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Heart failure risk with individual NSAIDs examined in study
Nine popular painkillers – including traditional NSAIDs and cyclo-oxygenase-2 (COX-2) inhibitors – are associated with an increased risk of hospitalization for heart failure in adults, based on data from a case-control study of approximately 92,000 hospital admissions. The findings were published online Sept. 28 in BMJ.
Although data from previous large studies suggest that high doses of NSAIDs as well as COX-2 inhibitors increase the risk of hospital admission for heart failure, “there is still limited information on the risk of heart failure associated with the use of individual NSAIDs in clinical practice,” wrote Andrea Arfè of the University of Milano-Bicocca, Milan, and his colleagues (BMJ. 2016 Sep;354:i4857 doi: 10.1136/bmj.i4857).
The researchers reviewed data from five electronic health databases in the Netherlands, Italy, Germany, and the United Kingdom as part of the SOS (Safety of Non-Steroidal Anti-Inflammatory Drugs) project and conducted a nested, case-control study including 92,163 hospital admissions for heart failure and 8,246,403 controls matched for age, sex, and year of study entry. The study included 23 traditional NSAIDs and four selective COX-2 inhibitors.
Overall, individual use of any of nine different NSAIDs within 14 days was associated with a nearly 20% higher likelihood of hospital admission for heart failure, compared with NSAID use more than 183 days in the past (odds ratio, 1.19). For seven traditional NSAIDS (diclofenac, ibuprofen, indomethacin, ketorolac, naproxen, nimesulide, and piroxicam) and the COX-2 inhibitors etoricoxib and rofecoxib, the odds ratios for heart failure with current use ranged from 1.16 for naproxen to 1.83 for ketorolac, compared with past use.
In addition, the odds of hospitalization for heart failure doubled for diclofenac, etoricoxib, indomethacin, piroxicam, and rofecoxib when dosed at two or more daily dose equivalents, the researchers noted. There was no increase in the odds of hospitalization for heart failure with celecoxib when dosed at standard levels, but “indomethacin and etoricoxib seemed to increase the risk of hospital admission for heart failure, even if used at medium doses,” they said. Other lesser-used NSAIDs were associated with an increased risk, but it was not statistically significant.
“The effect of individual NSAIDs could depend on a complex interaction of pharmacological properties, including duration and extent of platelet inhibition, extent of blood pressure increase, and properties possibly unique to the molecule,” the researchers said.
The findings were limited by several factors including misclassification of outcomes and the observational nature of the study, which prevents conclusions about cause and effect, the researchers noted. However, “Because any potential increased risk could have a considerable impact on public health, the risk effect estimates provided by this study may help inform both clinical practice and regulatory activities,” they said.
The study was funded in part by the European Community’s seventh Framework Programme. Mr. Arfè had no financial conflicts to disclose. Several study coauthors disclosed relationships with multiple companies including AstraZeneca, Bayer, Celgene, GlaxoSmithKline, Schwabe, and Novartis.
This report provides additional weight backing the association between increased risk of heart failure with NSAID use and gives better insight on the dose-response relationship between individual NSAIDs and heart failure. However, beyond that, its clinical impact is hurt by the lack of data on the magnitude of excess absolute risk of heart failure with NSAID use, which varies according to baseline cardiovascular risk.
Even though the risk of heart failure associated with NSAID use in the study occurred independent of a history of heart failure, it still is prudent to restrict NSAID use in patients with heart failure because of the high risk noted in this group in other studies.
The widespread use and ease of access to NSAIDs fuels the common misconception that NSAIDs are harmless drugs that are safe for everyone, and this warrants a more restrictive policy by regulatory authorities on the availability of NSAIDs and requirements for health care professionals providing advice on their use.
Gunnar H. Gislason, MD, PhD, is a professor of cardiology at Copenhagen University Hospital Herlev and Gentofte, Denmark, and Christian Torp-Pedersen, MD, is a professor of cardiology at Aalborg (Denmark) University. Dr. Gislason had no disclosures and Dr. Torp-Pedersen advises Bayer on anticoagulation for atrial fibrillation. Their remarks are taken from an editorial accompanying the study by Mr. Arfè and his colleagues (BMJ. 2016 Sep;354:i5163 doi: 10.1136/bmj.i5163).
This report provides additional weight backing the association between increased risk of heart failure with NSAID use and gives better insight on the dose-response relationship between individual NSAIDs and heart failure. However, beyond that, its clinical impact is hurt by the lack of data on the magnitude of excess absolute risk of heart failure with NSAID use, which varies according to baseline cardiovascular risk.
Even though the risk of heart failure associated with NSAID use in the study occurred independent of a history of heart failure, it still is prudent to restrict NSAID use in patients with heart failure because of the high risk noted in this group in other studies.
The widespread use and ease of access to NSAIDs fuels the common misconception that NSAIDs are harmless drugs that are safe for everyone, and this warrants a more restrictive policy by regulatory authorities on the availability of NSAIDs and requirements for health care professionals providing advice on their use.
Gunnar H. Gislason, MD, PhD, is a professor of cardiology at Copenhagen University Hospital Herlev and Gentofte, Denmark, and Christian Torp-Pedersen, MD, is a professor of cardiology at Aalborg (Denmark) University. Dr. Gislason had no disclosures and Dr. Torp-Pedersen advises Bayer on anticoagulation for atrial fibrillation. Their remarks are taken from an editorial accompanying the study by Mr. Arfè and his colleagues (BMJ. 2016 Sep;354:i5163 doi: 10.1136/bmj.i5163).
This report provides additional weight backing the association between increased risk of heart failure with NSAID use and gives better insight on the dose-response relationship between individual NSAIDs and heart failure. However, beyond that, its clinical impact is hurt by the lack of data on the magnitude of excess absolute risk of heart failure with NSAID use, which varies according to baseline cardiovascular risk.
Even though the risk of heart failure associated with NSAID use in the study occurred independent of a history of heart failure, it still is prudent to restrict NSAID use in patients with heart failure because of the high risk noted in this group in other studies.
The widespread use and ease of access to NSAIDs fuels the common misconception that NSAIDs are harmless drugs that are safe for everyone, and this warrants a more restrictive policy by regulatory authorities on the availability of NSAIDs and requirements for health care professionals providing advice on their use.
Gunnar H. Gislason, MD, PhD, is a professor of cardiology at Copenhagen University Hospital Herlev and Gentofte, Denmark, and Christian Torp-Pedersen, MD, is a professor of cardiology at Aalborg (Denmark) University. Dr. Gislason had no disclosures and Dr. Torp-Pedersen advises Bayer on anticoagulation for atrial fibrillation. Their remarks are taken from an editorial accompanying the study by Mr. Arfè and his colleagues (BMJ. 2016 Sep;354:i5163 doi: 10.1136/bmj.i5163).
Nine popular painkillers – including traditional NSAIDs and cyclo-oxygenase-2 (COX-2) inhibitors – are associated with an increased risk of hospitalization for heart failure in adults, based on data from a case-control study of approximately 92,000 hospital admissions. The findings were published online Sept. 28 in BMJ.
Although data from previous large studies suggest that high doses of NSAIDs as well as COX-2 inhibitors increase the risk of hospital admission for heart failure, “there is still limited information on the risk of heart failure associated with the use of individual NSAIDs in clinical practice,” wrote Andrea Arfè of the University of Milano-Bicocca, Milan, and his colleagues (BMJ. 2016 Sep;354:i4857 doi: 10.1136/bmj.i4857).
The researchers reviewed data from five electronic health databases in the Netherlands, Italy, Germany, and the United Kingdom as part of the SOS (Safety of Non-Steroidal Anti-Inflammatory Drugs) project and conducted a nested, case-control study including 92,163 hospital admissions for heart failure and 8,246,403 controls matched for age, sex, and year of study entry. The study included 23 traditional NSAIDs and four selective COX-2 inhibitors.
Overall, individual use of any of nine different NSAIDs within 14 days was associated with a nearly 20% higher likelihood of hospital admission for heart failure, compared with NSAID use more than 183 days in the past (odds ratio, 1.19). For seven traditional NSAIDS (diclofenac, ibuprofen, indomethacin, ketorolac, naproxen, nimesulide, and piroxicam) and the COX-2 inhibitors etoricoxib and rofecoxib, the odds ratios for heart failure with current use ranged from 1.16 for naproxen to 1.83 for ketorolac, compared with past use.
In addition, the odds of hospitalization for heart failure doubled for diclofenac, etoricoxib, indomethacin, piroxicam, and rofecoxib when dosed at two or more daily dose equivalents, the researchers noted. There was no increase in the odds of hospitalization for heart failure with celecoxib when dosed at standard levels, but “indomethacin and etoricoxib seemed to increase the risk of hospital admission for heart failure, even if used at medium doses,” they said. Other lesser-used NSAIDs were associated with an increased risk, but it was not statistically significant.
