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Potty pathogens in space, fundus photos, and ethnic microbiomes
The earth is not enough
Earthly competitors have proved to be unworthy, so this week, Bacteria vs. the World visits the International Space Station, which – and we double-checked this – is in space. It’s a pretty exclusive location, and admission is by invitation only. Unless, of, course, you happen to be the ultimate hitchhiker. Four samples taken from the toilet of the ISS (and one from a piece of exercise equipment) were found to contain unknown strains of antibiotic-resistant Enterobacter bugandensis, investigators reported (BMC Microbiol. 2018 Nov 23;18[1]:175).
These bacterial stowaways were not virulent, lead author Nitin Singh, PhD, of the Jet Propulsion Laboratory said in a separate statement. But an analysis conducted by the team “reveals that the ISS isolates have a 79% probability of being a human pathogen.”
So, what does this mean for future space exploration? Cue the “Star Trek” music: “Space … the final frontier. These are the voyages of the bacterial transport ship Enterprise.”
Putting the FUN in fundus photos
You just got even more dependent on your phone: The American Academy of Opthalmology has published guidelines on how to use smartphones to take fundus photography, a.k.a. photographs of the back of the eye.
Advancement in smartphone optical quality has turned them into an important clinical tool, especially for specialists in low-funded or rural areas who don’t have access to imaging systems. Doctors can purchase special lenses and phone software to take these photos and then can easily upload the images to their Instagram accounts. (Even doctors need likes.)
An eye hospital in India has taken fundus accessibility a step further and posted a video on YouTube showing how to make a functional fundus camera that costs only 100 rupees. All you need in some cardboard, a water bottle, and a lens. “MacGyver: Chennai Edition.”
I feel it in my gut
Whoever said “inside, we’re all the same” clearly wasn’t considering the gut. A study from Vanderbilt University comprising 1,700 American subjects found that differences in gut microbiomes are most consistently linked with ethnicity. Vanderbilt biologist Seth Bordenstein emphasized how changing the gut microbiome can lead to curing illness but that it’s imperative that medical professionals understand how the gut differs across ethnicities.
Researchers found 12 types of bacteria that vary in abundancy by ethnicity. No comment on whether this was linked to differences in cuisine, but this writer fervently hopes new research arrives proving that tacos produce the healthiest gut microbiome.
F-bombing blood cancer
Call it a tale of two Toms.
TV newsman Tom Brokaw, who has multiple myeloma, says he’s become the “poster boy” for blood cancer. At first, though, he kept his diagnosis secret from just about everyone. But occasionally he let his emotions get the best of him. Especially when he’d see a Manhattan bus stop ad spotlighting the chiseled body of another Tom: the quarterback named Brady.
As he explained in a presentation at the annual meeting of the American Society of Hematology, he found it harder to get around because of back problems, which are common in multiple myeloma. As a result, he couldn’t manage to get to the office.
Still, “every day I’d force myself to leave the walker at home,” he recalled. “In that cold and sleety fall, I’d walk half a block to the coffee shop to get a bagel. There was this enormous new bus stop, with an animated advertisement board. Looking right at me was Tom Brady, advertising Ugg boots. I’d look down 79th Street at every inch of Tom Brady, and all the little old ladies were mooning over him as they were getting on the bus.”
Brokaw knew just what to do to make himself feel better. “I’d hobble over and look at him and drop the F-bomb on him every morning. Frankly, it was therapeutic for me.”
Later, he met the New England Patriots quarterback and told him the story, replacing “F-bomb” with the real word. “He had this little posse with him, and they roared. They said nobody talks to Tom like that.”
Brokaw still resists pleas to slow down from concerned loved ones, such as his emergency physician daughter. “My birth certificate says I’m 78 years old,” he said, “but I still think I’m 38 anchoring the news.” And still tossing tight-spiral F-bombs at cancer and gridiron G.O.A.T.s alike.
The earth is not enough
Earthly competitors have proved to be unworthy, so this week, Bacteria vs. the World visits the International Space Station, which – and we double-checked this – is in space. It’s a pretty exclusive location, and admission is by invitation only. Unless, of, course, you happen to be the ultimate hitchhiker. Four samples taken from the toilet of the ISS (and one from a piece of exercise equipment) were found to contain unknown strains of antibiotic-resistant Enterobacter bugandensis, investigators reported (BMC Microbiol. 2018 Nov 23;18[1]:175).
These bacterial stowaways were not virulent, lead author Nitin Singh, PhD, of the Jet Propulsion Laboratory said in a separate statement. But an analysis conducted by the team “reveals that the ISS isolates have a 79% probability of being a human pathogen.”
So, what does this mean for future space exploration? Cue the “Star Trek” music: “Space … the final frontier. These are the voyages of the bacterial transport ship Enterprise.”
Putting the FUN in fundus photos
You just got even more dependent on your phone: The American Academy of Opthalmology has published guidelines on how to use smartphones to take fundus photography, a.k.a. photographs of the back of the eye.
Advancement in smartphone optical quality has turned them into an important clinical tool, especially for specialists in low-funded or rural areas who don’t have access to imaging systems. Doctors can purchase special lenses and phone software to take these photos and then can easily upload the images to their Instagram accounts. (Even doctors need likes.)
An eye hospital in India has taken fundus accessibility a step further and posted a video on YouTube showing how to make a functional fundus camera that costs only 100 rupees. All you need in some cardboard, a water bottle, and a lens. “MacGyver: Chennai Edition.”
I feel it in my gut
Whoever said “inside, we’re all the same” clearly wasn’t considering the gut. A study from Vanderbilt University comprising 1,700 American subjects found that differences in gut microbiomes are most consistently linked with ethnicity. Vanderbilt biologist Seth Bordenstein emphasized how changing the gut microbiome can lead to curing illness but that it’s imperative that medical professionals understand how the gut differs across ethnicities.
Researchers found 12 types of bacteria that vary in abundancy by ethnicity. No comment on whether this was linked to differences in cuisine, but this writer fervently hopes new research arrives proving that tacos produce the healthiest gut microbiome.
F-bombing blood cancer
Call it a tale of two Toms.
TV newsman Tom Brokaw, who has multiple myeloma, says he’s become the “poster boy” for blood cancer. At first, though, he kept his diagnosis secret from just about everyone. But occasionally he let his emotions get the best of him. Especially when he’d see a Manhattan bus stop ad spotlighting the chiseled body of another Tom: the quarterback named Brady.
As he explained in a presentation at the annual meeting of the American Society of Hematology, he found it harder to get around because of back problems, which are common in multiple myeloma. As a result, he couldn’t manage to get to the office.
Still, “every day I’d force myself to leave the walker at home,” he recalled. “In that cold and sleety fall, I’d walk half a block to the coffee shop to get a bagel. There was this enormous new bus stop, with an animated advertisement board. Looking right at me was Tom Brady, advertising Ugg boots. I’d look down 79th Street at every inch of Tom Brady, and all the little old ladies were mooning over him as they were getting on the bus.”
Brokaw knew just what to do to make himself feel better. “I’d hobble over and look at him and drop the F-bomb on him every morning. Frankly, it was therapeutic for me.”
Later, he met the New England Patriots quarterback and told him the story, replacing “F-bomb” with the real word. “He had this little posse with him, and they roared. They said nobody talks to Tom like that.”
Brokaw still resists pleas to slow down from concerned loved ones, such as his emergency physician daughter. “My birth certificate says I’m 78 years old,” he said, “but I still think I’m 38 anchoring the news.” And still tossing tight-spiral F-bombs at cancer and gridiron G.O.A.T.s alike.
The earth is not enough
Earthly competitors have proved to be unworthy, so this week, Bacteria vs. the World visits the International Space Station, which – and we double-checked this – is in space. It’s a pretty exclusive location, and admission is by invitation only. Unless, of, course, you happen to be the ultimate hitchhiker. Four samples taken from the toilet of the ISS (and one from a piece of exercise equipment) were found to contain unknown strains of antibiotic-resistant Enterobacter bugandensis, investigators reported (BMC Microbiol. 2018 Nov 23;18[1]:175).
These bacterial stowaways were not virulent, lead author Nitin Singh, PhD, of the Jet Propulsion Laboratory said in a separate statement. But an analysis conducted by the team “reveals that the ISS isolates have a 79% probability of being a human pathogen.”
So, what does this mean for future space exploration? Cue the “Star Trek” music: “Space … the final frontier. These are the voyages of the bacterial transport ship Enterprise.”
Putting the FUN in fundus photos
You just got even more dependent on your phone: The American Academy of Opthalmology has published guidelines on how to use smartphones to take fundus photography, a.k.a. photographs of the back of the eye.
Advancement in smartphone optical quality has turned them into an important clinical tool, especially for specialists in low-funded or rural areas who don’t have access to imaging systems. Doctors can purchase special lenses and phone software to take these photos and then can easily upload the images to their Instagram accounts. (Even doctors need likes.)
An eye hospital in India has taken fundus accessibility a step further and posted a video on YouTube showing how to make a functional fundus camera that costs only 100 rupees. All you need in some cardboard, a water bottle, and a lens. “MacGyver: Chennai Edition.”
I feel it in my gut
Whoever said “inside, we’re all the same” clearly wasn’t considering the gut. A study from Vanderbilt University comprising 1,700 American subjects found that differences in gut microbiomes are most consistently linked with ethnicity. Vanderbilt biologist Seth Bordenstein emphasized how changing the gut microbiome can lead to curing illness but that it’s imperative that medical professionals understand how the gut differs across ethnicities.
Researchers found 12 types of bacteria that vary in abundancy by ethnicity. No comment on whether this was linked to differences in cuisine, but this writer fervently hopes new research arrives proving that tacos produce the healthiest gut microbiome.
F-bombing blood cancer
Call it a tale of two Toms.
TV newsman Tom Brokaw, who has multiple myeloma, says he’s become the “poster boy” for blood cancer. At first, though, he kept his diagnosis secret from just about everyone. But occasionally he let his emotions get the best of him. Especially when he’d see a Manhattan bus stop ad spotlighting the chiseled body of another Tom: the quarterback named Brady.
As he explained in a presentation at the annual meeting of the American Society of Hematology, he found it harder to get around because of back problems, which are common in multiple myeloma. As a result, he couldn’t manage to get to the office.
Still, “every day I’d force myself to leave the walker at home,” he recalled. “In that cold and sleety fall, I’d walk half a block to the coffee shop to get a bagel. There was this enormous new bus stop, with an animated advertisement board. Looking right at me was Tom Brady, advertising Ugg boots. I’d look down 79th Street at every inch of Tom Brady, and all the little old ladies were mooning over him as they were getting on the bus.”
Brokaw knew just what to do to make himself feel better. “I’d hobble over and look at him and drop the F-bomb on him every morning. Frankly, it was therapeutic for me.”
Later, he met the New England Patriots quarterback and told him the story, replacing “F-bomb” with the real word. “He had this little posse with him, and they roared. They said nobody talks to Tom like that.”
Brokaw still resists pleas to slow down from concerned loved ones, such as his emergency physician daughter. “My birth certificate says I’m 78 years old,” he said, “but I still think I’m 38 anchoring the news.” And still tossing tight-spiral F-bombs at cancer and gridiron G.O.A.T.s alike.
Harnessing the power of urine tests in pain care
SAN DIEGO – Clinicians have few tools to in their patients. However, addiction specialist and internist Edwin Salsitz, MD, says an inexpensive and simple tool, the urine test, can provide an impressive amount of useful information.
“The urine drug test, or another matrix for testing, gives one of the only objective factors we have to see how a patient is doing, if they’re following the treatment plan,” said Dr. Salsitz, of Mount Sinai Beth Israel, New York, in a presentation at Pain Care for Primary Care, a symposium offered by the American Pain Society and the Global Academy for Medical Education.
Dr. Salsitz offered these tips about urine tests in pain care:
Consider urine tests before beginning opioid therapy
Dr. Salsitz pointed to this 2016 recommendation from the Centers for Disease Control and Prevention: “When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.” As Dr. Salsitz puts it, these tests “can help identify misuse, which hopefully hasn’t gotten to addiction yet.”
Ask the patient what the urine test will reveal
Dr. Salsitz likes to tell patients: “If you tell me the truth, no matter what’s in the urine, it’s going to be OK. I’m not going to stop prescribing or do anything harmful to you.” But, he tells patients, if they lie, “you’re going to start breaking the trust between us. Once you do that, it becomes a problem. I don’t know what’s true or not.” In some cases, he said, patients will fess up to drug use that wouldn’t have shown up in the urine tests because it didn’t happen recently enough. “We’ll talk about whether it’s a problem,” he said.
Begin with an immunoassay panel test (IA)
The CDC recommends using an immunoassay panel first in most situations. “You can do this in the office,” Dr. Salsitz said, using a dipstick-style test. Or you can “send it out to a lab, and they’ll do the same thing.”
Understand what IA tests do and don’t do
Standard 5-drug IA screening tests detect marijuana, cocaine, amphetamine/methamphetamine, PCP, and opiates (morphine/codeine). Keep in mind, Dr. Salsitz said, that opiates and opioids aren’t the same. That means IA tests don’t pick up oxycodone use, for example, he said. More sophisticated (and more expensive) tests can distinguish between types of drugs (for example, morphine vs. codeine) and can detect drugs that aren’t included in the IA tests.
Don’t make assumptions about positive or negative tests
A positive drug test for cocaine doesn’t necessarily mean the person is addicted, Dr. Salsitz said. “It just means they used that molecule in the last 3 days. It’s up to you to figure out what it actually means.” And if a patient’s urine fails to show that he or she is taking a prescribed medication, that doesn’t necessarily indicate that the drug is being illegally diverted. The patient could have run out of the drug or lost insurance coverage, Dr. Salsitz said.
