ANNAPOLIS, MD. – Three novel treatments for gonorrhea, currently in late stages of development, could give clinicians an edge in the fight against antibacterial resistance, according to a federal health official.

The pathogen Neisseria gonorrhoeae is already showing signs of besting first-line therapy ceftriaxone in Japan and parts of Europe, said Carolyn Deal, PhD, chief of the sexually transmitted diseases branch at the National Institute of Allergy and Infectious Diseases (NIAID). And the Centers for Disease Control and Prevention lists N. gonorrhoeae among its “urgent” antibiotic resistance threats.

“I think we have a new superbug,” Dr. Deal said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. “In my opinion, it’s just a matter of time in this country.”

But three agents in late-stage clinical trials for uncomplicated urogenital gonorrhea offer promise in fighting the gram-negative bacteria, according to Dr. Deal. The first is solithromycin, manufactured by Cempra. The company has a phase III study underway to compare a single dose of oral solithromycin with intramuscular ceftriaxone plus oral azithromycin for urogenital gonorrhea.

The other two drugs are first-in-class antibacterial agents. In partnership with the NIAID, the company Entasis recently completed a phase II study of zoliflodacin, an oral agent in a novel class of topoisomerase inhibitors. A phase III trial is expected to begin in 2017, also in partnership with the NIAID, according to an Entasis document. The third agent is gepotidacin, a novel triazaacenaphthylene antibacterial agent currently being investigated by GlaxoSmithKline in a phase II study.

Centers for Disease Control and Prevention

Because N. gonorrhoeae poses such an urgent threat, waiting to develop a vaccine is less feasible than working with companies to develop additional antibacterial agents, Dr. Deal said. But taking a compound out of the basic research lab and having enough data to get into the investigational new drug phase is a significant investment, she said, so pharmaceutical manufacturers look for as many indications for a drug as possible.

For instance, solithromycin was initially investigated for community-acquired pneumonia. Gepotidacin initially was developed in partnership with the NIAID and the Biomedical Advanced Research and Development Authority in case of an anthrax attack, Dr. Deal said. “The Entasis product is the only one specifically developed for Neisseria gonorrhoeae,” she said.

One reason that two of the drugs in the pipeline include N. gonorrhoeae as an indication is that the Food and Drug Administration has issued guidance on developing drugs in the area of uncomplicated gonorrhea. That guidance is lacking for nasopharyngeal and rectal gonorrhea, leaving a “vacuum” in the pipeline, Dr. Deal said. “Many of us have come to the conclusion that developing vaccines is the only real long-term solution.”

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

ANNAPOLIS, MD. – Three novel treatments for gonorrhea, currently in late stages of development, could give clinicians an edge in the fight against antibacterial resistance, according to a federal health official.

The pathogen Neisseria gonorrhoeae is already showing signs of besting first-line therapy ceftriaxone in Japan and parts of Europe, said Carolyn Deal, PhD, chief of the sexually transmitted diseases branch at the National Institute of Allergy and Infectious Diseases (NIAID). And the Centers for Disease Control and Prevention lists N. gonorrhoeae among its “urgent” antibiotic resistance threats.

“I think we have a new superbug,” Dr. Deal said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. “In my opinion, it’s just a matter of time in this country.”

But three agents in late-stage clinical trials for uncomplicated urogenital gonorrhea offer promise in fighting the gram-negative bacteria, according to Dr. Deal. The first is solithromycin, manufactured by Cempra. The company has a phase III study underway to compare a single dose of oral solithromycin with intramuscular ceftriaxone plus oral azithromycin for urogenital gonorrhea.

The other two drugs are first-in-class antibacterial agents. In partnership with the NIAID, the company Entasis recently completed a phase II study of zoliflodacin, an oral agent in a novel class of topoisomerase inhibitors. A phase III trial is expected to begin in 2017, also in partnership with the NIAID, according to an Entasis document. The third agent is gepotidacin, a novel triazaacenaphthylene antibacterial agent currently being investigated by GlaxoSmithKline in a phase II study.

Centers for Disease Control and Prevention

Because N. gonorrhoeae poses such an urgent threat, waiting to develop a vaccine is less feasible than working with companies to develop additional antibacterial agents, Dr. Deal said. But taking a compound out of the basic research lab and having enough data to get into the investigational new drug phase is a significant investment, she said, so pharmaceutical manufacturers look for as many indications for a drug as possible.

For instance, solithromycin was initially investigated for community-acquired pneumonia. Gepotidacin initially was developed in partnership with the NIAID and the Biomedical Advanced Research and Development Authority in case of an anthrax attack, Dr. Deal said. “The Entasis product is the only one specifically developed for Neisseria gonorrhoeae,” she said.

One reason that two of the drugs in the pipeline include N. gonorrhoeae as an indication is that the Food and Drug Administration has issued guidance on developing drugs in the area of uncomplicated gonorrhea. That guidance is lacking for nasopharyngeal and rectal gonorrhea, leaving a “vacuum” in the pipeline, Dr. Deal said. “Many of us have come to the conclusion that developing vaccines is the only real long-term solution.”

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

ANNAPOLIS, MD. – Three novel treatments for gonorrhea, currently in late stages of development, could give clinicians an edge in the fight against antibacterial resistance, according to a federal health official.

The pathogen Neisseria gonorrhoeae is already showing signs of besting first-line therapy ceftriaxone in Japan and parts of Europe, said Carolyn Deal, PhD, chief of the sexually transmitted diseases branch at the National Institute of Allergy and Infectious Diseases (NIAID). And the Centers for Disease Control and Prevention lists N. gonorrhoeae among its “urgent” antibiotic resistance threats.

“I think we have a new superbug,” Dr. Deal said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. “In my opinion, it’s just a matter of time in this country.”

But three agents in late-stage clinical trials for uncomplicated urogenital gonorrhea offer promise in fighting the gram-negative bacteria, according to Dr. Deal. The first is solithromycin, manufactured by Cempra. The company has a phase III study underway to compare a single dose of oral solithromycin with intramuscular ceftriaxone plus oral azithromycin for urogenital gonorrhea.

