Sharon Worcester

ATLANTA – Implementation of evidence-based practice bundles was associated with significant reductions in shoulder dystocia, brachial plexus injury, and operative vaginal delivery in a large multicenter hospital system.

From the 18 months prior to implementation of the bundles – which included a planned vaginal delivery tool to assess for shoulder dystocia risk – to the 36 months after implementation, the rate of shoulder dystocia decreased from 1.7 to 1.4 per 100 births, Dr. Laura Sienas reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

©PixelEmbargo/ thinkstockphotos.com

“This is a 17.6% reduction in the rate of shoulder dystocia. There was a statistically significant association with increasing bundle compliance of both bundles with a decrease in shoulder dystocia,” said Dr. Sienas, a 3rd-year resident at the University of California, Davis.

Additionally, the rate of brachial plexus injury decreased significantly from 2.1 to 1.5 per 1,000 births (a 29% reduction), and the rate of operative vaginal deliveries also decreased significantly, from 6.1 to 5.0 per 100 births (an 18% reduction).

At the same time, there was no significant change in the primary and total Cesarean section rates: 16.5 per 100 births and 30.1 per 100 births, respectively, she noted.

Key elements of the evidence-based practice bundles included an admission risk assessment, and a review and timeout prior to operative vaginal delivery. Low-fidelity shoulder dystocia drills were also introduced for nurses and physicians. While the drills improved teamwork and communication, they did not result in decreased brachial plexus injury rates, Dr. Sienas noted.

Future research should consider whether high-fidelity drills would lower the rate of brachial plexus injury, she added.

Data for this study was collected from 29 maternal centers, with size ranging from small and rural with fewer than 200 deliveries each year, to large urban hospitals with about 5,000 annual births. Baseline data included all singleton vertex births over 34 weeks’ gestation – about 169,000 total births. After all participating centers attained 90% compliance with the evidence-based practice bundles, about 103,000 deliveries occurred. Compliance with the bundles was scored as all or none.

The 29 hospitals in the health system where this study took place have average delivery volumes between 150 and 5,000 births per year, suggesting that the current findings would be applicable to nearly all delivery units in the United States, she said.

Dr. Sienas reported having no financial disclosures.

sworcester@frontlinemedcom.com

ATLANTA – Implementation of evidence-based practice bundles was associated with significant reductions in shoulder dystocia, brachial plexus injury, and operative vaginal delivery in a large multicenter hospital system.

From the 18 months prior to implementation of the bundles – which included a planned vaginal delivery tool to assess for shoulder dystocia risk – to the 36 months after implementation, the rate of shoulder dystocia decreased from 1.7 to 1.4 per 100 births, Dr. Laura Sienas reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

©PixelEmbargo/ thinkstockphotos.com

“This is a 17.6% reduction in the rate of shoulder dystocia. There was a statistically significant association with increasing bundle compliance of both bundles with a decrease in shoulder dystocia,” said Dr. Sienas, a 3rd-year resident at the University of California, Davis.

Additionally, the rate of brachial plexus injury decreased significantly from 2.1 to 1.5 per 1,000 births (a 29% reduction), and the rate of operative vaginal deliveries also decreased significantly, from 6.1 to 5.0 per 100 births (an 18% reduction).

At the same time, there was no significant change in the primary and total Cesarean section rates: 16.5 per 100 births and 30.1 per 100 births, respectively, she noted.

Key elements of the evidence-based practice bundles included an admission risk assessment, and a review and timeout prior to operative vaginal delivery. Low-fidelity shoulder dystocia drills were also introduced for nurses and physicians. While the drills improved teamwork and communication, they did not result in decreased brachial plexus injury rates, Dr. Sienas noted.

Future research should consider whether high-fidelity drills would lower the rate of brachial plexus injury, she added.

Data for this study was collected from 29 maternal centers, with size ranging from small and rural with fewer than 200 deliveries each year, to large urban hospitals with about 5,000 annual births. Baseline data included all singleton vertex births over 34 weeks’ gestation – about 169,000 total births. After all participating centers attained 90% compliance with the evidence-based practice bundles, about 103,000 deliveries occurred. Compliance with the bundles was scored as all or none.

The 29 hospitals in the health system where this study took place have average delivery volumes between 150 and 5,000 births per year, suggesting that the current findings would be applicable to nearly all delivery units in the United States, she said.

Dr. Sienas reported having no financial disclosures.

sworcester@frontlinemedcom.com

ATLANTA – Implementation of evidence-based practice bundles was associated with significant reductions in shoulder dystocia, brachial plexus injury, and operative vaginal delivery in a large multicenter hospital system.

From the 18 months prior to implementation of the bundles – which included a planned vaginal delivery tool to assess for shoulder dystocia risk – to the 36 months after implementation, the rate of shoulder dystocia decreased from 1.7 to 1.4 per 100 births, Dr. Laura Sienas reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

©PixelEmbargo/ thinkstockphotos.com

“This is a 17.6% reduction in the rate of shoulder dystocia. There was a statistically significant association with increasing bundle compliance of both bundles with a decrease in shoulder dystocia,” said Dr. Sienas, a 3rd-year resident at the University of California, Davis.

Additionally, the rate of brachial plexus injury decreased significantly from 2.1 to 1.5 per 1,000 births (a 29% reduction), and the rate of operative vaginal deliveries also decreased significantly, from 6.1 to 5.0 per 100 births (an 18% reduction).

At the same time, there was no significant change in the primary and total Cesarean section rates: 16.5 per 100 births and 30.1 per 100 births, respectively, she noted.

Key elements of the evidence-based practice bundles included an admission risk assessment, and a review and timeout prior to operative vaginal delivery. Low-fidelity shoulder dystocia drills were also introduced for nurses and physicians. While the drills improved teamwork and communication, they did not result in decreased brachial plexus injury rates, Dr. Sienas noted.

Future research should consider whether high-fidelity drills would lower the rate of brachial plexus injury, she added.

Data for this study was collected from 29 maternal centers, with size ranging from small and rural with fewer than 200 deliveries each year, to large urban hospitals with about 5,000 annual births. Baseline data included all singleton vertex births over 34 weeks’ gestation – about 169,000 total births. After all participating centers attained 90% compliance with the evidence-based practice bundles, about 103,000 deliveries occurred. Compliance with the bundles was scored as all or none.

The 29 hospitals in the health system where this study took place have average delivery volumes between 150 and 5,000 births per year, suggesting that the current findings would be applicable to nearly all delivery units in the United States, she said.

Dr. Sienas reported having no financial disclosures.

sworcester@frontlinemedcom.com

ATLANTA – Information about managing pregnant patients who have potential exposure to the Zika virus is evolving rapidly, and in light of new recommendations on sexual transmission of the infection, officials from the Society for Maternal-Fetal Medicine convened an expert panel to address the matter.

Leaders from the society joined officials from the Centers for Disease Control and Prevention to discuss the updated guidance – particularly a new recommendation for initially conducting serologic testing in pregnant women who have traveled to endemic areas.

Panel members advised physicians to keep a log of patients with possible Zika virus exposure, so those women can be managed properly in the event of future changes to the guidelines.

In an interview at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine, panelist Dr. Brenna Hughes of Brown University, Providence, R.I., stressed the need to work with state health officials to develop local guidelines and testing mechanisms. “It will take a little time to build up the infrastructure for that kind of testing,” she said, adding that it is important to avoid delays.

Dr. Hughes reported having no financial disclosures.

sworcester@frontlinemedcom.com

ATLANTA – Information about managing pregnant patients who have potential exposure to the Zika virus is evolving rapidly, and in light of new recommendations on sexual transmission of the infection, officials from the Society for Maternal-Fetal Medicine convened an expert panel to address the matter.

Leaders from the society joined officials from the Centers for Disease Control and Prevention to discuss the updated guidance – particularly a new recommendation for initially conducting serologic testing in pregnant women who have traveled to endemic areas.

Panel members advised physicians to keep a log of patients with possible Zika virus exposure, so those women can be managed properly in the event of future changes to the guidelines.

In an interview at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine, panelist Dr. Brenna Hughes of Brown University, Providence, R.I., stressed the need to work with state health officials to develop local guidelines and testing mechanisms. “It will take a little time to build up the infrastructure for that kind of testing,” she said, adding that it is important to avoid delays.

Dr. Hughes reported having no financial disclosures.

sworcester@frontlinemedcom.com

ATLANTA – Information about managing pregnant patients who have potential exposure to the Zika virus is evolving rapidly, and in light of new recommendations on sexual transmission of the infection, officials from the Society for Maternal-Fetal Medicine convened an expert panel to address the matter.

Leaders from the society joined officials from the Centers for Disease Control and Prevention to discuss the updated guidance – particularly a new recommendation for initially conducting serologic testing in pregnant women who have traveled to endemic areas.

Panel members advised physicians to keep a log of patients with possible Zika virus exposure, so those women can be managed properly in the event of future changes to the guidelines.

In an interview at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine, panelist Dr. Brenna Hughes of Brown University, Providence, R.I., stressed the need to work with state health officials to develop local guidelines and testing mechanisms. “It will take a little time to build up the infrastructure for that kind of testing,” she said, adding that it is important to avoid delays.

Dr. Hughes reported having no financial disclosures.

sworcester@frontlinemedcom.com

ATLANTA – Vaginal progesterone confers no obstetrical or neonatal benefit, and no long-term benefit with respect to cognitive and neurosensory outcomes in children when used to prevent preterm birth, according to findings from the randomized, controlled, double-blind OPPTIMUM trial.

The findings from OPPTIMUM – the largest trial to date looking at progesterone for the prevention of preterm birth – have important implications for current practice. Vaginal progesterone is not currently approved for the prevention of preterm birth in the United States, but is commonly used off label for this purpose.

Prior studies have demonstrated a benefit with respect to progesterone for the prevention of preterm birth, particularly in women with a short cervix, but no studies have looked at long-term outcomes, Dr. Jane E. Norman of the University of Edinburgh reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

In OPPTIMUM, the rate of the primary obstetric outcome of preterm birth or fetal death before 34 weeks’ gestation did not differ significantly for 618 women at risk for preterm birth who were randomized to receive 200 mg of vaginal progesterone daily starting at 22-24 weeks and continuing to 34 weeks’ gestation, compared with 600 women who received placebo (16% vs. 18%; odds ratio, 0.86), Dr. Norman said.

The rate of the primary neonatal composite outcome of death or major morbidity (brain injury or bronchopulmonary dysplasia) also did not differ significantly between the progesterone and placebo groups after a prespecified multiple comparisons procedure (6% vs. 10%; odds ratio, 0.62).

A secondary analysis looking at the individual components of the composite neonatal outcomes showed that progesterone reduced the risk of brain injury and neonatal death, but not bronchopulmonary dysplasia, she said.

Further, no difference was seen in Bayley III cognitive scores (with values imputed for deaths) at 2 years of age in 439 and 430 children born to mothers in the progesterone and placebo groups, respectively (average scores, 97.7 and 97.3; odds ratio, 0.48).

On secondary analyses, some safety signals were noted with respect to neurodevelopmental outcomes.

“We were really surprised that we didn’t show that progesterone prevented preterm birth, and we became concerned that perhaps our cutoff of 34 weeks was just the wrong time to choose a cutoff,” Dr. Norman said, noting that a post hoc survival curve analysis was performed to look at the trajectory to delivery, and a “very marginal benefit” was seen with progesterone, but the difference was not statistically significant.

