setting (OHCA). In OHCA, the patient depends on lay rescuers to not only recognize the situation but also call for help, initiate CPR, and, if available, administer defibrillation until emergency medical personnel arrive. However, IHCA involves prevention of cardiac arrest and smooth delivery of care in a multidisciplinary setting.

• Layperson CPR. Untrained lay rescuers should provide compression-only CPR for OHCA. Trained lay rescuers who are able to provide rescue breaths should begin CPR with compressions followed by breaths at a ratio of 30 compressions to two breaths. Compression-only CPR is easier to perform for untrained lay rescuers, the guidelines note, and survival rates are similar using CPR with or without rescue breaths in adult cardiac arrest with a cardiac etiology.

• Compression rate and depth. The new guidelines set upper limits on chest compression depth and heart rate, recommending a compression rate of 100-120 compressions per minute with a depth of at least 2 inches, not to exceed 2.4 inches in adults.

• Social media dispatching. Despite limited evidence, the guideline authors said that it may be reasonable for communities to use social media technologies to alert lay rescuers with mobile phones about nearby OHCA cases.

• Naloxone and opioid addiction. Also new to the guidelines is the recommended use of naloxone for patients with suspected or known opioid addiction by appropriately trained lay rescuers or basic life support (BLS) providers.

• CPR training. The guidelines highlight several changes to simplify health care provider training in CPR. For example, trained rescuers can simultaneously perform some tasks to reduce the time to initiate chest compressions. Likewise, in a team of trained rescuers, multiple steps such as activating the emergency response system, chest compression, ventilation, and defibrillator retrieval can be accomplished simultaneously.

• High-quality CPR. Finally, the guidelines focus on emphasizing high-quality CPR with adequate compression rate and depth, complete chest recoil, few interruptions to compressions, and appropriate ventilation.

The guidelines offer several changes to advanced cardiac life support (ACLS). The algorithm was simplified by removing vasopressin, because the authors note that “the combined use of vasopressin and epinephrine offers no advantage to using standard-dose epinephrine in cardiac arrest.”

Likewise, the guidelines note conflicting studies to support the use of lidocaine after return of spontaneous circulation (ROSC). “However, the initiation or continuation of lidocaine may be considered immediately after ROSC from VF/pulseless ventricular tachycardia cardiac arrest,” the guideline authors wrote. Finally, the guidelines highlight updates in post–cardiac arrest care, including a wider range of target temperatures, between 32° C and 36° C, to be maintained for at least 24 hours in comatose adults with ROSC after cardiac arrest. In comparison, the 2010 guidelines called for a target temperature range of 32° C to 34° C for 12-24 hours. The guidelines also detail new updates for acute coronary syndrome, pediatric BLS, pediatric ACLS, and neonatal resuscitation.

As the AHA updates its CPR guidelines, it’s also important for lay rescuers and health providers to update their own training, noted Dr. Clifton Callaway, chair of the AHA’s Emergency Cardiovascular Care (ECC) committee.

“Research shows resuscitation skills can decline within a few months after training – far before the 2-year period in which basic and advanced life support skills are currently evaluated,” cautioned Dr. Callaway, professor of emergency medicine at the University of Pittsburgh. “Frequent training with shorter intervals of basic and advanced cardiovascular life support skills may be helpful for providers who are likely to encounter a cardiac arrest to ensure the patient receives high-quality CPR,” he added.

LAS VEGAS – Though fertility declines precipitously as menopause nears, women in midlife may still conceive. Clinicians and patients need guidance to develop a rational plan for contraceptive management and a clear path to transition to menopausal symptom management, said Dr. Petra Casey at the NAMS 2015 Annual Meeting.

Dr. Casey, professor of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn., noted that the rate of infertility approaches, but does not reach, 100% by age 50, so women need a game plan to take them through the end of their fertile years. These needs are not always met, she said, noting that 75% of pregnancies in women over the age of 40 are unintended.

The rate of spontaneous abortion may exceed 50% by age 45, and chronic diabetes and hypertension are more likely to result after pregnancies in older women. The substantial increase in risk for undesirable outcomes means that an unexpected pregnancy in midlife may cause considerable distress.