The other two drugs are first-in-class antibacterial agents. In partnership with the NIAID, the company Entasis recently completed a phase II study of zoliflodacin, an oral agent in a novel class of topoisomerase inhibitors. A phase III trial is expected to begin in 2017, also in partnership with the NIAID, according to an Entasis document. The third agent is gepotidacin, a novel triazaacenaphthylene antibacterial agent currently being investigated by GlaxoSmithKline in a phase II study.

Centers for Disease Control and Prevention

Because N. gonorrhoeae poses such an urgent threat, waiting to develop a vaccine is less feasible than working with companies to develop additional antibacterial agents, Dr. Deal said. But taking a compound out of the basic research lab and having enough data to get into the investigational new drug phase is a significant investment, she said, so pharmaceutical manufacturers look for as many indications for a drug as possible.

For instance, solithromycin was initially investigated for community-acquired pneumonia. Gepotidacin initially was developed in partnership with the NIAID and the Biomedical Advanced Research and Development Authority in case of an anthrax attack, Dr. Deal said. “The Entasis product is the only one specifically developed for Neisseria gonorrhoeae,” she said.

One reason that two of the drugs in the pipeline include N. gonorrhoeae as an indication is that the Food and Drug Administration has issued guidance on developing drugs in the area of uncomplicated gonorrhea. That guidance is lacking for nasopharyngeal and rectal gonorrhea, leaving a “vacuum” in the pipeline, Dr. Deal said. “Many of us have come to the conclusion that developing vaccines is the only real long-term solution.”

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

As the United States becomes increasingly diverse, with predictions that by 2045 minorities will comprise 50% or more of the population,¹ the demographics of the orthopedic surgery population will also likely diversify. It is important that orthopedic surgeons shift in their diversity as well. Lack of diversity in orthopedics (women and racial minorities are underrepresented) relative to the national population and other surgical specialties and their training programs is well documented.^2-8

More concerning, the diversity of orthopedic residents does not compare favorably with that of medical school attendees.^4,9 The difference suggests the greatest loss of potential diversity occurs during the transition from medical school to residency. A national study demonstrated that instruction in musculoskeletal medicine led to an increase in application rates nationally.¹⁰ However, the authors of that study stated they were unexpectedly limited by its large size—they could not validate the accuracy of curriculum data and could not differentiate between a 1-day required experience and a 4-week rotation.

In the present study, which accounted for curricular factors, we compared our medical students’ application rates to orthopedics residencies based on sex and race before and after introduction of a required third-year musculoskeletal clerkship. We hypothesized that making the curriculum a requirement would increase the number of applicants and increase the diversity of applicants in terms of both women and underrepresented minorities. This hypothesis was based on the rationale that these groups might not consider an orthopedics residency without first being directly exposed to orthopedics. We also wanted to determine what factors influenced applicants to choose orthopedic surgery.

Methods

Curriculum

Before 2006, third-year students spent 3 months completing a surgery clerkship. Some students interested in orthopedic surgery would have to wait until their fourth year to complete an elective in orthopedic surgery, and uninterested students would not be exposed at all. Starting in 2006, 1 month of the third-year surgery clerkship was required to be completed in musculoskeletal surgery: orthopedic surgery, plastic surgery, or neurosurgical spine. Plastic surgery was an option, as it exposed students to hand surgery and flap reconstruction.

During the 12-year study period, overall teaching hours in the preclinical curriculum did not change, and there were no other structural changes to the preclinical or clinical curriculum. The orthopedics department increased its faculty from 23 in 2000 to 34 in 2012. Number of female faculty increased from 1 to 3, representing a 4% to 9% increase in department faculty. Throughout the 12 years, there were no underrepresented minority faculty. Total number of residents increased from 26 in 2000 to 30 in 2012. Number of female residents varied year to year, from a low of 3 in the period 2003–2004 to a high of 11 in the period 2009–2010. Number of underrepresented minority residents varied yearly as well, from 1 to 2.

Data Collection

After this study was granted exempt status by our Institutional Review Board, we obtained student data from our registrar. Data included graduation year, self-identified sex and race, exposure to orthopedic surgery during clerkships, and matching residency specialty. National data were obtained from the Electronic Residency Application Service for the periods 2002–2007 and 2009–2012. These data included all US allopathic medical students’ self-identified sex and race, and applied-to primary residency specialty. National data from 2008 and national data on sex differences in orthopedic applications from 2009 were not available.

Graduates who matched into orthopedic surgery were asked to complete an anonymous survey on what influenced their decision to apply to orthopedic surgery and when this decision was made. Our goal with the survey was to substantiate or refute the conclusion that application rates depended on third-year exposure to musculoskeletal medicine.

Statistical Methods

Students were divided into 2 groups: precurriculum (graduated within 7-year period, 2000–2006) and postcurriculum (graduated within 6-year period, 2007–2012). A 2-sample test for proportions was used to compare percentage of total students who applied to orthopedics in each group. In the group of students who applied to orthopedics, we compared precurriculum and postcurriculum proportions of women and underrepresented minorities (non-white, non-Asian). We also compared these proportions with national data (using 2-sample tests for proportions) to determine if any change in diversity of our institution’s applicants was mirroring a national trend. Our definition of underrepresented minority was based on work that showed that the proportion of Asian matriculants in medical school and the proportion of applicants to orthopedics are higher than their respective national proportions.⁵ Survey data are reported descriptively. Statistical significance was defined with a 2-tailed α of 0.05 for all tests.

Results

Over the 2000–2012 period, 1507 students from our institution successfully applied to residency programs: 792 in the precurriculum group and 715 in the postcurriculum group. Of these students, 91 successfully applied to orthopedic surgery: 48 in the precurriculum group (applied before introduction of the required clerkship) and 43 in the postcurriculum group (applied afterward).

Over the 2002–2012 period, 10,100 US allopathic medical students applied to orthopedic residency programs: 4769 students between 2002 and 2006 and 5331 students between 2007 and 2012.