In addition, subgroup analyses showed no significant benefit of progesterone on obstetrical, neonatal, or childhood outcomes. For example, in women with a short cervix, no evidence was seen that progesterone was more or less effective than in women with a longer cervix. Other subgroups studied included fibronectin-positive and fibronectin-negative women and women with a history of preterm birth. Progesterone was no more or less effective in any of the subgroups, Dr. Norman said.

OPPTIMUM study subjects were women at risk of preterm birth because of a positive fetal fibronectin test result, a history of spontaneous preterm birth at or before 34 weeks’ gestation, or a short cervix (25 mm or less).

All outcomes were adjusted for a previous pregnancy of 14 weeks’ gestation or greater, with study center as a random effect.

“OPPTIMUM is the largest trial of progesterone to prevent preterm birth, and after adjusting for multiple comparisons as we planned, we did not disprove the null hypothesis that progesterone doesn’t prevent preterm birth, it doesn’t reduce adverse neonatal outcomes, and it doesn’t have a beneficial effect on childhood outcomes,” Dr. Norman said, concluding that “there is a remaining unmet need for a safe and effective agent to prevent preterm birth.”

Asked about the safety of progesterone given the findings from secondary analyses in OPPTIMUM, she said, “I would not advise my daughter to take progesterone if she’s pregnant.”

The study drug and placebo were donated by Besins, but the company was not involved in study design or analysis. Funding was provided by the Medical Research Council. Dr. Norman reported having no relevant financial disclosures.

sworcester@frontlinemedcom.com

ATLANTA – Vaginal progesterone confers no obstetrical or neonatal benefit, and no long-term benefit with respect to cognitive and neurosensory outcomes in children when used to prevent preterm birth, according to findings from the randomized, controlled, double-blind OPPTIMUM trial.

The findings from OPPTIMUM – the largest trial to date looking at progesterone for the prevention of preterm birth – have important implications for current practice. Vaginal progesterone is not currently approved for the prevention of preterm birth in the United States, but is commonly used off label for this purpose.

Prior studies have demonstrated a benefit with respect to progesterone for the prevention of preterm birth, particularly in women with a short cervix, but no studies have looked at long-term outcomes, Dr. Jane E. Norman of the University of Edinburgh reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

In OPPTIMUM, the rate of the primary obstetric outcome of preterm birth or fetal death before 34 weeks’ gestation did not differ significantly for 618 women at risk for preterm birth who were randomized to receive 200 mg of vaginal progesterone daily starting at 22-24 weeks and continuing to 34 weeks’ gestation, compared with 600 women who received placebo (16% vs. 18%; odds ratio, 0.86), Dr. Norman said.

The rate of the primary neonatal composite outcome of death or major morbidity (brain injury or bronchopulmonary dysplasia) also did not differ significantly between the progesterone and placebo groups after a prespecified multiple comparisons procedure (6% vs. 10%; odds ratio, 0.62).

A secondary analysis looking at the individual components of the composite neonatal outcomes showed that progesterone reduced the risk of brain injury and neonatal death, but not bronchopulmonary dysplasia, she said.

Further, no difference was seen in Bayley III cognitive scores (with values imputed for deaths) at 2 years of age in 439 and 430 children born to mothers in the progesterone and placebo groups, respectively (average scores, 97.7 and 97.3; odds ratio, 0.48).

On secondary analyses, some safety signals were noted with respect to neurodevelopmental outcomes.

“We were really surprised that we didn’t show that progesterone prevented preterm birth, and we became concerned that perhaps our cutoff of 34 weeks was just the wrong time to choose a cutoff,” Dr. Norman said, noting that a post hoc survival curve analysis was performed to look at the trajectory to delivery, and a “very marginal benefit” was seen with progesterone, but the difference was not statistically significant.

In addition, subgroup analyses showed no significant benefit of progesterone on obstetrical, neonatal, or childhood outcomes. For example, in women with a short cervix, no evidence was seen that progesterone was more or less effective than in women with a longer cervix. Other subgroups studied included fibronectin-positive and fibronectin-negative women and women with a history of preterm birth. Progesterone was no more or less effective in any of the subgroups, Dr. Norman said.

OPPTIMUM study subjects were women at risk of preterm birth because of a positive fetal fibronectin test result, a history of spontaneous preterm birth at or before 34 weeks’ gestation, or a short cervix (25 mm or less).

All outcomes were adjusted for a previous pregnancy of 14 weeks’ gestation or greater, with study center as a random effect.

“OPPTIMUM is the largest trial of progesterone to prevent preterm birth, and after adjusting for multiple comparisons as we planned, we did not disprove the null hypothesis that progesterone doesn’t prevent preterm birth, it doesn’t reduce adverse neonatal outcomes, and it doesn’t have a beneficial effect on childhood outcomes,” Dr. Norman said, concluding that “there is a remaining unmet need for a safe and effective agent to prevent preterm birth.”

Asked about the safety of progesterone given the findings from secondary analyses in OPPTIMUM, she said, “I would not advise my daughter to take progesterone if she’s pregnant.”

The study drug and placebo were donated by Besins, but the company was not involved in study design or analysis. Funding was provided by the Medical Research Council. Dr. Norman reported having no relevant financial disclosures.

sworcester@frontlinemedcom.com

ATLANTA – Vaginal progesterone confers no obstetrical or neonatal benefit, and no long-term benefit with respect to cognitive and neurosensory outcomes in children when used to prevent preterm birth, according to findings from the randomized, controlled, double-blind OPPTIMUM trial.

The findings from OPPTIMUM – the largest trial to date looking at progesterone for the prevention of preterm birth – have important implications for current practice. Vaginal progesterone is not currently approved for the prevention of preterm birth in the United States, but is commonly used off label for this purpose.

Prior studies have demonstrated a benefit with respect to progesterone for the prevention of preterm birth, particularly in women with a short cervix, but no studies have looked at long-term outcomes, Dr. Jane E. Norman of the University of Edinburgh reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

In OPPTIMUM, the rate of the primary obstetric outcome of preterm birth or fetal death before 34 weeks’ gestation did not differ significantly for 618 women at risk for preterm birth who were randomized to receive 200 mg of vaginal progesterone daily starting at 22-24 weeks and continuing to 34 weeks’ gestation, compared with 600 women who received placebo (16% vs. 18%; odds ratio, 0.86), Dr. Norman said.

The rate of the primary neonatal composite outcome of death or major morbidity (brain injury or bronchopulmonary dysplasia) also did not differ significantly between the progesterone and placebo groups after a prespecified multiple comparisons procedure (6% vs. 10%; odds ratio, 0.62).

A secondary analysis looking at the individual components of the composite neonatal outcomes showed that progesterone reduced the risk of brain injury and neonatal death, but not bronchopulmonary dysplasia, she said.

Further, no difference was seen in Bayley III cognitive scores (with values imputed for deaths) at 2 years of age in 439 and 430 children born to mothers in the progesterone and placebo groups, respectively (average scores, 97.7 and 97.3; odds ratio, 0.48).

On secondary analyses, some safety signals were noted with respect to neurodevelopmental outcomes.

“We were really surprised that we didn’t show that progesterone prevented preterm birth, and we became concerned that perhaps our cutoff of 34 weeks was just the wrong time to choose a cutoff,” Dr. Norman said, noting that a post hoc survival curve analysis was performed to look at the trajectory to delivery, and a “very marginal benefit” was seen with progesterone, but the difference was not statistically significant.

In addition, subgroup analyses showed no significant benefit of progesterone on obstetrical, neonatal, or childhood outcomes. For example, in women with a short cervix, no evidence was seen that progesterone was more or less effective than in women with a longer cervix. Other subgroups studied included fibronectin-positive and fibronectin-negative women and women with a history of preterm birth. Progesterone was no more or less effective in any of the subgroups, Dr. Norman said.

OPPTIMUM study subjects were women at risk of preterm birth because of a positive fetal fibronectin test result, a history of spontaneous preterm birth at or before 34 weeks’ gestation, or a short cervix (25 mm or less).

All outcomes were adjusted for a previous pregnancy of 14 weeks’ gestation or greater, with study center as a random effect.

“OPPTIMUM is the largest trial of progesterone to prevent preterm birth, and after adjusting for multiple comparisons as we planned, we did not disprove the null hypothesis that progesterone doesn’t prevent preterm birth, it doesn’t reduce adverse neonatal outcomes, and it doesn’t have a beneficial effect on childhood outcomes,” Dr. Norman said, concluding that “there is a remaining unmet need for a safe and effective agent to prevent preterm birth.”

Asked about the safety of progesterone given the findings from secondary analyses in OPPTIMUM, she said, “I would not advise my daughter to take progesterone if she’s pregnant.”

The study drug and placebo were donated by Besins, but the company was not involved in study design or analysis. Funding was provided by the Medical Research Council. Dr. Norman reported having no relevant financial disclosures.

sworcester@frontlinemedcom.com

ATLANTA – A novel, noninvasive, “red dye on paper” diagnostic test allows for rapid screening and identification of preeclampsia at the point of care, according to findings from a prospective clinical study.

Of 343 women enrolled consecutively from a labor and delivery triage unit, 112 had a clinical diagnosis of preeclampsia. The diagnostic test – the Congo Red Dot (CRD) paper test – had an 86% rate of accuracy for detecting preeclampsia, which was superior to several other biochemical tests that were also evaluated, Dr. Kara Rood reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

©Sohel_Parvez_Haque/Thinkstock

Among the comparator tests, which were conducted using stored urine samples to strengthen the final diagnosis, were the laboratory “gold standard” CRD nitrocellulose test, as well as Protein/Creatinine ratio, and urine and serum placental growth factor (PlGF), sFlt-1, and urine sFlt-1/PlGF (uFP) ratio. Accuracy rates ranged from 60% to 83%, said Dr. Rood, a maternal-fetal medicine fellow at the Ohio State University Wexner Medical Center, Columbus.

The CRD point-of-care test was developed by researchers at Ohio State and Nationwide Children’s Hospital, also in Columbus, in an effort to reduce morbidity among expecting mothers and their unborn children. The current study is the first to test the affordable tool, and the findings promise to have an important impact on the health of women and children, she said.

Study subjects were consecutive women evaluated for preeclampsia at Wexner Medical Center. The CRD test was performed using 0.45 cc of fresh crude urine, and results were scored by trained clinical nurses at the bedside.

The average latency period between a positive paper-based CRD test and delivery was 14 days, which was significantly shorter than the interval for those who tested negative, Dr. Rood said.

Courtesy of the Ohio State University

The CRD test was developed based on previous findings by Dr. Irina A. Buhimschi of the Center for Perinatal Research in the the Research Institute at Nationwide Children’s Hospital and her colleagues, who discovered that preeclampsia may result from a collection of misfolded proteins that are identifiable in the urine of pregnant women. Congo Red is a dye used by pathologists to identify amyloid plaques in the brains of patients with Alzheimer’s disease, and it was found to bind and incorporate into the abnormally folded proteins in the urine of pregnant women with preeclampsia. The initial CRD test for preeclampsia had an 89% accuracy rate, according to preliminary findings published in 2014.

“This new point-of-care test is a more user-friendly version than the one in the [2014] publication, and can help identify preeclampsia even before clinical symptoms appear,” Dr. Buhimschi said in a press statement, which also noted that the research team is “currently investigating how each misfolded protein collection affects pregnant women. The answer might assist with developing an effective treatment or even preventing preeclampsia.”