“The effect of individual NSAIDs could depend on a complex interaction of pharmacological properties, including duration and extent of platelet inhibition, extent of blood pressure increase, and properties possibly unique to the molecule,” the researchers said.
The findings were limited by several factors including misclassification of outcomes and the observational nature of the study, which prevents conclusions about cause and effect, the researchers noted. However, “Because any potential increased risk could have a considerable impact on public health, the risk effect estimates provided by this study may help inform both clinical practice and regulatory activities,” they said.
The study was funded in part by the European Community’s seventh Framework Programme. Mr. Arfè had no financial conflicts to disclose. Several study coauthors disclosed relationships with multiple companies including AstraZeneca, Bayer, Celgene, GlaxoSmithKline, Schwabe, and Novartis.
Nine popular painkillers – including traditional NSAIDs and cyclo-oxygenase-2 (COX-2) inhibitors – are associated with an increased risk of hospitalization for heart failure in adults, based on data from a case-control study of approximately 92,000 hospital admissions. The findings were published online Sept. 28 in BMJ.
Although data from previous large studies suggest that high doses of NSAIDs as well as COX-2 inhibitors increase the risk of hospital admission for heart failure, “there is still limited information on the risk of heart failure associated with the use of individual NSAIDs in clinical practice,” wrote Andrea Arfè of the University of Milano-Bicocca, Milan, and his colleagues (BMJ. 2016 Sep;354:i4857 doi: 10.1136/bmj.i4857).
The researchers reviewed data from five electronic health databases in the Netherlands, Italy, Germany, and the United Kingdom as part of the SOS (Safety of Non-Steroidal Anti-Inflammatory Drugs) project and conducted a nested, case-control study including 92,163 hospital admissions for heart failure and 8,246,403 controls matched for age, sex, and year of study entry. The study included 23 traditional NSAIDs and four selective COX-2 inhibitors.
Overall, individual use of any of nine different NSAIDs within 14 days was associated with a nearly 20% higher likelihood of hospital admission for heart failure, compared with NSAID use more than 183 days in the past (odds ratio, 1.19). For seven traditional NSAIDS (diclofenac, ibuprofen, indomethacin, ketorolac, naproxen, nimesulide, and piroxicam) and the COX-2 inhibitors etoricoxib and rofecoxib, the odds ratios for heart failure with current use ranged from 1.16 for naproxen to 1.83 for ketorolac, compared with past use.
In addition, the odds of hospitalization for heart failure doubled for diclofenac, etoricoxib, indomethacin, piroxicam, and rofecoxib when dosed at two or more daily dose equivalents, the researchers noted. There was no increase in the odds of hospitalization for heart failure with celecoxib when dosed at standard levels, but “indomethacin and etoricoxib seemed to increase the risk of hospital admission for heart failure, even if used at medium doses,” they said. Other lesser-used NSAIDs were associated with an increased risk, but it was not statistically significant.
“The effect of individual NSAIDs could depend on a complex interaction of pharmacological properties, including duration and extent of platelet inhibition, extent of blood pressure increase, and properties possibly unique to the molecule,” the researchers said.
The findings were limited by several factors including misclassification of outcomes and the observational nature of the study, which prevents conclusions about cause and effect, the researchers noted. However, “Because any potential increased risk could have a considerable impact on public health, the risk effect estimates provided by this study may help inform both clinical practice and regulatory activities,” they said.
The study was funded in part by the European Community’s seventh Framework Programme. Mr. Arfè had no financial conflicts to disclose. Several study coauthors disclosed relationships with multiple companies including AstraZeneca, Bayer, Celgene, GlaxoSmithKline, Schwabe, and Novartis.
FROM BMJ
Key clinical point: Patients taking high doses of certain NSAIDS had significantly higher odds of hospital admission for heart failure, compared with controls not currently taking the medications.
Major finding: The odds of hospitalization for heart failure increased by 19% overall for adults currently using certain NSAIDS and doubled for users of certain NSAIDs at high doses.
Data source: The data come from approximately 10 million hospital admissions taken from databases in the Netherlands, Italy, Germany, and the United Kingdom.
Disclosures: The study was funded in part by the European Community’s seventh Framework Programme. Mr. Arfè had no financial conflicts to disclose. Several study coauthors disclosed relationships with multiple companies including AstraZeneca, Bayer, Celgene, GlaxoSmithKline, Schwabe, and Novartis.
MRSA patients report signs of stigma tied to illness
About half of individuals infected with methicillin-resistant Staphylococcus aureus report feeling stigmatized in interactions with hospital staff, data from a survey of 61 adult patients show.
“Hospital care for people who carry MRSA calls for a dedicated and patient-centered approach in both the way the care is delivered ... as well as the way the care is organized at the institutional level,” wrote Babette Rump, MD, of the Regional Health Service Utrecht region, Zeist, the Netherlands, and her coauthors (J Hosp Infect. 2016. doi: 10.1016/j.jhin.2016.09.010). “Prevention of unnecessary intrusive measures, while as the same time applying appropriate precautionary measures, is key to successful and respectful MRSA management.”
Dr. Rump and her associates set out to identify and quantify stigma tied to MRSA and “explore its association with mental health within a country with a MRSA ‘search and destroy’ policy.” In the Netherlands and Scandinavian countries, this policy includes isolating MRSA carriers, wearing personal protective equipment, and disinfecting the room after patients are discharged (Antimicrob Resist Infect Control. 2014 Jan 15;3[1]3). The U.S. Centers for Disease Control and Prevention, in its 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, recommends similar methods, including application of infection control precautions during patient care and environmental measures, such as cleaning and disinfection of the patient care environment and dedicated single-patient use of noncritical equipment.
In the current study, 60-item questionnaires were provided to all adult patients at two hospitals and two regional health services who had acquired MRSA between Oct. 1, 2013, and April 1, 2014. Stigma was assessed using the 40-item Berger HIV Stigma Scale, reported Dr. Rump.
Overall, 56% of survey respondents reported stigma, including 14% who reported clear stigma and 42% who reported suggestive stigma. The remaining 44% reported no stigma. A total of 80% of the patients received MRSA eradication treatment, which was strongly associated with higher stigma, the researchers noted.
Written comments provided by 40 patients (68%) along with the questionnaires “offer valuable insights to set the focus for improvement,” the researchers said.
The most frequent comments involved patients’ perceived organizational problems with the hospital (8 patients), lack of staff knowledge (4 patients), as well as little attention paid to patient perspectives (4 patients) and unnecessarily intrusive treatments (3 patients). Also of note, 5 patients blamed and 2 “shamed” the hospital as their source of MRSA.
The results were limited by several factors, including the small study size, the researchers wrote. However, the findings suggest that “a substantial proportion of people that carry MRSA experience signs of stigma and that anticipation on MRSA-associated stigma is warranted,” they said.
The researchers had no financial conflicts to disclose.
About half of individuals infected with methicillin-resistant Staphylococcus aureus report feeling stigmatized in interactions with hospital staff, data from a survey of 61 adult patients show.
“Hospital care for people who carry MRSA calls for a dedicated and patient-centered approach in both the way the care is delivered ... as well as the way the care is organized at the institutional level,” wrote Babette Rump, MD, of the Regional Health Service Utrecht region, Zeist, the Netherlands, and her coauthors (J Hosp Infect. 2016. doi: 10.1016/j.jhin.2016.09.010). “Prevention of unnecessary intrusive measures, while as the same time applying appropriate precautionary measures, is key to successful and respectful MRSA management.”
Dr. Rump and her associates set out to identify and quantify stigma tied to MRSA and “explore its association with mental health within a country with a MRSA ‘search and destroy’ policy.” In the Netherlands and Scandinavian countries, this policy includes isolating MRSA carriers, wearing personal protective equipment, and disinfecting the room after patients are discharged (Antimicrob Resist Infect Control. 2014 Jan 15;3[1]3). The U.S. Centers for Disease Control and Prevention, in its 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, recommends similar methods, including application of infection control precautions during patient care and environmental measures, such as cleaning and disinfection of the patient care environment and dedicated single-patient use of noncritical equipment.
In the current study, 60-item questionnaires were provided to all adult patients at two hospitals and two regional health services who had acquired MRSA between Oct. 1, 2013, and April 1, 2014. Stigma was assessed using the 40-item Berger HIV Stigma Scale, reported Dr. Rump.
Overall, 56% of survey respondents reported stigma, including 14% who reported clear stigma and 42% who reported suggestive stigma. The remaining 44% reported no stigma. A total of 80% of the patients received MRSA eradication treatment, which was strongly associated with higher stigma, the researchers noted.
Written comments provided by 40 patients (68%) along with the questionnaires “offer valuable insights to set the focus for improvement,” the researchers said.