Be aware that patients may fake urine tests
“Cheating is a huge problem,” Dr. Salsitz said. “Is it their urine or not their urine?” Many kits promise to help people provide fake urine, and some have even provided fake penises to foil observed urine collection. What to do? Alternative tests that rely on hair, saliva, and even sweat are available, Dr. Salsitz said, and these make cheating more difficult. However, they have various limitations. Saliva, for example, only tells you what patients are using now, not what they used days ago, he said, and it’s not sensitive for marijuana.
Dr. Salsitz reported no disclosures.
The Global Academy for Medical Education, which offered the Pain Care for Primary Care symposium, and this news organization are owned by the same parent company.
SAN DIEGO – Clinicians have few tools to in their patients. However, addiction specialist and internist Edwin Salsitz, MD, says an inexpensive and simple tool, the urine test, can provide an impressive amount of useful information.
“The urine drug test, or another matrix for testing, gives one of the only objective factors we have to see how a patient is doing, if they’re following the treatment plan,” said Dr. Salsitz, of Mount Sinai Beth Israel, New York, in a presentation at Pain Care for Primary Care, a symposium offered by the American Pain Society and the Global Academy for Medical Education.
Dr. Salsitz offered these tips about urine tests in pain care:
Consider urine tests before beginning opioid therapy
Dr. Salsitz pointed to this 2016 recommendation from the Centers for Disease Control and Prevention: “When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.” As Dr. Salsitz puts it, these tests “can help identify misuse, which hopefully hasn’t gotten to addiction yet.”
Ask the patient what the urine test will reveal
Dr. Salsitz likes to tell patients: “If you tell me the truth, no matter what’s in the urine, it’s going to be OK. I’m not going to stop prescribing or do anything harmful to you.” But, he tells patients, if they lie, “you’re going to start breaking the trust between us. Once you do that, it becomes a problem. I don’t know what’s true or not.” In some cases, he said, patients will fess up to drug use that wouldn’t have shown up in the urine tests because it didn’t happen recently enough. “We’ll talk about whether it’s a problem,” he said.
Begin with an immunoassay panel test (IA)
The CDC recommends using an immunoassay panel first in most situations. “You can do this in the office,” Dr. Salsitz said, using a dipstick-style test. Or you can “send it out to a lab, and they’ll do the same thing.”
Understand what IA tests do and don’t do
Standard 5-drug IA screening tests detect marijuana, cocaine, amphetamine/methamphetamine, PCP, and opiates (morphine/codeine). Keep in mind, Dr. Salsitz said, that opiates and opioids aren’t the same. That means IA tests don’t pick up oxycodone use, for example, he said. More sophisticated (and more expensive) tests can distinguish between types of drugs (for example, morphine vs. codeine) and can detect drugs that aren’t included in the IA tests.
Don’t make assumptions about positive or negative tests
A positive drug test for cocaine doesn’t necessarily mean the person is addicted, Dr. Salsitz said. “It just means they used that molecule in the last 3 days. It’s up to you to figure out what it actually means.” And if a patient’s urine fails to show that he or she is taking a prescribed medication, that doesn’t necessarily indicate that the drug is being illegally diverted. The patient could have run out of the drug or lost insurance coverage, Dr. Salsitz said.
Be aware that patients may fake urine tests
“Cheating is a huge problem,” Dr. Salsitz said. “Is it their urine or not their urine?” Many kits promise to help people provide fake urine, and some have even provided fake penises to foil observed urine collection. What to do? Alternative tests that rely on hair, saliva, and even sweat are available, Dr. Salsitz said, and these make cheating more difficult. However, they have various limitations. Saliva, for example, only tells you what patients are using now, not what they used days ago, he said, and it’s not sensitive for marijuana.
Dr. Salsitz reported no disclosures.
The Global Academy for Medical Education, which offered the Pain Care for Primary Care symposium, and this news organization are owned by the same parent company.
SAN DIEGO – Clinicians have few tools to in their patients. However, addiction specialist and internist Edwin Salsitz, MD, says an inexpensive and simple tool, the urine test, can provide an impressive amount of useful information.
“The urine drug test, or another matrix for testing, gives one of the only objective factors we have to see how a patient is doing, if they’re following the treatment plan,” said Dr. Salsitz, of Mount Sinai Beth Israel, New York, in a presentation at Pain Care for Primary Care, a symposium offered by the American Pain Society and the Global Academy for Medical Education.
Dr. Salsitz offered these tips about urine tests in pain care:
Consider urine tests before beginning opioid therapy
Dr. Salsitz pointed to this 2016 recommendation from the Centers for Disease Control and Prevention: “When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.” As Dr. Salsitz puts it, these tests “can help identify misuse, which hopefully hasn’t gotten to addiction yet.”
Ask the patient what the urine test will reveal
Dr. Salsitz likes to tell patients: “If you tell me the truth, no matter what’s in the urine, it’s going to be OK. I’m not going to stop prescribing or do anything harmful to you.” But, he tells patients, if they lie, “you’re going to start breaking the trust between us. Once you do that, it becomes a problem. I don’t know what’s true or not.” In some cases, he said, patients will fess up to drug use that wouldn’t have shown up in the urine tests because it didn’t happen recently enough. “We’ll talk about whether it’s a problem,” he said.
Begin with an immunoassay panel test (IA)
The CDC recommends using an immunoassay panel first in most situations. “You can do this in the office,” Dr. Salsitz said, using a dipstick-style test. Or you can “send it out to a lab, and they’ll do the same thing.”
Understand what IA tests do and don’t do
Standard 5-drug IA screening tests detect marijuana, cocaine, amphetamine/methamphetamine, PCP, and opiates (morphine/codeine). Keep in mind, Dr. Salsitz said, that opiates and opioids aren’t the same. That means IA tests don’t pick up oxycodone use, for example, he said. More sophisticated (and more expensive) tests can distinguish between types of drugs (for example, morphine vs. codeine) and can detect drugs that aren’t included in the IA tests.
Don’t make assumptions about positive or negative tests
A positive drug test for cocaine doesn’t necessarily mean the person is addicted, Dr. Salsitz said. “It just means they used that molecule in the last 3 days. It’s up to you to figure out what it actually means.” And if a patient’s urine fails to show that he or she is taking a prescribed medication, that doesn’t necessarily indicate that the drug is being illegally diverted. The patient could have run out of the drug or lost insurance coverage, Dr. Salsitz said.
Be aware that patients may fake urine tests
“Cheating is a huge problem,” Dr. Salsitz said. “Is it their urine or not their urine?” Many kits promise to help people provide fake urine, and some have even provided fake penises to foil observed urine collection. What to do? Alternative tests that rely on hair, saliva, and even sweat are available, Dr. Salsitz said, and these make cheating more difficult. However, they have various limitations. Saliva, for example, only tells you what patients are using now, not what they used days ago, he said, and it’s not sensitive for marijuana.
Dr. Salsitz reported no disclosures.
The Global Academy for Medical Education, which offered the Pain Care for Primary Care symposium, and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM PAIN CARE FOR PRIMARY CARE
Pot for chronic pain? The jury is still out
SAN DIEGO – Is pot a valid alternative to opioids for patients with chronic pain? The verdict on the use of medical marijuana is still hazy, a pain specialist told primary care colleagues. “There’s some evidence for pain, but it’s not extensive,” said Timothy Furnish, MD, of the University of California at San Diego.
Still, he said, studies suggest that the expanding legal use of medical marijuana isn’t boosting opioid use or worsening traffic accident rates. (JAMA Intern Med. 2018;178[5]:667-72; Am J Public Health. 2016 Nov;106[11]:2032-7) And, he said, two things are clear: “There is no one who has overdosed and died specifically from marijuana ... and compared to opioids, cannabinoids have a relatively good safety profile.”
Dr. Furnish spoke in a presentation at Pain Care for Primary Care, a symposium held by the American Pain Society and Global Academy for Medical Education.
Thirty-three states and the District of Columbia allow – or will soon allow – the medical use of marijuana, although their laws and policies vary widely. The newest states to join the list are Utah, Missouri, and Oklahoma, where voters passed medical marijuana measures this year.
Ten states and the District of Columbia also allow the recreational use of marijuana.
However, most states in the South, including Texas and Georgia, don’t allow medical marijuana. The other states that continue to forbid it are in the Midwest and Rocky Mountain regions.
How does cannabis fare against pain? Dr. Furnish pointed to a 2011 systematic review of 18 randomized trials in noncancer chronic pain that showed that “overall there is evidence that cannabinoids are safe and modestly effective in neuropathic pain with preliminary evidence of efficacy in fibromyalgia and rheumatoid arthritis” (Br J Clin Pharmacol. 2011 Nov;72[5]:735-44).
More recently, a 2018 systematic review and meta-analysis of 104 studies found that “it seems unlikely that cannabinoids are highly effective medicines” for chronic noncancer pain (Pain. 2018 Oct;159[10]:1932-54).
In cancer pain, Dr. Furnish said, evidence supporting marijuana is limited and mainly involves nabiximols (Sativex), a cannabis-based inhaled spray that is approved in several nations outside the United States as a treatment for muscle stiffness and spasm in MS. The drug is still an investigational medication in the United States.
How much marijuana should patients with pain take? In the clinic, Dr. Furnish said, “patients actually do best on a relatively modest dose or low dose. High doses are probably more escape than pain relief.”
Dr. Furnish said that because of safety concerns, he never advises patients to smoke marijuana. “Vaporizing may be safer,” he said, noting that the inhaled route has a relatively rapid onset (2-10 minutes) and lasts for 2-4 hours.
Be aware, he said, that cannabis taken orally may not kick in for 30-90 minutes – “it will depend on what they’ve already ingested, and if they have recently consumed a fatty meal” – and patients may have trouble titrating their doses properly. “It’s a little bit easier to ingest more than they intended,” he said.
If you do want to give patients guidance about medical marijuana, keep in mind that “we can’t write a prescription. We only make recommendations,” he said.
“Use some of the same criteria that you’d use in suggesting a patient for opioid therapy,” he said. For example, exclude patients with active psychosis and schizophrenia.
Another red flag is a significant substance abuse history, since there is “abuse and dependence” in marijuana, he said. “Regular heavy users can experience withdrawal, but it tends to be a lot lighter than opioid withdrawal.”
Also be aware, he said, that there’s no federal oversight of medical marijuana, and “production, purity, potency, and state oversight vary widely.”
Global Academy for Medical Education and this news organization are owned by the same parent company.
Dr. Furnish has no disclosures.
SAN DIEGO – Is pot a valid alternative to opioids for patients with chronic pain? The verdict on the use of medical marijuana is still hazy, a pain specialist told primary care colleagues. “There’s some evidence for pain, but it’s not extensive,” said Timothy Furnish, MD, of the University of California at San Diego.
Still, he said, studies suggest that the expanding legal use of medical marijuana isn’t boosting opioid use or worsening traffic accident rates. (JAMA Intern Med. 2018;178[5]:667-72; Am J Public Health. 2016 Nov;106[11]:2032-7) And, he said, two things are clear: “There is no one who has overdosed and died specifically from marijuana ... and compared to opioids, cannabinoids have a relatively good safety profile.”
Dr. Furnish spoke in a presentation at Pain Care for Primary Care, a symposium held by the American Pain Society and Global Academy for Medical Education.
Thirty-three states and the District of Columbia allow – or will soon allow – the medical use of marijuana, although their laws and policies vary widely. The newest states to join the list are Utah, Missouri, and Oklahoma, where voters passed medical marijuana measures this year.
Ten states and the District of Columbia also allow the recreational use of marijuana.
However, most states in the South, including Texas and Georgia, don’t allow medical marijuana. The other states that continue to forbid it are in the Midwest and Rocky Mountain regions.
How does cannabis fare against pain? Dr. Furnish pointed to a 2011 systematic review of 18 randomized trials in noncancer chronic pain that showed that “overall there is evidence that cannabinoids are safe and modestly effective in neuropathic pain with preliminary evidence of efficacy in fibromyalgia and rheumatoid arthritis” (Br J Clin Pharmacol. 2011 Nov;72[5]:735-44).
More recently, a 2018 systematic review and meta-analysis of 104 studies found that “it seems unlikely that cannabinoids are highly effective medicines” for chronic noncancer pain (Pain. 2018 Oct;159[10]:1932-54).
In cancer pain, Dr. Furnish said, evidence supporting marijuana is limited and mainly involves nabiximols (Sativex), a cannabis-based inhaled spray that is approved in several nations outside the United States as a treatment for muscle stiffness and spasm in MS. The drug is still an investigational medication in the United States.
How much marijuana should patients with pain take? In the clinic, Dr. Furnish said, “patients actually do best on a relatively modest dose or low dose. High doses are probably more escape than pain relief.”
Dr. Furnish said that because of safety concerns, he never advises patients to smoke marijuana. “Vaporizing may be safer,” he said, noting that the inhaled route has a relatively rapid onset (2-10 minutes) and lasts for 2-4 hours.
Be aware, he said, that cannabis taken orally may not kick in for 30-90 minutes – “it will depend on what they’ve already ingested, and if they have recently consumed a fatty meal” – and patients may have trouble titrating their doses properly. “It’s a little bit easier to ingest more than they intended,” he said.
If you do want to give patients guidance about medical marijuana, keep in mind that “we can’t write a prescription. We only make recommendations,” he said.
“Use some of the same criteria that you’d use in suggesting a patient for opioid therapy,” he said. For example, exclude patients with active psychosis and schizophrenia.
Another red flag is a significant substance abuse history, since there is “abuse and dependence” in marijuana, he said. “Regular heavy users can experience withdrawal, but it tends to be a lot lighter than opioid withdrawal.”
Also be aware, he said, that there’s no federal oversight of medical marijuana, and “production, purity, potency, and state oversight vary widely.”
Global Academy for Medical Education and this news organization are owned by the same parent company.
Dr. Furnish has no disclosures.
SAN DIEGO – Is pot a valid alternative to opioids for patients with chronic pain? The verdict on the use of medical marijuana is still hazy, a pain specialist told primary care colleagues. “There’s some evidence for pain, but it’s not extensive,” said Timothy Furnish, MD, of the University of California at San Diego.