Dr. Rood disclosed that concepts outlined during her presentation are the subject of patents and patent applications filed by Yale University and licensed to private entities for development and commercialization. Some of the study authors are named as inventors of the Congo Red Dot test.

ATLANTA – A novel, noninvasive, “red dye on paper” diagnostic test allows for rapid screening and identification of preeclampsia at the point of care, according to findings from a prospective clinical study.

Of 343 women enrolled consecutively from a labor and delivery triage unit, 112 had a clinical diagnosis of preeclampsia. The diagnostic test – the Congo Red Dot (CRD) paper test – had an 86% rate of accuracy for detecting preeclampsia, which was superior to several other biochemical tests that were also evaluated, Dr. Kara Rood reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

©Sohel_Parvez_Haque/Thinkstock

Among the comparator tests, which were conducted using stored urine samples to strengthen the final diagnosis, were the laboratory “gold standard” CRD nitrocellulose test, as well as Protein/Creatinine ratio, and urine and serum placental growth factor (PlGF), sFlt-1, and urine sFlt-1/PlGF (uFP) ratio. Accuracy rates ranged from 60% to 83%, said Dr. Rood, a maternal-fetal medicine fellow at the Ohio State University Wexner Medical Center, Columbus.

The CRD point-of-care test was developed by researchers at Ohio State and Nationwide Children’s Hospital, also in Columbus, in an effort to reduce morbidity among expecting mothers and their unborn children. The current study is the first to test the affordable tool, and the findings promise to have an important impact on the health of women and children, she said.

Study subjects were consecutive women evaluated for preeclampsia at Wexner Medical Center. The CRD test was performed using 0.45 cc of fresh crude urine, and results were scored by trained clinical nurses at the bedside.

The average latency period between a positive paper-based CRD test and delivery was 14 days, which was significantly shorter than the interval for those who tested negative, Dr. Rood said.

Courtesy of the Ohio State University

The CRD test was developed based on previous findings by Dr. Irina A. Buhimschi of the Center for Perinatal Research in the the Research Institute at Nationwide Children’s Hospital and her colleagues, who discovered that preeclampsia may result from a collection of misfolded proteins that are identifiable in the urine of pregnant women. Congo Red is a dye used by pathologists to identify amyloid plaques in the brains of patients with Alzheimer’s disease, and it was found to bind and incorporate into the abnormally folded proteins in the urine of pregnant women with preeclampsia. The initial CRD test for preeclampsia had an 89% accuracy rate, according to preliminary findings published in 2014.

“This new point-of-care test is a more user-friendly version than the one in the [2014] publication, and can help identify preeclampsia even before clinical symptoms appear,” Dr. Buhimschi said in a press statement, which also noted that the research team is “currently investigating how each misfolded protein collection affects pregnant women. The answer might assist with developing an effective treatment or even preventing preeclampsia.”

Dr. Rood disclosed that concepts outlined during her presentation are the subject of patents and patent applications filed by Yale University and licensed to private entities for development and commercialization. Some of the study authors are named as inventors of the Congo Red Dot test.

ATLANTA – A novel, noninvasive, “red dye on paper” diagnostic test allows for rapid screening and identification of preeclampsia at the point of care, according to findings from a prospective clinical study.

Of 343 women enrolled consecutively from a labor and delivery triage unit, 112 had a clinical diagnosis of preeclampsia. The diagnostic test – the Congo Red Dot (CRD) paper test – had an 86% rate of accuracy for detecting preeclampsia, which was superior to several other biochemical tests that were also evaluated, Dr. Kara Rood reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

©Sohel_Parvez_Haque/Thinkstock

Among the comparator tests, which were conducted using stored urine samples to strengthen the final diagnosis, were the laboratory “gold standard” CRD nitrocellulose test, as well as Protein/Creatinine ratio, and urine and serum placental growth factor (PlGF), sFlt-1, and urine sFlt-1/PlGF (uFP) ratio. Accuracy rates ranged from 60% to 83%, said Dr. Rood, a maternal-fetal medicine fellow at the Ohio State University Wexner Medical Center, Columbus.

The CRD point-of-care test was developed by researchers at Ohio State and Nationwide Children’s Hospital, also in Columbus, in an effort to reduce morbidity among expecting mothers and their unborn children. The current study is the first to test the affordable tool, and the findings promise to have an important impact on the health of women and children, she said.

Study subjects were consecutive women evaluated for preeclampsia at Wexner Medical Center. The CRD test was performed using 0.45 cc of fresh crude urine, and results were scored by trained clinical nurses at the bedside.

The average latency period between a positive paper-based CRD test and delivery was 14 days, which was significantly shorter than the interval for those who tested negative, Dr. Rood said.

Courtesy of the Ohio State University

The CRD test was developed based on previous findings by Dr. Irina A. Buhimschi of the Center for Perinatal Research in the the Research Institute at Nationwide Children’s Hospital and her colleagues, who discovered that preeclampsia may result from a collection of misfolded proteins that are identifiable in the urine of pregnant women. Congo Red is a dye used by pathologists to identify amyloid plaques in the brains of patients with Alzheimer’s disease, and it was found to bind and incorporate into the abnormally folded proteins in the urine of pregnant women with preeclampsia. The initial CRD test for preeclampsia had an 89% accuracy rate, according to preliminary findings published in 2014.

“This new point-of-care test is a more user-friendly version than the one in the [2014] publication, and can help identify preeclampsia even before clinical symptoms appear,” Dr. Buhimschi said in a press statement, which also noted that the research team is “currently investigating how each misfolded protein collection affects pregnant women. The answer might assist with developing an effective treatment or even preventing preeclampsia.”

Dr. Rood disclosed that concepts outlined during her presentation are the subject of patents and patent applications filed by Yale University and licensed to private entities for development and commercialization. Some of the study authors are named as inventors of the Congo Red Dot test.

ATLANTA – A novel, noninvasive, “red dye on paper” diagnostic test allows for rapid screening and identification of preeclampsia at the point of care, according to findings from a prospective clinical study.

Of 343 women enrolled consecutively from a labor and delivery triage unit, 112 had a clinical diagnosis of preeclampsia. The diagnostic test – the Congo Red Dot (CRD) paper test – had an 86% rate of accuracy for detecting preeclampsia, which was superior to several other biochemical tests that were also evaluated, Dr. Kara Rood reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

©Sohel_Parvez_Haque/Thinkstock

Among the comparator tests, which were conducted using stored urine samples to strengthen the final diagnosis, were the laboratory “gold standard” CRD nitrocellulose test, as well as Protein/Creatinine ratio, and urine and serum placental growth factor (PlGF), sFlt-1, and urine sFlt-1/PlGF (uFP) ratio. Accuracy rates ranged from 60% to 83%, said Dr. Rood, a maternal-fetal medicine fellow at the Ohio State University Wexner Medical Center, Columbus.

The CRD point-of-care test was developed by researchers at Ohio State and Nationwide Children’s Hospital, also in Columbus, in an effort to reduce morbidity among expecting mothers and their unborn children. The current study is the first to test the affordable tool, and the findings promise to have an important impact on the health of women and children, she said.

Study subjects were consecutive women evaluated for preeclampsia at Wexner Medical Center. The CRD test was performed using 0.45 cc of fresh crude urine, and results were scored by trained clinical nurses at the bedside.

The average latency period between a positive paper-based CRD test and delivery was 14 days, which was significantly shorter than the interval for those who tested negative, Dr. Rood said.

Courtesy of the Ohio State University

The CRD test was developed based on previous findings by Dr. Irina A. Buhimschi of the Center for Perinatal Research in the the Research Institute at Nationwide Children’s Hospital and her colleagues, who discovered that preeclampsia may result from a collection of misfolded proteins that are identifiable in the urine of pregnant women. Congo Red is a dye used by pathologists to identify amyloid plaques in the brains of patients with Alzheimer’s disease, and it was found to bind and incorporate into the abnormally folded proteins in the urine of pregnant women with preeclampsia. The initial CRD test for preeclampsia had an 89% accuracy rate, according to preliminary findings published in 2014.

“This new point-of-care test is a more user-friendly version than the one in the [2014] publication, and can help identify preeclampsia even before clinical symptoms appear,” Dr. Buhimschi said in a press statement, which also noted that the research team is “currently investigating how each misfolded protein collection affects pregnant women. The answer might assist with developing an effective treatment or even preventing preeclampsia.”

Dr. Rood disclosed that concepts outlined during her presentation are the subject of patents and patent applications filed by Yale University and licensed to private entities for development and commercialization. Some of the study authors are named as inventors of the Congo Red Dot test.

sworcester@frontlinemedcom.com

ATLANTA – A novel, noninvasive, “red dye on paper” diagnostic test allows for rapid screening and identification of preeclampsia at the point of care, according to findings from a prospective clinical study.

Of 343 women enrolled consecutively from a labor and delivery triage unit, 112 had a clinical diagnosis of preeclampsia. The diagnostic test – the Congo Red Dot (CRD) paper test – had an 86% rate of accuracy for detecting preeclampsia, which was superior to several other biochemical tests that were also evaluated, Dr. Kara Rood reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

©Sohel_Parvez_Haque/Thinkstock

Among the comparator tests, which were conducted using stored urine samples to strengthen the final diagnosis, were the laboratory “gold standard” CRD nitrocellulose test, as well as Protein/Creatinine ratio, and urine and serum placental growth factor (PlGF), sFlt-1, and urine sFlt-1/PlGF (uFP) ratio. Accuracy rates ranged from 60% to 83%, said Dr. Rood, a maternal-fetal medicine fellow at the Ohio State University Wexner Medical Center, Columbus.

The CRD point-of-care test was developed by researchers at Ohio State and Nationwide Children’s Hospital, also in Columbus, in an effort to reduce morbidity among expecting mothers and their unborn children. The current study is the first to test the affordable tool, and the findings promise to have an important impact on the health of women and children, she said.

Study subjects were consecutive women evaluated for preeclampsia at Wexner Medical Center. The CRD test was performed using 0.45 cc of fresh crude urine, and results were scored by trained clinical nurses at the bedside.

The average latency period between a positive paper-based CRD test and delivery was 14 days, which was significantly shorter than the interval for those who tested negative, Dr. Rood said.

Courtesy of the Ohio State University

The CRD test was developed based on previous findings by Dr. Irina A. Buhimschi of the Center for Perinatal Research in the the Research Institute at Nationwide Children’s Hospital and her colleagues, who discovered that preeclampsia may result from a collection of misfolded proteins that are identifiable in the urine of pregnant women. Congo Red is a dye used by pathologists to identify amyloid plaques in the brains of patients with Alzheimer’s disease, and it was found to bind and incorporate into the abnormally folded proteins in the urine of pregnant women with preeclampsia. The initial CRD test for preeclampsia had an 89% accuracy rate, according to preliminary findings published in 2014.

“This new point-of-care test is a more user-friendly version than the one in the [2014] publication, and can help identify preeclampsia even before clinical symptoms appear,” Dr. Buhimschi said in a press statement, which also noted that the research team is “currently investigating how each misfolded protein collection affects pregnant women. The answer might assist with developing an effective treatment or even preventing preeclampsia.”

Dr. Rood disclosed that concepts outlined during her presentation are the subject of patents and patent applications filed by Yale University and licensed to private entities for development and commercialization. Some of the study authors are named as inventors of the Congo Red Dot test.

sworcester@frontlinemedcom.com

ATLANTA – A novel, noninvasive, “red dye on paper” diagnostic test allows for rapid screening and identification of preeclampsia at the point of care, according to findings from a prospective clinical study.