Discussion

Orthopedic surgery needs a more diverse workforce^11-17 in order to better mirror the population served, bring care to underserved areas,^18-26 and provide better training environments.²⁷ Several hypotheses about the lack of diversity have been posited: stereotypes about the specialty,^28-31 lack of interest among minority medical students, and lack of exposure to the specialty.^5,6,32,33

Lack of exposure deserves scrutiny, as a large proportion of medical students who choose to apply to orthopedic surgery make their decision before entering medical school, which is not typical.³³ Such a finding suggests that exposure to orthopedic surgery is lacking, especially given that an orthopedic surgery rotation is usually not required during the clinical years. The idea that increased exposure to orthopedics affects application patterns is logical, as clinical exposure has been shown to play a role in medical students’ choice of specialty.³⁴

Exposure helps in several key areas. Firsthand experience can help dispel stereotypes, such as the idea that success in orthopedic surgery depends on physical strength and that only former athletes pursue orthopedics.^28-31 Authors have also reported on a perceived negative bias against women: Orthopedics is an “old boys’ network”; women will not fit in and need not apply; the orthopedic lifestyle is difficult and not conducive to a satisfying personal life.⁹ Requiring exposure ensures that all students, but especially women, can gain firsthand experience that can show these stereotypes to be false. Beyond dispelling these stereotypes, exposure to orthopedic surgery is essential for women, as studies have shown that clinical rotations play a larger role in determining specialty choice for women compared to men,³³ and this would be particularly critical for specialties they may not be initially considering.

A national study found that requiring an orthopedic/musculoskeletal clerkship led to a 12% relative increase in the application rate, from 5.1% to 5.7%, and to an increase in applicant diversity (race, sex).¹⁰ However, the investigators could not determine individual reasons for specialty choice or the exact nature of each institution’s musculoskeletal curriculum. Confirming these factors, we found an 81% increase in number of female applicants and a 101% increase in number of underrepresented minority applicants after introduction of the required third-year musculoskeletal surgery clerkship at our institution.

We were unable to replicate the 12% relative increase in the overall application rate; our orthopedic surgery match rate remained 6%. Our findings cannot directly explain this, but we have several hypotheses. First, whereas other studies measured the application rate, we measured the successful match rate, given our data structure. This difference in data definition could account for some of the discrepancy. Second, we did not account for individuals’ academic success, and career counseling is paramount in decisions regarding residency specialties. It is possible we are substituting qualified female and underrepresented minority candidates for less-than-qualified male applicants. Third, the 25% increase in medical student exposure to orthopedic surgery led to a corresponding increase in number of orthopedic faculty providing undergraduate medical education. Some of these faculty could have been inexperienced in undergraduate medical education, and thus the teaching environment may not have been optimal.

Our study had several limitations. First, our institution has limited racial diversity. Over the past 12 years, only 15% of our students have been underrepresented minorities. (Nationally, the proportion is closer to 18%.) This may have limited the ability of our orthopedic rotation to affect the proportion of underrepresented minority applicants. Second, this study involved medical students at only one institution, which limits generalizability of findings. Third, we were unable to obtain records specifying which faculty and residents interacted with which medical students, and the increased number of female faculty and residents coinciding with the curriculum change may also be a factor. However, we expect that, without the curriculum change, these students would have had smaller odds of interacting with these potential female role models in orthopedics, negating any affect they may have had. Last, although we contacted former students to ask about their reasons for choosing the orthopedics residency, those findings are limited by a potential respondent selection bias.

The qualities and characteristics of successful orthopedic surgeons, as presented in both medical and lay cultures, are subject to numerous stereotypes. By increasing medical student exposure to orthopedics during the third year of medical school, we are giving a larger proportion of our students direct clinical experience in a field they may not have been considering. This exposure allows students to interact with mentors who can be positive role models—orthopedic surgeons who are dispelling stereotypes. By increasing medical student exposure and reaching students who may not have been considering orthopedics, we have increased diversity among our applicants. Third-year medical students’ exposure to orthopedic surgery is essential in promoting a more diverse workforce.

Am J Orthop. 2016;45(6):E347-E351. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

As the United States becomes increasingly diverse, with predictions that by 2045 minorities will comprise 50% or more of the population,¹ the demographics of the orthopedic surgery population will also likely diversify. It is important that orthopedic surgeons shift in their diversity as well. Lack of diversity in orthopedics (women and racial minorities are underrepresented) relative to the national population and other surgical specialties and their training programs is well documented.^2-8

More concerning, the diversity of orthopedic residents does not compare favorably with that of medical school attendees.^4,9 The difference suggests the greatest loss of potential diversity occurs during the transition from medical school to residency. A national study demonstrated that instruction in musculoskeletal medicine led to an increase in application rates nationally.¹⁰ However, the authors of that study stated they were unexpectedly limited by its large size—they could not validate the accuracy of curriculum data and could not differentiate between a 1-day required experience and a 4-week rotation.

In the present study, which accounted for curricular factors, we compared our medical students’ application rates to orthopedics residencies based on sex and race before and after introduction of a required third-year musculoskeletal clerkship. We hypothesized that making the curriculum a requirement would increase the number of applicants and increase the diversity of applicants in terms of both women and underrepresented minorities. This hypothesis was based on the rationale that these groups might not consider an orthopedics residency without first being directly exposed to orthopedics. We also wanted to determine what factors influenced applicants to choose orthopedic surgery.

Methods

Curriculum

Before 2006, third-year students spent 3 months completing a surgery clerkship. Some students interested in orthopedic surgery would have to wait until their fourth year to complete an elective in orthopedic surgery, and uninterested students would not be exposed at all. Starting in 2006, 1 month of the third-year surgery clerkship was required to be completed in musculoskeletal surgery: orthopedic surgery, plastic surgery, or neurosurgical spine. Plastic surgery was an option, as it exposed students to hand surgery and flap reconstruction.

During the 12-year study period, overall teaching hours in the preclinical curriculum did not change, and there were no other structural changes to the preclinical or clinical curriculum. The orthopedics department increased its faculty from 23 in 2000 to 34 in 2012. Number of female faculty increased from 1 to 3, representing a 4% to 9% increase in department faculty. Throughout the 12 years, there were no underrepresented minority faculty. Total number of residents increased from 26 in 2000 to 30 in 2012. Number of female residents varied year to year, from a low of 3 in the period 2003–2004 to a high of 11 in the period 2009–2010. Number of underrepresented minority residents varied yearly as well, from 1 to 2.

Data Collection

After this study was granted exempt status by our Institutional Review Board, we obtained student data from our registrar. Data included graduation year, self-identified sex and race, exposure to orthopedic surgery during clerkships, and matching residency specialty. National data were obtained from the Electronic Residency Application Service for the periods 2002–2007 and 2009–2012. These data included all US allopathic medical students’ self-identified sex and race, and applied-to primary residency specialty. National data from 2008 and national data on sex differences in orthopedic applications from 2009 were not available.