No contraceptive method is contraindicated by a patient’s age alone, said Dr. Casey, though it may be wise to reserve combined hormonal contraception (CHC) for women without cardiovascular disease and thrombotic risk. Reminding the audience that risk stratification for CHC for those over 40 years of age is category 2, meaning that benefits generally outweigh the risks, Dr. Casey said, “ ‘What? So a 55-year-old can use combined hormonal contraception?’ Yes!”

Patients may also wish to consider a progestin-only contraception method, a choice that provides endometrial protection. This option allows the judicious addition of estrogen by the most appropriate method to manage symptoms. Choices include a contraceptive implant, a progestin-only pill, or a levonorgestrel-emitting intrauterine device. Depot medroxyprogesterone acetate (DMPA) may be less desirable because of the theoretical risk of bone loss, said Dr. Casey.

Transdermal estrogen delivery is preferred for menopausal doses of estrogen, according to the North American Menopause Society’s guidance for clinical care for midlife. If perimenopausal women are having cyclic vasomotor symptoms or headaches associated with estrogen nadir, transdermal estrogen therapy can be used during the menstrual week. With this option, a higher-dose patch of 0.1 mg will work better to replace endogenous estrogen.

For women who desire nonhormonal contraceptive and menopausal symptom management, a copper IUD, barrier contraception, or sterilization of the patient or her partner can be used in combination with a nonhormonal medication to manage vasomotor symptoms. Though the only Food and Drug Administration–approved nonhormonal option is paroxetine (Paxil) 7.5 mg/day, a variety of choices have been found effective in clinical trials. These include citalopram (Celexa) and escitalopram (Lexapro), venlafaxine (Effexor), desvenlafaxine (Pristiq), gabapentin (Neurontin), and pregabalin (Lyrica).

Contraception should be continued until the patient has experienced 12 months of continuous amenorrhea if over the age of 50 years, or 2 years of amenorrhea if she is younger than 50 years, said Dr. Casey. A predictive model for onset of menopause has been developed that takes age, smoking, bleeding patterns, and estrogen and follicle-stimulating hormone levels into account, but “further study is needed before applying this model clinically,” said Dr. Casey. The decision about when to discontinue contraception also depends on the impact it will have on the particular couple. “Shared decision making is of the utmost importance,” she said.

Dr. Casey disclosed that she is a certified Nexplanon trainer and has received research grant support from Merck.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – Though fertility declines precipitously as menopause nears, women in midlife may still conceive. Clinicians and patients need guidance to develop a rational plan for contraceptive management and a clear path to transition to menopausal symptom management, said Dr. Petra Casey at the NAMS 2015 Annual Meeting.

Dr. Casey, professor of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn., noted that the rate of infertility approaches, but does not reach, 100% by age 50, so women need a game plan to take them through the end of their fertile years. These needs are not always met, she said, noting that 75% of pregnancies in women over the age of 40 are unintended.

The rate of spontaneous abortion may exceed 50% by age 45, and chronic diabetes and hypertension are more likely to result after pregnancies in older women. The substantial increase in risk for undesirable outcomes means that an unexpected pregnancy in midlife may cause considerable distress.

No contraceptive method is contraindicated by a patient’s age alone, said Dr. Casey, though it may be wise to reserve combined hormonal contraception (CHC) for women without cardiovascular disease and thrombotic risk. Reminding the audience that risk stratification for CHC for those over 40 years of age is category 2, meaning that benefits generally outweigh the risks, Dr. Casey said, “ ‘What? So a 55-year-old can use combined hormonal contraception?’ Yes!”

Patients may also wish to consider a progestin-only contraception method, a choice that provides endometrial protection. This option allows the judicious addition of estrogen by the most appropriate method to manage symptoms. Choices include a contraceptive implant, a progestin-only pill, or a levonorgestrel-emitting intrauterine device. Depot medroxyprogesterone acetate (DMPA) may be less desirable because of the theoretical risk of bone loss, said Dr. Casey.