Of 343 women enrolled consecutively from a labor and delivery triage unit, 112 had a clinical diagnosis of preeclampsia. The diagnostic test – the Congo Red Dot (CRD) paper test – had an 86% rate of accuracy for detecting preeclampsia, which was superior to several other biochemical tests that were also evaluated, Dr. Kara Rood reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

©Sohel_Parvez_Haque/Thinkstock

Among the comparator tests, which were conducted using stored urine samples to strengthen the final diagnosis, were the laboratory “gold standard” CRD nitrocellulose test, as well as Protein/Creatinine ratio, and urine and serum placental growth factor (PlGF), sFlt-1, and urine sFlt-1/PlGF (uFP) ratio. Accuracy rates ranged from 60% to 83%, said Dr. Rood, a maternal-fetal medicine fellow at the Ohio State University Wexner Medical Center, Columbus.

The CRD point-of-care test was developed by researchers at Ohio State and Nationwide Children’s Hospital, also in Columbus, in an effort to reduce morbidity among expecting mothers and their unborn children. The current study is the first to test the affordable tool, and the findings promise to have an important impact on the health of women and children, she said.

Study subjects were consecutive women evaluated for preeclampsia at Wexner Medical Center. The CRD test was performed using 0.45 cc of fresh crude urine, and results were scored by trained clinical nurses at the bedside.

The average latency period between a positive paper-based CRD test and delivery was 14 days, which was significantly shorter than the interval for those who tested negative, Dr. Rood said.

Courtesy of the Ohio State University

The CRD test was developed based on previous findings by Dr. Irina A. Buhimschi of the Center for Perinatal Research in the the Research Institute at Nationwide Children’s Hospital and her colleagues, who discovered that preeclampsia may result from a collection of misfolded proteins that are identifiable in the urine of pregnant women. Congo Red is a dye used by pathologists to identify amyloid plaques in the brains of patients with Alzheimer’s disease, and it was found to bind and incorporate into the abnormally folded proteins in the urine of pregnant women with preeclampsia. The initial CRD test for preeclampsia had an 89% accuracy rate, according to preliminary findings published in 2014.

“This new point-of-care test is a more user-friendly version than the one in the [2014] publication, and can help identify preeclampsia even before clinical symptoms appear,” Dr. Buhimschi said in a press statement, which also noted that the research team is “currently investigating how each misfolded protein collection affects pregnant women. The answer might assist with developing an effective treatment or even preventing preeclampsia.”

Dr. Rood disclosed that concepts outlined during her presentation are the subject of patents and patent applications filed by Yale University and licensed to private entities for development and commercialization. Some of the study authors are named as inventors of the Congo Red Dot test.

sworcester@frontlinemedcom.com

Treatment with vemurafenib may result in severe skin toxicity, and dabrafenib appears to be useful in patients who discontinue vemurafenib due to such toxicity, according to a retrospective analysis of the cohort.

About a quarter (26%) of 131 melanoma patients treated in real life conditions with the BRAF inhibitor vemurafenib developed grade 3-4 skin toxicity, and 44% (34) of those patients permanently discontinued treatment, corresponding to 11% of the overall cohort, Dr. Lucie Peuvrel of Nantes (France) University Hospital and colleagues reported in Journal of the European Academy of Dermatology and Venereology.

©The National Cancer Institute

Discontinuations were mainly due to rash and classic adverse skin reactions, including Stevens-Johnson syndrome, drug reaction with eosinophilia, and systemic symptoms, whereas reactions involving only photosensitivity or cutaneous carcinomas rarely resulted in treatment adjustment; 14 of the remaining 19 patients with grade 3-4 toxicity who continued treatment had no dose adjustment, and 5 had a dose reduction.

Clinical or biological abnormalities occurred in 94% of those with grade 3-4 rashes, the investigators noted (J Eur Acad Dermatol Venereol. 2016 Feb;30[2]:250-7).

Study subjects were patients with a mean age of 60 years who were treated with vemurafenib for melanoma between November 2010 and December 2014. Grade 3-4 skin toxicity that emerged within the first 4-8 weeks of treatment was significantly associated with prolonged overall survival; severe skin rashes also were associated with prolonged median overall survival. Of seven patients who switched to dabrafenib due to their skin reaction, only one experienced recurrence of the reaction.

Vemurafenib, which is approved for the treatment of unresectable stage III-IV BRAF mutant melanoma, is commonly associated with skin toxicity, with severe cases occurring only rarely; the impact of severe forms of toxicity on treatment and patient outcomes was unknown, the investigators said.

The current findings reaffirm that vemurafenib is commonly associated with skin toxicity, but rarely with severe cases. Severe skin adverse reactions permanently preclude use of vemurafenib, but dabrafenib – the only other BRAF inhibitor with market authorization for unresectable stage III-IV BRAF mutant melanoma – “seems to be beneficial in case of vemurafenib-induced skin intolerance,” they noted, adding that for other skin toxicities, including photosensitivity and cutaneous carcinoma, treatment adjustment is generally not required, and that treatment resumption at a reduced dose should be considered after skin improvement in patients with rashes.

The finding of increased survival in cases involving severe skin toxicity that emerges within 4-8 weeks of treatment initiation should be confirmed in other studies, Dr. Peuvrel and associates said.

The authors reported having no conflicts of interest.

sworcester@frontlinemedcom.com

Treatment with vemurafenib may result in severe skin toxicity, and dabrafenib appears to be useful in patients who discontinue vemurafenib due to such toxicity, according to a retrospective analysis of the cohort.

About a quarter (26%) of 131 melanoma patients treated in real life conditions with the BRAF inhibitor vemurafenib developed grade 3-4 skin toxicity, and 44% (34) of those patients permanently discontinued treatment, corresponding to 11% of the overall cohort, Dr. Lucie Peuvrel of Nantes (France) University Hospital and colleagues reported in Journal of the European Academy of Dermatology and Venereology.

©The National Cancer Institute

Discontinuations were mainly due to rash and classic adverse skin reactions, including Stevens-Johnson syndrome, drug reaction with eosinophilia, and systemic symptoms, whereas reactions involving only photosensitivity or cutaneous carcinomas rarely resulted in treatment adjustment; 14 of the remaining 19 patients with grade 3-4 toxicity who continued treatment had no dose adjustment, and 5 had a dose reduction.

Clinical or biological abnormalities occurred in 94% of those with grade 3-4 rashes, the investigators noted (J Eur Acad Dermatol Venereol. 2016 Feb;30[2]:250-7).

Study subjects were patients with a mean age of 60 years who were treated with vemurafenib for melanoma between November 2010 and December 2014. Grade 3-4 skin toxicity that emerged within the first 4-8 weeks of treatment was significantly associated with prolonged overall survival; severe skin rashes also were associated with prolonged median overall survival. Of seven patients who switched to dabrafenib due to their skin reaction, only one experienced recurrence of the reaction.

Vemurafenib, which is approved for the treatment of unresectable stage III-IV BRAF mutant melanoma, is commonly associated with skin toxicity, with severe cases occurring only rarely; the impact of severe forms of toxicity on treatment and patient outcomes was unknown, the investigators said.

The current findings reaffirm that vemurafenib is commonly associated with skin toxicity, but rarely with severe cases. Severe skin adverse reactions permanently preclude use of vemurafenib, but dabrafenib – the only other BRAF inhibitor with market authorization for unresectable stage III-IV BRAF mutant melanoma – “seems to be beneficial in case of vemurafenib-induced skin intolerance,” they noted, adding that for other skin toxicities, including photosensitivity and cutaneous carcinoma, treatment adjustment is generally not required, and that treatment resumption at a reduced dose should be considered after skin improvement in patients with rashes.

The finding of increased survival in cases involving severe skin toxicity that emerges within 4-8 weeks of treatment initiation should be confirmed in other studies, Dr. Peuvrel and associates said.

The authors reported having no conflicts of interest.

sworcester@frontlinemedcom.com

Treatment with vemurafenib may result in severe skin toxicity, and dabrafenib appears to be useful in patients who discontinue vemurafenib due to such toxicity, according to a retrospective analysis of the cohort.

About a quarter (26%) of 131 melanoma patients treated in real life conditions with the BRAF inhibitor vemurafenib developed grade 3-4 skin toxicity, and 44% (34) of those patients permanently discontinued treatment, corresponding to 11% of the overall cohort, Dr. Lucie Peuvrel of Nantes (France) University Hospital and colleagues reported in Journal of the European Academy of Dermatology and Venereology.

©The National Cancer Institute

Discontinuations were mainly due to rash and classic adverse skin reactions, including Stevens-Johnson syndrome, drug reaction with eosinophilia, and systemic symptoms, whereas reactions involving only photosensitivity or cutaneous carcinomas rarely resulted in treatment adjustment; 14 of the remaining 19 patients with grade 3-4 toxicity who continued treatment had no dose adjustment, and 5 had a dose reduction.

Clinical or biological abnormalities occurred in 94% of those with grade 3-4 rashes, the investigators noted (J Eur Acad Dermatol Venereol. 2016 Feb;30[2]:250-7).

Study subjects were patients with a mean age of 60 years who were treated with vemurafenib for melanoma between November 2010 and December 2014. Grade 3-4 skin toxicity that emerged within the first 4-8 weeks of treatment was significantly associated with prolonged overall survival; severe skin rashes also were associated with prolonged median overall survival. Of seven patients who switched to dabrafenib due to their skin reaction, only one experienced recurrence of the reaction.

Vemurafenib, which is approved for the treatment of unresectable stage III-IV BRAF mutant melanoma, is commonly associated with skin toxicity, with severe cases occurring only rarely; the impact of severe forms of toxicity on treatment and patient outcomes was unknown, the investigators said.

The current findings reaffirm that vemurafenib is commonly associated with skin toxicity, but rarely with severe cases. Severe skin adverse reactions permanently preclude use of vemurafenib, but dabrafenib – the only other BRAF inhibitor with market authorization for unresectable stage III-IV BRAF mutant melanoma – “seems to be beneficial in case of vemurafenib-induced skin intolerance,” they noted, adding that for other skin toxicities, including photosensitivity and cutaneous carcinoma, treatment adjustment is generally not required, and that treatment resumption at a reduced dose should be considered after skin improvement in patients with rashes.

The finding of increased survival in cases involving severe skin toxicity that emerges within 4-8 weeks of treatment initiation should be confirmed in other studies, Dr. Peuvrel and associates said.

The authors reported having no conflicts of interest.

sworcester@frontlinemedcom.com

Physicians appear to have much greater odds of substance abuse and dependence disorders related to alcohol, opiates, and sedatives than their nonphysician counterparts, some estimates showed.

The good news is that physicians with substance abuse and addiction respond particularly well to treatment – so much so that experts have recommended that the treatment methods employed in specialized programs for impaired health professionals be disseminated and used in programs for the general public.

“In a nutshell, for a physician with addiction who goes to an appropriate program that has expertise working with physicians and then follows up with 5-year monitoring, the average rate of abstinence of about 80% is the polar opposite of that in the general population, Dr. Daniel H. Angres of Northwestern University in Chicago said in an interview.

At best, the abstinence rate after treatment is about 20% for the general population, said Dr. Angres, an addiction psychiatrist and medical director of the Positive Sobriety Institute in Chicago, who has spent more than 3 decades working with physicians and other health care professionals struggling with drug abuse and dependence.