Still, he said, studies suggest that the expanding legal use of medical marijuana isn’t boosting opioid use or worsening traffic accident rates. (JAMA Intern Med. 2018;178[5]:667-72; Am J Public Health. 2016 Nov;106[11]:2032-7) And, he said, two things are clear: “There is no one who has overdosed and died specifically from marijuana ... and compared to opioids, cannabinoids have a relatively good safety profile.”
Dr. Furnish spoke in a presentation at Pain Care for Primary Care, a symposium held by the American Pain Society and Global Academy for Medical Education.
Thirty-three states and the District of Columbia allow – or will soon allow – the medical use of marijuana, although their laws and policies vary widely. The newest states to join the list are Utah, Missouri, and Oklahoma, where voters passed medical marijuana measures this year.
Ten states and the District of Columbia also allow the recreational use of marijuana.
However, most states in the South, including Texas and Georgia, don’t allow medical marijuana. The other states that continue to forbid it are in the Midwest and Rocky Mountain regions.
How does cannabis fare against pain? Dr. Furnish pointed to a 2011 systematic review of 18 randomized trials in noncancer chronic pain that showed that “overall there is evidence that cannabinoids are safe and modestly effective in neuropathic pain with preliminary evidence of efficacy in fibromyalgia and rheumatoid arthritis” (Br J Clin Pharmacol. 2011 Nov;72[5]:735-44).
More recently, a 2018 systematic review and meta-analysis of 104 studies found that “it seems unlikely that cannabinoids are highly effective medicines” for chronic noncancer pain (Pain. 2018 Oct;159[10]:1932-54).
In cancer pain, Dr. Furnish said, evidence supporting marijuana is limited and mainly involves nabiximols (Sativex), a cannabis-based inhaled spray that is approved in several nations outside the United States as a treatment for muscle stiffness and spasm in MS. The drug is still an investigational medication in the United States.
How much marijuana should patients with pain take? In the clinic, Dr. Furnish said, “patients actually do best on a relatively modest dose or low dose. High doses are probably more escape than pain relief.”
Dr. Furnish said that because of safety concerns, he never advises patients to smoke marijuana. “Vaporizing may be safer,” he said, noting that the inhaled route has a relatively rapid onset (2-10 minutes) and lasts for 2-4 hours.
Be aware, he said, that cannabis taken orally may not kick in for 30-90 minutes – “it will depend on what they’ve already ingested, and if they have recently consumed a fatty meal” – and patients may have trouble titrating their doses properly. “It’s a little bit easier to ingest more than they intended,” he said.
If you do want to give patients guidance about medical marijuana, keep in mind that “we can’t write a prescription. We only make recommendations,” he said.
“Use some of the same criteria that you’d use in suggesting a patient for opioid therapy,” he said. For example, exclude patients with active psychosis and schizophrenia.
Another red flag is a significant substance abuse history, since there is “abuse and dependence” in marijuana, he said. “Regular heavy users can experience withdrawal, but it tends to be a lot lighter than opioid withdrawal.”
Also be aware, he said, that there’s no federal oversight of medical marijuana, and “production, purity, potency, and state oversight vary widely.”
Global Academy for Medical Education and this news organization are owned by the same parent company.
Dr. Furnish has no disclosures.
EXPERT ANALYSIS FROM PAIN CARE FOR PRIMARY CARE
Probative pee, Pilgrim obesity, and med school baked bribes
He tweets, he (doesn’t) score!
We all know that less sleep equals poor job performance. Up way too late on a Sunday night means you might fall face first into your keyboard the next morning and accidentally send an email that ends with “hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh.” So, yeah, sleep is important.
It’s especially important when you are a professional athlete and your entire livelihood depends on you being in tip-top shape. Researchers from the State University of New York at Stony Brook studied the performance of NBA players in relation to their late-night Twitter binges. Unsurprisingly, tweeting in the wee hours correlated with fewer points and fewer rebounds in the next day’s game. We’re sure coaches are just thrilled to hear about their players spending precious night hours @-ing random trolls on Twitter. Does this mean less tweeting and more sleep means anyone can be the next LeBron? Or, um, the next @KingJames? Probably not … but give it a try.
Poppy seeds and probative pee
As you tuck into your Thanksgiving leftovers, give a thought to a valiant physician who ate and drank – and peed – for science. Not just once, but twice.
At the recent Pain Care for Primary Care symposium in San Diego, Mount Sinai Beth Israel addiction specialist Edwin Salsitz, MD, gave a presentation about drug screening and mentioned his own homegrown investigation into two reputed sources of false positives.
A few years ago, a patient tested positive for opiates and, like many before him, blamed his fondness for poppy-seed bagels. Dr. Salsitz asked the patient to buy him a poppy bagel from his usual source, then the doctor went home and ate it on a Sunday prior to collecting his own pee. The doctor’s subsequent urine test was positive for opiates, and the patient was off the hook. (For more about the poppy-seed menace to accurate opiate testing, check this clinical update from the Aegis testing company.)
Later, it was time to check another possible urban legend. Dr. Salsitz got some mate de coca tea from a friend who’d returned from South America. Again, he took time out of a Sunday, this time to enjoy a hot beverage, mate de coca style, and collect his own pee. The urine test was positive this time, too – for cocaine.
The moral of the story? If you have a drug test looming, be safe and just stick to a croissant and coffee.
Psst … want a cookie?
In medical school, the best and brightest sacrifice their bodies and social lives to absorb knowledge like human sponges. Or maybe it’s where they absorb cookies in exchange for positive end-of-course evaluations.
Investigators from the University of Münster (Germany) decided to give 118 of the school’s third-year medical students a little test. During a course on emergency medicine, some groups were given access to free chocolate cookies (Discus deliciosum spp.) in their sessions, and some groups were not. When it came time to fill out their “student evaluations of teaching” at the end of the semester, the “cookie group” was more generous in its ratings of the course material and gave significantly higher scores to the teachers and to the course overall, compared with the control group (Med Educ. 2018 Oct;52[10]:1064-72).
This all seemed a little suspicious, so we did a little digging. Turns out that the cookie group – the one that provided all that warm, chocolatey positive reinforcement – was chock full of the usual suspects: Ernie the elf, Mrs. Fields, Famous Amos, and Mr. Big himself, Cookie Monster.
Why Myles Standish wasn’t fat
In the autumn of 1621, obesity didn’t dine with the 53 Pilgrims who gave culinary thanks for surviving their first disappointing Boston Bruins season. Er, for their first harvest after a brutal New England winter. Why was that first Thanksgiving such a svelte affair, free of the high-BMI epidemic that afflicts so many Bruins faithful nearly 4 centuries later? Was it the free-range turkey? The lean venison? The Wampanoag guests’ demands for a DASH-diet dinner?
A modern study may help reveal the historical truth: 17th century Plymouth Plantation wasn’t yet bisected by the 21st century Cape Cod traffic snarling the Pilgrims Highway, a.k.a. Massachusetts Route 3.
It was Spanish researchers, not English Puritans, who unbuckled the portly puzzle’s Pilgrim hat. Investigators with the Barcelona Institute for Global Health examined the link between traffic noise exposure and obesity markers among a group of Swiss adults. The verdict? Those exposed to the highest levels of traffic noise ran the greatest risk of becoming obese. Specifically, every 10-decibel rise in road noise packed on another 17% increase in obesity. Seems tractor-trailer downshifts and honking horns may disturb sleep, gridlocking glucose metabolism and diverting everyone to the nearest drive-thru.
Next on the Spaniards’ research to-do list: Can your New England uncle’s annual Turkey Day tales of Red Sox triumphs trigger psychosis among familial Yankees fans?
He tweets, he (doesn’t) score!
We all know that less sleep equals poor job performance. Up way too late on a Sunday night means you might fall face first into your keyboard the next morning and accidentally send an email that ends with “hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh.” So, yeah, sleep is important.
It’s especially important when you are a professional athlete and your entire livelihood depends on you being in tip-top shape. Researchers from the State University of New York at Stony Brook studied the performance of NBA players in relation to their late-night Twitter binges. Unsurprisingly, tweeting in the wee hours correlated with fewer points and fewer rebounds in the next day’s game. We’re sure coaches are just thrilled to hear about their players spending precious night hours @-ing random trolls on Twitter. Does this mean less tweeting and more sleep means anyone can be the next LeBron? Or, um, the next @KingJames? Probably not … but give it a try.
Poppy seeds and probative pee
As you tuck into your Thanksgiving leftovers, give a thought to a valiant physician who ate and drank – and peed – for science. Not just once, but twice.
At the recent Pain Care for Primary Care symposium in San Diego, Mount Sinai Beth Israel addiction specialist Edwin Salsitz, MD, gave a presentation about drug screening and mentioned his own homegrown investigation into two reputed sources of false positives.
A few years ago, a patient tested positive for opiates and, like many before him, blamed his fondness for poppy-seed bagels. Dr. Salsitz asked the patient to buy him a poppy bagel from his usual source, then the doctor went home and ate it on a Sunday prior to collecting his own pee. The doctor’s subsequent urine test was positive for opiates, and the patient was off the hook. (For more about the poppy-seed menace to accurate opiate testing, check this clinical update from the Aegis testing company.)
Later, it was time to check another possible urban legend. Dr. Salsitz got some mate de coca tea from a friend who’d returned from South America. Again, he took time out of a Sunday, this time to enjoy a hot beverage, mate de coca style, and collect his own pee. The urine test was positive this time, too – for cocaine.
The moral of the story? If you have a drug test looming, be safe and just stick to a croissant and coffee.
Psst … want a cookie?
In medical school, the best and brightest sacrifice their bodies and social lives to absorb knowledge like human sponges. Or maybe it’s where they absorb cookies in exchange for positive end-of-course evaluations.
Investigators from the University of Münster (Germany) decided to give 118 of the school’s third-year medical students a little test. During a course on emergency medicine, some groups were given access to free chocolate cookies (Discus deliciosum spp.) in their sessions, and some groups were not. When it came time to fill out their “student evaluations of teaching” at the end of the semester, the “cookie group” was more generous in its ratings of the course material and gave significantly higher scores to the teachers and to the course overall, compared with the control group (Med Educ. 2018 Oct;52[10]:1064-72).
This all seemed a little suspicious, so we did a little digging. Turns out that the cookie group – the one that provided all that warm, chocolatey positive reinforcement – was chock full of the usual suspects: Ernie the elf, Mrs. Fields, Famous Amos, and Mr. Big himself, Cookie Monster.
Why Myles Standish wasn’t fat
In the autumn of 1621, obesity didn’t dine with the 53 Pilgrims who gave culinary thanks for surviving their first disappointing Boston Bruins season. Er, for their first harvest after a brutal New England winter. Why was that first Thanksgiving such a svelte affair, free of the high-BMI epidemic that afflicts so many Bruins faithful nearly 4 centuries later? Was it the free-range turkey? The lean venison? The Wampanoag guests’ demands for a DASH-diet dinner?
A modern study may help reveal the historical truth: 17th century Plymouth Plantation wasn’t yet bisected by the 21st century Cape Cod traffic snarling the Pilgrims Highway, a.k.a. Massachusetts Route 3.
It was Spanish researchers, not English Puritans, who unbuckled the portly puzzle’s Pilgrim hat. Investigators with the Barcelona Institute for Global Health examined the link between traffic noise exposure and obesity markers among a group of Swiss adults. The verdict? Those exposed to the highest levels of traffic noise ran the greatest risk of becoming obese. Specifically, every 10-decibel rise in road noise packed on another 17% increase in obesity. Seems tractor-trailer downshifts and honking horns may disturb sleep, gridlocking glucose metabolism and diverting everyone to the nearest drive-thru.
Next on the Spaniards’ research to-do list: Can your New England uncle’s annual Turkey Day tales of Red Sox triumphs trigger psychosis among familial Yankees fans?
He tweets, he (doesn’t) score!
We all know that less sleep equals poor job performance. Up way too late on a Sunday night means you might fall face first into your keyboard the next morning and accidentally send an email that ends with “hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh.” So, yeah, sleep is important.
It’s especially important when you are a professional athlete and your entire livelihood depends on you being in tip-top shape. Researchers from the State University of New York at Stony Brook studied the performance of NBA players in relation to their late-night Twitter binges. Unsurprisingly, tweeting in the wee hours correlated with fewer points and fewer rebounds in the next day’s game. We’re sure coaches are just thrilled to hear about their players spending precious night hours @-ing random trolls on Twitter. Does this mean less tweeting and more sleep means anyone can be the next LeBron? Or, um, the next @KingJames? Probably not … but give it a try.
Poppy seeds and probative pee
As you tuck into your Thanksgiving leftovers, give a thought to a valiant physician who ate and drank – and peed – for science. Not just once, but twice.
At the recent Pain Care for Primary Care symposium in San Diego, Mount Sinai Beth Israel addiction specialist Edwin Salsitz, MD, gave a presentation about drug screening and mentioned his own homegrown investigation into two reputed sources of false positives.
A few years ago, a patient tested positive for opiates and, like many before him, blamed his fondness for poppy-seed bagels. Dr. Salsitz asked the patient to buy him a poppy bagel from his usual source, then the doctor went home and ate it on a Sunday prior to collecting his own pee. The doctor’s subsequent urine test was positive for opiates, and the patient was off the hook. (For more about the poppy-seed menace to accurate opiate testing, check this clinical update from the Aegis testing company.)
Later, it was time to check another possible urban legend. Dr. Salsitz got some mate de coca tea from a friend who’d returned from South America. Again, he took time out of a Sunday, this time to enjoy a hot beverage, mate de coca style, and collect his own pee. The urine test was positive this time, too – for cocaine.
The moral of the story? If you have a drug test looming, be safe and just stick to a croissant and coffee.
Psst … want a cookie?
In medical school, the best and brightest sacrifice their bodies and social lives to absorb knowledge like human sponges. Or maybe it’s where they absorb cookies in exchange for positive end-of-course evaluations.