Graduates who matched into orthopedic surgery were asked to complete an anonymous survey on what influenced their decision to apply to orthopedic surgery and when this decision was made. Our goal with the survey was to substantiate or refute the conclusion that application rates depended on third-year exposure to musculoskeletal medicine.

Statistical Methods

Students were divided into 2 groups: precurriculum (graduated within 7-year period, 2000–2006) and postcurriculum (graduated within 6-year period, 2007–2012). A 2-sample test for proportions was used to compare percentage of total students who applied to orthopedics in each group. In the group of students who applied to orthopedics, we compared precurriculum and postcurriculum proportions of women and underrepresented minorities (non-white, non-Asian). We also compared these proportions with national data (using 2-sample tests for proportions) to determine if any change in diversity of our institution’s applicants was mirroring a national trend. Our definition of underrepresented minority was based on work that showed that the proportion of Asian matriculants in medical school and the proportion of applicants to orthopedics are higher than their respective national proportions.⁵ Survey data are reported descriptively. Statistical significance was defined with a 2-tailed α of 0.05 for all tests.

Results

Over the 2000–2012 period, 1507 students from our institution successfully applied to residency programs: 792 in the precurriculum group and 715 in the postcurriculum group. Of these students, 91 successfully applied to orthopedic surgery: 48 in the precurriculum group (applied before introduction of the required clerkship) and 43 in the postcurriculum group (applied afterward).

Over the 2002–2012 period, 10,100 US allopathic medical students applied to orthopedic residency programs: 4769 students between 2002 and 2006 and 5331 students between 2007 and 2012.

Discussion

Orthopedic surgery needs a more diverse workforce^11-17 in order to better mirror the population served, bring care to underserved areas,^18-26 and provide better training environments.²⁷ Several hypotheses about the lack of diversity have been posited: stereotypes about the specialty,^28-31 lack of interest among minority medical students, and lack of exposure to the specialty.^5,6,32,33

Lack of exposure deserves scrutiny, as a large proportion of medical students who choose to apply to orthopedic surgery make their decision before entering medical school, which is not typical.³³ Such a finding suggests that exposure to orthopedic surgery is lacking, especially given that an orthopedic surgery rotation is usually not required during the clinical years. The idea that increased exposure to orthopedics affects application patterns is logical, as clinical exposure has been shown to play a role in medical students’ choice of specialty.³⁴

Exposure helps in several key areas. Firsthand experience can help dispel stereotypes, such as the idea that success in orthopedic surgery depends on physical strength and that only former athletes pursue orthopedics.^28-31 Authors have also reported on a perceived negative bias against women: Orthopedics is an “old boys’ network”; women will not fit in and need not apply; the orthopedic lifestyle is difficult and not conducive to a satisfying personal life.⁹ Requiring exposure ensures that all students, but especially women, can gain firsthand experience that can show these stereotypes to be false. Beyond dispelling these stereotypes, exposure to orthopedic surgery is essential for women, as studies have shown that clinical rotations play a larger role in determining specialty choice for women compared to men,³³ and this would be particularly critical for specialties they may not be initially considering.

A national study found that requiring an orthopedic/musculoskeletal clerkship led to a 12% relative increase in the application rate, from 5.1% to 5.7%, and to an increase in applicant diversity (race, sex).¹⁰ However, the investigators could not determine individual reasons for specialty choice or the exact nature of each institution’s musculoskeletal curriculum. Confirming these factors, we found an 81% increase in number of female applicants and a 101% increase in number of underrepresented minority applicants after introduction of the required third-year musculoskeletal surgery clerkship at our institution.

We were unable to replicate the 12% relative increase in the overall application rate; our orthopedic surgery match rate remained 6%. Our findings cannot directly explain this, but we have several hypotheses. First, whereas other studies measured the application rate, we measured the successful match rate, given our data structure. This difference in data definition could account for some of the discrepancy. Second, we did not account for individuals’ academic success, and career counseling is paramount in decisions regarding residency specialties. It is possible we are substituting qualified female and underrepresented minority candidates for less-than-qualified male applicants. Third, the 25% increase in medical student exposure to orthopedic surgery led to a corresponding increase in number of orthopedic faculty providing undergraduate medical education. Some of these faculty could have been inexperienced in undergraduate medical education, and thus the teaching environment may not have been optimal.

Our study had several limitations. First, our institution has limited racial diversity. Over the past 12 years, only 15% of our students have been underrepresented minorities. (Nationally, the proportion is closer to 18%.) This may have limited the ability of our orthopedic rotation to affect the proportion of underrepresented minority applicants. Second, this study involved medical students at only one institution, which limits generalizability of findings. Third, we were unable to obtain records specifying which faculty and residents interacted with which medical students, and the increased number of female faculty and residents coinciding with the curriculum change may also be a factor. However, we expect that, without the curriculum change, these students would have had smaller odds of interacting with these potential female role models in orthopedics, negating any affect they may have had. Last, although we contacted former students to ask about their reasons for choosing the orthopedics residency, those findings are limited by a potential respondent selection bias.

The qualities and characteristics of successful orthopedic surgeons, as presented in both medical and lay cultures, are subject to numerous stereotypes. By increasing medical student exposure to orthopedics during the third year of medical school, we are giving a larger proportion of our students direct clinical experience in a field they may not have been considering. This exposure allows students to interact with mentors who can be positive role models—orthopedic surgeons who are dispelling stereotypes. By increasing medical student exposure and reaching students who may not have been considering orthopedics, we have increased diversity among our applicants. Third-year medical students’ exposure to orthopedic surgery is essential in promoting a more diverse workforce.

Am J Orthop. 2016;45(6):E347-E351. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

As the United States becomes increasingly diverse, with predictions that by 2045 minorities will comprise 50% or more of the population,¹ the demographics of the orthopedic surgery population will also likely diversify. It is important that orthopedic surgeons shift in their diversity as well. Lack of diversity in orthopedics (women and racial minorities are underrepresented) relative to the national population and other surgical specialties and their training programs is well documented.^2-8

More concerning, the diversity of orthopedic residents does not compare favorably with that of medical school attendees.^4,9 The difference suggests the greatest loss of potential diversity occurs during the transition from medical school to residency. A national study demonstrated that instruction in musculoskeletal medicine led to an increase in application rates nationally.¹⁰ However, the authors of that study stated they were unexpectedly limited by its large size—they could not validate the accuracy of curriculum data and could not differentiate between a 1-day required experience and a 4-week rotation.