The key is proper treatment in a setting with other health professionals and long-term monitoring; without both, the outcomes won’t be as good, he stressed. But Dr. Angres added that there is more to it than that. Often, the very factors that drive a person to become a physician and help that person succeed in the endeavor are the factors that can improve the odds of beating addiction, he explained.

Scope of the problem

Substance abuse and dependence in general are on the rise. This is true among physicians as well as the general public. Opioid use has been a particular problem. A 2008 review by Dr. Mark S. Gold, former chair of the psychiatry department at the University of Florida, Gainesville, and Lisa J. Merlo, Ph.D., also of the university, noted that 12%-23% of physicians admit to prescription opioid use, compared with 1%-4% of nonphysicians (Harv Rev Psychiatry. 2008;16[3]:181-94).

However, Dr. Angres said there are few data to suggest that physicians are at substantially increased risk of addiction.

“The rule of thumb is that addiction affects probably 1 in 10 people. We can comfortably say about 10% will have an addiction problem at some point in their lives,” he said.

But addiction is a disease with genetic underpinnings, and while there was a time when it was thought that perhaps physicians had greater risk because they had greater access, the playing field with respect to access has been leveled over time. There are no good data to suggest that more than 15% of physicians are affected, Dr. Angres noted.

That’s not to say certain specialties aren’t overrepresented among addicts, he added.

Anesthesiologists, for example, have been shown to have a greater risk of addiction – perhaps as a result of their having access to, and/or excess exposure to, drugs like fentanyl and propofol. In fact, the review by Dr. Gold and Dr. Merlo also noted an increasing trend for abuse of sublingual and intravenously administered analgesics among health care professionals. Not far behind anesthesiologists are surgeons, pain doctors, and emergency physicians, Dr. Gold said in an interview. “We have proposed a number of theories to explain this, from self-selection bias to selecting anesthesia because of student drug use to second- and third-hand occupational exposure risks.”

Meanwhile, another 2008 study by Dr. Gold, Dr. Merlo, and their colleagues demonstrated that chronic secondhand exposure to low doses of drugs such as fentanyl and propofol among health care professionals in the operating room might sensitize vulnerable individuals to the “rewarding effects of these drugs, placing them at higher risk for developing an addiction.” The authors concluded that the findings, while they served only as “preliminary support for an unproven hypothesis,” suggest a need for workplace protections (J Addict Dis. 2008;27[3]:67-75).

Dr. Gold also led a more recent study comparing psychiatric and substance use disorders among physicians in a state Physician’s Health Program (PHP) with those in a general treatment population. He and his colleagues found that 99 physicians referred to the PHP for suspected impairment had similar lifetime use of alcohol, opiates, and sedatives as a group of age, sex, and education status–matched persons in a general treatment population.

However, the physicians had significantly higher odds of meeting DSM-IV criteria for abuse/dependence disorders related to alcohol (odds ratio, 2.56), opiates (OR, 86.58), and sedatives (OR, 54.76), the authors reported (J Addic Med. 2013 Mar-Apr;7[2]:108-12).

Further, the physicians had significantly lower odds of lifetime use, but higher odds of lifetime abuse/dependence, for cocaine/crack cocaine and cannabis vs. the comparison group, as well as lower lifetime amphetamine use (OR, 0.21) with no difference in abuse/dependence vs. the comparison group, and lower odds of psychiatric disorders, including obsessive-compulsive disorder, major depression, and specific phobias.

While Dr. Gold and his colleagues concluded that more research is needed to understand psychiatric morbidity in physicians, and while physicians in certain specialties may have an increased likelihood of addiction in relation to exposure to drugs in the operating room setting, most physicians “get addicted in ways that are similar to others in the population,” Dr. Angres said: They have a pain problem, they get a drug like hydrocodone or other narcotic, they have a particular kind of experience that “goes above and beyond the pain management” (some individuals have a paradoxical effect in which they feel connected and energized, for example), and they become addicted.

The main drug of choice, even among physicians, is alcohol, he noted, explaining that stress is another common precipitating factor.

There is a definite relationship between stress and addiction; alcohol may be used to cope with stress, and those who are vulnerable to addiction can become dependent.

“Physicians are more stressed today than ever. The whole landscape of medicine, the economics of medicine means physicians have to see more patients and spend less time with patients,” Dr. Angres said, adding that factors like electronic medical records requirements and concerns about malpractice all contribute to increasing stress levels and are likely also increasing the rate of addiction and other forms of physician impairment or distress, including cognitive difficulties, depression, and anxiety.

Affected physicians, sometimes referred to as “disruptive physicians,” are increasingly a focus of programs and protocols to promote physician wellness.*

Northwestern and other high-level academic centers are “gearing up” for the problem. It is becoming more common for physicians to undergo screening when they are hired, and to undergo random screening to make sure they aren’t under the influence, he explained.

“And I also think that the medical community is much more attuned to detecting this and helping people gain access to proper assessment, rehabilitation, and reentry,” he added.

Treatment and outcomes

Treatment for physicians is often provided through state PHPs, some of which are under the umbrella of a licensing board or are part of a diversion program involving an autonomous entity.

“PHPs are really critical,” Dr. Angres said, explaining that they provide education, conduct research to help reduce malpractice claims, and ensure proper assessment of physicians, and they do long-term monitoring involving wellness checks.

While there is some controversy about the role of PHPs – some physicians have resented the monitoring, say they have felt coerced into participating, and have demanded more choice regarding treatment options – these programs are highly successful and data driven, Dr. Angres said.

“When the outcomes are clearly very good with a certain kind of protocol, you want to stick with that, particularly if public safety is involved,” he said, adding that these programs work because they are more supportive than punitive, they treat affected physicians for their disease, and they help physicians do what they need to do to safely reenter the practice of medicine.

Punitive programs would drive substance abuse/dependence problems underground, making them more dangerous, he said.

There is a great deal of debate about the appropriate duration of treatment, but most importantly, physicians should be with other physicians.

“What gets people sober is really being with other people who are sober,” he said, adding that a peer group of others with similar experiences and a similar life path is critical.

Twelve-step programs, which employ this principle as part of treatment and aftercare, result in better outcomes, and it is also crucial that physicians be treated by personnel who are experienced and conversant with working with physicians, because there are important factors necessary for successful reentry and engagement in the workplace.

Medications also are an important part of care, in many cases.

Dr. Gold’s research has long focused on the evaluation and treatment of impaired health professionals.

“After the discovery of the antiopiate withdrawal efficacy of clonidine, we tried an experimental medication – naltrexone – as a treatment for impaired health professional opiate addicts. … Naltrexone was both safe and effective. Injectable naltrexone is now widely recognized as a safe and effective treatment to prevent opiate relapse,” he said in an interview.

Naltrexone is particularly important for the treatment of addicted anesthesiologists, as they are at high risk of relapse when they return to work; their relapses are often overdoses after detoxification, he said.

Five-year outcomes studies suggest that with appropriate treatment, outcomes are indeed excellent among physicians, compared with their peers. Two such studies, led by researchers from the Institute of Behavior and Health in Rockville, Md., respectively showed that 102 anesthesiologists treated and monitored under PHP supervision had excellent outcomes similar to those of other impaired physicians (Anesth Analg. 2009;109[3]:891-6), and that 144 surgeons treated under PHP supervision had positive outcomes similar to those of nonsurgeons (Arch Surg. 2011;146[11]:1286-91).

In their review article, Dr. Gold and Dr. Merlo concluded that for physicians overall, “appropriate intervention (e.g., typically in with the state PHP), methods of evaluation and treatment for addicted physicians are extremely effective. The combination of medical, psychosocial, and support group interventions, combined with extensive posttreatment monitoring and drug testing, generally results in sustained recovery among the physicians who attend specialized treatment programs. These outcomes are typically obtained even when physicians did not enter treatment voluntarily. Thus, it is likely that impaired professional programs represent the best treatment available for opioid use disorders, and nonphysician addicts would likely experience a similar benefit from participating in such a program.”

Dr. Angres agreed that physicians in general are “a good outcome group.”

“If treated and monitored appropriately, these are some of the best outcomes we see in addiction treatment,” he said.

Many factors are involved in the superior results among physicians vs. their nonphysician counterparts, he said, explaining that physicians tend to be particularly conscientious, hard-working individuals with good support systems and personality variables that allow them to persevere under difficult circumstances. They also have a great deal riding on recovery in terms of reentering the practice of medicine.

“So motivation is a big issue. ... All of these things come together,” he said.

Changing trends

In addition to the stress-related factors that appear to be contributing to increased substance abuse and dependence, concerning cultural trends are emerging.

“We have an epidemic among young adults,” Dr. Angres said.

Heroin, prescription opiates, psychostimulants, binge drinking – all are occurring in epidemic proportions throughout our culture, including among the new generation of medical students and young physicians, he added.

“We are seeing for the first time, even in the last year or so, medical students, residents, and young adults who are addicted to drugs like heroin because it is so ubiquitous. So this is a new phenomenon. This is just a new reality. It’s not a massive problem [in medicine], but it is something that we’re seeing that we didn’t see before. ... These are emerging issues that are disconcerting,” he said.

Dr. Gold also noted the changing trends, explaining that over the course of his career, substance misuse and dependence have emerged and changed.

“In the ’70s and ’80s, medical students rarely presented in need of treatment, but when they did, they had alcohol, tobacco, and benzodiazepine problems. Residents ... had problems with prescription opiates, and many programs reported overdoses. More recently, medical students no longer smoke cigarettes. ... Now it is marijuana,” he said, adding that binge drinking, club drugs, and psychostimulant abuse also are on the rise.

Students now are more like their peers and unlike their mentors with respect to drug misuse, use, and dependence, and there is an emerging concern that the most heavily involved students in terms of drug abuse and addiction will select one specialty or another based on drug access, said Dr. Gold, now professor (adjunct) at the University of Southern California, Los Angeles, and at Washington University in St. Louis.

“They often are surprised that the college of medicine, their patients, and professors do not accept as appropriate behavior the taking of another person’s [attention-deficit/hyperactivity disorder] medication, or smoking cannabis, or taking drugs for their mentees,” he said.

As for treatment in this new era of substance abuse and dependence, the approach remains much the same, Dr. Angres said, noting that medication-assisted treatment may be necessary for heroin addiction. A concern, however, is that the relapse rate may be higher.

“We don’t know what that will mean,” he said. “It will be years before we can see how it plays out with physicians with [heroin], but you do the same things, with perhaps some extra support above and beyond [the standard approach].”

Dr. Angres disclosed that he is part owner of the Positive Sobriety Institute, which treats addicted professionals, including physicians. Dr. Gold reported having no relevant financial disclosures.

*Correction, 03/09/2016: An earlier version of this story misstated the term sometimes used to describe physicians with addictive behaviors

sworcester@frontlinemedcom.com

Physicians appear to have much greater odds of substance abuse and dependence disorders related to alcohol, opiates, and sedatives than their nonphysician counterparts, some estimates showed.

The good news is that physicians with substance abuse and addiction respond particularly well to treatment – so much so that experts have recommended that the treatment methods employed in specialized programs for impaired health professionals be disseminated and used in programs for the general public.

“In a nutshell, for a physician with addiction who goes to an appropriate program that has expertise working with physicians and then follows up with 5-year monitoring, the average rate of abstinence of about 80% is the polar opposite of that in the general population, Dr. Daniel H. Angres of Northwestern University in Chicago said in an interview.