Transdermal estrogen delivery is preferred for menopausal doses of estrogen, according to the North American Menopause Society’s guidance for clinical care for midlife. If perimenopausal women are having cyclic vasomotor symptoms or headaches associated with estrogen nadir, transdermal estrogen therapy can be used during the menstrual week. With this option, a higher-dose patch of 0.1 mg will work better to replace endogenous estrogen.

For women who desire nonhormonal contraceptive and menopausal symptom management, a copper IUD, barrier contraception, or sterilization of the patient or her partner can be used in combination with a nonhormonal medication to manage vasomotor symptoms. Though the only Food and Drug Administration–approved nonhormonal option is paroxetine (Paxil) 7.5 mg/day, a variety of choices have been found effective in clinical trials. These include citalopram (Celexa) and escitalopram (Lexapro), venlafaxine (Effexor), desvenlafaxine (Pristiq), gabapentin (Neurontin), and pregabalin (Lyrica).

Contraception should be continued until the patient has experienced 12 months of continuous amenorrhea if over the age of 50 years, or 2 years of amenorrhea if she is younger than 50 years, said Dr. Casey. A predictive model for onset of menopause has been developed that takes age, smoking, bleeding patterns, and estrogen and follicle-stimulating hormone levels into account, but “further study is needed before applying this model clinically,” said Dr. Casey. The decision about when to discontinue contraception also depends on the impact it will have on the particular couple. “Shared decision making is of the utmost importance,” she said.

Dr. Casey disclosed that she is a certified Nexplanon trainer and has received research grant support from Merck.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – Though fertility declines precipitously as menopause nears, women in midlife may still conceive. Clinicians and patients need guidance to develop a rational plan for contraceptive management and a clear path to transition to menopausal symptom management, said Dr. Petra Casey at the NAMS 2015 Annual Meeting.

Dr. Casey, professor of obstetrics and gynecology at the Mayo Clinic, Rochester, Minn., noted that the rate of infertility approaches, but does not reach, 100% by age 50, so women need a game plan to take them through the end of their fertile years. These needs are not always met, she said, noting that 75% of pregnancies in women over the age of 40 are unintended.

The rate of spontaneous abortion may exceed 50% by age 45, and chronic diabetes and hypertension are more likely to result after pregnancies in older women. The substantial increase in risk for undesirable outcomes means that an unexpected pregnancy in midlife may cause considerable distress.

No contraceptive method is contraindicated by a patient’s age alone, said Dr. Casey, though it may be wise to reserve combined hormonal contraception (CHC) for women without cardiovascular disease and thrombotic risk. Reminding the audience that risk stratification for CHC for those over 40 years of age is category 2, meaning that benefits generally outweigh the risks, Dr. Casey said, “ ‘What? So a 55-year-old can use combined hormonal contraception?’ Yes!”

Patients may also wish to consider a progestin-only contraception method, a choice that provides endometrial protection. This option allows the judicious addition of estrogen by the most appropriate method to manage symptoms. Choices include a contraceptive implant, a progestin-only pill, or a levonorgestrel-emitting intrauterine device. Depot medroxyprogesterone acetate (DMPA) may be less desirable because of the theoretical risk of bone loss, said Dr. Casey.

Transdermal estrogen delivery is preferred for menopausal doses of estrogen, according to the North American Menopause Society’s guidance for clinical care for midlife. If perimenopausal women are having cyclic vasomotor symptoms or headaches associated with estrogen nadir, transdermal estrogen therapy can be used during the menstrual week. With this option, a higher-dose patch of 0.1 mg will work better to replace endogenous estrogen.

For women who desire nonhormonal contraceptive and menopausal symptom management, a copper IUD, barrier contraception, or sterilization of the patient or her partner can be used in combination with a nonhormonal medication to manage vasomotor symptoms. Though the only Food and Drug Administration–approved nonhormonal option is paroxetine (Paxil) 7.5 mg/day, a variety of choices have been found effective in clinical trials. These include citalopram (Celexa) and escitalopram (Lexapro), venlafaxine (Effexor), desvenlafaxine (Pristiq), gabapentin (Neurontin), and pregabalin (Lyrica).