In the present study, which accounted for curricular factors, we compared our medical students’ application rates to orthopedics residencies based on sex and race before and after introduction of a required third-year musculoskeletal clerkship. We hypothesized that making the curriculum a requirement would increase the number of applicants and increase the diversity of applicants in terms of both women and underrepresented minorities. This hypothesis was based on the rationale that these groups might not consider an orthopedics residency without first being directly exposed to orthopedics. We also wanted to determine what factors influenced applicants to choose orthopedic surgery.

Methods

Curriculum

Before 2006, third-year students spent 3 months completing a surgery clerkship. Some students interested in orthopedic surgery would have to wait until their fourth year to complete an elective in orthopedic surgery, and uninterested students would not be exposed at all. Starting in 2006, 1 month of the third-year surgery clerkship was required to be completed in musculoskeletal surgery: orthopedic surgery, plastic surgery, or neurosurgical spine. Plastic surgery was an option, as it exposed students to hand surgery and flap reconstruction.

During the 12-year study period, overall teaching hours in the preclinical curriculum did not change, and there were no other structural changes to the preclinical or clinical curriculum. The orthopedics department increased its faculty from 23 in 2000 to 34 in 2012. Number of female faculty increased from 1 to 3, representing a 4% to 9% increase in department faculty. Throughout the 12 years, there were no underrepresented minority faculty. Total number of residents increased from 26 in 2000 to 30 in 2012. Number of female residents varied year to year, from a low of 3 in the period 2003–2004 to a high of 11 in the period 2009–2010. Number of underrepresented minority residents varied yearly as well, from 1 to 2.

Data Collection

After this study was granted exempt status by our Institutional Review Board, we obtained student data from our registrar. Data included graduation year, self-identified sex and race, exposure to orthopedic surgery during clerkships, and matching residency specialty. National data were obtained from the Electronic Residency Application Service for the periods 2002–2007 and 2009–2012. These data included all US allopathic medical students’ self-identified sex and race, and applied-to primary residency specialty. National data from 2008 and national data on sex differences in orthopedic applications from 2009 were not available.

Graduates who matched into orthopedic surgery were asked to complete an anonymous survey on what influenced their decision to apply to orthopedic surgery and when this decision was made. Our goal with the survey was to substantiate or refute the conclusion that application rates depended on third-year exposure to musculoskeletal medicine.

Statistical Methods

Students were divided into 2 groups: precurriculum (graduated within 7-year period, 2000–2006) and postcurriculum (graduated within 6-year period, 2007–2012). A 2-sample test for proportions was used to compare percentage of total students who applied to orthopedics in each group. In the group of students who applied to orthopedics, we compared precurriculum and postcurriculum proportions of women and underrepresented minorities (non-white, non-Asian). We also compared these proportions with national data (using 2-sample tests for proportions) to determine if any change in diversity of our institution’s applicants was mirroring a national trend. Our definition of underrepresented minority was based on work that showed that the proportion of Asian matriculants in medical school and the proportion of applicants to orthopedics are higher than their respective national proportions.⁵ Survey data are reported descriptively. Statistical significance was defined with a 2-tailed α of 0.05 for all tests.

Results

Over the 2000–2012 period, 1507 students from our institution successfully applied to residency programs: 792 in the precurriculum group and 715 in the postcurriculum group. Of these students, 91 successfully applied to orthopedic surgery: 48 in the precurriculum group (applied before introduction of the required clerkship) and 43 in the postcurriculum group (applied afterward).

Over the 2002–2012 period, 10,100 US allopathic medical students applied to orthopedic residency programs: 4769 students between 2002 and 2006 and 5331 students between 2007 and 2012.

Discussion

Orthopedic surgery needs a more diverse workforce^11-17 in order to better mirror the population served, bring care to underserved areas,^18-26 and provide better training environments.²⁷ Several hypotheses about the lack of diversity have been posited: stereotypes about the specialty,^28-31 lack of interest among minority medical students, and lack of exposure to the specialty.^5,6,32,33

Lack of exposure deserves scrutiny, as a large proportion of medical students who choose to apply to orthopedic surgery make their decision before entering medical school, which is not typical.³³ Such a finding suggests that exposure to orthopedic surgery is lacking, especially given that an orthopedic surgery rotation is usually not required during the clinical years. The idea that increased exposure to orthopedics affects application patterns is logical, as clinical exposure has been shown to play a role in medical students’ choice of specialty.³⁴

Exposure helps in several key areas. Firsthand experience can help dispel stereotypes, such as the idea that success in orthopedic surgery depends on physical strength and that only former athletes pursue orthopedics.^28-31 Authors have also reported on a perceived negative bias against women: Orthopedics is an “old boys’ network”; women will not fit in and need not apply; the orthopedic lifestyle is difficult and not conducive to a satisfying personal life.⁹ Requiring exposure ensures that all students, but especially women, can gain firsthand experience that can show these stereotypes to be false. Beyond dispelling these stereotypes, exposure to orthopedic surgery is essential for women, as studies have shown that clinical rotations play a larger role in determining specialty choice for women compared to men,³³ and this would be particularly critical for specialties they may not be initially considering.

A national study found that requiring an orthopedic/musculoskeletal clerkship led to a 12% relative increase in the application rate, from 5.1% to 5.7%, and to an increase in applicant diversity (race, sex).¹⁰ However, the investigators could not determine individual reasons for specialty choice or the exact nature of each institution’s musculoskeletal curriculum. Confirming these factors, we found an 81% increase in number of female applicants and a 101% increase in number of underrepresented minority applicants after introduction of the required third-year musculoskeletal surgery clerkship at our institution.