At best, the abstinence rate after treatment is about 20% for the general population, said Dr. Angres, an addiction psychiatrist and medical director of the Positive Sobriety Institute in Chicago, who has spent more than 3 decades working with physicians and other health care professionals struggling with drug abuse and dependence.

The key is proper treatment in a setting with other health professionals and long-term monitoring; without both, the outcomes won’t be as good, he stressed. But Dr. Angres added that there is more to it than that. Often, the very factors that drive a person to become a physician and help that person succeed in the endeavor are the factors that can improve the odds of beating addiction, he explained.

Scope of the problem

Substance abuse and dependence in general are on the rise. This is true among physicians as well as the general public. Opioid use has been a particular problem. A 2008 review by Dr. Mark S. Gold, former chair of the psychiatry department at the University of Florida, Gainesville, and Lisa J. Merlo, Ph.D., also of the university, noted that 12%-23% of physicians admit to prescription opioid use, compared with 1%-4% of nonphysicians (Harv Rev Psychiatry. 2008;16[3]:181-94).

However, Dr. Angres said there are few data to suggest that physicians are at substantially increased risk of addiction.

“The rule of thumb is that addiction affects probably 1 in 10 people. We can comfortably say about 10% will have an addiction problem at some point in their lives,” he said.

But addiction is a disease with genetic underpinnings, and while there was a time when it was thought that perhaps physicians had greater risk because they had greater access, the playing field with respect to access has been leveled over time. There are no good data to suggest that more than 15% of physicians are affected, Dr. Angres noted.

That’s not to say certain specialties aren’t overrepresented among addicts, he added.

Anesthesiologists, for example, have been shown to have a greater risk of addiction – perhaps as a result of their having access to, and/or excess exposure to, drugs like fentanyl and propofol. In fact, the review by Dr. Gold and Dr. Merlo also noted an increasing trend for abuse of sublingual and intravenously administered analgesics among health care professionals. Not far behind anesthesiologists are surgeons, pain doctors, and emergency physicians, Dr. Gold said in an interview. “We have proposed a number of theories to explain this, from self-selection bias to selecting anesthesia because of student drug use to second- and third-hand occupational exposure risks.”

Meanwhile, another 2008 study by Dr. Gold, Dr. Merlo, and their colleagues demonstrated that chronic secondhand exposure to low doses of drugs such as fentanyl and propofol among health care professionals in the operating room might sensitize vulnerable individuals to the “rewarding effects of these drugs, placing them at higher risk for developing an addiction.” The authors concluded that the findings, while they served only as “preliminary support for an unproven hypothesis,” suggest a need for workplace protections (J Addict Dis. 2008;27[3]:67-75).

Dr. Gold also led a more recent study comparing psychiatric and substance use disorders among physicians in a state Physician’s Health Program (PHP) with those in a general treatment population. He and his colleagues found that 99 physicians referred to the PHP for suspected impairment had similar lifetime use of alcohol, opiates, and sedatives as a group of age, sex, and education status–matched persons in a general treatment population.

However, the physicians had significantly higher odds of meeting DSM-IV criteria for abuse/dependence disorders related to alcohol (odds ratio, 2.56), opiates (OR, 86.58), and sedatives (OR, 54.76), the authors reported (J Addic Med. 2013 Mar-Apr;7[2]:108-12).

Further, the physicians had significantly lower odds of lifetime use, but higher odds of lifetime abuse/dependence, for cocaine/crack cocaine and cannabis vs. the comparison group, as well as lower lifetime amphetamine use (OR, 0.21) with no difference in abuse/dependence vs. the comparison group, and lower odds of psychiatric disorders, including obsessive-compulsive disorder, major depression, and specific phobias.

While Dr. Gold and his colleagues concluded that more research is needed to understand psychiatric morbidity in physicians, and while physicians in certain specialties may have an increased likelihood of addiction in relation to exposure to drugs in the operating room setting, most physicians “get addicted in ways that are similar to others in the population,” Dr. Angres said: They have a pain problem, they get a drug like hydrocodone or other narcotic, they have a particular kind of experience that “goes above and beyond the pain management” (some individuals have a paradoxical effect in which they feel connected and energized, for example), and they become addicted.

The main drug of choice, even among physicians, is alcohol, he noted, explaining that stress is another common precipitating factor.

There is a definite relationship between stress and addiction; alcohol may be used to cope with stress, and those who are vulnerable to addiction can become dependent.

“Physicians are more stressed today than ever. The whole landscape of medicine, the economics of medicine means physicians have to see more patients and spend less time with patients,” Dr. Angres said, adding that factors like electronic medical records requirements and concerns about malpractice all contribute to increasing stress levels and are likely also increasing the rate of addiction and other forms of physician impairment or distress, including cognitive difficulties, depression, and anxiety.

Affected physicians, sometimes referred to as “disruptive physicians,” are increasingly a focus of programs and protocols to promote physician wellness.*

Northwestern and other high-level academic centers are “gearing up” for the problem. It is becoming more common for physicians to undergo screening when they are hired, and to undergo random screening to make sure they aren’t under the influence, he explained.

“And I also think that the medical community is much more attuned to detecting this and helping people gain access to proper assessment, rehabilitation, and reentry,” he added.

Treatment and outcomes

Treatment for physicians is often provided through state PHPs, some of which are under the umbrella of a licensing board or are part of a diversion program involving an autonomous entity.

“PHPs are really critical,” Dr. Angres said, explaining that they provide education, conduct research to help reduce malpractice claims, and ensure proper assessment of physicians, and they do long-term monitoring involving wellness checks.

While there is some controversy about the role of PHPs – some physicians have resented the monitoring, say they have felt coerced into participating, and have demanded more choice regarding treatment options – these programs are highly successful and data driven, Dr. Angres said.

“When the outcomes are clearly very good with a certain kind of protocol, you want to stick with that, particularly if public safety is involved,” he said, adding that these programs work because they are more supportive than punitive, they treat affected physicians for their disease, and they help physicians do what they need to do to safely reenter the practice of medicine.

Punitive programs would drive substance abuse/dependence problems underground, making them more dangerous, he said.

There is a great deal of debate about the appropriate duration of treatment, but most importantly, physicians should be with other physicians.

“What gets people sober is really being with other people who are sober,” he said, adding that a peer group of others with similar experiences and a similar life path is critical.

Twelve-step programs, which employ this principle as part of treatment and aftercare, result in better outcomes, and it is also crucial that physicians be treated by personnel who are experienced and conversant with working with physicians, because there are important factors necessary for successful reentry and engagement in the workplace.

Medications also are an important part of care, in many cases.

Dr. Gold’s research has long focused on the evaluation and treatment of impaired health professionals.

“After the discovery of the antiopiate withdrawal efficacy of clonidine, we tried an experimental medication – naltrexone – as a treatment for impaired health professional opiate addicts. … Naltrexone was both safe and effective. Injectable naltrexone is now widely recognized as a safe and effective treatment to prevent opiate relapse,” he said in an interview.

Naltrexone is particularly important for the treatment of addicted anesthesiologists, as they are at high risk of relapse when they return to work; their relapses are often overdoses after detoxification, he said.

Five-year outcomes studies suggest that with appropriate treatment, outcomes are indeed excellent among physicians, compared with their peers. Two such studies, led by researchers from the Institute of Behavior and Health in Rockville, Md., respectively showed that 102 anesthesiologists treated and monitored under PHP supervision had excellent outcomes similar to those of other impaired physicians (Anesth Analg. 2009;109[3]:891-6), and that 144 surgeons treated under PHP supervision had positive outcomes similar to those of nonsurgeons (Arch Surg. 2011;146[11]:1286-91).

In their review article, Dr. Gold and Dr. Merlo concluded that for physicians overall, “appropriate intervention (e.g., typically in with the state PHP), methods of evaluation and treatment for addicted physicians are extremely effective. The combination of medical, psychosocial, and support group interventions, combined with extensive posttreatment monitoring and drug testing, generally results in sustained recovery among the physicians who attend specialized treatment programs. These outcomes are typically obtained even when physicians did not enter treatment voluntarily. Thus, it is likely that impaired professional programs represent the best treatment available for opioid use disorders, and nonphysician addicts would likely experience a similar benefit from participating in such a program.”

Dr. Angres agreed that physicians in general are “a good outcome group.”

“If treated and monitored appropriately, these are some of the best outcomes we see in addiction treatment,” he said.

Many factors are involved in the superior results among physicians vs. their nonphysician counterparts, he said, explaining that physicians tend to be particularly conscientious, hard-working individuals with good support systems and personality variables that allow them to persevere under difficult circumstances. They also have a great deal riding on recovery in terms of reentering the practice of medicine.

“So motivation is a big issue. ... All of these things come together,” he said.

Changing trends

In addition to the stress-related factors that appear to be contributing to increased substance abuse and dependence, concerning cultural trends are emerging.

“We have an epidemic among young adults,” Dr. Angres said.

Heroin, prescription opiates, psychostimulants, binge drinking – all are occurring in epidemic proportions throughout our culture, including among the new generation of medical students and young physicians, he added.

“We are seeing for the first time, even in the last year or so, medical students, residents, and young adults who are addicted to drugs like heroin because it is so ubiquitous. So this is a new phenomenon. This is just a new reality. It’s not a massive problem [in medicine], but it is something that we’re seeing that we didn’t see before. ... These are emerging issues that are disconcerting,” he said.

Dr. Gold also noted the changing trends, explaining that over the course of his career, substance misuse and dependence have emerged and changed.

“In the ’70s and ’80s, medical students rarely presented in need of treatment, but when they did, they had alcohol, tobacco, and benzodiazepine problems. Residents ... had problems with prescription opiates, and many programs reported overdoses. More recently, medical students no longer smoke cigarettes. ... Now it is marijuana,” he said, adding that binge drinking, club drugs, and psychostimulant abuse also are on the rise.

Students now are more like their peers and unlike their mentors with respect to drug misuse, use, and dependence, and there is an emerging concern that the most heavily involved students in terms of drug abuse and addiction will select one specialty or another based on drug access, said Dr. Gold, now professor (adjunct) at the University of Southern California, Los Angeles, and at Washington University in St. Louis.

“They often are surprised that the college of medicine, their patients, and professors do not accept as appropriate behavior the taking of another person’s [attention-deficit/hyperactivity disorder] medication, or smoking cannabis, or taking drugs for their mentees,” he said.

As for treatment in this new era of substance abuse and dependence, the approach remains much the same, Dr. Angres said, noting that medication-assisted treatment may be necessary for heroin addiction. A concern, however, is that the relapse rate may be higher.

“We don’t know what that will mean,” he said. “It will be years before we can see how it plays out with physicians with [heroin], but you do the same things, with perhaps some extra support above and beyond [the standard approach].”

Dr. Angres disclosed that he is part owner of the Positive Sobriety Institute, which treats addicted professionals, including physicians. Dr. Gold reported having no relevant financial disclosures.

*Correction, 03/09/2016: An earlier version of this story misstated the term sometimes used to describe physicians with addictive behaviors

sworcester@frontlinemedcom.com

Physicians appear to have much greater odds of substance abuse and dependence disorders related to alcohol, opiates, and sedatives than their nonphysician counterparts, some estimates showed.

The good news is that physicians with substance abuse and addiction respond particularly well to treatment – so much so that experts have recommended that the treatment methods employed in specialized programs for impaired health professionals be disseminated and used in programs for the general public.