Investigators from the University of Münster (Germany) decided to give 118 of the school’s third-year medical students a little test. During a course on emergency medicine, some groups were given access to free chocolate cookies (Discus deliciosum spp.) in their sessions, and some groups were not. When it came time to fill out their “student evaluations of teaching” at the end of the semester, the “cookie group” was more generous in its ratings of the course material and gave significantly higher scores to the teachers and to the course overall, compared with the control group (Med Educ. 2018 Oct;52[10]:1064-72).
This all seemed a little suspicious, so we did a little digging. Turns out that the cookie group – the one that provided all that warm, chocolatey positive reinforcement – was chock full of the usual suspects: Ernie the elf, Mrs. Fields, Famous Amos, and Mr. Big himself, Cookie Monster.
Why Myles Standish wasn’t fat
In the autumn of 1621, obesity didn’t dine with the 53 Pilgrims who gave culinary thanks for surviving their first disappointing Boston Bruins season. Er, for their first harvest after a brutal New England winter. Why was that first Thanksgiving such a svelte affair, free of the high-BMI epidemic that afflicts so many Bruins faithful nearly 4 centuries later? Was it the free-range turkey? The lean venison? The Wampanoag guests’ demands for a DASH-diet dinner?
A modern study may help reveal the historical truth: 17th century Plymouth Plantation wasn’t yet bisected by the 21st century Cape Cod traffic snarling the Pilgrims Highway, a.k.a. Massachusetts Route 3.
It was Spanish researchers, not English Puritans, who unbuckled the portly puzzle’s Pilgrim hat. Investigators with the Barcelona Institute for Global Health examined the link between traffic noise exposure and obesity markers among a group of Swiss adults. The verdict? Those exposed to the highest levels of traffic noise ran the greatest risk of becoming obese. Specifically, every 10-decibel rise in road noise packed on another 17% increase in obesity. Seems tractor-trailer downshifts and honking horns may disturb sleep, gridlocking glucose metabolism and diverting everyone to the nearest drive-thru.
Next on the Spaniards’ research to-do list: Can your New England uncle’s annual Turkey Day tales of Red Sox triumphs trigger psychosis among familial Yankees fans?
Expert Q&A: What’s new in alopecia areata research and treatment?
LAS VEGAS – Alopecia is hard to bear for patients and has been difficult to treat, but “,” according to Maria Hordinsky, MD.
Dr. Hordinsky, professor and chair of the department of dermatology, University of Minnesota, Minneapolis, discussed hair disorders in multiple presentations at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. In an interview after her session on alopecia areata, she elaborated on the state of research and treatment for patients with this diagnosis.
DERMATOLOGY NEWS: What has changed in alopecia areata treatment over the last few years?
Dr. Hordinsky: There is still no Food and Drug Administration–approved treatment for this disease. But recent studies have helped us understand how alopecia areata occurs, how important interleukin-15 is, and how to target this cytokine as well as others. At the same time, expertise has developed at several centers across the United States with using the Janus kinase inhibitor tofacitinib [Xeljanz] at 5 milligrams twice a day. This has led to more off-label use. Concurrently, many pharmaceutical companies with interest in alopecia areata have begun to study different JAK inhibitors that target different cytokine receptors. Researchers also are exploring topical JAK inhibitors.
DN: What about the high costs of these drugs?
Dr. Hordinsky: Some insurers are covering tofacitinib, and patient assistance programs are very helpful and beneficial. In my own practice, most patients taking these drugs are using those programs.
DN: Are any treatments being used less than in the past?
Dr. Hordinsky: We’re still using tools that we have in the toolbox because we don’t have an approved treatment. We use topical steroids and intralesional steroids. We also use prednisone as needed, and we use contact sensitization therapy.
DN: In your presentation, you talked about alopecia areata in body areas outside of the scalp. What should dermatologists know about the eyebrows in patients with alopecia areata?
Dr. Hordinsky: Some patients don’t care as much about the scalp hair loss because they’ve figured out how to deal with it. What really bothers some patients is their eyebrow hair loss. You can think of situations where alopecia areata creates a circle in the middle of the eyebrow on the left side, but not the right, or you lose one eyebrow but not the other. We use techniques such as intralesional steroids. If there’s some hair growth present that’s lightly pigmented, we may apply topical minoxidil or Latisse [bimatoprost] to the brow area. Patients may also do microblading.
DN: Are there eyebrow prosthetics?
Dr. Hordinsky: Yes, there are. The National Alopecia Areata Foundation provides a lot of information to patients and providers about these devices. There are devices that you can tape on your brow area. Some don’t look great cosmetically, but some look fantastic. Microblading may create the most normal appearance.
DN: What about eyelashes?
Dr. Hordinsky: Eyelash loss is tough and really bothersome to patients if they don’t wear glasses because of the protection provided by eyelashes, such as when you blink against airborne dust. If there is some hair present in the eyebrow regions, one can try to regrow hair and use something that’s safe in that region, like topical Latisse. These treatments have to be tried for a couple of months before you say yea or nay, and you and the patient have to have reasonable expectations.
DN: What about men’s beards?
Dr. Hordinsky: You can treat those areas with topical or intralesional steroids. My own experience is that you have to use intralesional steroids, and overall, this form of alopecia areata may be one of the most difficult to manage successfully.
DN: Do men complain about missing chest hair?
Dr. Hordinsky: Chest hair doesn’t come up a lot for me. For men, it’s mainly the beard area. But people with alopecia areata may sometimes minimize or not bring up discussion of loss of hair in the underarms, the genital region, or the chest. It may be because they’ve figured out how to deal with it.
DN: How do you think treatments will improve over the next 5-10 years?
Dr. Hordinsky: We have a number of companies putting JAK inhibitors into clinical trials. A major step forward will be figuring out which one works the best, and then the next hurdle will be sustainability. There are very few studies in alopecia areata about how long a response to treatment can be maintained. Another big step will be the development of a topical agent that is able to penetrate through the skin to the level of the immune attack at the lower part of the hair follicle and provide the opportunity to possibly not only grow hair but also to maintain hair growth. So there’s a lot of evolution going on right now.
Dr. Hordinsky disclosed consulting work with Procter & Gamble, Concert, and Cassiopea, and grant/research support from Aclaris, National Alopecia Areata Foundation, Allergan.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – Alopecia is hard to bear for patients and has been difficult to treat, but “,” according to Maria Hordinsky, MD.
Dr. Hordinsky, professor and chair of the department of dermatology, University of Minnesota, Minneapolis, discussed hair disorders in multiple presentations at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. In an interview after her session on alopecia areata, she elaborated on the state of research and treatment for patients with this diagnosis.
DERMATOLOGY NEWS: What has changed in alopecia areata treatment over the last few years?
Dr. Hordinsky: There is still no Food and Drug Administration–approved treatment for this disease. But recent studies have helped us understand how alopecia areata occurs, how important interleukin-15 is, and how to target this cytokine as well as others. At the same time, expertise has developed at several centers across the United States with using the Janus kinase inhibitor tofacitinib [Xeljanz] at 5 milligrams twice a day. This has led to more off-label use. Concurrently, many pharmaceutical companies with interest in alopecia areata have begun to study different JAK inhibitors that target different cytokine receptors. Researchers also are exploring topical JAK inhibitors.
DN: What about the high costs of these drugs?
Dr. Hordinsky: Some insurers are covering tofacitinib, and patient assistance programs are very helpful and beneficial. In my own practice, most patients taking these drugs are using those programs.
DN: Are any treatments being used less than in the past?
Dr. Hordinsky: We’re still using tools that we have in the toolbox because we don’t have an approved treatment. We use topical steroids and intralesional steroids. We also use prednisone as needed, and we use contact sensitization therapy.
DN: In your presentation, you talked about alopecia areata in body areas outside of the scalp. What should dermatologists know about the eyebrows in patients with alopecia areata?
Dr. Hordinsky: Some patients don’t care as much about the scalp hair loss because they’ve figured out how to deal with it. What really bothers some patients is their eyebrow hair loss. You can think of situations where alopecia areata creates a circle in the middle of the eyebrow on the left side, but not the right, or you lose one eyebrow but not the other. We use techniques such as intralesional steroids. If there’s some hair growth present that’s lightly pigmented, we may apply topical minoxidil or Latisse [bimatoprost] to the brow area. Patients may also do microblading.
DN: Are there eyebrow prosthetics?
Dr. Hordinsky: Yes, there are. The National Alopecia Areata Foundation provides a lot of information to patients and providers about these devices. There are devices that you can tape on your brow area. Some don’t look great cosmetically, but some look fantastic. Microblading may create the most normal appearance.
DN: What about eyelashes?
Dr. Hordinsky: Eyelash loss is tough and really bothersome to patients if they don’t wear glasses because of the protection provided by eyelashes, such as when you blink against airborne dust. If there is some hair present in the eyebrow regions, one can try to regrow hair and use something that’s safe in that region, like topical Latisse. These treatments have to be tried for a couple of months before you say yea or nay, and you and the patient have to have reasonable expectations.
DN: What about men’s beards?
Dr. Hordinsky: You can treat those areas with topical or intralesional steroids. My own experience is that you have to use intralesional steroids, and overall, this form of alopecia areata may be one of the most difficult to manage successfully.
DN: Do men complain about missing chest hair?
Dr. Hordinsky: Chest hair doesn’t come up a lot for me. For men, it’s mainly the beard area. But people with alopecia areata may sometimes minimize or not bring up discussion of loss of hair in the underarms, the genital region, or the chest. It may be because they’ve figured out how to deal with it.
DN: How do you think treatments will improve over the next 5-10 years?
Dr. Hordinsky: We have a number of companies putting JAK inhibitors into clinical trials. A major step forward will be figuring out which one works the best, and then the next hurdle will be sustainability. There are very few studies in alopecia areata about how long a response to treatment can be maintained. Another big step will be the development of a topical agent that is able to penetrate through the skin to the level of the immune attack at the lower part of the hair follicle and provide the opportunity to possibly not only grow hair but also to maintain hair growth. So there’s a lot of evolution going on right now.
Dr. Hordinsky disclosed consulting work with Procter & Gamble, Concert, and Cassiopea, and grant/research support from Aclaris, National Alopecia Areata Foundation, Allergan.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – Alopecia is hard to bear for patients and has been difficult to treat, but “,” according to Maria Hordinsky, MD.
Dr. Hordinsky, professor and chair of the department of dermatology, University of Minnesota, Minneapolis, discussed hair disorders in multiple presentations at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. In an interview after her session on alopecia areata, she elaborated on the state of research and treatment for patients with this diagnosis.
DERMATOLOGY NEWS: What has changed in alopecia areata treatment over the last few years?
Dr. Hordinsky: There is still no Food and Drug Administration–approved treatment for this disease. But recent studies have helped us understand how alopecia areata occurs, how important interleukin-15 is, and how to target this cytokine as well as others. At the same time, expertise has developed at several centers across the United States with using the Janus kinase inhibitor tofacitinib [Xeljanz] at 5 milligrams twice a day. This has led to more off-label use. Concurrently, many pharmaceutical companies with interest in alopecia areata have begun to study different JAK inhibitors that target different cytokine receptors. Researchers also are exploring topical JAK inhibitors.
DN: What about the high costs of these drugs?
Dr. Hordinsky: Some insurers are covering tofacitinib, and patient assistance programs are very helpful and beneficial. In my own practice, most patients taking these drugs are using those programs.
DN: Are any treatments being used less than in the past?
Dr. Hordinsky: We’re still using tools that we have in the toolbox because we don’t have an approved treatment. We use topical steroids and intralesional steroids. We also use prednisone as needed, and we use contact sensitization therapy.
DN: In your presentation, you talked about alopecia areata in body areas outside of the scalp. What should dermatologists know about the eyebrows in patients with alopecia areata?
Dr. Hordinsky: Some patients don’t care as much about the scalp hair loss because they’ve figured out how to deal with it. What really bothers some patients is their eyebrow hair loss. You can think of situations where alopecia areata creates a circle in the middle of the eyebrow on the left side, but not the right, or you lose one eyebrow but not the other. We use techniques such as intralesional steroids. If there’s some hair growth present that’s lightly pigmented, we may apply topical minoxidil or Latisse [bimatoprost] to the brow area. Patients may also do microblading.
DN: Are there eyebrow prosthetics?
Dr. Hordinsky: Yes, there are. The National Alopecia Areata Foundation provides a lot of information to patients and providers about these devices. There are devices that you can tape on your brow area. Some don’t look great cosmetically, but some look fantastic. Microblading may create the most normal appearance.
DN: What about eyelashes?
Dr. Hordinsky: Eyelash loss is tough and really bothersome to patients if they don’t wear glasses because of the protection provided by eyelashes, such as when you blink against airborne dust. If there is some hair present in the eyebrow regions, one can try to regrow hair and use something that’s safe in that region, like topical Latisse. These treatments have to be tried for a couple of months before you say yea or nay, and you and the patient have to have reasonable expectations.
DN: What about men’s beards?
Dr. Hordinsky: You can treat those areas with topical or intralesional steroids. My own experience is that you have to use intralesional steroids, and overall, this form of alopecia areata may be one of the most difficult to manage successfully.
DN: Do men complain about missing chest hair?
Dr. Hordinsky: Chest hair doesn’t come up a lot for me. For men, it’s mainly the beard area. But people with alopecia areata may sometimes minimize or not bring up discussion of loss of hair in the underarms, the genital region, or the chest. It may be because they’ve figured out how to deal with it.
DN: How do you think treatments will improve over the next 5-10 years?
Dr. Hordinsky: We have a number of companies putting JAK inhibitors into clinical trials. A major step forward will be figuring out which one works the best, and then the next hurdle will be sustainability. There are very few studies in alopecia areata about how long a response to treatment can be maintained. Another big step will be the development of a topical agent that is able to penetrate through the skin to the level of the immune attack at the lower part of the hair follicle and provide the opportunity to possibly not only grow hair but also to maintain hair growth. So there’s a lot of evolution going on right now.