Contraception should be continued until the patient has experienced 12 months of continuous amenorrhea if over the age of 50 years, or 2 years of amenorrhea if she is younger than 50 years, said Dr. Casey. A predictive model for onset of menopause has been developed that takes age, smoking, bleeding patterns, and estrogen and follicle-stimulating hormone levels into account, but “further study is needed before applying this model clinically,” said Dr. Casey. The decision about when to discontinue contraception also depends on the impact it will have on the particular couple. “Shared decision making is of the utmost importance,” she said.

Dr. Casey disclosed that she is a certified Nexplanon trainer and has received research grant support from Merck.

koakes@frontlinemedcom.com

On Twitter @karioakes

What Matters prides itself on reviewing the literature and presenting thoughtful commentary on articles that are relevant and applicable to the practicing clinician. We separate the wheat from the chaff. We are not, however, above taking on attention-grabbing articles.

Over the years, this column has reported on various methods to facilitate the expulsion of kidney stones, including tamsulosin, phosphodiesterase type 5 (PDE5) inhibitors, and steroids. But this one called out for our assessment: sex to expel kidney stones. Erroneously perceived prurient interests must be forgiven.

Dr. Omer Gokhan Doluoglu of the Clinic of Ankara (Turkey) Training and Research Hospital and colleagues conducted a randomized trial evaluating the effectiveness of sexual intercourse, tamsulosin, or standard medical therapy for kidney stone expulsion (Urology. 2015;86[1]:19-24). Potential subjects were eligible for inclusion if they had radiopaque distal ureteral stones. Subjects were excluded if the stones were larger than 6 mm.

Subjects were randomized to encouragement to have sexual intercourse at least three times per week, tamsulosin 0.4 mg/day, or symptomatic therapy alone. All patients received an antispasmodic and an anti-inflammatory, and were told to drink 2 L of water per day. Sexual intercourse and masturbation were prohibited in groups 2 and 3 during the treatment period, which lasted 4 weeks.

Ninety patients were randomized to the three groups. The mean stone size was 4.7-5.0 mm and not significantly different between the groups.

At 2 weeks, 83.9% (26 of 31) of the patients in the intercourse group, 47.6% (10 of 21) in the tamsulosin group, and 34.8% (8 of 23) passed the stones (P = .001). There was no difference between the groups at 4 weeks. Mean expulsion times were 10 days, 16.6 days, and 18 days, respectively (P = .0001).

The study’s authors propose that nitrous oxide is operant here by causing ureteric relaxation when released to create penile tumescence and during sexual activity. Because masturbation could achieve the same effect, patients in the other groups were told they could not. How effective this instruction was in the current study is unknown, because only “sexual intercourses” were collected on follow-up.

The random-envelope method used is less than ideal, and no data were reported on differences in the number of sexual experiences between groups. If we assume for a moment that a real effect exists, one is left wondering if more would be better. Does the requirement of a partner decrease the likelihood of more frequent stone-expelling sexual experiences? If our patients do not have sexual partners, do we not share these data with them?

And if we use PDE5 inhibitors and encourage sexual activity, do we … kill two birds with one stone?

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

What Matters prides itself on reviewing the literature and presenting thoughtful commentary on articles that are relevant and applicable to the practicing clinician. We separate the wheat from the chaff. We are not, however, above taking on attention-grabbing articles.

Over the years, this column has reported on various methods to facilitate the expulsion of kidney stones, including tamsulosin, phosphodiesterase type 5 (PDE5) inhibitors, and steroids. But this one called out for our assessment: sex to expel kidney stones. Erroneously perceived prurient interests must be forgiven.

Dr. Omer Gokhan Doluoglu of the Clinic of Ankara (Turkey) Training and Research Hospital and colleagues conducted a randomized trial evaluating the effectiveness of sexual intercourse, tamsulosin, or standard medical therapy for kidney stone expulsion (Urology. 2015;86[1]:19-24). Potential subjects were eligible for inclusion if they had radiopaque distal ureteral stones. Subjects were excluded if the stones were larger than 6 mm.