“In a nutshell, for a physician with addiction who goes to an appropriate program that has expertise working with physicians and then follows up with 5-year monitoring, the average rate of abstinence of about 80% is the polar opposite of that in the general population, Dr. Daniel H. Angres of Northwestern University in Chicago said in an interview.

At best, the abstinence rate after treatment is about 20% for the general population, said Dr. Angres, an addiction psychiatrist and medical director of the Positive Sobriety Institute in Chicago, who has spent more than 3 decades working with physicians and other health care professionals struggling with drug abuse and dependence.

The key is proper treatment in a setting with other health professionals and long-term monitoring; without both, the outcomes won’t be as good, he stressed. But Dr. Angres added that there is more to it than that. Often, the very factors that drive a person to become a physician and help that person succeed in the endeavor are the factors that can improve the odds of beating addiction, he explained.

Scope of the problem

Substance abuse and dependence in general are on the rise. This is true among physicians as well as the general public. Opioid use has been a particular problem. A 2008 review by Dr. Mark S. Gold, former chair of the psychiatry department at the University of Florida, Gainesville, and Lisa J. Merlo, Ph.D., also of the university, noted that 12%-23% of physicians admit to prescription opioid use, compared with 1%-4% of nonphysicians (Harv Rev Psychiatry. 2008;16[3]:181-94).

However, Dr. Angres said there are few data to suggest that physicians are at substantially increased risk of addiction.

“The rule of thumb is that addiction affects probably 1 in 10 people. We can comfortably say about 10% will have an addiction problem at some point in their lives,” he said.

But addiction is a disease with genetic underpinnings, and while there was a time when it was thought that perhaps physicians had greater risk because they had greater access, the playing field with respect to access has been leveled over time. There are no good data to suggest that more than 15% of physicians are affected, Dr. Angres noted.

That’s not to say certain specialties aren’t overrepresented among addicts, he added.

Anesthesiologists, for example, have been shown to have a greater risk of addiction – perhaps as a result of their having access to, and/or excess exposure to, drugs like fentanyl and propofol. In fact, the review by Dr. Gold and Dr. Merlo also noted an increasing trend for abuse of sublingual and intravenously administered analgesics among health care professionals. Not far behind anesthesiologists are surgeons, pain doctors, and emergency physicians, Dr. Gold said in an interview. “We have proposed a number of theories to explain this, from self-selection bias to selecting anesthesia because of student drug use to second- and third-hand occupational exposure risks.”

Meanwhile, another 2008 study by Dr. Gold, Dr. Merlo, and their colleagues demonstrated that chronic secondhand exposure to low doses of drugs such as fentanyl and propofol among health care professionals in the operating room might sensitize vulnerable individuals to the “rewarding effects of these drugs, placing them at higher risk for developing an addiction.” The authors concluded that the findings, while they served only as “preliminary support for an unproven hypothesis,” suggest a need for workplace protections (J Addict Dis. 2008;27[3]:67-75).

Dr. Gold also led a more recent study comparing psychiatric and substance use disorders among physicians in a state Physician’s Health Program (PHP) with those in a general treatment population. He and his colleagues found that 99 physicians referred to the PHP for suspected impairment had similar lifetime use of alcohol, opiates, and sedatives as a group of age, sex, and education status–matched persons in a general treatment population.

However, the physicians had significantly higher odds of meeting DSM-IV criteria for abuse/dependence disorders related to alcohol (odds ratio, 2.56), opiates (OR, 86.58), and sedatives (OR, 54.76), the authors reported (J Addic Med. 2013 Mar-Apr;7[2]:108-12).

Further, the physicians had significantly lower odds of lifetime use, but higher odds of lifetime abuse/dependence, for cocaine/crack cocaine and cannabis vs. the comparison group, as well as lower lifetime amphetamine use (OR, 0.21) with no difference in abuse/dependence vs. the comparison group, and lower odds of psychiatric disorders, including obsessive-compulsive disorder, major depression, and specific phobias.

While Dr. Gold and his colleagues concluded that more research is needed to understand psychiatric morbidity in physicians, and while physicians in certain specialties may have an increased likelihood of addiction in relation to exposure to drugs in the operating room setting, most physicians “get addicted in ways that are similar to others in the population,” Dr. Angres said: They have a pain problem, they get a drug like hydrocodone or other narcotic, they have a particular kind of experience that “goes above and beyond the pain management” (some individuals have a paradoxical effect in which they feel connected and energized, for example), and they become addicted.

The main drug of choice, even among physicians, is alcohol, he noted, explaining that stress is another common precipitating factor.

There is a definite relationship between stress and addiction; alcohol may be used to cope with stress, and those who are vulnerable to addiction can become dependent.

“Physicians are more stressed today than ever. The whole landscape of medicine, the economics of medicine means physicians have to see more patients and spend less time with patients,” Dr. Angres said, adding that factors like electronic medical records requirements and concerns about malpractice all contribute to increasing stress levels and are likely also increasing the rate of addiction and other forms of physician impairment or distress, including cognitive difficulties, depression, and anxiety.

Affected physicians, sometimes referred to as “disruptive physicians,” are increasingly a focus of programs and protocols to promote physician wellness.*

Northwestern and other high-level academic centers are “gearing up” for the problem. It is becoming more common for physicians to undergo screening when they are hired, and to undergo random screening to make sure they aren’t under the influence, he explained.

“And I also think that the medical community is much more attuned to detecting this and helping people gain access to proper assessment, rehabilitation, and reentry,” he added.

Treatment and outcomes

Treatment for physicians is often provided through state PHPs, some of which are under the umbrella of a licensing board or are part of a diversion program involving an autonomous entity.

“PHPs are really critical,” Dr. Angres said, explaining that they provide education, conduct research to help reduce malpractice claims, and ensure proper assessment of physicians, and they do long-term monitoring involving wellness checks.

While there is some controversy about the role of PHPs – some physicians have resented the monitoring, say they have felt coerced into participating, and have demanded more choice regarding treatment options – these programs are highly successful and data driven, Dr. Angres said.

“When the outcomes are clearly very good with a certain kind of protocol, you want to stick with that, particularly if public safety is involved,” he said, adding that these programs work because they are more supportive than punitive, they treat affected physicians for their disease, and they help physicians do what they need to do to safely reenter the practice of medicine.

Punitive programs would drive substance abuse/dependence problems underground, making them more dangerous, he said.

There is a great deal of debate about the appropriate duration of treatment, but most importantly, physicians should be with other physicians.

“What gets people sober is really being with other people who are sober,” he said, adding that a peer group of others with similar experiences and a similar life path is critical.

Twelve-step programs, which employ this principle as part of treatment and aftercare, result in better outcomes, and it is also crucial that physicians be treated by personnel who are experienced and conversant with working with physicians, because there are important factors necessary for successful reentry and engagement in the workplace.

Medications also are an important part of care, in many cases.

Dr. Gold’s research has long focused on the evaluation and treatment of impaired health professionals.

“After the discovery of the antiopiate withdrawal efficacy of clonidine, we tried an experimental medication – naltrexone – as a treatment for impaired health professional opiate addicts. … Naltrexone was both safe and effective. Injectable naltrexone is now widely recognized as a safe and effective treatment to prevent opiate relapse,” he said in an interview.

Naltrexone is particularly important for the treatment of addicted anesthesiologists, as they are at high risk of relapse when they return to work; their relapses are often overdoses after detoxification, he said.

Five-year outcomes studies suggest that with appropriate treatment, outcomes are indeed excellent among physicians, compared with their peers. Two such studies, led by researchers from the Institute of Behavior and Health in Rockville, Md., respectively showed that 102 anesthesiologists treated and monitored under PHP supervision had excellent outcomes similar to those of other impaired physicians (Anesth Analg. 2009;109[3]:891-6), and that 144 surgeons treated under PHP supervision had positive outcomes similar to those of nonsurgeons (Arch Surg. 2011;146[11]:1286-91).

In their review article, Dr. Gold and Dr. Merlo concluded that for physicians overall, “appropriate intervention (e.g., typically in with the state PHP), methods of evaluation and treatment for addicted physicians are extremely effective. The combination of medical, psychosocial, and support group interventions, combined with extensive posttreatment monitoring and drug testing, generally results in sustained recovery among the physicians who attend specialized treatment programs. These outcomes are typically obtained even when physicians did not enter treatment voluntarily. Thus, it is likely that impaired professional programs represent the best treatment available for opioid use disorders, and nonphysician addicts would likely experience a similar benefit from participating in such a program.”

Dr. Angres agreed that physicians in general are “a good outcome group.”

“If treated and monitored appropriately, these are some of the best outcomes we see in addiction treatment,” he said.

Many factors are involved in the superior results among physicians vs. their nonphysician counterparts, he said, explaining that physicians tend to be particularly conscientious, hard-working individuals with good support systems and personality variables that allow them to persevere under difficult circumstances. They also have a great deal riding on recovery in terms of reentering the practice of medicine.

“So motivation is a big issue. ... All of these things come together,” he said.

Changing trends

In addition to the stress-related factors that appear to be contributing to increased substance abuse and dependence, concerning cultural trends are emerging.

“We have an epidemic among young adults,” Dr. Angres said.

Heroin, prescription opiates, psychostimulants, binge drinking – all are occurring in epidemic proportions throughout our culture, including among the new generation of medical students and young physicians, he added.

“We are seeing for the first time, even in the last year or so, medical students, residents, and young adults who are addicted to drugs like heroin because it is so ubiquitous. So this is a new phenomenon. This is just a new reality. It’s not a massive problem [in medicine], but it is something that we’re seeing that we didn’t see before. ... These are emerging issues that are disconcerting,” he said.

Dr. Gold also noted the changing trends, explaining that over the course of his career, substance misuse and dependence have emerged and changed.

“In the ’70s and ’80s, medical students rarely presented in need of treatment, but when they did, they had alcohol, tobacco, and benzodiazepine problems. Residents ... had problems with prescription opiates, and many programs reported overdoses. More recently, medical students no longer smoke cigarettes. ... Now it is marijuana,” he said, adding that binge drinking, club drugs, and psychostimulant abuse also are on the rise.

Students now are more like their peers and unlike their mentors with respect to drug misuse, use, and dependence, and there is an emerging concern that the most heavily involved students in terms of drug abuse and addiction will select one specialty or another based on drug access, said Dr. Gold, now professor (adjunct) at the University of Southern California, Los Angeles, and at Washington University in St. Louis.

“They often are surprised that the college of medicine, their patients, and professors do not accept as appropriate behavior the taking of another person’s [attention-deficit/hyperactivity disorder] medication, or smoking cannabis, or taking drugs for their mentees,” he said.

As for treatment in this new era of substance abuse and dependence, the approach remains much the same, Dr. Angres said, noting that medication-assisted treatment may be necessary for heroin addiction. A concern, however, is that the relapse rate may be higher.

“We don’t know what that will mean,” he said. “It will be years before we can see how it plays out with physicians with [heroin], but you do the same things, with perhaps some extra support above and beyond [the standard approach].”

Dr. Angres disclosed that he is part owner of the Positive Sobriety Institute, which treats addicted professionals, including physicians. Dr. Gold reported having no relevant financial disclosures.

*Correction, 03/09/2016: An earlier version of this story misstated the term sometimes used to describe physicians with addictive behaviors

sworcester@frontlinemedcom.com

The Centers for Disease Control and Prevention has released interim guidelines for U.S. clinicians caring for infants born to mothers who traveled to or resided in an area with Zika virus transmission during pregnancy.