Dr. Hordinsky disclosed consulting work with Procter & Gamble, Concert, and Cassiopea, and grant/research support from Aclaris, National Alopecia Areata Foundation, Allergan.
SDEF and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF LAS VEGAS DERMATOLOGY SEMINAR
Topical treatments remain a good option for psoriasis
LAS VEGAS – in mild cases of psoriasis.
Topicals often are a worthwhile complement to even the most advanced systemic medications, according to Linda Stein Gold, MD, director of clinical research in the department of dermatology at the Henry Ford Health System, Detroit.
Speaking at the Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar, she pointed out that as the variety of vehicles for topical treatments has grown, so has the need to pay attention to the potency of these treatments. “Traditionally, we had thought we had to use a thick ointment to drive the drug in and get the best efficacy,” she said. “But we’ve changed our thought process.”
For example, betamethasone dipropionate 0.05%, now comes in multiple types of ointments and creams, with different potency classes, including Diprolene ointment, 0.05%, Diprosone cream, 0.05%, Diprolene cream AF, 0.05%, and Diprolene cream, 0.05%, as well as a lotion and an emollient spray.
“It’s the same active drug, but different vehicles absolutely change the potency of the drug,” Dr. Stein Gold said.
So which is the most potent? She said you can’t tell just by the vehicle. In this case, the most potent forms – in the “superpotent” class 1 – are Diprolene cream, 0.05%, and Diprolene ointment, 0.05%. (The National Psoriasis Foundation has a potency chart for topical psoriasis medications.)
She also recommended considering combination therapy with tazarotene. Tazarotene, a vitamin A derivative, is associated with a variety of side effects in 10%-30% of patients, including pruritus, erythema, irritation, skin pain, psoriasis worsening, and burning/stinging. But combination therapy with topical corticosteroids can reduce adverse effects, and it boosts efficacy as well, Dr. Stein Gold said.
She added that tazarotene can be a tool against acne. The 0.1% cream and gel formulations are approved by the Food and Drug Administration for treating acne; the 0.05% cream and gel forms are approved only for psoriasis. “Both concentrations work well and hit the different pillars of the pathogenesis of acne,” she said.
In addition, Dr. Stein Gold noted that she led two 2018 studies that found a fixed combination of halobetasol propionate 0.01% and tazarotene 0.045% lotion in moderate to severe plaque psoriasis was associated with significant reductions in the severity of the clinical signs of psoriasis, and minimal safety concerns (J Am Acad Dermatol. 2018 Aug;79[2]:287-93).
As for the future in topical treatment for psoriasis, she said researchers are exploring phosphodiesterase-4 inhibitors, Janus kinase inhibitors, and aryl hydrocarbon receptor agonists.
Dr. Stein Gold disclosed speaker bureau relationships with Galderma, Leo, Valeant, Novartis, Celgene and Allergan; consulting for Sol‐Gel, Galderma, Leo, Novan, Valeant, Dermira, Novartis, Celgene, Allergan, Foamix, Promius, Anacor and Medimetriks; receiving grant/research support from Galderma, Leo, Novan, Valeant, Dermira, Novartis, Celgene, Allergan and Foamix; and serving on scientific advisory boards for Galderma, Leo, Novan, Valeant, Dermira, Novartis, Celgene, Allergan, Foamix and Promius.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – in mild cases of psoriasis.
Topicals often are a worthwhile complement to even the most advanced systemic medications, according to Linda Stein Gold, MD, director of clinical research in the department of dermatology at the Henry Ford Health System, Detroit.
Speaking at the Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar, she pointed out that as the variety of vehicles for topical treatments has grown, so has the need to pay attention to the potency of these treatments. “Traditionally, we had thought we had to use a thick ointment to drive the drug in and get the best efficacy,” she said. “But we’ve changed our thought process.”
For example, betamethasone dipropionate 0.05%, now comes in multiple types of ointments and creams, with different potency classes, including Diprolene ointment, 0.05%, Diprosone cream, 0.05%, Diprolene cream AF, 0.05%, and Diprolene cream, 0.05%, as well as a lotion and an emollient spray.
“It’s the same active drug, but different vehicles absolutely change the potency of the drug,” Dr. Stein Gold said.
So which is the most potent? She said you can’t tell just by the vehicle. In this case, the most potent forms – in the “superpotent” class 1 – are Diprolene cream, 0.05%, and Diprolene ointment, 0.05%. (The National Psoriasis Foundation has a potency chart for topical psoriasis medications.)
She also recommended considering combination therapy with tazarotene. Tazarotene, a vitamin A derivative, is associated with a variety of side effects in 10%-30% of patients, including pruritus, erythema, irritation, skin pain, psoriasis worsening, and burning/stinging. But combination therapy with topical corticosteroids can reduce adverse effects, and it boosts efficacy as well, Dr. Stein Gold said.
She added that tazarotene can be a tool against acne. The 0.1% cream and gel formulations are approved by the Food and Drug Administration for treating acne; the 0.05% cream and gel forms are approved only for psoriasis. “Both concentrations work well and hit the different pillars of the pathogenesis of acne,” she said.
In addition, Dr. Stein Gold noted that she led two 2018 studies that found a fixed combination of halobetasol propionate 0.01% and tazarotene 0.045% lotion in moderate to severe plaque psoriasis was associated with significant reductions in the severity of the clinical signs of psoriasis, and minimal safety concerns (J Am Acad Dermatol. 2018 Aug;79[2]:287-93).
As for the future in topical treatment for psoriasis, she said researchers are exploring phosphodiesterase-4 inhibitors, Janus kinase inhibitors, and aryl hydrocarbon receptor agonists.
Dr. Stein Gold disclosed speaker bureau relationships with Galderma, Leo, Valeant, Novartis, Celgene and Allergan; consulting for Sol‐Gel, Galderma, Leo, Novan, Valeant, Dermira, Novartis, Celgene, Allergan, Foamix, Promius, Anacor and Medimetriks; receiving grant/research support from Galderma, Leo, Novan, Valeant, Dermira, Novartis, Celgene, Allergan and Foamix; and serving on scientific advisory boards for Galderma, Leo, Novan, Valeant, Dermira, Novartis, Celgene, Allergan, Foamix and Promius.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – in mild cases of psoriasis.
Topicals often are a worthwhile complement to even the most advanced systemic medications, according to Linda Stein Gold, MD, director of clinical research in the department of dermatology at the Henry Ford Health System, Detroit.
Speaking at the Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar, she pointed out that as the variety of vehicles for topical treatments has grown, so has the need to pay attention to the potency of these treatments. “Traditionally, we had thought we had to use a thick ointment to drive the drug in and get the best efficacy,” she said. “But we’ve changed our thought process.”
For example, betamethasone dipropionate 0.05%, now comes in multiple types of ointments and creams, with different potency classes, including Diprolene ointment, 0.05%, Diprosone cream, 0.05%, Diprolene cream AF, 0.05%, and Diprolene cream, 0.05%, as well as a lotion and an emollient spray.
“It’s the same active drug, but different vehicles absolutely change the potency of the drug,” Dr. Stein Gold said.
So which is the most potent? She said you can’t tell just by the vehicle. In this case, the most potent forms – in the “superpotent” class 1 – are Diprolene cream, 0.05%, and Diprolene ointment, 0.05%. (The National Psoriasis Foundation has a potency chart for topical psoriasis medications.)
She also recommended considering combination therapy with tazarotene. Tazarotene, a vitamin A derivative, is associated with a variety of side effects in 10%-30% of patients, including pruritus, erythema, irritation, skin pain, psoriasis worsening, and burning/stinging. But combination therapy with topical corticosteroids can reduce adverse effects, and it boosts efficacy as well, Dr. Stein Gold said.
She added that tazarotene can be a tool against acne. The 0.1% cream and gel formulations are approved by the Food and Drug Administration for treating acne; the 0.05% cream and gel forms are approved only for psoriasis. “Both concentrations work well and hit the different pillars of the pathogenesis of acne,” she said.
In addition, Dr. Stein Gold noted that she led two 2018 studies that found a fixed combination of halobetasol propionate 0.01% and tazarotene 0.045% lotion in moderate to severe plaque psoriasis was associated with significant reductions in the severity of the clinical signs of psoriasis, and minimal safety concerns (J Am Acad Dermatol. 2018 Aug;79[2]:287-93).
As for the future in topical treatment for psoriasis, she said researchers are exploring phosphodiesterase-4 inhibitors, Janus kinase inhibitors, and aryl hydrocarbon receptor agonists.
Dr. Stein Gold disclosed speaker bureau relationships with Galderma, Leo, Valeant, Novartis, Celgene and Allergan; consulting for Sol‐Gel, Galderma, Leo, Novan, Valeant, Dermira, Novartis, Celgene, Allergan, Foamix, Promius, Anacor and Medimetriks; receiving grant/research support from Galderma, Leo, Novan, Valeant, Dermira, Novartis, Celgene, Allergan and Foamix; and serving on scientific advisory boards for Galderma, Leo, Novan, Valeant, Dermira, Novartis, Celgene, Allergan, Foamix and Promius.
SDEF and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF LAS VEGAS DERMATOLOGY SEMINAR
Treating psoriasis with biologics: Recommendations from an expert
LAS VEGAS – If you’re considering adding biologics for psoriasis to your clinical practice, dermatologist Kristina C. Duffin, MD, has some advice: Don’t expect to just use one drug, focus on comorbidities, and embrace strategies to bypass the potential obstacle of prior-authorization approvals.
Here are some tips from Dr. Duffin, who spoke at the Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar:
- Don’t expect a one-size-fits-all medication. “There is no one, single go-to drug,” said Dr. Duffin, who is cochair of the department of dermatology at the University of Utah, Salt Lake City. “Maybe someday, we will have a biological personalized medicine marker to say this is the right drug, but for now we don’t.” More than 10 biologics are available to treat psoriasis, she said, and more are in the pipeline.
- Pay close attention to comorbidities. It’s important to “have a good grasp” of a patient’s comorbidities, which can help focus the choice of a biologic, Dr. Duffin said. She recommends starting with an anti–tumor necrosis factor (TNF) agents for patients with psoriatic arthritis. For patients with Crohn’s disease, she recommends anti-TNF (adalimumab, infliximab) and anti-interleukin–12/23 or anti-IL-23 agents (ustekinumab). Anti-TNF agents should be avoided in patients with multiple sclerosis, and anti-IL-17 agents shouldn’t be given to patients with recurrent candidiasis, she noted.
- Encourage patients to make prompt decisions. Dr. Duffin sits down with patients to discuss various biologic options, and she goes over information in handouts. She also focuses on their needs: “Are they interested in getting better fast? Do they want to be clear for their wedding in a month?” She prefers to not let patients go home to think about what they’d like to do. Instead, she advises patients to make choices while at the office visit.
- Order lab tests and be careful about vaccines. Dr. Duffin orders the following tests for all patients who are starting on biologics: CBC, comprehensive metabolic panel, hepatitis B and C, and tuberculosis. She orders HIV, Hba1c and lipid tests, if appropriate. She prefers that patients treated with biologics avoid live vaccines. She suggests other vaccines, if indicated, such as seasonal influenza and pneumonia vaccines, and for those aged 50 years and older, herpes zoster vaccine. She urges patients to call the office if they have an infection or need surgery because they may need to discuss putting a temporary hold on the biologics.
- Understand how to navigate formularies.“Getting drugs approved for patients with Medicare is a challenge,” Dr. Duffin said. It’s helpful to understand how insurers handle specific psoriasis drugs so you can choose one that’s likely to be covered if you’re unsure which one is best. The website www.covermymeds.com allows physicians to easily check insurer formularies, free of charge, she said.
- Documentation is crucial when you’re dealing with an insurer. Document body surface area, Psoriasis Area Severity Index scores, or physician global assessment measures, she advised. An app provided by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, is a helpful in determining these measurements, she said. Also include information about failed treatments and the rationale behind why you chose a specific treatment, she said. “If denial happens, get the details,” she said. This may turn up a clerical error on the insurer’s part that incorrectly led to a denial.
- Escalate challenges to drug denials. If the preferred treatment is denied, one option is to appeal the denial. As a resource, Dr. Duffin pointed to sample letters for appealing denials for physicians and patients on the websites for the American Academy of Dermatology and the National Psoriasis Foundation. Ask for a limited 6-month approval, she said, or have the patient write a letter to the insurer using one of the sample letter templates. Another option is to ask the insurer for a “peer-to-peer” review, she said. “Sometimes it’s really hard for insurance company folks to say no to you if you have a really good story,” she commented.
- Help your patients get financial assistance. Almost every biologic manufacturer has a patient assistance plan, which can also help with deductibles and copays, Dr. Duffin said.
Dr. Duffin discloses consulting for AbbVie, Amgen, Celgene, Janssen, Lilly, Novartis, Pfizer, and Sienna. She has received grant/contracted research support from AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, Sienna, Stiefel, and UCB.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – If you’re considering adding biologics for psoriasis to your clinical practice, dermatologist Kristina C. Duffin, MD, has some advice: Don’t expect to just use one drug, focus on comorbidities, and embrace strategies to bypass the potential obstacle of prior-authorization approvals.
Here are some tips from Dr. Duffin, who spoke at the Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar:
- Don’t expect a one-size-fits-all medication. “There is no one, single go-to drug,” said Dr. Duffin, who is cochair of the department of dermatology at the University of Utah, Salt Lake City. “Maybe someday, we will have a biological personalized medicine marker to say this is the right drug, but for now we don’t.” More than 10 biologics are available to treat psoriasis, she said, and more are in the pipeline.
- Pay close attention to comorbidities. It’s important to “have a good grasp” of a patient’s comorbidities, which can help focus the choice of a biologic, Dr. Duffin said. She recommends starting with an anti–tumor necrosis factor (TNF) agents for patients with psoriatic arthritis. For patients with Crohn’s disease, she recommends anti-TNF (adalimumab, infliximab) and anti-interleukin–12/23 or anti-IL-23 agents (ustekinumab). Anti-TNF agents should be avoided in patients with multiple sclerosis, and anti-IL-17 agents shouldn’t be given to patients with recurrent candidiasis, she noted.