The most frequent comments involved patients’ perceived organizational problems with the hospital (8 patients), lack of staff knowledge (4 patients), as well as little attention paid to patient perspectives (4 patients) and unnecessarily intrusive treatments (3 patients). Also of note, 5 patients blamed and 2 “shamed” the hospital as their source of MRSA.
The results were limited by several factors, including the small study size, the researchers wrote. However, the findings suggest that “a substantial proportion of people that carry MRSA experience signs of stigma and that anticipation on MRSA-associated stigma is warranted,” they said.
The researchers had no financial conflicts to disclose.
About half of individuals infected with methicillin-resistant Staphylococcus aureus report feeling stigmatized in interactions with hospital staff, data from a survey of 61 adult patients show.
“Hospital care for people who carry MRSA calls for a dedicated and patient-centered approach in both the way the care is delivered ... as well as the way the care is organized at the institutional level,” wrote Babette Rump, MD, of the Regional Health Service Utrecht region, Zeist, the Netherlands, and her coauthors (J Hosp Infect. 2016. doi: 10.1016/j.jhin.2016.09.010). “Prevention of unnecessary intrusive measures, while as the same time applying appropriate precautionary measures, is key to successful and respectful MRSA management.”
Dr. Rump and her associates set out to identify and quantify stigma tied to MRSA and “explore its association with mental health within a country with a MRSA ‘search and destroy’ policy.” In the Netherlands and Scandinavian countries, this policy includes isolating MRSA carriers, wearing personal protective equipment, and disinfecting the room after patients are discharged (Antimicrob Resist Infect Control. 2014 Jan 15;3[1]3). The U.S. Centers for Disease Control and Prevention, in its 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, recommends similar methods, including application of infection control precautions during patient care and environmental measures, such as cleaning and disinfection of the patient care environment and dedicated single-patient use of noncritical equipment.
In the current study, 60-item questionnaires were provided to all adult patients at two hospitals and two regional health services who had acquired MRSA between Oct. 1, 2013, and April 1, 2014. Stigma was assessed using the 40-item Berger HIV Stigma Scale, reported Dr. Rump.
Overall, 56% of survey respondents reported stigma, including 14% who reported clear stigma and 42% who reported suggestive stigma. The remaining 44% reported no stigma. A total of 80% of the patients received MRSA eradication treatment, which was strongly associated with higher stigma, the researchers noted.
Written comments provided by 40 patients (68%) along with the questionnaires “offer valuable insights to set the focus for improvement,” the researchers said.
The most frequent comments involved patients’ perceived organizational problems with the hospital (8 patients), lack of staff knowledge (4 patients), as well as little attention paid to patient perspectives (4 patients) and unnecessarily intrusive treatments (3 patients). Also of note, 5 patients blamed and 2 “shamed” the hospital as their source of MRSA.
The results were limited by several factors, including the small study size, the researchers wrote. However, the findings suggest that “a substantial proportion of people that carry MRSA experience signs of stigma and that anticipation on MRSA-associated stigma is warranted,” they said.
The researchers had no financial conflicts to disclose.
FROM THE JOURNAL OF HOSPITAL INFECTION
Key clinical point: Adults with methicillin-resistant Staphylococcus aureus (MRSA) are susceptible to stigma.
Major finding: Approximately half (56%) of adults being treated for MRSA reported stigma associated with their illness.
Data source: A cross-sectional study including 61 adults with MRSA.
Disclosures: The researchers had no financial conflicts to disclose.
Cutting routine glucometer readings saves time and money
Eliminating routine glucometer readings makes primary care visits more efficient, according to a 6-month review of activity at a primary care clinic. The results were published online Sept. 26 in JAMA Internal Medicine.
“The routine tasks that are components of rooming the clinic patient are increasing in number,” wrote James L Wofford, MD, of Wake Forest University, Winston-Salem, N.C., and his colleagues (JAMA Intern Med. 2016 Sep 26. doi: 10.1001/jamainternmed.2016.5769). Routine glucometer readings are costly in terms of time, money, and mental energy of clinicians, and do not add value, they wrote.
The researchers compared data from a primary care clinic in North Carolina for 3 months before and 3 months after the clinic eliminated routine glucometer readings (Jan. 1, 2015, to March 15, 2015, and March 16, 2015, to June 30, 2015). After a 1-week trial during which no routine clinical glucometry was performed, the option remained available at the request of a nurse or patient.
The number of glucometer readings decreased from approximately 400 per month to 100 per month after the change in policy, yielded a cost savings of at least $2,000 per month, and time saving of 25 hours of nursing time per month.
“Despite the fear of missing an occasional markedly elevated glucose level, clinicians gradually grew comfortable and never reconsidered reinstitution of routine glucometer readings,” Dr. Wofford and his associates wrote. However, some patient education was needed to reassure those who were disappointed by the change.
“As important as the lesson that routine glucometer readings in the clinic is a wasteful practice, the more important lesson is that examining office routines for foolish consistencies should be a regular component of making primary care more efficient,” the researchers added.
They had no financial conflicts to disclose.
Cutting down on unnecessary procedures allows primary care physicians to optimize their time with patients, and curbing routine glucose testing saves time and money, Adam J. Schoenfeld, MD, and Patrick G. O’Malley, MD, wrote in an editorial.
“Changing this policy to leave glucose testing to the discretion of the patient and nurse resulted in a decrease of 300 glucometer tests per month, saving the clinic $2, 000 and 25 hours of nursing time,” they wrote.
“Patients without infectious symptoms likely do not need their temperature taken, and we probably do not need to elicit a pain severity scale in patients without an active complaint of pain,” they noted. “Instead, other issues could take priority, such as medication reconciliation; collection of important psychosocial information, such as screening for commonly undiagnosed illnesses like depression; discussing advanced directives; and preparing the patient to be more active and engaged in addressing their agenda for the visit.”
Dr. Schoenfeld is affiliated with the University of California, San Francisco, and Dr. O’Malley is associated with the Uniformed Services University, Bethesda, Md. They had no financial conflicts to disclose.
Cutting down on unnecessary procedures allows primary care physicians to optimize their time with patients, and curbing routine glucose testing saves time and money, Adam J. Schoenfeld, MD, and Patrick G. O’Malley, MD, wrote in an editorial.
“Changing this policy to leave glucose testing to the discretion of the patient and nurse resulted in a decrease of 300 glucometer tests per month, saving the clinic $2, 000 and 25 hours of nursing time,” they wrote.
“Patients without infectious symptoms likely do not need their temperature taken, and we probably do not need to elicit a pain severity scale in patients without an active complaint of pain,” they noted. “Instead, other issues could take priority, such as medication reconciliation; collection of important psychosocial information, such as screening for commonly undiagnosed illnesses like depression; discussing advanced directives; and preparing the patient to be more active and engaged in addressing their agenda for the visit.”
Dr. Schoenfeld is affiliated with the University of California, San Francisco, and Dr. O’Malley is associated with the Uniformed Services University, Bethesda, Md. They had no financial conflicts to disclose.
Cutting down on unnecessary procedures allows primary care physicians to optimize their time with patients, and curbing routine glucose testing saves time and money, Adam J. Schoenfeld, MD, and Patrick G. O’Malley, MD, wrote in an editorial.
“Changing this policy to leave glucose testing to the discretion of the patient and nurse resulted in a decrease of 300 glucometer tests per month, saving the clinic $2, 000 and 25 hours of nursing time,” they wrote.
“Patients without infectious symptoms likely do not need their temperature taken, and we probably do not need to elicit a pain severity scale in patients without an active complaint of pain,” they noted. “Instead, other issues could take priority, such as medication reconciliation; collection of important psychosocial information, such as screening for commonly undiagnosed illnesses like depression; discussing advanced directives; and preparing the patient to be more active and engaged in addressing their agenda for the visit.”
Dr. Schoenfeld is affiliated with the University of California, San Francisco, and Dr. O’Malley is associated with the Uniformed Services University, Bethesda, Md. They had no financial conflicts to disclose.
Eliminating routine glucometer readings makes primary care visits more efficient, according to a 6-month review of activity at a primary care clinic. The results were published online Sept. 26 in JAMA Internal Medicine.
“The routine tasks that are components of rooming the clinic patient are increasing in number,” wrote James L Wofford, MD, of Wake Forest University, Winston-Salem, N.C., and his colleagues (JAMA Intern Med. 2016 Sep 26. doi: 10.1001/jamainternmed.2016.5769). Routine glucometer readings are costly in terms of time, money, and mental energy of clinicians, and do not add value, they wrote.
The researchers compared data from a primary care clinic in North Carolina for 3 months before and 3 months after the clinic eliminated routine glucometer readings (Jan. 1, 2015, to March 15, 2015, and March 16, 2015, to June 30, 2015). After a 1-week trial during which no routine clinical glucometry was performed, the option remained available at the request of a nurse or patient.