We were unable to replicate the 12% relative increase in the overall application rate; our orthopedic surgery match rate remained 6%. Our findings cannot directly explain this, but we have several hypotheses. First, whereas other studies measured the application rate, we measured the successful match rate, given our data structure. This difference in data definition could account for some of the discrepancy. Second, we did not account for individuals’ academic success, and career counseling is paramount in decisions regarding residency specialties. It is possible we are substituting qualified female and underrepresented minority candidates for less-than-qualified male applicants. Third, the 25% increase in medical student exposure to orthopedic surgery led to a corresponding increase in number of orthopedic faculty providing undergraduate medical education. Some of these faculty could have been inexperienced in undergraduate medical education, and thus the teaching environment may not have been optimal.

Our study had several limitations. First, our institution has limited racial diversity. Over the past 12 years, only 15% of our students have been underrepresented minorities. (Nationally, the proportion is closer to 18%.) This may have limited the ability of our orthopedic rotation to affect the proportion of underrepresented minority applicants. Second, this study involved medical students at only one institution, which limits generalizability of findings. Third, we were unable to obtain records specifying which faculty and residents interacted with which medical students, and the increased number of female faculty and residents coinciding with the curriculum change may also be a factor. However, we expect that, without the curriculum change, these students would have had smaller odds of interacting with these potential female role models in orthopedics, negating any affect they may have had. Last, although we contacted former students to ask about their reasons for choosing the orthopedics residency, those findings are limited by a potential respondent selection bias.

The qualities and characteristics of successful orthopedic surgeons, as presented in both medical and lay cultures, are subject to numerous stereotypes. By increasing medical student exposure to orthopedics during the third year of medical school, we are giving a larger proportion of our students direct clinical experience in a field they may not have been considering. This exposure allows students to interact with mentors who can be positive role models—orthopedic surgeons who are dispelling stereotypes. By increasing medical student exposure and reaching students who may not have been considering orthopedics, we have increased diversity among our applicants. Third-year medical students’ exposure to orthopedic surgery is essential in promoting a more diverse workforce.

Am J Orthop. 2016;45(6):E347-E351. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

When using biologic therapies for psoriasis, it is important to evaluate long-term efficacy (>4 years of follow-up). Biologic drug survival in psoriasis reflects long-term performance in real-life settings. Prior studies have yielded inconsistent results.

Vilarrasa et al (J Am Acad Dermatol. 2016;74:1066-1072) conducted an observational retrospective study called ORBIT (Outcome and Retention Rate of Biologic Treatments for Psoriasis) to determine drug survival (the mean length of time patients remain on a drug) in a cohort of 427 patients (63.5% male; mean age, 50.2 years) with moderate to severe psoriasis vulgaris (mean baseline psoriasis area and severity index [PASI], 16.4). In addition to determining mean drug survival times for etanercept, infliximab, adalimumab, and ustekinumab, investigators searched for variables that positively or negatively affected drug survival times. Data were extracted from clinical records of patients treated with biologic agents over a 4-year period. Drug survival was analyzed using the Kaplan-Meier method and the influence of several covariates was assessed using Cox regression.

The investigators evaluated 703 treatment courses. The overall median drug survival was 31.0 months. Cumulative probability of drug survival was lower in obese patients (23.0 months; 95% CI, 17.4-28.6) than in patients with body mass index less than 30 (37.3 months; 95% CI, 29.4-45.1; P=.001). Drug survival was significantly higher for ustekinumab than for any other biologic agent (log-rank test, P<.001). Multivariate analysis showed that obesity, etanercept treatment, and strict adherence to approved doses were associated with an increased probability of drug withdrawal, whereas ustekinumab treatment and PASI 75 and PASI 90 responses at week 16 prolonged drug survival. Data were collected retrospectively.

What’s the issue?

These results should help to educate patients and to manage expectations about drug efficacy. They should also give guidance to physicians. Patients who respond rapidly to biologics—PASI 70 or PASI 90 clearance during the induction phase—are more likely to enjoy long-term remission. In contrast, those with a high body mass index should be advised that their psoriasis may take longer to respond to treatment and may need combination therapy for optimal clearance.

We want to know your views! Tell us what you think.

When using biologic therapies for psoriasis, it is important to evaluate long-term efficacy (>4 years of follow-up). Biologic drug survival in psoriasis reflects long-term performance in real-life settings. Prior studies have yielded inconsistent results.

Vilarrasa et al (J Am Acad Dermatol. 2016;74:1066-1072) conducted an observational retrospective study called ORBIT (Outcome and Retention Rate of Biologic Treatments for Psoriasis) to determine drug survival (the mean length of time patients remain on a drug) in a cohort of 427 patients (63.5% male; mean age, 50.2 years) with moderate to severe psoriasis vulgaris (mean baseline psoriasis area and severity index [PASI], 16.4). In addition to determining mean drug survival times for etanercept, infliximab, adalimumab, and ustekinumab, investigators searched for variables that positively or negatively affected drug survival times. Data were extracted from clinical records of patients treated with biologic agents over a 4-year period. Drug survival was analyzed using the Kaplan-Meier method and the influence of several covariates was assessed using Cox regression.

The investigators evaluated 703 treatment courses. The overall median drug survival was 31.0 months. Cumulative probability of drug survival was lower in obese patients (23.0 months; 95% CI, 17.4-28.6) than in patients with body mass index less than 30 (37.3 months; 95% CI, 29.4-45.1; P=.001). Drug survival was significantly higher for ustekinumab than for any other biologic agent (log-rank test, P<.001). Multivariate analysis showed that obesity, etanercept treatment, and strict adherence to approved doses were associated with an increased probability of drug withdrawal, whereas ustekinumab treatment and PASI 75 and PASI 90 responses at week 16 prolonged drug survival. Data were collected retrospectively.

What’s the issue?

These results should help to educate patients and to manage expectations about drug efficacy. They should also give guidance to physicians. Patients who respond rapidly to biologics—PASI 70 or PASI 90 clearance during the induction phase—are more likely to enjoy long-term remission. In contrast, those with a high body mass index should be advised that their psoriasis may take longer to respond to treatment and may need combination therapy for optimal clearance.

We want to know your views! Tell us what you think.

When using biologic therapies for psoriasis, it is important to evaluate long-term efficacy (>4 years of follow-up). Biologic drug survival in psoriasis reflects long-term performance in real-life settings. Prior studies have yielded inconsistent results.