- Encourage patients to make prompt decisions. Dr. Duffin sits down with patients to discuss various biologic options, and she goes over information in handouts. She also focuses on their needs: “Are they interested in getting better fast? Do they want to be clear for their wedding in a month?” She prefers to not let patients go home to think about what they’d like to do. Instead, she advises patients to make choices while at the office visit.
- Order lab tests and be careful about vaccines. Dr. Duffin orders the following tests for all patients who are starting on biologics: CBC, comprehensive metabolic panel, hepatitis B and C, and tuberculosis. She orders HIV, Hba1c and lipid tests, if appropriate. She prefers that patients treated with biologics avoid live vaccines. She suggests other vaccines, if indicated, such as seasonal influenza and pneumonia vaccines, and for those aged 50 years and older, herpes zoster vaccine. She urges patients to call the office if they have an infection or need surgery because they may need to discuss putting a temporary hold on the biologics.
- Understand how to navigate formularies.“Getting drugs approved for patients with Medicare is a challenge,” Dr. Duffin said. It’s helpful to understand how insurers handle specific psoriasis drugs so you can choose one that’s likely to be covered if you’re unsure which one is best. The website www.covermymeds.com allows physicians to easily check insurer formularies, free of charge, she said.
- Documentation is crucial when you’re dealing with an insurer. Document body surface area, Psoriasis Area Severity Index scores, or physician global assessment measures, she advised. An app provided by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, is a helpful in determining these measurements, she said. Also include information about failed treatments and the rationale behind why you chose a specific treatment, she said. “If denial happens, get the details,” she said. This may turn up a clerical error on the insurer’s part that incorrectly led to a denial.
- Escalate challenges to drug denials. If the preferred treatment is denied, one option is to appeal the denial. As a resource, Dr. Duffin pointed to sample letters for appealing denials for physicians and patients on the websites for the American Academy of Dermatology and the National Psoriasis Foundation. Ask for a limited 6-month approval, she said, or have the patient write a letter to the insurer using one of the sample letter templates. Another option is to ask the insurer for a “peer-to-peer” review, she said. “Sometimes it’s really hard for insurance company folks to say no to you if you have a really good story,” she commented.
- Help your patients get financial assistance. Almost every biologic manufacturer has a patient assistance plan, which can also help with deductibles and copays, Dr. Duffin said.
Dr. Duffin discloses consulting for AbbVie, Amgen, Celgene, Janssen, Lilly, Novartis, Pfizer, and Sienna. She has received grant/contracted research support from AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, Sienna, Stiefel, and UCB.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – If you’re considering adding biologics for psoriasis to your clinical practice, dermatologist Kristina C. Duffin, MD, has some advice: Don’t expect to just use one drug, focus on comorbidities, and embrace strategies to bypass the potential obstacle of prior-authorization approvals.
Here are some tips from Dr. Duffin, who spoke at the Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar:
- Don’t expect a one-size-fits-all medication. “There is no one, single go-to drug,” said Dr. Duffin, who is cochair of the department of dermatology at the University of Utah, Salt Lake City. “Maybe someday, we will have a biological personalized medicine marker to say this is the right drug, but for now we don’t.” More than 10 biologics are available to treat psoriasis, she said, and more are in the pipeline.
- Pay close attention to comorbidities. It’s important to “have a good grasp” of a patient’s comorbidities, which can help focus the choice of a biologic, Dr. Duffin said. She recommends starting with an anti–tumor necrosis factor (TNF) agents for patients with psoriatic arthritis. For patients with Crohn’s disease, she recommends anti-TNF (adalimumab, infliximab) and anti-interleukin–12/23 or anti-IL-23 agents (ustekinumab). Anti-TNF agents should be avoided in patients with multiple sclerosis, and anti-IL-17 agents shouldn’t be given to patients with recurrent candidiasis, she noted.
- Encourage patients to make prompt decisions. Dr. Duffin sits down with patients to discuss various biologic options, and she goes over information in handouts. She also focuses on their needs: “Are they interested in getting better fast? Do they want to be clear for their wedding in a month?” She prefers to not let patients go home to think about what they’d like to do. Instead, she advises patients to make choices while at the office visit.
- Order lab tests and be careful about vaccines. Dr. Duffin orders the following tests for all patients who are starting on biologics: CBC, comprehensive metabolic panel, hepatitis B and C, and tuberculosis. She orders HIV, Hba1c and lipid tests, if appropriate. She prefers that patients treated with biologics avoid live vaccines. She suggests other vaccines, if indicated, such as seasonal influenza and pneumonia vaccines, and for those aged 50 years and older, herpes zoster vaccine. She urges patients to call the office if they have an infection or need surgery because they may need to discuss putting a temporary hold on the biologics.
- Understand how to navigate formularies.“Getting drugs approved for patients with Medicare is a challenge,” Dr. Duffin said. It’s helpful to understand how insurers handle specific psoriasis drugs so you can choose one that’s likely to be covered if you’re unsure which one is best. The website www.covermymeds.com allows physicians to easily check insurer formularies, free of charge, she said.
- Documentation is crucial when you’re dealing with an insurer. Document body surface area, Psoriasis Area Severity Index scores, or physician global assessment measures, she advised. An app provided by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, is a helpful in determining these measurements, she said. Also include information about failed treatments and the rationale behind why you chose a specific treatment, she said. “If denial happens, get the details,” she said. This may turn up a clerical error on the insurer’s part that incorrectly led to a denial.
- Escalate challenges to drug denials. If the preferred treatment is denied, one option is to appeal the denial. As a resource, Dr. Duffin pointed to sample letters for appealing denials for physicians and patients on the websites for the American Academy of Dermatology and the National Psoriasis Foundation. Ask for a limited 6-month approval, she said, or have the patient write a letter to the insurer using one of the sample letter templates. Another option is to ask the insurer for a “peer-to-peer” review, she said. “Sometimes it’s really hard for insurance company folks to say no to you if you have a really good story,” she commented.
- Help your patients get financial assistance. Almost every biologic manufacturer has a patient assistance plan, which can also help with deductibles and copays, Dr. Duffin said.
Dr. Duffin discloses consulting for AbbVie, Amgen, Celgene, Janssen, Lilly, Novartis, Pfizer, and Sienna. She has received grant/contracted research support from AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, Sienna, Stiefel, and UCB.
SDEF and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF LAS VEGAS DERMATOLOGY SEMINAR
Use CARE MD protocol to treat somatic disorders
SAN DIEGO – Patients with somatic symptom and related disorders can get better in primary care when clinicians use a few key strategies, according to an expert.
When it comes to these disorders, “a lot of our anxiety and gallows humor comes from a place of not knowing what we want to do, how we can treat these individuals,” said Matthew Reed, MD, MPH, a psychiatrist and pain specialist at the University of California, Irvine. “It became more appealing once I learned a little bit more about what was going on with some of these disorders and how I might be able to intervene.”
Dr. Reed spoke at Pain Care for Primary Care, held by the American Pain Society and Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.
Throughout his presentation, Dr. Reed drew upon the listing of somatic symptom and related disorders as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Among the disorders he discussed:
Somatic symptom disorder
This disorder causes significant distress because of at least one somatic symptom and is persistent (lasting over 6 months). A medical illness might be present, and depression and anxiety are common.
“This diagnosis says you have pathology – this somatic disorder – which is making your life miserable,” Dr. Reed said.
He’s often thrilled when patients also have comorbid depression and/or anxiety. “You treat that primary issue, and the somatic disorder melts away,” he said. “It’s harder when you have the pure version of somatic disorder, and there is no anxiety or depressive disorder.”
Illness anxiety disorder (formerly known as hypochondriasis)
Patients with this disorder have been preoccupied about having a serious illness for at least 6 months but do not have somatic symptoms. Reassurance typically is not effective, Dr. Reed said. In response to a statement such as “nothing’s wrong,” he said, patients might reply with a statement along the lines of “something’s wrong because I’m suffering.”
Patients with this condition can command “high rates of medical utilization, often pretty inappropriate,” especially if they are VIPs, he said.
Conversion disorder (also known as functional neurological symptom disorder)
This is less common than the other disorders. Patients with this condition develop “one or more symptoms of altered voluntary motor or sensory function” that’s “not better explained by another medical condition.”
A “listening ear” and physical therapy can prove helpful, Dr. Reed said.
Factitious disorder
Patients with this condition falsify or induce signs of illness, impairment, or injury. “There’s more of an overt feigning of symptoms in order to maintain that sick role,” said Dr. Reed, who cautioned that some people with this condition actually might be suffering.
Protocol can guide treatment
How can these conditions be treated in patients? Dr. Reed pointed to the protocol discussed by Robert McCarron, DO, and embedded in the mnemonic “CARE MD”: Cognitive-behavioral therapy (CBT)/consultation, regular visits, empathy, med-psych interface, and do no harm.
“Reassure them that you value them,” he said. Under CARE MD, the idea of multiple visits is to help the patient develop coping strategies and stop overusing medical care.
Return visits should not be too frequent, Dr. Reed said, and they should be short. Physicians must remember to take care of themselves and other patients, he said, and not spend too much time with these patients. “We need to be compassionate,” he said, but “we don’t need to be compassionate in a way that we don’t have our sanity after clinic.”
As for CBT, Dr. Reed likes to suggest it in a way that doesn’t aggravate patients who are sensitive to the idea that their condition is all in their heads.
Physicians, he said, can say: “Wow, this is really affecting your life. You have 17 specialists working on you. You’ll continue to see them, I know. But I worry. I look at your chart, and we’re missing a whole area of treatment.”
He then mentions CBT. “Other providers may have told you about it,” he’ll say. “I’ve seen such good benefits with CBT, even with patients who were in motor vehicle accidents. It doesn’t matter where it’s coming from. This CBT seems to work.”
Ideally, he said, patients agree to try it.
Dr. Reed had no disclosures.
SAN DIEGO – Patients with somatic symptom and related disorders can get better in primary care when clinicians use a few key strategies, according to an expert.
When it comes to these disorders, “a lot of our anxiety and gallows humor comes from a place of not knowing what we want to do, how we can treat these individuals,” said Matthew Reed, MD, MPH, a psychiatrist and pain specialist at the University of California, Irvine. “It became more appealing once I learned a little bit more about what was going on with some of these disorders and how I might be able to intervene.”
Dr. Reed spoke at Pain Care for Primary Care, held by the American Pain Society and Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.
Throughout his presentation, Dr. Reed drew upon the listing of somatic symptom and related disorders as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Among the disorders he discussed:
Somatic symptom disorder
This disorder causes significant distress because of at least one somatic symptom and is persistent (lasting over 6 months). A medical illness might be present, and depression and anxiety are common.
“This diagnosis says you have pathology – this somatic disorder – which is making your life miserable,” Dr. Reed said.
He’s often thrilled when patients also have comorbid depression and/or anxiety. “You treat that primary issue, and the somatic disorder melts away,” he said. “It’s harder when you have the pure version of somatic disorder, and there is no anxiety or depressive disorder.”
Illness anxiety disorder (formerly known as hypochondriasis)
Patients with this disorder have been preoccupied about having a serious illness for at least 6 months but do not have somatic symptoms. Reassurance typically is not effective, Dr. Reed said. In response to a statement such as “nothing’s wrong,” he said, patients might reply with a statement along the lines of “something’s wrong because I’m suffering.”
Patients with this condition can command “high rates of medical utilization, often pretty inappropriate,” especially if they are VIPs, he said.
Conversion disorder (also known as functional neurological symptom disorder)
This is less common than the other disorders. Patients with this condition develop “one or more symptoms of altered voluntary motor or sensory function” that’s “not better explained by another medical condition.”
A “listening ear” and physical therapy can prove helpful, Dr. Reed said.
Factitious disorder
Patients with this condition falsify or induce signs of illness, impairment, or injury. “There’s more of an overt feigning of symptoms in order to maintain that sick role,” said Dr. Reed, who cautioned that some people with this condition actually might be suffering.
Protocol can guide treatment
How can these conditions be treated in patients? Dr. Reed pointed to the protocol discussed by Robert McCarron, DO, and embedded in the mnemonic “CARE MD”: Cognitive-behavioral therapy (CBT)/consultation, regular visits, empathy, med-psych interface, and do no harm.
“Reassure them that you value them,” he said. Under CARE MD, the idea of multiple visits is to help the patient develop coping strategies and stop overusing medical care.
Return visits should not be too frequent, Dr. Reed said, and they should be short. Physicians must remember to take care of themselves and other patients, he said, and not spend too much time with these patients. “We need to be compassionate,” he said, but “we don’t need to be compassionate in a way that we don’t have our sanity after clinic.”
As for CBT, Dr. Reed likes to suggest it in a way that doesn’t aggravate patients who are sensitive to the idea that their condition is all in their heads.
Physicians, he said, can say: “Wow, this is really affecting your life. You have 17 specialists working on you. You’ll continue to see them, I know. But I worry. I look at your chart, and we’re missing a whole area of treatment.”
He then mentions CBT. “Other providers may have told you about it,” he’ll say. “I’ve seen such good benefits with CBT, even with patients who were in motor vehicle accidents. It doesn’t matter where it’s coming from. This CBT seems to work.”
Ideally, he said, patients agree to try it.
Dr. Reed had no disclosures.
SAN DIEGO – Patients with somatic symptom and related disorders can get better in primary care when clinicians use a few key strategies, according to an expert.
When it comes to these disorders, “a lot of our anxiety and gallows humor comes from a place of not knowing what we want to do, how we can treat these individuals,” said Matthew Reed, MD, MPH, a psychiatrist and pain specialist at the University of California, Irvine. “It became more appealing once I learned a little bit more about what was going on with some of these disorders and how I might be able to intervene.”
Dr. Reed spoke at Pain Care for Primary Care, held by the American Pain Society and Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.