The number of glucometer readings decreased from approximately 400 per month to 100 per month after the change in policy, yielded a cost savings of at least $2,000 per month, and time saving of 25 hours of nursing time per month.
“Despite the fear of missing an occasional markedly elevated glucose level, clinicians gradually grew comfortable and never reconsidered reinstitution of routine glucometer readings,” Dr. Wofford and his associates wrote. However, some patient education was needed to reassure those who were disappointed by the change.
“As important as the lesson that routine glucometer readings in the clinic is a wasteful practice, the more important lesson is that examining office routines for foolish consistencies should be a regular component of making primary care more efficient,” the researchers added.
They had no financial conflicts to disclose.
Eliminating routine glucometer readings makes primary care visits more efficient, according to a 6-month review of activity at a primary care clinic. The results were published online Sept. 26 in JAMA Internal Medicine.
“The routine tasks that are components of rooming the clinic patient are increasing in number,” wrote James L Wofford, MD, of Wake Forest University, Winston-Salem, N.C., and his colleagues (JAMA Intern Med. 2016 Sep 26. doi: 10.1001/jamainternmed.2016.5769). Routine glucometer readings are costly in terms of time, money, and mental energy of clinicians, and do not add value, they wrote.
The researchers compared data from a primary care clinic in North Carolina for 3 months before and 3 months after the clinic eliminated routine glucometer readings (Jan. 1, 2015, to March 15, 2015, and March 16, 2015, to June 30, 2015). After a 1-week trial during which no routine clinical glucometry was performed, the option remained available at the request of a nurse or patient.
The number of glucometer readings decreased from approximately 400 per month to 100 per month after the change in policy, yielded a cost savings of at least $2,000 per month, and time saving of 25 hours of nursing time per month.
“Despite the fear of missing an occasional markedly elevated glucose level, clinicians gradually grew comfortable and never reconsidered reinstitution of routine glucometer readings,” Dr. Wofford and his associates wrote. However, some patient education was needed to reassure those who were disappointed by the change.
“As important as the lesson that routine glucometer readings in the clinic is a wasteful practice, the more important lesson is that examining office routines for foolish consistencies should be a regular component of making primary care more efficient,” the researchers added.
They had no financial conflicts to disclose.
FROM JAMA INTERNAL MEDICINE
Key clinical point: Routine glucometer readings are unnecessary as part of a primary care visit.
Major finding: Decreasing glucometer readings from approximately 400 per month to approximately 100 per month saved more than $2,000 and 25 hours of nursing time.
Data source: A comparison of 3 months before and after a policy change eliminating routine glucometer readings in a primary care clinic.
Disclosures: The researchers had no financial conflicts to disclose.
Try non-TNF biologics for RA if anti-TNF fails
Rheumatoid arthritis patients who were unsuccessfully treated with anti–tumor necrosis factor drugs fared significantly better when treated with a non-TNF biologic than with a second anti-TNF drug in a 52-week, randomized, clinical trial of 300 adults.
Overall, 69% of patients who received a non-TNF biologic achieved clinical response, defined as a good or moderate EULAR response at 24 weeks, compared with 52% of patients who received a second anti-TNF drug, wrote Jacques-Eric Gottenberg, MD, PhD, of Strasbourg (France) University Hospital and his colleagues.
Patients were randomized to a non-TNF biologic or a second anti-TNF drug, with the choice of biologic left to the clinician. Patients were assessed at 12, 24, and 52 weeks.
“In addition to the superiority of the non-TNF treatment for the primary outcome at week 24, the non-TNF treatment was associated with a better EULAR response than a second anti-TNF drug at weeks 12 and 52,” the researchers noted. Significantly more patients in the non-TNF group reported low disease activity at 6 months and 12 months, compared with the second anti-TNF group, they added.
A total of 18 patients in the non-TNF group and 13 patients in the second anti-TNF group experienced serious adverse events; the most common were serious infections (in 33% and 77% of the non-TNF and anti-TNF groups, respectively) and cardiovascular events (33% vs. 8%, respectively).
The study was supported by the French Ministry of Health and promoted by Strasbourg University Hospital. Dr. Gottenberg disclosed financial support from AbbVie, Pfizer, and Roche, and personal fees from Bristol-Myers Squibb, Merck Sharp & Dohme, UCB, GlaxoSmithKline, and Novartis.
The findings were published online Sept. 20 (JAMA 2016;316[11]:1172-80).
Rheumatoid arthritis patients who were unsuccessfully treated with anti–tumor necrosis factor drugs fared significantly better when treated with a non-TNF biologic than with a second anti-TNF drug in a 52-week, randomized, clinical trial of 300 adults.
Overall, 69% of patients who received a non-TNF biologic achieved clinical response, defined as a good or moderate EULAR response at 24 weeks, compared with 52% of patients who received a second anti-TNF drug, wrote Jacques-Eric Gottenberg, MD, PhD, of Strasbourg (France) University Hospital and his colleagues.
Patients were randomized to a non-TNF biologic or a second anti-TNF drug, with the choice of biologic left to the clinician. Patients were assessed at 12, 24, and 52 weeks.
“In addition to the superiority of the non-TNF treatment for the primary outcome at week 24, the non-TNF treatment was associated with a better EULAR response than a second anti-TNF drug at weeks 12 and 52,” the researchers noted. Significantly more patients in the non-TNF group reported low disease activity at 6 months and 12 months, compared with the second anti-TNF group, they added.
A total of 18 patients in the non-TNF group and 13 patients in the second anti-TNF group experienced serious adverse events; the most common were serious infections (in 33% and 77% of the non-TNF and anti-TNF groups, respectively) and cardiovascular events (33% vs. 8%, respectively).
The study was supported by the French Ministry of Health and promoted by Strasbourg University Hospital. Dr. Gottenberg disclosed financial support from AbbVie, Pfizer, and Roche, and personal fees from Bristol-Myers Squibb, Merck Sharp & Dohme, UCB, GlaxoSmithKline, and Novartis.
The findings were published online Sept. 20 (JAMA 2016;316[11]:1172-80).
Rheumatoid arthritis patients who were unsuccessfully treated with anti–tumor necrosis factor drugs fared significantly better when treated with a non-TNF biologic than with a second anti-TNF drug in a 52-week, randomized, clinical trial of 300 adults.
Overall, 69% of patients who received a non-TNF biologic achieved clinical response, defined as a good or moderate EULAR response at 24 weeks, compared with 52% of patients who received a second anti-TNF drug, wrote Jacques-Eric Gottenberg, MD, PhD, of Strasbourg (France) University Hospital and his colleagues.
Patients were randomized to a non-TNF biologic or a second anti-TNF drug, with the choice of biologic left to the clinician. Patients were assessed at 12, 24, and 52 weeks.
“In addition to the superiority of the non-TNF treatment for the primary outcome at week 24, the non-TNF treatment was associated with a better EULAR response than a second anti-TNF drug at weeks 12 and 52,” the researchers noted. Significantly more patients in the non-TNF group reported low disease activity at 6 months and 12 months, compared with the second anti-TNF group, they added.
A total of 18 patients in the non-TNF group and 13 patients in the second anti-TNF group experienced serious adverse events; the most common were serious infections (in 33% and 77% of the non-TNF and anti-TNF groups, respectively) and cardiovascular events (33% vs. 8%, respectively).
The study was supported by the French Ministry of Health and promoted by Strasbourg University Hospital. Dr. Gottenberg disclosed financial support from AbbVie, Pfizer, and Roche, and personal fees from Bristol-Myers Squibb, Merck Sharp & Dohme, UCB, GlaxoSmithKline, and Novartis.
The findings were published online Sept. 20 (JAMA 2016;316[11]:1172-80).
FROM JAMA
Obstetric VTE safety recommendations stress routine risk assessment
Routine thromboembolism risk assessment and use of both pharmacologic and mechanical thromboprophylaxis is an important part of obstetrics care, according to new recommendations from the National Partnership for Maternal Safety.
Although obstetric venous thromboembolism (VTE) remains a common cause of maternal morbidity and mortality, prophylaxis recommendations are varied and nonspecific across obstetric organizations. The new maternity safety bundle from the National Partnership for Maternal Safety (NPMS) aims to eliminate some of the confusion.
“Based on increasing maternal risk of obstetric venous thromboembolism in the United States, the failure of current strategies to decrease venous thromboembolism as a proportionate cause of maternal death, and observational evidence from the United Kingdom that risk factor–based prophylaxis may reduce risk, the NPMS working group has interpreted current epidemiology and clinical research evidence to support routine thromboembolism risk assessment and consideration of more extensive risk factor–based prophylaxis,” the authors wrote (Obstet Gynecol. 2016;128:688-98).
In the recommendations, prophylactic management of obstetric thromboembolism is organized into four categories: readiness, recognition, response, and reporting and systems learning.