The guidelines, released Jan. 26, address the evaluation and testing of infants with possible congenital Zika virus infection, and follow the Jan. 19 release of similar guidelines for the care of pregnant women with possible exposure to the mosquito-borne virus. Most importantly, the new guidelines say Zika virus testing should be performed for infants with microcephaly or intracranial calcifications who are born to women with possible Zika virus exposure during pregnancy, and for infants born to women with positive or inconclusive Zika virus test results.

©DamrongpanThongwat/ThinkStock

“Pediatric health are providers should work closely with obstetric providers to identify infants whose mothers were potentially infected with Zika virus during pregnancy (based on travel to or residence in an area with Zika virus transmission),” according to the guidelines, which were published in Morbidity and Mortality Weekly Report (MMWR. 2016 Jan 26;65[Early Release:1-5]).

Infants with laboratory evidence of a possible congenital Zika virus infection should undergo additional clinical evaluation, and state or territorial health departments should be contacted to facilitate testing. Zika virus disease is an arboviral disease and thus is a nationally notifiable condition, according to guideline authors Dr. J. Erin Staples and her colleagues at the CDC, Atlanta.

Both molecular and serologic tests are recommended for infants undergoing evaluation for possible congenital Zika virus infection, they noted.

Serum specimens for reverse-transcription-polymerase chain reaction testing should be collected from the umbilical cord or directly from the infant within 2 days of birth, and cerebrospinal fluid collected for other studies, as well as frozen and fixed placenta obtained at delivery, should also be tested by RT-PCR.

IgM ELISA for Zika virus and dengue virus should also be performed on infant serum, infant CSF, and maternal serum, but results from these assays can be falsely positive because of cross-reacting antibodies, the authors noted.

Other tests that can be considered include a plaque reduction neutralization test to measure virus-specific neutralizing antibodies and to discriminate between cross-reacting antibodies and closely related flaviviruses, and immunohistochemical staining to detect the virus antigen on fixed placenta and umbilical cord tissues.

Further clinical evaluation and laboratory testing is recommended for infants with microcephaly or intracranial calcifications detected prenatally or at birth if the mother was potentially infected during pregnancy, they said.

In infants with possible Zika virus exposure during pregnancy, but without microcephaly or intracranial calcification, subsequent evaluation depends on maternal testing results. Routine care is recommended if maternal test results are negative, and testing for a possible congenital infection is recommended if maternal results are positive or inconclusive.

If all of an infant’s tests are negative for Zika virus infection, no further Zika virus testing or evaluation is recommended. In the event of any positive or inconclusive test, further evaluation and follow-up is recommended.

Other considerations

Abnormal eye findings have been reported in infants with possible congenital infection, therefore an opthalmologic evaluation, including retinal examination is advised during the first month of life, as is a repeat hearing screen at age 6 months – even if the initial screen was normal, the authors said.

The infant should be followed to assess for long-term sequelae, and the case should be reported. Follow-up should include a cranial ultrasound to assess for subclinical findings, unless a third trimester ultrasound showed no brain abnormalities, they added.

No specific antiviral treatment or vaccine exists for Zika virus infection; treatment is supportive and should address specific medical and neurodevelopmental issues, and mothers should be encouraged to breastfeed infants regardless of exposure, as available evidence suggests the benefits of breastfeeding outweigh the theoretical risks of transmission through breast milk, they said.

The authors stressed that prevention of maternal infection is the only way to prevent congenital Zika virus infection and is achieved by avoiding areas with ongoing Zika virus transmission or by strictly following steps to avoid mosquito bites by using air-conditioning or window and door screens, wearing protective clothing, and using insect repellents.

Environmental Protection Agency–registered insect repellents are safe for pregnant women when used according to the product label, they noted.

The Centers for Disease Control and Prevention has released interim guidelines for U.S. clinicians caring for infants born to mothers who traveled to or resided in an area with Zika virus transmission during pregnancy.

The guidelines, released Jan. 26, address the evaluation and testing of infants with possible congenital Zika virus infection, and follow the Jan. 19 release of similar guidelines for the care of pregnant women with possible exposure to the mosquito-borne virus. Most importantly, the new guidelines say Zika virus testing should be performed for infants with microcephaly or intracranial calcifications who are born to women with possible Zika virus exposure during pregnancy, and for infants born to women with positive or inconclusive Zika virus test results.

©DamrongpanThongwat/ThinkStock

“Pediatric health are providers should work closely with obstetric providers to identify infants whose mothers were potentially infected with Zika virus during pregnancy (based on travel to or residence in an area with Zika virus transmission),” according to the guidelines, which were published in Morbidity and Mortality Weekly Report (MMWR. 2016 Jan 26;65[Early Release:1-5]).

Infants with laboratory evidence of a possible congenital Zika virus infection should undergo additional clinical evaluation, and state or territorial health departments should be contacted to facilitate testing. Zika virus disease is an arboviral disease and thus is a nationally notifiable condition, according to guideline authors Dr. J. Erin Staples and her colleagues at the CDC, Atlanta.

Both molecular and serologic tests are recommended for infants undergoing evaluation for possible congenital Zika virus infection, they noted.

Serum specimens for reverse-transcription-polymerase chain reaction testing should be collected from the umbilical cord or directly from the infant within 2 days of birth, and cerebrospinal fluid collected for other studies, as well as frozen and fixed placenta obtained at delivery, should also be tested by RT-PCR.

IgM ELISA for Zika virus and dengue virus should also be performed on infant serum, infant CSF, and maternal serum, but results from these assays can be falsely positive because of cross-reacting antibodies, the authors noted.

Other tests that can be considered include a plaque reduction neutralization test to measure virus-specific neutralizing antibodies and to discriminate between cross-reacting antibodies and closely related flaviviruses, and immunohistochemical staining to detect the virus antigen on fixed placenta and umbilical cord tissues.

Further clinical evaluation and laboratory testing is recommended for infants with microcephaly or intracranial calcifications detected prenatally or at birth if the mother was potentially infected during pregnancy, they said.

In infants with possible Zika virus exposure during pregnancy, but without microcephaly or intracranial calcification, subsequent evaluation depends on maternal testing results. Routine care is recommended if maternal test results are negative, and testing for a possible congenital infection is recommended if maternal results are positive or inconclusive.

If all of an infant’s tests are negative for Zika virus infection, no further Zika virus testing or evaluation is recommended. In the event of any positive or inconclusive test, further evaluation and follow-up is recommended.

Other considerations

Abnormal eye findings have been reported in infants with possible congenital infection, therefore an opthalmologic evaluation, including retinal examination is advised during the first month of life, as is a repeat hearing screen at age 6 months – even if the initial screen was normal, the authors said.

The infant should be followed to assess for long-term sequelae, and the case should be reported. Follow-up should include a cranial ultrasound to assess for subclinical findings, unless a third trimester ultrasound showed no brain abnormalities, they added.

No specific antiviral treatment or vaccine exists for Zika virus infection; treatment is supportive and should address specific medical and neurodevelopmental issues, and mothers should be encouraged to breastfeed infants regardless of exposure, as available evidence suggests the benefits of breastfeeding outweigh the theoretical risks of transmission through breast milk, they said.

The authors stressed that prevention of maternal infection is the only way to prevent congenital Zika virus infection and is achieved by avoiding areas with ongoing Zika virus transmission or by strictly following steps to avoid mosquito bites by using air-conditioning or window and door screens, wearing protective clothing, and using insect repellents.

Environmental Protection Agency–registered insect repellents are safe for pregnant women when used according to the product label, they noted.

The Centers for Disease Control and Prevention has released interim guidelines for U.S. clinicians caring for infants born to mothers who traveled to or resided in an area with Zika virus transmission during pregnancy.

The guidelines, released Jan. 26, address the evaluation and testing of infants with possible congenital Zika virus infection, and follow the Jan. 19 release of similar guidelines for the care of pregnant women with possible exposure to the mosquito-borne virus. Most importantly, the new guidelines say Zika virus testing should be performed for infants with microcephaly or intracranial calcifications who are born to women with possible Zika virus exposure during pregnancy, and for infants born to women with positive or inconclusive Zika virus test results.

©DamrongpanThongwat/ThinkStock

“Pediatric health are providers should work closely with obstetric providers to identify infants whose mothers were potentially infected with Zika virus during pregnancy (based on travel to or residence in an area with Zika virus transmission),” according to the guidelines, which were published in Morbidity and Mortality Weekly Report (MMWR. 2016 Jan 26;65[Early Release:1-5]).

Infants with laboratory evidence of a possible congenital Zika virus infection should undergo additional clinical evaluation, and state or territorial health departments should be contacted to facilitate testing. Zika virus disease is an arboviral disease and thus is a nationally notifiable condition, according to guideline authors Dr. J. Erin Staples and her colleagues at the CDC, Atlanta.

Both molecular and serologic tests are recommended for infants undergoing evaluation for possible congenital Zika virus infection, they noted.

Serum specimens for reverse-transcription-polymerase chain reaction testing should be collected from the umbilical cord or directly from the infant within 2 days of birth, and cerebrospinal fluid collected for other studies, as well as frozen and fixed placenta obtained at delivery, should also be tested by RT-PCR.

IgM ELISA for Zika virus and dengue virus should also be performed on infant serum, infant CSF, and maternal serum, but results from these assays can be falsely positive because of cross-reacting antibodies, the authors noted.

Other tests that can be considered include a plaque reduction neutralization test to measure virus-specific neutralizing antibodies and to discriminate between cross-reacting antibodies and closely related flaviviruses, and immunohistochemical staining to detect the virus antigen on fixed placenta and umbilical cord tissues.

Further clinical evaluation and laboratory testing is recommended for infants with microcephaly or intracranial calcifications detected prenatally or at birth if the mother was potentially infected during pregnancy, they said.

In infants with possible Zika virus exposure during pregnancy, but without microcephaly or intracranial calcification, subsequent evaluation depends on maternal testing results. Routine care is recommended if maternal test results are negative, and testing for a possible congenital infection is recommended if maternal results are positive or inconclusive.

If all of an infant’s tests are negative for Zika virus infection, no further Zika virus testing or evaluation is recommended. In the event of any positive or inconclusive test, further evaluation and follow-up is recommended.

Other considerations

Abnormal eye findings have been reported in infants with possible congenital infection, therefore an opthalmologic evaluation, including retinal examination is advised during the first month of life, as is a repeat hearing screen at age 6 months – even if the initial screen was normal, the authors said.

The infant should be followed to assess for long-term sequelae, and the case should be reported. Follow-up should include a cranial ultrasound to assess for subclinical findings, unless a third trimester ultrasound showed no brain abnormalities, they added.

No specific antiviral treatment or vaccine exists for Zika virus infection; treatment is supportive and should address specific medical and neurodevelopmental issues, and mothers should be encouraged to breastfeed infants regardless of exposure, as available evidence suggests the benefits of breastfeeding outweigh the theoretical risks of transmission through breast milk, they said.

The authors stressed that prevention of maternal infection is the only way to prevent congenital Zika virus infection and is achieved by avoiding areas with ongoing Zika virus transmission or by strictly following steps to avoid mosquito bites by using air-conditioning or window and door screens, wearing protective clothing, and using insect repellents.

Environmental Protection Agency–registered insect repellents are safe for pregnant women when used according to the product label, they noted.