Subjects were randomized to encouragement to have sexual intercourse at least three times per week, tamsulosin 0.4 mg/day, or symptomatic therapy alone. All patients received an antispasmodic and an anti-inflammatory, and were told to drink 2 L of water per day. Sexual intercourse and masturbation were prohibited in groups 2 and 3 during the treatment period, which lasted 4 weeks.

Ninety patients were randomized to the three groups. The mean stone size was 4.7-5.0 mm and not significantly different between the groups.

At 2 weeks, 83.9% (26 of 31) of the patients in the intercourse group, 47.6% (10 of 21) in the tamsulosin group, and 34.8% (8 of 23) passed the stones (P = .001). There was no difference between the groups at 4 weeks. Mean expulsion times were 10 days, 16.6 days, and 18 days, respectively (P = .0001).

The study’s authors propose that nitrous oxide is operant here by causing ureteric relaxation when released to create penile tumescence and during sexual activity. Because masturbation could achieve the same effect, patients in the other groups were told they could not. How effective this instruction was in the current study is unknown, because only “sexual intercourses” were collected on follow-up.

The random-envelope method used is less than ideal, and no data were reported on differences in the number of sexual experiences between groups. If we assume for a moment that a real effect exists, one is left wondering if more would be better. Does the requirement of a partner decrease the likelihood of more frequent stone-expelling sexual experiences? If our patients do not have sexual partners, do we not share these data with them?

And if we use PDE5 inhibitors and encourage sexual activity, do we … kill two birds with one stone?

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

What Matters prides itself on reviewing the literature and presenting thoughtful commentary on articles that are relevant and applicable to the practicing clinician. We separate the wheat from the chaff. We are not, however, above taking on attention-grabbing articles.

Over the years, this column has reported on various methods to facilitate the expulsion of kidney stones, including tamsulosin, phosphodiesterase type 5 (PDE5) inhibitors, and steroids. But this one called out for our assessment: sex to expel kidney stones. Erroneously perceived prurient interests must be forgiven.

Dr. Omer Gokhan Doluoglu of the Clinic of Ankara (Turkey) Training and Research Hospital and colleagues conducted a randomized trial evaluating the effectiveness of sexual intercourse, tamsulosin, or standard medical therapy for kidney stone expulsion (Urology. 2015;86[1]:19-24). Potential subjects were eligible for inclusion if they had radiopaque distal ureteral stones. Subjects were excluded if the stones were larger than 6 mm.

Subjects were randomized to encouragement to have sexual intercourse at least three times per week, tamsulosin 0.4 mg/day, or symptomatic therapy alone. All patients received an antispasmodic and an anti-inflammatory, and were told to drink 2 L of water per day. Sexual intercourse and masturbation were prohibited in groups 2 and 3 during the treatment period, which lasted 4 weeks.

Ninety patients were randomized to the three groups. The mean stone size was 4.7-5.0 mm and not significantly different between the groups.

At 2 weeks, 83.9% (26 of 31) of the patients in the intercourse group, 47.6% (10 of 21) in the tamsulosin group, and 34.8% (8 of 23) passed the stones (P = .001). There was no difference between the groups at 4 weeks. Mean expulsion times were 10 days, 16.6 days, and 18 days, respectively (P = .0001).

The study’s authors propose that nitrous oxide is operant here by causing ureteric relaxation when released to create penile tumescence and during sexual activity. Because masturbation could achieve the same effect, patients in the other groups were told they could not. How effective this instruction was in the current study is unknown, because only “sexual intercourses” were collected on follow-up.

The random-envelope method used is less than ideal, and no data were reported on differences in the number of sexual experiences between groups. If we assume for a moment that a real effect exists, one is left wondering if more would be better. Does the requirement of a partner decrease the likelihood of more frequent stone-expelling sexual experiences? If our patients do not have sexual partners, do we not share these data with them?

And if we use PDE5 inhibitors and encourage sexual activity, do we … kill two birds with one stone?

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.