The readiness component includes a recommendation to use a standard thromboembolism risk assessment tool at the first prenatal visit, all antepartum admissions, immediately post partum during childbirth hospitalization, and on discharge from the hospital after a birth. The Caprini and Padua scoring systems, which are tools designed for nonobstetric hospitalized patients, can be modified for obstetric patients, according to the recommendations.
The recognition component of the bundle emphasizes the use of education and guidelines to help physicians identify obstetric patients at risk for thromboembolism. The response component proposes a thromboembolism risk assessment at the first prenatal visit, followed by the use of standardized recommendations for mechanical thromboprophylaxis, dosing of prophylactic and therapeutic pharmacologic anticoagulation, and appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia.
The reporting and systems learning component calls for reviews of a sample of a facility’s obstetric population to determine comorbid risk factors for VTE, followed by routine auditing of records to monitor risk assessment programs and patient care.
The NPMS suggests applying the American College of Chest Physicians recommendations for hospitalized, nonsurgical patients to pregnant women and postpartum women who have had a vaginal birth. However, they recommend using the American College of Obstetricians and Gynecologists’ guidelines for pregnant and postpartum women with thrombophilia.
The NPMS also recommends that women receiving pharmacologic VTE prophylaxis plus low-dose aspirin for the prevention of preeclampsia, should discontinue aspirin at 35-36 weeks of gestation.
“Given the wide diversity of birthing facilities, a single national protocol is not recommended; instead, each facility should adapt a single protocol to improve maternal safety based on its patient population and resources,” the NPMS members wrote.
The NPMS is a joint effort including leaders from a range of women’s health care organizations, hospitals, professional societies, and regulators.
The authors reported having no financial disclosures.
Routine thromboembolism risk assessment and use of both pharmacologic and mechanical thromboprophylaxis is an important part of obstetrics care, according to new recommendations from the National Partnership for Maternal Safety.
Although obstetric venous thromboembolism (VTE) remains a common cause of maternal morbidity and mortality, prophylaxis recommendations are varied and nonspecific across obstetric organizations. The new maternity safety bundle from the National Partnership for Maternal Safety (NPMS) aims to eliminate some of the confusion.
“Based on increasing maternal risk of obstetric venous thromboembolism in the United States, the failure of current strategies to decrease venous thromboembolism as a proportionate cause of maternal death, and observational evidence from the United Kingdom that risk factor–based prophylaxis may reduce risk, the NPMS working group has interpreted current epidemiology and clinical research evidence to support routine thromboembolism risk assessment and consideration of more extensive risk factor–based prophylaxis,” the authors wrote (Obstet Gynecol. 2016;128:688-98).
In the recommendations, prophylactic management of obstetric thromboembolism is organized into four categories: readiness, recognition, response, and reporting and systems learning.
The readiness component includes a recommendation to use a standard thromboembolism risk assessment tool at the first prenatal visit, all antepartum admissions, immediately post partum during childbirth hospitalization, and on discharge from the hospital after a birth. The Caprini and Padua scoring systems, which are tools designed for nonobstetric hospitalized patients, can be modified for obstetric patients, according to the recommendations.
The recognition component of the bundle emphasizes the use of education and guidelines to help physicians identify obstetric patients at risk for thromboembolism. The response component proposes a thromboembolism risk assessment at the first prenatal visit, followed by the use of standardized recommendations for mechanical thromboprophylaxis, dosing of prophylactic and therapeutic pharmacologic anticoagulation, and appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia.
The reporting and systems learning component calls for reviews of a sample of a facility’s obstetric population to determine comorbid risk factors for VTE, followed by routine auditing of records to monitor risk assessment programs and patient care.
The NPMS suggests applying the American College of Chest Physicians recommendations for hospitalized, nonsurgical patients to pregnant women and postpartum women who have had a vaginal birth. However, they recommend using the American College of Obstetricians and Gynecologists’ guidelines for pregnant and postpartum women with thrombophilia.
The NPMS also recommends that women receiving pharmacologic VTE prophylaxis plus low-dose aspirin for the prevention of preeclampsia, should discontinue aspirin at 35-36 weeks of gestation.
“Given the wide diversity of birthing facilities, a single national protocol is not recommended; instead, each facility should adapt a single protocol to improve maternal safety based on its patient population and resources,” the NPMS members wrote.
The NPMS is a joint effort including leaders from a range of women’s health care organizations, hospitals, professional societies, and regulators.
The authors reported having no financial disclosures.
Routine thromboembolism risk assessment and use of both pharmacologic and mechanical thromboprophylaxis is an important part of obstetrics care, according to new recommendations from the National Partnership for Maternal Safety.
Although obstetric venous thromboembolism (VTE) remains a common cause of maternal morbidity and mortality, prophylaxis recommendations are varied and nonspecific across obstetric organizations. The new maternity safety bundle from the National Partnership for Maternal Safety (NPMS) aims to eliminate some of the confusion.
“Based on increasing maternal risk of obstetric venous thromboembolism in the United States, the failure of current strategies to decrease venous thromboembolism as a proportionate cause of maternal death, and observational evidence from the United Kingdom that risk factor–based prophylaxis may reduce risk, the NPMS working group has interpreted current epidemiology and clinical research evidence to support routine thromboembolism risk assessment and consideration of more extensive risk factor–based prophylaxis,” the authors wrote (Obstet Gynecol. 2016;128:688-98).
In the recommendations, prophylactic management of obstetric thromboembolism is organized into four categories: readiness, recognition, response, and reporting and systems learning.
The readiness component includes a recommendation to use a standard thromboembolism risk assessment tool at the first prenatal visit, all antepartum admissions, immediately post partum during childbirth hospitalization, and on discharge from the hospital after a birth. The Caprini and Padua scoring systems, which are tools designed for nonobstetric hospitalized patients, can be modified for obstetric patients, according to the recommendations.
The recognition component of the bundle emphasizes the use of education and guidelines to help physicians identify obstetric patients at risk for thromboembolism. The response component proposes a thromboembolism risk assessment at the first prenatal visit, followed by the use of standardized recommendations for mechanical thromboprophylaxis, dosing of prophylactic and therapeutic pharmacologic anticoagulation, and appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia.
The reporting and systems learning component calls for reviews of a sample of a facility’s obstetric population to determine comorbid risk factors for VTE, followed by routine auditing of records to monitor risk assessment programs and patient care.
The NPMS suggests applying the American College of Chest Physicians recommendations for hospitalized, nonsurgical patients to pregnant women and postpartum women who have had a vaginal birth. However, they recommend using the American College of Obstetricians and Gynecologists’ guidelines for pregnant and postpartum women with thrombophilia.
The NPMS also recommends that women receiving pharmacologic VTE prophylaxis plus low-dose aspirin for the prevention of preeclampsia, should discontinue aspirin at 35-36 weeks of gestation.
“Given the wide diversity of birthing facilities, a single national protocol is not recommended; instead, each facility should adapt a single protocol to improve maternal safety based on its patient population and resources,” the NPMS members wrote.
The NPMS is a joint effort including leaders from a range of women’s health care organizations, hospitals, professional societies, and regulators.
The authors reported having no financial disclosures.
FROM OBSTETRICS & GYNECOLOGY
Yosprala offers aspirin mitigator for ulcer risk patients
The Food and Drug Administration has approved the aspirin/omeprazole combination drug Yosprala for patients who seek to prevent secondary cardiovascular events but who avoid aspirin because of their risk for gastric ulcers. The approval was announced in a press release Sept. 15 from Aralez Pharmaceuticals.
The medication contains 40 mg of immediate-release omeprazole and either 81 mg or 325 mg of aspirin in an enteric-coated core for delayed release. The immediate-release omeprazole “is designed to elevate the gastric pH into a gastroprotective zone,” according to the company. “The enteric-coated aspirin dissolves after the pH has been elevated to at least 5.5 within the gastroprotective zone, thereby reducing stomach ulcer risk.”
The approval is based on data from a pair of randomized, double-blind, controlled trials. In these studies, patients at risk for gastric ulcers were significantly less likely to report ulcers and significantly less likely to discontinue the medication than were controls who received aspirin alone. Side effects were not significantly different between the groups; the most common side effects were indigestion, stomach pain, nausea, diarrhea, gastric polyps, and chest pain.
The studies did not examine whether the medication had an impact on the risk of GI bleeding. The drug is not approved for use in children.
The Food and Drug Administration has approved the aspirin/omeprazole combination drug Yosprala for patients who seek to prevent secondary cardiovascular events but who avoid aspirin because of their risk for gastric ulcers. The approval was announced in a press release Sept. 15 from Aralez Pharmaceuticals.
The medication contains 40 mg of immediate-release omeprazole and either 81 mg or 325 mg of aspirin in an enteric-coated core for delayed release. The immediate-release omeprazole “is designed to elevate the gastric pH into a gastroprotective zone,” according to the company. “The enteric-coated aspirin dissolves after the pH has been elevated to at least 5.5 within the gastroprotective zone, thereby reducing stomach ulcer risk.”