Throughout his presentation, Dr. Reed drew upon the listing of somatic symptom and related disorders as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Among the disorders he discussed:
Somatic symptom disorder
This disorder causes significant distress because of at least one somatic symptom and is persistent (lasting over 6 months). A medical illness might be present, and depression and anxiety are common.
“This diagnosis says you have pathology – this somatic disorder – which is making your life miserable,” Dr. Reed said.
He’s often thrilled when patients also have comorbid depression and/or anxiety. “You treat that primary issue, and the somatic disorder melts away,” he said. “It’s harder when you have the pure version of somatic disorder, and there is no anxiety or depressive disorder.”
Illness anxiety disorder (formerly known as hypochondriasis)
Patients with this disorder have been preoccupied about having a serious illness for at least 6 months but do not have somatic symptoms. Reassurance typically is not effective, Dr. Reed said. In response to a statement such as “nothing’s wrong,” he said, patients might reply with a statement along the lines of “something’s wrong because I’m suffering.”
Patients with this condition can command “high rates of medical utilization, often pretty inappropriate,” especially if they are VIPs, he said.
Conversion disorder (also known as functional neurological symptom disorder)
This is less common than the other disorders. Patients with this condition develop “one or more symptoms of altered voluntary motor or sensory function” that’s “not better explained by another medical condition.”
A “listening ear” and physical therapy can prove helpful, Dr. Reed said.
Factitious disorder
Patients with this condition falsify or induce signs of illness, impairment, or injury. “There’s more of an overt feigning of symptoms in order to maintain that sick role,” said Dr. Reed, who cautioned that some people with this condition actually might be suffering.
Protocol can guide treatment
How can these conditions be treated in patients? Dr. Reed pointed to the protocol discussed by Robert McCarron, DO, and embedded in the mnemonic “CARE MD”: Cognitive-behavioral therapy (CBT)/consultation, regular visits, empathy, med-psych interface, and do no harm.
“Reassure them that you value them,” he said. Under CARE MD, the idea of multiple visits is to help the patient develop coping strategies and stop overusing medical care.
Return visits should not be too frequent, Dr. Reed said, and they should be short. Physicians must remember to take care of themselves and other patients, he said, and not spend too much time with these patients. “We need to be compassionate,” he said, but “we don’t need to be compassionate in a way that we don’t have our sanity after clinic.”
As for CBT, Dr. Reed likes to suggest it in a way that doesn’t aggravate patients who are sensitive to the idea that their condition is all in their heads.
Physicians, he said, can say: “Wow, this is really affecting your life. You have 17 specialists working on you. You’ll continue to see them, I know. But I worry. I look at your chart, and we’re missing a whole area of treatment.”
He then mentions CBT. “Other providers may have told you about it,” he’ll say. “I’ve seen such good benefits with CBT, even with patients who were in motor vehicle accidents. It doesn’t matter where it’s coming from. This CBT seems to work.”
Ideally, he said, patients agree to try it.
Dr. Reed had no disclosures.
REPORTING FROM PAIN CARE FOR PRIMARY CARE
CKD, and even dialysis, may not be barriers to pregnancy
SAN DIEGO – Nephrologists are often uncomfortable with the idea of advising women with chronic kidney disease (CKD) about pregnancy, a physician told colleagues. They must do better, she said, with sensitivity and insight into once-extreme possibilities like pregnancy during dialysis.
“For many women, having a child is a life goal, and our women with chronic kidney disease are not different,” said Michelle Hladunewich, MD, of Toronto’s Sunnybrook Health Sciences Center. “When we don’t know what we should do, we tend to over-aggressively counsel our women, and that can traumatize them. It’s our role as nephrologists to help them find the safest window to have their pregnancy,” she said at the meeting sponsored by the American Society of Nephrology.
According to Dr. Hladunewich, there are tens of thousands of women of child-bearing age in the United States who have CKD, end-stage renal disease (ESRD), and kidney transplants. However, she said, research presented at Kidney Week 2018 suggested that many nephrologists do not feel confident about counseling patients regarding issues such as pregnancy outcomes in CKD. “We are not that comfortable with it, but we have to become more comfortable,” she said. “We need to be prepared to talk about contraception if they don’t want to have a child or the plan about how to have a child if they do.”
It’s especially important to understand that while women can fear birth defects and the exacerbation of their disease, they may also feel “they’re not fulfilling a societal norm to have a child like everyone else,” she said.
The risks of pregnancy in CKD can affect the mother (via worse kidney function) and/or the fetus (preeclampsia, poor fetal growth, preterm delivery).
In a 2015 study, Italian researchers compared 504 pregnancies in women with CKD to 836 low-risk pregnancies in women without CKD. They found that the risks of adverse outcomes increased in women at higher stages of CKD, compared with those at lower stages: “Renal function matters, and a stepwise increase in the risk of adverse maternal-fetal outcomes is observed from stage 1 to stages 4-5.”
In addition, the researchers noted that their research suggests “the presence of a baseline risk linked to CKD per se” (J Am Soc Nephrol. 2015 Aug; 26[8]:2011-22).
Dr. Hladunewich recommended focusing on “the safest window of opportunity.” Some patients will progress to end-stage renal disease, and an earlier pregnancy during CKD is a better option, she said. As a result, encouraging an earlier pregnancy can be a wise idea.
In some cases, though, a patient may be far into the stages of CKD. Dr. Hladunewich spoke about the case of a 31-year-old patient with a 29-year history of type 1 diabetes mellitus. She’d had one miscarriage, one preterm birth, and one twin pregnancy that was terminated because of safety concerns including rapid loss of kidney function.
The patient saw Dr. Hladunewich when she had a glomerular filtration rate of 25 mL/min, 3.5 g per 24 hour of proteinuria, and hypertension. The patient had a question: “Dr. Michelle, when can I try again?”
Dr. Hladunewich joked that “I had a small stroke.” But then, she said, “I got to the business of pregnancy counseling.”
She told the woman that her progression to end-stage renal disease was likely inevitable, and “adverse pregnancy outcomes were almost guaranteed.”
The woman responded: “Not now? When?” That, Dr. Hladunewich said, “was when I had my second stroke.”
But there is a possible solution: Pregnancy during dialysis. “Historically, we’ve said absolutely no pregnancy on dialysis,” she said, “but times are changing. We believe aggressive dialysis improves fetal maternal and fetal outcomes.”
Indeed, Dr. Hladunewich led a 2014 study that linked extensive dialysis during pregnancy (compared with less dialysis) to a better likelihood of outcomes such as live birth rate and normal birth weight (JASN May 2014;25[5]:1103-9).
As she noted, “we do offer it as a reproductive option” to patients like the one she mentioned – those who are in ESRD, approaching it, or are nearing the end of their child-bearing years with no transplant in sight. In transplant cases, she said, adequate graft function is linked to good pregnancy outcomes.
Dr. Hladunewich added that it’s important to monitor and adjust treatment of patients during the postpartum period. She said it’s especially important to understand the risks of drugs during breastfeeding. Both dialysis and transplant patients can breastfeed, she said.
Dr. Hladunewich reports no disclosures.
SOURCE: Kidney Week 2018, Abstract FR-OR078.
SAN DIEGO – Nephrologists are often uncomfortable with the idea of advising women with chronic kidney disease (CKD) about pregnancy, a physician told colleagues. They must do better, she said, with sensitivity and insight into once-extreme possibilities like pregnancy during dialysis.
“For many women, having a child is a life goal, and our women with chronic kidney disease are not different,” said Michelle Hladunewich, MD, of Toronto’s Sunnybrook Health Sciences Center. “When we don’t know what we should do, we tend to over-aggressively counsel our women, and that can traumatize them. It’s our role as nephrologists to help them find the safest window to have their pregnancy,” she said at the meeting sponsored by the American Society of Nephrology.
According to Dr. Hladunewich, there are tens of thousands of women of child-bearing age in the United States who have CKD, end-stage renal disease (ESRD), and kidney transplants. However, she said, research presented at Kidney Week 2018 suggested that many nephrologists do not feel confident about counseling patients regarding issues such as pregnancy outcomes in CKD. “We are not that comfortable with it, but we have to become more comfortable,” she said. “We need to be prepared to talk about contraception if they don’t want to have a child or the plan about how to have a child if they do.”
It’s especially important to understand that while women can fear birth defects and the exacerbation of their disease, they may also feel “they’re not fulfilling a societal norm to have a child like everyone else,” she said.
The risks of pregnancy in CKD can affect the mother (via worse kidney function) and/or the fetus (preeclampsia, poor fetal growth, preterm delivery).
In a 2015 study, Italian researchers compared 504 pregnancies in women with CKD to 836 low-risk pregnancies in women without CKD. They found that the risks of adverse outcomes increased in women at higher stages of CKD, compared with those at lower stages: “Renal function matters, and a stepwise increase in the risk of adverse maternal-fetal outcomes is observed from stage 1 to stages 4-5.”
In addition, the researchers noted that their research suggests “the presence of a baseline risk linked to CKD per se” (J Am Soc Nephrol. 2015 Aug; 26[8]:2011-22).
Dr. Hladunewich recommended focusing on “the safest window of opportunity.” Some patients will progress to end-stage renal disease, and an earlier pregnancy during CKD is a better option, she said. As a result, encouraging an earlier pregnancy can be a wise idea.
In some cases, though, a patient may be far into the stages of CKD. Dr. Hladunewich spoke about the case of a 31-year-old patient with a 29-year history of type 1 diabetes mellitus. She’d had one miscarriage, one preterm birth, and one twin pregnancy that was terminated because of safety concerns including rapid loss of kidney function.
The patient saw Dr. Hladunewich when she had a glomerular filtration rate of 25 mL/min, 3.5 g per 24 hour of proteinuria, and hypertension. The patient had a question: “Dr. Michelle, when can I try again?”
Dr. Hladunewich joked that “I had a small stroke.” But then, she said, “I got to the business of pregnancy counseling.”
She told the woman that her progression to end-stage renal disease was likely inevitable, and “adverse pregnancy outcomes were almost guaranteed.”
The woman responded: “Not now? When?” That, Dr. Hladunewich said, “was when I had my second stroke.”
But there is a possible solution: Pregnancy during dialysis. “Historically, we’ve said absolutely no pregnancy on dialysis,” she said, “but times are changing. We believe aggressive dialysis improves fetal maternal and fetal outcomes.”
Indeed, Dr. Hladunewich led a 2014 study that linked extensive dialysis during pregnancy (compared with less dialysis) to a better likelihood of outcomes such as live birth rate and normal birth weight (JASN May 2014;25[5]:1103-9).
As she noted, “we do offer it as a reproductive option” to patients like the one she mentioned – those who are in ESRD, approaching it, or are nearing the end of their child-bearing years with no transplant in sight. In transplant cases, she said, adequate graft function is linked to good pregnancy outcomes.
Dr. Hladunewich added that it’s important to monitor and adjust treatment of patients during the postpartum period. She said it’s especially important to understand the risks of drugs during breastfeeding. Both dialysis and transplant patients can breastfeed, she said.
Dr. Hladunewich reports no disclosures.
SOURCE: Kidney Week 2018, Abstract FR-OR078.
SAN DIEGO – Nephrologists are often uncomfortable with the idea of advising women with chronic kidney disease (CKD) about pregnancy, a physician told colleagues. They must do better, she said, with sensitivity and insight into once-extreme possibilities like pregnancy during dialysis.
“For many women, having a child is a life goal, and our women with chronic kidney disease are not different,” said Michelle Hladunewich, MD, of Toronto’s Sunnybrook Health Sciences Center. “When we don’t know what we should do, we tend to over-aggressively counsel our women, and that can traumatize them. It’s our role as nephrologists to help them find the safest window to have their pregnancy,” she said at the meeting sponsored by the American Society of Nephrology.
According to Dr. Hladunewich, there are tens of thousands of women of child-bearing age in the United States who have CKD, end-stage renal disease (ESRD), and kidney transplants. However, she said, research presented at Kidney Week 2018 suggested that many nephrologists do not feel confident about counseling patients regarding issues such as pregnancy outcomes in CKD. “We are not that comfortable with it, but we have to become more comfortable,” she said. “We need to be prepared to talk about contraception if they don’t want to have a child or the plan about how to have a child if they do.”
It’s especially important to understand that while women can fear birth defects and the exacerbation of their disease, they may also feel “they’re not fulfilling a societal norm to have a child like everyone else,” she said.
The risks of pregnancy in CKD can affect the mother (via worse kidney function) and/or the fetus (preeclampsia, poor fetal growth, preterm delivery).
In a 2015 study, Italian researchers compared 504 pregnancies in women with CKD to 836 low-risk pregnancies in women without CKD. They found that the risks of adverse outcomes increased in women at higher stages of CKD, compared with those at lower stages: “Renal function matters, and a stepwise increase in the risk of adverse maternal-fetal outcomes is observed from stage 1 to stages 4-5.”
In addition, the researchers noted that their research suggests “the presence of a baseline risk linked to CKD per se” (J Am Soc Nephrol. 2015 Aug; 26[8]:2011-22).
Dr. Hladunewich recommended focusing on “the safest window of opportunity.” Some patients will progress to end-stage renal disease, and an earlier pregnancy during CKD is a better option, she said. As a result, encouraging an earlier pregnancy can be a wise idea.
In some cases, though, a patient may be far into the stages of CKD. Dr. Hladunewich spoke about the case of a 31-year-old patient with a 29-year history of type 1 diabetes mellitus. She’d had one miscarriage, one preterm birth, and one twin pregnancy that was terminated because of safety concerns including rapid loss of kidney function.
The patient saw Dr. Hladunewich when she had a glomerular filtration rate of 25 mL/min, 3.5 g per 24 hour of proteinuria, and hypertension. The patient had a question: “Dr. Michelle, when can I try again?”
Dr. Hladunewich joked that “I had a small stroke.” But then, she said, “I got to the business of pregnancy counseling.”
She told the woman that her progression to end-stage renal disease was likely inevitable, and “adverse pregnancy outcomes were almost guaranteed.”