Vilarrasa et al (J Am Acad Dermatol. 2016;74:1066-1072) conducted an observational retrospective study called ORBIT (Outcome and Retention Rate of Biologic Treatments for Psoriasis) to determine drug survival (the mean length of time patients remain on a drug) in a cohort of 427 patients (63.5% male; mean age, 50.2 years) with moderate to severe psoriasis vulgaris (mean baseline psoriasis area and severity index [PASI], 16.4). In addition to determining mean drug survival times for etanercept, infliximab, adalimumab, and ustekinumab, investigators searched for variables that positively or negatively affected drug survival times. Data were extracted from clinical records of patients treated with biologic agents over a 4-year period. Drug survival was analyzed using the Kaplan-Meier method and the influence of several covariates was assessed using Cox regression.

The investigators evaluated 703 treatment courses. The overall median drug survival was 31.0 months. Cumulative probability of drug survival was lower in obese patients (23.0 months; 95% CI, 17.4-28.6) than in patients with body mass index less than 30 (37.3 months; 95% CI, 29.4-45.1; P=.001). Drug survival was significantly higher for ustekinumab than for any other biologic agent (log-rank test, P<.001). Multivariate analysis showed that obesity, etanercept treatment, and strict adherence to approved doses were associated with an increased probability of drug withdrawal, whereas ustekinumab treatment and PASI 75 and PASI 90 responses at week 16 prolonged drug survival. Data were collected retrospectively.

What’s the issue?

These results should help to educate patients and to manage expectations about drug efficacy. They should also give guidance to physicians. Patients who respond rapidly to biologics—PASI 70 or PASI 90 clearance during the induction phase—are more likely to enjoy long-term remission. In contrast, those with a high body mass index should be advised that their psoriasis may take longer to respond to treatment and may need combination therapy for optimal clearance.

We want to know your views! Tell us what you think.

Illicit drug use in the United States continues to rise. In 2014, 27 million people reported using an illicit drug in the previous 30 days. This corresponds to nearly 1 in every 10 Americans.

Use of marijuana has the highest prevalence, followed distantly by pain relievers, tranquilizers, stimulants, and cocaine. Resources for drug users who want to quit are difficult to access – and even if those resources are available, they may be constrained.

For patients struggling with alcohol dependence who want to quit, Alcoholics Anonymous (AA) is the most well-known and ubiquitous 12-step mutual help organization (MHO). Other MHOs, such as Narcotics Anonymous (NA), exist for illicit substances such as opiates (e.g., heroin), stimulants, or cannabis. Shared experiences are hypothesized to maximize therapeutic benefit.

But what, then, should we do if somebody struggling with illicit substance dependence wants to remain abstinent from drugs and there are only AA groups around?

Harvard investigators suggest that support from AA for patients with illicit substance addiction is not associated with early discontinuation or compromised recovery. To evaluate this, researchers examined treatment outcomes among young adults participating in residential treatment in Minnesota (Alcohol Alcohol. 2014 Nov;49[6]:645-3).

Four groups of patients with drug use disorder were evaluated: alcohol, cannabis, opiates, or stimulants. The goal was to compare the relative success of individuals with fellowship “mismatch” (e.g., attending AA but was a primary user of cannabis), compared with those who had a fellowship match. Success during aftercare was defined as percentage of days abstinent and attendance at the MHO.

Investigators observed that in the first 3 months after discharge from the residential treatment program, a significant proportion (79%) of the meetings attended by the cannabis, opiates, or stimulant users were AA meetings. This mismatch was unrelated to 12-step attendance at 6 and 12 months, or to percentage of days abstinent.

Available literature suggests that 12-step MHO participation is a predictor of better treatment outcomes. The findings from this study suggest that AA attendance among patients recovering from cannabis, opiates, or stimulant use disorder is beneficial. Patients with illicit drug use disorder should be encouraged to attend AA if other MHOs are not accessible.

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

Illicit drug use in the United States continues to rise. In 2014, 27 million people reported using an illicit drug in the previous 30 days. This corresponds to nearly 1 in every 10 Americans.

Use of marijuana has the highest prevalence, followed distantly by pain relievers, tranquilizers, stimulants, and cocaine. Resources for drug users who want to quit are difficult to access – and even if those resources are available, they may be constrained.

For patients struggling with alcohol dependence who want to quit, Alcoholics Anonymous (AA) is the most well-known and ubiquitous 12-step mutual help organization (MHO). Other MHOs, such as Narcotics Anonymous (NA), exist for illicit substances such as opiates (e.g., heroin), stimulants, or cannabis. Shared experiences are hypothesized to maximize therapeutic benefit.

But what, then, should we do if somebody struggling with illicit substance dependence wants to remain abstinent from drugs and there are only AA groups around?

Harvard investigators suggest that support from AA for patients with illicit substance addiction is not associated with early discontinuation or compromised recovery. To evaluate this, researchers examined treatment outcomes among young adults participating in residential treatment in Minnesota (Alcohol Alcohol. 2014 Nov;49[6]:645-3).

Four groups of patients with drug use disorder were evaluated: alcohol, cannabis, opiates, or stimulants. The goal was to compare the relative success of individuals with fellowship “mismatch” (e.g., attending AA but was a primary user of cannabis), compared with those who had a fellowship match. Success during aftercare was defined as percentage of days abstinent and attendance at the MHO.

Investigators observed that in the first 3 months after discharge from the residential treatment program, a significant proportion (79%) of the meetings attended by the cannabis, opiates, or stimulant users were AA meetings. This mismatch was unrelated to 12-step attendance at 6 and 12 months, or to percentage of days abstinent.

Available literature suggests that 12-step MHO participation is a predictor of better treatment outcomes. The findings from this study suggest that AA attendance among patients recovering from cannabis, opiates, or stimulant use disorder is beneficial. Patients with illicit drug use disorder should be encouraged to attend AA if other MHOs are not accessible.

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

Illicit drug use in the United States continues to rise. In 2014, 27 million people reported using an illicit drug in the previous 30 days. This corresponds to nearly 1 in every 10 Americans.

Use of marijuana has the highest prevalence, followed distantly by pain relievers, tranquilizers, stimulants, and cocaine. Resources for drug users who want to quit are difficult to access – and even if those resources are available, they may be constrained.

For patients struggling with alcohol dependence who want to quit, Alcoholics Anonymous (AA) is the most well-known and ubiquitous 12-step mutual help organization (MHO). Other MHOs, such as Narcotics Anonymous (NA), exist for illicit substances such as opiates (e.g., heroin), stimulants, or cannabis. Shared experiences are hypothesized to maximize therapeutic benefit.