The approval is based on data from a pair of randomized, double-blind, controlled trials. In these studies, patients at risk for gastric ulcers were significantly less likely to report ulcers and significantly less likely to discontinue the medication than were controls who received aspirin alone. Side effects were not significantly different between the groups; the most common side effects were indigestion, stomach pain, nausea, diarrhea, gastric polyps, and chest pain.
The studies did not examine whether the medication had an impact on the risk of GI bleeding. The drug is not approved for use in children.
The Food and Drug Administration has approved the aspirin/omeprazole combination drug Yosprala for patients who seek to prevent secondary cardiovascular events but who avoid aspirin because of their risk for gastric ulcers. The approval was announced in a press release Sept. 15 from Aralez Pharmaceuticals.
The medication contains 40 mg of immediate-release omeprazole and either 81 mg or 325 mg of aspirin in an enteric-coated core for delayed release. The immediate-release omeprazole “is designed to elevate the gastric pH into a gastroprotective zone,” according to the company. “The enteric-coated aspirin dissolves after the pH has been elevated to at least 5.5 within the gastroprotective zone, thereby reducing stomach ulcer risk.”
The approval is based on data from a pair of randomized, double-blind, controlled trials. In these studies, patients at risk for gastric ulcers were significantly less likely to report ulcers and significantly less likely to discontinue the medication than were controls who received aspirin alone. Side effects were not significantly different between the groups; the most common side effects were indigestion, stomach pain, nausea, diarrhea, gastric polyps, and chest pain.
The studies did not examine whether the medication had an impact on the risk of GI bleeding. The drug is not approved for use in children.
Cognitive-behavioral therapy eases postconcussive symptoms in teens
Adolescents who underwent cognitive-behavioral therapy (CBT) as part of postconcussion care reported significantly lower levels of postconcussive symptoms and depressive symptoms in a randomized trial of 49 patients aged 11-17 years. The report was published online Sept. 12 in Pediatrics.
“Affective symptoms, including depression and anxiety, commonly co-occur with cognitive and somatic symptoms and may prolong recovery from postconcussive symptoms, wrote Carolyn A. McCarty, PhD, of Seattle Children’s Hospital, Washington, and her colleagues. “The complexities of managing persistent postconcussive symptoms in conjunction with comorbid psychological symptoms create a significant burden for injured children and adolescents, their families, and schools” (Pediatrics. 2016. doi: 10.1542/peds.2016-0459).
To determine the impact of CBT on persistent symptoms in adolescents with concussions, the researchers randomized 49 patients to usual care or a collaborative care plan that included usual care plus CBT.
After 6 months, approximately 13% of the teens in the CBT group reported high levels of postconcussive symptoms, compared with 42% of controls. In addition, 78% of CBT patients reported a depressive symptom reduction of more than 50%, compared with 46% of controls.
Concussions were diagnosed by sports medicine or rehabilitative medicine specialists. The patients assigned to CBT received usual care management, CBT, and possible psychopharmacological consultation. Control patients received usual concussion care, generally defined as an initial visit with a sports medicine physician and assessments at 1, 3, and 6 months. Usual care also could include MRI, sleep medication, and subthreshold exercise, depending on the patient. No serious adverse events were reported. The average age of the patients was 15 years, approximately 65% were girls, and 76% were white.
Overall, 83% of the CBT patients and 87% of their parents were “very satisfied” with their care, compared with 46% of patients and 29% of parents in the control group.
“Although patients in both groups showed symptom reduction in the first 3 months, only those who received collaborative care demonstrated sustained improvements through 6 months of follow-up,” Dr. McCarty and her colleagues wrote.
The results were limited by several factors including the small size of the study, the researchers said. However, the findings “prompt more investigation into the role of affective symptoms in perpetuating physical symptoms secondary to prolonged recovery from sports-related concussion,” and also suggest that collaborative care can help improve persistent postconcussive symptoms in teens.
Dr. McCarty and her colleagues had no relevant financial conflicts to disclose. The Seattle Sports Concussion Research Collaborative supported the study.
Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than 2 weeks, 10%-15% will have prolonged symptoms (greater than 1 month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.
I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient’s being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.
I am not surprised by these results of the study. A large proportion of the adolescents I treat for concussions are those referred from their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including CBT, patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills, and the bonus is that these skills are incredibly useful across one’s lifetime, not just for concussion recovery.
Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10-20 years down the road.
Cynthia LaBella, MD, is director of the concussion program at Ann & Robert H. Lurie Children’s Hospital of Chicago. Dr. LaBella said she had no relevant financial disclosures.
Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than 2 weeks, 10%-15% will have prolonged symptoms (greater than 1 month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.
I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient’s being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.
I am not surprised by these results of the study. A large proportion of the adolescents I treat for concussions are those referred from their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including CBT, patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills, and the bonus is that these skills are incredibly useful across one’s lifetime, not just for concussion recovery.
Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10-20 years down the road.
Cynthia LaBella, MD, is director of the concussion program at Ann & Robert H. Lurie Children’s Hospital of Chicago. Dr. LaBella said she had no relevant financial disclosures.
Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than 2 weeks, 10%-15% will have prolonged symptoms (greater than 1 month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.
I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient’s being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.
I am not surprised by these results of the study. A large proportion of the adolescents I treat for concussions are those referred from their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including CBT, patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills, and the bonus is that these skills are incredibly useful across one’s lifetime, not just for concussion recovery.
Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10-20 years down the road.
Cynthia LaBella, MD, is director of the concussion program at Ann & Robert H. Lurie Children’s Hospital of Chicago. Dr. LaBella said she had no relevant financial disclosures.
Adolescents who underwent cognitive-behavioral therapy (CBT) as part of postconcussion care reported significantly lower levels of postconcussive symptoms and depressive symptoms in a randomized trial of 49 patients aged 11-17 years. The report was published online Sept. 12 in Pediatrics.
“Affective symptoms, including depression and anxiety, commonly co-occur with cognitive and somatic symptoms and may prolong recovery from postconcussive symptoms, wrote Carolyn A. McCarty, PhD, of Seattle Children’s Hospital, Washington, and her colleagues. “The complexities of managing persistent postconcussive symptoms in conjunction with comorbid psychological symptoms create a significant burden for injured children and adolescents, their families, and schools” (Pediatrics. 2016. doi: 10.1542/peds.2016-0459).
To determine the impact of CBT on persistent symptoms in adolescents with concussions, the researchers randomized 49 patients to usual care or a collaborative care plan that included usual care plus CBT.
After 6 months, approximately 13% of the teens in the CBT group reported high levels of postconcussive symptoms, compared with 42% of controls. In addition, 78% of CBT patients reported a depressive symptom reduction of more than 50%, compared with 46% of controls.
Concussions were diagnosed by sports medicine or rehabilitative medicine specialists. The patients assigned to CBT received usual care management, CBT, and possible psychopharmacological consultation. Control patients received usual concussion care, generally defined as an initial visit with a sports medicine physician and assessments at 1, 3, and 6 months. Usual care also could include MRI, sleep medication, and subthreshold exercise, depending on the patient. No serious adverse events were reported. The average age of the patients was 15 years, approximately 65% were girls, and 76% were white.
Overall, 83% of the CBT patients and 87% of their parents were “very satisfied” with their care, compared with 46% of patients and 29% of parents in the control group.
“Although patients in both groups showed symptom reduction in the first 3 months, only those who received collaborative care demonstrated sustained improvements through 6 months of follow-up,” Dr. McCarty and her colleagues wrote.
The results were limited by several factors including the small size of the study, the researchers said. However, the findings “prompt more investigation into the role of affective symptoms in perpetuating physical symptoms secondary to prolonged recovery from sports-related concussion,” and also suggest that collaborative care can help improve persistent postconcussive symptoms in teens.
Dr. McCarty and her colleagues had no relevant financial conflicts to disclose. The Seattle Sports Concussion Research Collaborative supported the study.
Adolescents who underwent cognitive-behavioral therapy (CBT) as part of postconcussion care reported significantly lower levels of postconcussive symptoms and depressive symptoms in a randomized trial of 49 patients aged 11-17 years. The report was published online Sept. 12 in Pediatrics.
“Affective symptoms, including depression and anxiety, commonly co-occur with cognitive and somatic symptoms and may prolong recovery from postconcussive symptoms, wrote Carolyn A. McCarty, PhD, of Seattle Children’s Hospital, Washington, and her colleagues. “The complexities of managing persistent postconcussive symptoms in conjunction with comorbid psychological symptoms create a significant burden for injured children and adolescents, their families, and schools” (Pediatrics. 2016. doi: 10.1542/peds.2016-0459).