The woman responded: “Not now? When?” That, Dr. Hladunewich said, “was when I had my second stroke.”
But there is a possible solution: Pregnancy during dialysis. “Historically, we’ve said absolutely no pregnancy on dialysis,” she said, “but times are changing. We believe aggressive dialysis improves fetal maternal and fetal outcomes.”
Indeed, Dr. Hladunewich led a 2014 study that linked extensive dialysis during pregnancy (compared with less dialysis) to a better likelihood of outcomes such as live birth rate and normal birth weight (JASN May 2014;25[5]:1103-9).
As she noted, “we do offer it as a reproductive option” to patients like the one she mentioned – those who are in ESRD, approaching it, or are nearing the end of their child-bearing years with no transplant in sight. In transplant cases, she said, adequate graft function is linked to good pregnancy outcomes.
Dr. Hladunewich added that it’s important to monitor and adjust treatment of patients during the postpartum period. She said it’s especially important to understand the risks of drugs during breastfeeding. Both dialysis and transplant patients can breastfeed, she said.
Dr. Hladunewich reports no disclosures.
SOURCE: Kidney Week 2018, Abstract FR-OR078.
REPORTING FROM KIDNEY WEEK 2018
Necrotizing lunchitis, pneumonia throwdown, global gamete warming
Global gamete warming
Apparently, increasing deadly wildfires, hurricanes, and global famine aren’t enough. Turns out, climate change has found yet another way to harm its arch nemeses, a.k.a. every single species on the planet. A study originally published in Nature Communications found that rising temperatures also have a significant effect on male (but not female) fertility. Men: so fragile.
Testing fertility in flour beetles, researchers concluded that successive heat waves of 5-7° C above normal for 5 days reduced sperm competitiveness and practically sterilized the males. Inseminated sperm inside females were also not spared the devastating effects of the heat-wave conditions. And, as the icing on the cake, reduced fertility persisted amongst later generations.
Unless we can figure out how robot sperm can deliver DNA, we’re in trouble.
Pneumonia throwdown
Previously, we pitted Clostridium difficile against cockroaches in a battle of toughness. In this week’s edition of Bacteria vs. the World, bacterial pneumonia goes up against another worthy adversary, viral pneumonia.
“We’ve always known pneumonia was a risk factor for a major adverse cardiac event,” said J. Brent Muhlestein, MD, of Intermountain Medical Center in Salt Lake City. “What we didn’t know was which type of pneumonia was more dangerous.”
To find out, he and his associates followed almost 4,800 patients hospitalized with pneumonia and tracked nonfatal heart attacks, stroke, heart failure, or death. Data they presented at the American Heart Association scientific sessions in Chicago show that 34% of patients with bacterial pneumonia had a major cardiovascular event within 90 days, compared with 26% of those diagnosed with viral pneumonia. It is likely “that bacterial pneumonia causes greater inflammation of the arteries compared to viral pneumonia,” Dr. Muhlestein said.
So the bacteria stay undefeated, and somewhere Chuck Norris, who will never have a heart attack – even a heart isn’t foolish enough to attack Chuck Norris – is smiling.
Ch-ch-check it out
Drop the beat! Researchers at the University of California were interested in examining beatboxing processes to explore how the human mind works.
These crazy scientists threw some beatboxers into an MRI for an exclusive performance and studied the movements of their mouth and tongue. Researchers hypothesized that beatboxers base their sounds on already-known speech. But they discovered that these talented virtuosos are creating a whole new language.
“They’re coming up with ways to create these really complex acrobatic sounds by taking approaches drawn from different parts of the mouth that they don’t use in any language, and nobody uses for any language,” according to the lead researcher.
Does that mean beatboxing will be taught in schools as a foreign language? Perhaps. It might be more useful than learning Latin.
Keloid castration
Keloids – those pesky overgrowths of scar tissue – can be mighty hard to treat.
“Virtually every patient says, ‘I want this cut off – I want it gone,’ ” dermatologist Hilary E. Baldwin, MD, said in a presentation at the recent Las Vegas Dermatology Seminar. She responds to patients with reality checks about what’s actually possible in keloid treatment.
But sometimes, they just want to adjust the appearance of their keloids. Like the man who complained that “my keloid looks like my junk.” Dr. Baldwin took a look and had to agree – the keloid on his deltoid was the spitting image of male genitalia. She treated the keloid with the equivalent of castration (removing its “testicles” via surgery) and circumcision of sorts (flattening its “glans penis” via corticosteroids).
“It didn’t look pretty,” she said, as at least one male member of the audience squirmed, “but it no longer looked offensive to him.”
‘Necrotizing lunchitis’
Here at the Bureau of Livin’ on the MDedge, we pride ourselves on having the best words. And being University of Michigan graduates. So, the pain is Likert-scale 10 when Big Ten rivals have better words – and worse office fridges.
Exhibit A: the operative report surgical-taped to a Penn State University call room refrigerator, which general surgery resident and American hero Dr. Cassie Sonntag shared on Twitter. The 18-cubic-foot communal Kenmore’s diagnosis? “Necrotizing lunchitis.”
The grave condition called for immediate intervention by surgeon “Whitt,” with assistance from circulating nurse “Liu.” The surgical team performed “debridement of the upper, middle, and lower compartments of the call room refrigerator with extension into the fridge door, disarticulation and washout of the lower chamber, explantation of necrotic lunches of varying ages.” Complications? “Multiple never-before-seen species of mold casually exterminated.” The patient’s postprocedure condition is “guarded.” The complete report is well worth your review. Even if the Sears appliance’s specimens were “refused by path.”
Global gamete warming
Apparently, increasing deadly wildfires, hurricanes, and global famine aren’t enough. Turns out, climate change has found yet another way to harm its arch nemeses, a.k.a. every single species on the planet. A study originally published in Nature Communications found that rising temperatures also have a significant effect on male (but not female) fertility. Men: so fragile.
Testing fertility in flour beetles, researchers concluded that successive heat waves of 5-7° C above normal for 5 days reduced sperm competitiveness and practically sterilized the males. Inseminated sperm inside females were also not spared the devastating effects of the heat-wave conditions. And, as the icing on the cake, reduced fertility persisted amongst later generations.
Unless we can figure out how robot sperm can deliver DNA, we’re in trouble.
Pneumonia throwdown
Previously, we pitted Clostridium difficile against cockroaches in a battle of toughness. In this week’s edition of Bacteria vs. the World, bacterial pneumonia goes up against another worthy adversary, viral pneumonia.
“We’ve always known pneumonia was a risk factor for a major adverse cardiac event,” said J. Brent Muhlestein, MD, of Intermountain Medical Center in Salt Lake City. “What we didn’t know was which type of pneumonia was more dangerous.”
To find out, he and his associates followed almost 4,800 patients hospitalized with pneumonia and tracked nonfatal heart attacks, stroke, heart failure, or death. Data they presented at the American Heart Association scientific sessions in Chicago show that 34% of patients with bacterial pneumonia had a major cardiovascular event within 90 days, compared with 26% of those diagnosed with viral pneumonia. It is likely “that bacterial pneumonia causes greater inflammation of the arteries compared to viral pneumonia,” Dr. Muhlestein said.
So the bacteria stay undefeated, and somewhere Chuck Norris, who will never have a heart attack – even a heart isn’t foolish enough to attack Chuck Norris – is smiling.
Ch-ch-check it out
Drop the beat! Researchers at the University of California were interested in examining beatboxing processes to explore how the human mind works.
These crazy scientists threw some beatboxers into an MRI for an exclusive performance and studied the movements of their mouth and tongue. Researchers hypothesized that beatboxers base their sounds on already-known speech. But they discovered that these talented virtuosos are creating a whole new language.
“They’re coming up with ways to create these really complex acrobatic sounds by taking approaches drawn from different parts of the mouth that they don’t use in any language, and nobody uses for any language,” according to the lead researcher.
Does that mean beatboxing will be taught in schools as a foreign language? Perhaps. It might be more useful than learning Latin.
Keloid castration
Keloids – those pesky overgrowths of scar tissue – can be mighty hard to treat.
“Virtually every patient says, ‘I want this cut off – I want it gone,’ ” dermatologist Hilary E. Baldwin, MD, said in a presentation at the recent Las Vegas Dermatology Seminar. She responds to patients with reality checks about what’s actually possible in keloid treatment.
But sometimes, they just want to adjust the appearance of their keloids. Like the man who complained that “my keloid looks like my junk.” Dr. Baldwin took a look and had to agree – the keloid on his deltoid was the spitting image of male genitalia. She treated the keloid with the equivalent of castration (removing its “testicles” via surgery) and circumcision of sorts (flattening its “glans penis” via corticosteroids).
“It didn’t look pretty,” she said, as at least one male member of the audience squirmed, “but it no longer looked offensive to him.”
‘Necrotizing lunchitis’
Here at the Bureau of Livin’ on the MDedge, we pride ourselves on having the best words. And being University of Michigan graduates. So, the pain is Likert-scale 10 when Big Ten rivals have better words – and worse office fridges.
Exhibit A: the operative report surgical-taped to a Penn State University call room refrigerator, which general surgery resident and American hero Dr. Cassie Sonntag shared on Twitter. The 18-cubic-foot communal Kenmore’s diagnosis? “Necrotizing lunchitis.”
The grave condition called for immediate intervention by surgeon “Whitt,” with assistance from circulating nurse “Liu.” The surgical team performed “debridement of the upper, middle, and lower compartments of the call room refrigerator with extension into the fridge door, disarticulation and washout of the lower chamber, explantation of necrotic lunches of varying ages.” Complications? “Multiple never-before-seen species of mold casually exterminated.” The patient’s postprocedure condition is “guarded.” The complete report is well worth your review. Even if the Sears appliance’s specimens were “refused by path.”
Global gamete warming
Apparently, increasing deadly wildfires, hurricanes, and global famine aren’t enough. Turns out, climate change has found yet another way to harm its arch nemeses, a.k.a. every single species on the planet. A study originally published in Nature Communications found that rising temperatures also have a significant effect on male (but not female) fertility. Men: so fragile.
Testing fertility in flour beetles, researchers concluded that successive heat waves of 5-7° C above normal for 5 days reduced sperm competitiveness and practically sterilized the males. Inseminated sperm inside females were also not spared the devastating effects of the heat-wave conditions. And, as the icing on the cake, reduced fertility persisted amongst later generations.
Unless we can figure out how robot sperm can deliver DNA, we’re in trouble.
Pneumonia throwdown
Previously, we pitted Clostridium difficile against cockroaches in a battle of toughness. In this week’s edition of Bacteria vs. the World, bacterial pneumonia goes up against another worthy adversary, viral pneumonia.
“We’ve always known pneumonia was a risk factor for a major adverse cardiac event,” said J. Brent Muhlestein, MD, of Intermountain Medical Center in Salt Lake City. “What we didn’t know was which type of pneumonia was more dangerous.”
To find out, he and his associates followed almost 4,800 patients hospitalized with pneumonia and tracked nonfatal heart attacks, stroke, heart failure, or death. Data they presented at the American Heart Association scientific sessions in Chicago show that 34% of patients with bacterial pneumonia had a major cardiovascular event within 90 days, compared with 26% of those diagnosed with viral pneumonia. It is likely “that bacterial pneumonia causes greater inflammation of the arteries compared to viral pneumonia,” Dr. Muhlestein said.
So the bacteria stay undefeated, and somewhere Chuck Norris, who will never have a heart attack – even a heart isn’t foolish enough to attack Chuck Norris – is smiling.
Ch-ch-check it out
Drop the beat! Researchers at the University of California were interested in examining beatboxing processes to explore how the human mind works.
These crazy scientists threw some beatboxers into an MRI for an exclusive performance and studied the movements of their mouth and tongue. Researchers hypothesized that beatboxers base their sounds on already-known speech. But they discovered that these talented virtuosos are creating a whole new language.
“They’re coming up with ways to create these really complex acrobatic sounds by taking approaches drawn from different parts of the mouth that they don’t use in any language, and nobody uses for any language,” according to the lead researcher.
Does that mean beatboxing will be taught in schools as a foreign language? Perhaps. It might be more useful than learning Latin.
Keloid castration
Keloids – those pesky overgrowths of scar tissue – can be mighty hard to treat.
“Virtually every patient says, ‘I want this cut off – I want it gone,’ ” dermatologist Hilary E. Baldwin, MD, said in a presentation at the recent Las Vegas Dermatology Seminar. She responds to patients with reality checks about what’s actually possible in keloid treatment.
But sometimes, they just want to adjust the appearance of their keloids. Like the man who complained that “my keloid looks like my junk.” Dr. Baldwin took a look and had to agree – the keloid on his deltoid was the spitting image of male genitalia. She treated the keloid with the equivalent of castration (removing its “testicles” via surgery) and circumcision of sorts (flattening its “glans penis” via corticosteroids).
“It didn’t look pretty,” she said, as at least one male member of the audience squirmed, “but it no longer looked offensive to him.”
‘Necrotizing lunchitis’
Here at the Bureau of Livin’ on the MDedge, we pride ourselves on having the best words. And being University of Michigan graduates. So, the pain is Likert-scale 10 when Big Ten rivals have better words – and worse office fridges.
Exhibit A: the operative report surgical-taped to a Penn State University call room refrigerator, which general surgery resident and American hero Dr. Cassie Sonntag shared on Twitter. The 18-cubic-foot communal Kenmore’s diagnosis? “Necrotizing lunchitis.”
The grave condition called for immediate intervention by surgeon “Whitt,” with assistance from circulating nurse “Liu.” The surgical team performed “debridement of the upper, middle, and lower compartments of the call room refrigerator with extension into the fridge door, disarticulation and washout of the lower chamber, explantation of necrotic lunches of varying ages.” Complications? “Multiple never-before-seen species of mold casually exterminated.” The patient’s postprocedure condition is “guarded.” The complete report is well worth your review. Even if the Sears appliance’s specimens were “refused by path.”