To determine the impact of CBT on persistent symptoms in adolescents with concussions, the researchers randomized 49 patients to usual care or a collaborative care plan that included usual care plus CBT.
After 6 months, approximately 13% of the teens in the CBT group reported high levels of postconcussive symptoms, compared with 42% of controls. In addition, 78% of CBT patients reported a depressive symptom reduction of more than 50%, compared with 46% of controls.
Concussions were diagnosed by sports medicine or rehabilitative medicine specialists. The patients assigned to CBT received usual care management, CBT, and possible psychopharmacological consultation. Control patients received usual concussion care, generally defined as an initial visit with a sports medicine physician and assessments at 1, 3, and 6 months. Usual care also could include MRI, sleep medication, and subthreshold exercise, depending on the patient. No serious adverse events were reported. The average age of the patients was 15 years, approximately 65% were girls, and 76% were white.
Overall, 83% of the CBT patients and 87% of their parents were “very satisfied” with their care, compared with 46% of patients and 29% of parents in the control group.
“Although patients in both groups showed symptom reduction in the first 3 months, only those who received collaborative care demonstrated sustained improvements through 6 months of follow-up,” Dr. McCarty and her colleagues wrote.
The results were limited by several factors including the small size of the study, the researchers said. However, the findings “prompt more investigation into the role of affective symptoms in perpetuating physical symptoms secondary to prolonged recovery from sports-related concussion,” and also suggest that collaborative care can help improve persistent postconcussive symptoms in teens.
Dr. McCarty and her colleagues had no relevant financial conflicts to disclose. The Seattle Sports Concussion Research Collaborative supported the study.
FROM PEDIATRICS
Key clinical point: Adolescents with persistent postconcussive symptoms and depressive symptoms improved significantly after the addition of CBT to usual care.
Major finding: After 6 months, 13% of teens who underwent CBT plus usual care reported high levels of postconcussive symptoms, compared with 42% of controls.
Data source: A randomized trial of 49 adolescents aged 11-17 years with persistent postconcussive symptoms at least 1 month after a sports-related concussion,
Disclosures: The researchers had no financial conflicts to disclose. The Seattle Sports Concussion Research Collaborative supported the study.
USPSTF: Screen for tuberculosis in those at greatest risk
Screening for latent tuberculosis infection (LTBI) can help prevent progression to active disease, and the availability of effective tests supports screening asymptomatic adults aged 18 years and older at increased risk for infection, according to new recommendations from the U.S. Preventive Services Task Force.
The recommendations were published online Sept. 6 in JAMA.
“The USPSTF concludes with moderate certainty that the net benefit of screening for LTBI in persons at increased risk for tuberculosis is moderate,” wrote lead author Kirsten Bibbins-Domingo, MD, PhD, of the University of California, San Francisco, and her colleagues (JAMA 2016 Sep 6;316[9]:962-9).
TB infection spreads through the coughing or sneezing of someone with active disease. Individuals at high risk for TB include those who are immunocompromised, residents of long-term care facilities or correctional facilities, or homeless individuals, as well as those born in countries known to have a high incidence of TB, including China, India, Mexico, and Vietnam.
Other populations at increased risk for TB are contacts of patients with active TB, health care workers, and workers in high-risk settings, the researchers noted.
TB remains a preventable disease in the United States, with a prevalence of approximately 5%, the researchers said. The two most effective screening tests, tuberculin skin test (TST) and interferon-gamma release assays (IGRA), demonstrated sensitivity and specificity of 79% and 97%, and at least 80% and 95%, respectively.
The recommendations are supported by an evidence review, also published in JAMA (2016 Sep 6;316[9]:970-83). The review included 72 studies and 51,711 adults.
The studies in the evidence review did not assess the benefits vs. harms of TB screening, compared with no screening, noted Leila C. Kahwati, MD, of RTI International in Research Triangle Park, N.C., and her colleagues.
“The applicability of the evidence on accuracy and reliability of screening tests to primary care practice settings and populations is uncertain for several reasons,” the investigators said. However, the findings suggest that “treatment reduced the risk of active TB among the populations included in this review.”
The researchers had no financial conflicts to disclose.
Screening for latent tuberculosis infection (LTBI) can help prevent progression to active disease, and the availability of effective tests supports screening asymptomatic adults aged 18 years and older at increased risk for infection, according to new recommendations from the U.S. Preventive Services Task Force.
The recommendations were published online Sept. 6 in JAMA.
“The USPSTF concludes with moderate certainty that the net benefit of screening for LTBI in persons at increased risk for tuberculosis is moderate,” wrote lead author Kirsten Bibbins-Domingo, MD, PhD, of the University of California, San Francisco, and her colleagues (JAMA 2016 Sep 6;316[9]:962-9).
TB infection spreads through the coughing or sneezing of someone with active disease. Individuals at high risk for TB include those who are immunocompromised, residents of long-term care facilities or correctional facilities, or homeless individuals, as well as those born in countries known to have a high incidence of TB, including China, India, Mexico, and Vietnam.
Other populations at increased risk for TB are contacts of patients with active TB, health care workers, and workers in high-risk settings, the researchers noted.
TB remains a preventable disease in the United States, with a prevalence of approximately 5%, the researchers said. The two most effective screening tests, tuberculin skin test (TST) and interferon-gamma release assays (IGRA), demonstrated sensitivity and specificity of 79% and 97%, and at least 80% and 95%, respectively.
The recommendations are supported by an evidence review, also published in JAMA (2016 Sep 6;316[9]:970-83). The review included 72 studies and 51,711 adults.
The studies in the evidence review did not assess the benefits vs. harms of TB screening, compared with no screening, noted Leila C. Kahwati, MD, of RTI International in Research Triangle Park, N.C., and her colleagues.
“The applicability of the evidence on accuracy and reliability of screening tests to primary care practice settings and populations is uncertain for several reasons,” the investigators said. However, the findings suggest that “treatment reduced the risk of active TB among the populations included in this review.”
The researchers had no financial conflicts to disclose.
Screening for latent tuberculosis infection (LTBI) can help prevent progression to active disease, and the availability of effective tests supports screening asymptomatic adults aged 18 years and older at increased risk for infection, according to new recommendations from the U.S. Preventive Services Task Force.
The recommendations were published online Sept. 6 in JAMA.
“The USPSTF concludes with moderate certainty that the net benefit of screening for LTBI in persons at increased risk for tuberculosis is moderate,” wrote lead author Kirsten Bibbins-Domingo, MD, PhD, of the University of California, San Francisco, and her colleagues (JAMA 2016 Sep 6;316[9]:962-9).
TB infection spreads through the coughing or sneezing of someone with active disease. Individuals at high risk for TB include those who are immunocompromised, residents of long-term care facilities or correctional facilities, or homeless individuals, as well as those born in countries known to have a high incidence of TB, including China, India, Mexico, and Vietnam.
Other populations at increased risk for TB are contacts of patients with active TB, health care workers, and workers in high-risk settings, the researchers noted.
TB remains a preventable disease in the United States, with a prevalence of approximately 5%, the researchers said. The two most effective screening tests, tuberculin skin test (TST) and interferon-gamma release assays (IGRA), demonstrated sensitivity and specificity of 79% and 97%, and at least 80% and 95%, respectively.
The recommendations are supported by an evidence review, also published in JAMA (2016 Sep 6;316[9]:970-83). The review included 72 studies and 51,711 adults.
The studies in the evidence review did not assess the benefits vs. harms of TB screening, compared with no screening, noted Leila C. Kahwati, MD, of RTI International in Research Triangle Park, N.C., and her colleagues.
“The applicability of the evidence on accuracy and reliability of screening tests to primary care practice settings and populations is uncertain for several reasons,” the investigators said. However, the findings suggest that “treatment reduced the risk of active TB among the populations included in this review.”
The researchers had no financial conflicts to disclose.
FROM JAMA
Key clinical point: Latent tuberculosis infection is a significant problem, and both the tuberculin skin test (TST) and interferon-gamma release assays (IGRA) were moderately sensitive and highly specific in areas with a low tuberculosis burden.
Major finding: Approximately 5%-10% of individuals with latent TB progress to active disease, according to the USPSTF, and treatment reduces the risk of progression.
Data source: An evidence review including 72 studies and 51,711 individuals.
Disclosures: The researchers had no financial conflicts to disclose.
Parents support school-based HPV vaccination
Approximately 86% of middle school students were vaccinated against HPV in a school setting in a review of data from a service project involving more than 8,000 students.
“School-located vaccination programs (SLVPs) provide access to vaccination for those adolescents whose parents cannot miss work or other daytime commitments or those who have multiple after-school commitments,” wrote Dr. Amy Middleman of the University of Oklahoma Health Science Center, Oklahoma City, and her colleagues. Data from previous studies suggest reluctance on the part of parents to allow their children to receive the human papillomavirus vaccine (HPV) in a school setting, but such data may not reflect parents’ opinions when a school-based program is actually available, the researchers noted.
The researchers tested SLVPs at eight middle schools including 8,333 students; 80% were Hispanic, 17% were black, 1% were white, and the remainder of students’ ethnicities were not identified (Human Vaccines & Immunotherapeutics. 2016 Aug. doi: 10.1080/21645515.2016.1208326).
School-based vaccinations were scheduled for three times: September/October 2012, March/April 2013, and September/October 2013; the findings reflect the first two visits.
The SLVPs included the following vaccines: HPV, influenza, Tdap, meningococcal conjugate vaccine (MCV4), hepatitis A, varicella, and MMR. A total of 1,674 vaccines were administered in the fall of 2012, and 532 were administered in the spring of 2013. Overall, 449 of 524 (86%) students in the fall program and 161 of 188 (86%) in the spring program received the HPV vaccine.
The study was limited by several factors including the descriptive nature of the service project and the inability to obtain the vaccination status of all enrolled students. In addition, the schools were located in lower income areas, which might limit the generalizability of the findings, the researchers noted. However, the results suggest that “SLVPs may be more successful not only when they include all vaccines, but also when conducted in the fall prior to the onset of preparation for high-stakes state testing,” they said.
The study was supported by the Society for Adolescent Health through a grant from Merck. One study coauthor previously received salary support from Merck.
Approximately 86% of middle school students were vaccinated against HPV in a school setting in a review of data from a service project involving more than 8,000 students.
“School-located vaccination programs (SLVPs) provide access to vaccination for those adolescents whose parents cannot miss work or other daytime commitments or those who have multiple after-school commitments,” wrote Dr. Amy Middleman of the University of Oklahoma Health Science Center, Oklahoma City, and her colleagues. Data from previous studies suggest reluctance on the part of parents to allow their children to receive the human papillomavirus vaccine (HPV) in a school setting, but such data may not reflect parents’ opinions when a school-based program is actually available, the researchers noted.
The researchers tested SLVPs at eight middle schools including 8,333 students; 80% were Hispanic, 17% were black, 1% were white, and the remainder of students’ ethnicities were not identified (Human Vaccines & Immunotherapeutics. 2016 Aug. doi: 10.1080/21645515.2016.1208326).
School-based vaccinations were scheduled for three times: September/October 2012, March/April 2013, and September/October 2013; the findings reflect the first two visits.
The SLVPs included the following vaccines: HPV, influenza, Tdap, meningococcal conjugate vaccine (MCV4), hepatitis A, varicella, and MMR. A total of 1,674 vaccines were administered in the fall of 2012, and 532 were administered in the spring of 2013. Overall, 449 of 524 (86%) students in the fall program and 161 of 188 (86%) in the spring program received the HPV vaccine.
The study was limited by several factors including the descriptive nature of the service project and the inability to obtain the vaccination status of all enrolled students. In addition, the schools were located in lower income areas, which might limit the generalizability of the findings, the researchers noted. However, the results suggest that “SLVPs may be more successful not only when they include all vaccines, but also when conducted in the fall prior to the onset of preparation for high-stakes state testing,” they said.
The study was supported by the Society for Adolescent Health through a grant from Merck. One study coauthor previously received salary support from Merck.
Approximately 86% of middle school students were vaccinated against HPV in a school setting in a review of data from a service project involving more than 8,000 students.
“School-located vaccination programs (SLVPs) provide access to vaccination for those adolescents whose parents cannot miss work or other daytime commitments or those who have multiple after-school commitments,” wrote Dr. Amy Middleman of the University of Oklahoma Health Science Center, Oklahoma City, and her colleagues. Data from previous studies suggest reluctance on the part of parents to allow their children to receive the human papillomavirus vaccine (HPV) in a school setting, but such data may not reflect parents’ opinions when a school-based program is actually available, the researchers noted.
The researchers tested SLVPs at eight middle schools including 8,333 students; 80% were Hispanic, 17% were black, 1% were white, and the remainder of students’ ethnicities were not identified (Human Vaccines & Immunotherapeutics. 2016 Aug. doi: 10.1080/21645515.2016.1208326).
School-based vaccinations were scheduled for three times: September/October 2012, March/April 2013, and September/October 2013; the findings reflect the first two visits.
The SLVPs included the following vaccines: HPV, influenza, Tdap, meningococcal conjugate vaccine (MCV4), hepatitis A, varicella, and MMR. A total of 1,674 vaccines were administered in the fall of 2012, and 532 were administered in the spring of 2013. Overall, 449 of 524 (86%) students in the fall program and 161 of 188 (86%) in the spring program received the HPV vaccine.
The study was limited by several factors including the descriptive nature of the service project and the inability to obtain the vaccination status of all enrolled students. In addition, the schools were located in lower income areas, which might limit the generalizability of the findings, the researchers noted. However, the results suggest that “SLVPs may be more successful not only when they include all vaccines, but also when conducted in the fall prior to the onset of preparation for high-stakes state testing,” they said.
The study was supported by the Society for Adolescent Health through a grant from Merck. One study coauthor previously received salary support from Merck.
FROM HUMAN VACCINES & IMMUNOTHERAPEUTICS
Key clinical point: Parents already supportive of school-based vaccination are likely to support school-based HPV vaccination as well.
Major finding: Approximately 86% of adolescents participating in a school-based program received an HPV vaccine.
Data source: A descriptive study based on a service project that included 8,333 middle school students and parents.
Disclosures: The study was supported by the Society for Adolescent Health through a grant from Merck. One study coauthor previously received salary support from Merck.
ASH launches sickle cell coalition
To improve the lives of individuals with sickle cell disease, the American Society of Hematology has launched the Sickle Cell Disease Coalition (SCDC). Creation of the coalition with 20 other organizations coincides with the release of “State of Sickle Cell Disease: 2016” – a report detailing the status of access to care for patients with sickle cell disease, gaps in the training and education of health care professionals, areas of interest for research and clinical trials, and the global state of the disease. All four of these areas need improvement, ASH officials said in a statement.
“Not only are individuals with [sickle cell disease] burdened by the pain and disability that comes with a chronic condition, but they also have very few accessible treatment options due to our fragmented health care system,” Dr. Charles S. Abrams, president of ASH, said in the statement. Sickle cell disease affects approximately 100,000 Americans and remains a growing global health concern, according to the statement.
The coalition’s goals include development of evidence-based treatment guidelines to improve quality of care, education of clinicians to increase the number of health care providers available to treat sickle cell disease, investment in research and clinical trials to improve existing treatments and develop new ones, and expansion of early intervention programs to help ease the global burden of sickle cell disease.
For more information regarding the coalition, click here.
To improve the lives of individuals with sickle cell disease, the American Society of Hematology has launched the Sickle Cell Disease Coalition (SCDC). Creation of the coalition with 20 other organizations coincides with the release of “State of Sickle Cell Disease: 2016” – a report detailing the status of access to care for patients with sickle cell disease, gaps in the training and education of health care professionals, areas of interest for research and clinical trials, and the global state of the disease. All four of these areas need improvement, ASH officials said in a statement.
“Not only are individuals with [sickle cell disease] burdened by the pain and disability that comes with a chronic condition, but they also have very few accessible treatment options due to our fragmented health care system,” Dr. Charles S. Abrams, president of ASH, said in the statement. Sickle cell disease affects approximately 100,000 Americans and remains a growing global health concern, according to the statement.
The coalition’s goals include development of evidence-based treatment guidelines to improve quality of care, education of clinicians to increase the number of health care providers available to treat sickle cell disease, investment in research and clinical trials to improve existing treatments and develop new ones, and expansion of early intervention programs to help ease the global burden of sickle cell disease.
For more information regarding the coalition, click here.
To improve the lives of individuals with sickle cell disease, the American Society of Hematology has launched the Sickle Cell Disease Coalition (SCDC). Creation of the coalition with 20 other organizations coincides with the release of “State of Sickle Cell Disease: 2016” – a report detailing the status of access to care for patients with sickle cell disease, gaps in the training and education of health care professionals, areas of interest for research and clinical trials, and the global state of the disease. All four of these areas need improvement, ASH officials said in a statement.
“Not only are individuals with [sickle cell disease] burdened by the pain and disability that comes with a chronic condition, but they also have very few accessible treatment options due to our fragmented health care system,” Dr. Charles S. Abrams, president of ASH, said in the statement. Sickle cell disease affects approximately 100,000 Americans and remains a growing global health concern, according to the statement.
The coalition’s goals include development of evidence-based treatment guidelines to improve quality of care, education of clinicians to increase the number of health care providers available to treat sickle cell disease, investment in research and clinical trials to improve existing treatments and develop new ones, and expansion of early intervention programs to help ease the global burden of sickle cell disease.
For more information regarding the coalition, click here.