But what, then, should we do if somebody struggling with illicit substance dependence wants to remain abstinent from drugs and there are only AA groups around?

Harvard investigators suggest that support from AA for patients with illicit substance addiction is not associated with early discontinuation or compromised recovery. To evaluate this, researchers examined treatment outcomes among young adults participating in residential treatment in Minnesota (Alcohol Alcohol. 2014 Nov;49[6]:645-3).

Four groups of patients with drug use disorder were evaluated: alcohol, cannabis, opiates, or stimulants. The goal was to compare the relative success of individuals with fellowship “mismatch” (e.g., attending AA but was a primary user of cannabis), compared with those who had a fellowship match. Success during aftercare was defined as percentage of days abstinent and attendance at the MHO.

Investigators observed that in the first 3 months after discharge from the residential treatment program, a significant proportion (79%) of the meetings attended by the cannabis, opiates, or stimulant users were AA meetings. This mismatch was unrelated to 12-step attendance at 6 and 12 months, or to percentage of days abstinent.

Available literature suggests that 12-step MHO participation is a predictor of better treatment outcomes. The findings from this study suggest that AA attendance among patients recovering from cannabis, opiates, or stimulant use disorder is beneficial. Patients with illicit drug use disorder should be encouraged to attend AA if other MHOs are not accessible.

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

Myth: Psoriasis Is Infectious The precise cause of psoriasis is unknown, but researchers believe the immune system and genetics play major roles in its development, according to the National Psoriasis Foundation. The skin cells in patients with psoriasis grow at an abnormally fast rate, which causes the buildup of psoriasis lesions. Usually, something triggers psoriasis to flare.

A common misconception among patients is that psoriasis is caused by an infection. Psoriasis is not contagious and psoriasis lesions are not infectious.

However, psoriasis patients are more prone to infections than those without psoriasis. Risk factors for serious infections in psoriasis patients include immune dysregulation, systemic immunosuppressive medications, and comorbid health conditions such as diabetes mellitus or obesity. A 2016 study revealed an increased incidence of serious infections (eg, cellulitis, herpes simplex virus infection, any fungal infection, infectious arthritis, methicillin-resistant Staphylococcus aureus) in hospitalized patients with psoriasis. Higher rates were seen among nonwhite and non-privately insured patients.

In a 2011 study, the likelihood of infectious diseases in patients with psoriasis was twice as high as the reference population. The risk was highest in patients with more severe psoriasis but was not associated with recent systemic antipsoriatic drug dispensing. Respiratory tract, abdominal, and skin infections occurred most frequently in patients with psoriasis.

Poor access to adequate dermatologic care may contribute to higher rates of infections. Dermatologists must closely monitor patients with psoriasis for infection. More research is needed to develop interventions for prevention.

Expert Commentary Psoriasis patients have long faced discrimination because of an  irrational fear that their disease was somehow contagious. In fact this is completely false. This highlights the need for education of the public, so that they understand the true causes and nature of the disease.
—Jeffrey M. Weinberg, MD (New York, New York)

Myth: Psoriasis Is Infectious The precise cause of psoriasis is unknown, but researchers believe the immune system and genetics play major roles in its development, according to the National Psoriasis Foundation. The skin cells in patients with psoriasis grow at an abnormally fast rate, which causes the buildup of psoriasis lesions. Usually, something triggers psoriasis to flare.

A common misconception among patients is that psoriasis is caused by an infection. Psoriasis is not contagious and psoriasis lesions are not infectious.

However, psoriasis patients are more prone to infections than those without psoriasis. Risk factors for serious infections in psoriasis patients include immune dysregulation, systemic immunosuppressive medications, and comorbid health conditions such as diabetes mellitus or obesity. A 2016 study revealed an increased incidence of serious infections (eg, cellulitis, herpes simplex virus infection, any fungal infection, infectious arthritis, methicillin-resistant Staphylococcus aureus) in hospitalized patients with psoriasis. Higher rates were seen among nonwhite and non-privately insured patients.

In a 2011 study, the likelihood of infectious diseases in patients with psoriasis was twice as high as the reference population. The risk was highest in patients with more severe psoriasis but was not associated with recent systemic antipsoriatic drug dispensing. Respiratory tract, abdominal, and skin infections occurred most frequently in patients with psoriasis.

Poor access to adequate dermatologic care may contribute to higher rates of infections. Dermatologists must closely monitor patients with psoriasis for infection. More research is needed to develop interventions for prevention.

Expert Commentary Psoriasis patients have long faced discrimination because of an  irrational fear that their disease was somehow contagious. In fact this is completely false. This highlights the need for education of the public, so that they understand the true causes and nature of the disease.
—Jeffrey M. Weinberg, MD (New York, New York)

Myth: Psoriasis Is Infectious The precise cause of psoriasis is unknown, but researchers believe the immune system and genetics play major roles in its development, according to the National Psoriasis Foundation. The skin cells in patients with psoriasis grow at an abnormally fast rate, which causes the buildup of psoriasis lesions. Usually, something triggers psoriasis to flare.

A common misconception among patients is that psoriasis is caused by an infection. Psoriasis is not contagious and psoriasis lesions are not infectious.

However, psoriasis patients are more prone to infections than those without psoriasis. Risk factors for serious infections in psoriasis patients include immune dysregulation, systemic immunosuppressive medications, and comorbid health conditions such as diabetes mellitus or obesity. A 2016 study revealed an increased incidence of serious infections (eg, cellulitis, herpes simplex virus infection, any fungal infection, infectious arthritis, methicillin-resistant Staphylococcus aureus) in hospitalized patients with psoriasis. Higher rates were seen among nonwhite and non-privately insured patients.

In a 2011 study, the likelihood of infectious diseases in patients with psoriasis was twice as high as the reference population. The risk was highest in patients with more severe psoriasis but was not associated with recent systemic antipsoriatic drug dispensing. Respiratory tract, abdominal, and skin infections occurred most frequently in patients with psoriasis.

Poor access to adequate dermatologic care may contribute to higher rates of infections. Dermatologists must closely monitor patients with psoriasis for infection. More research is needed to develop interventions for prevention.

Expert Commentary Psoriasis patients have long faced discrimination because of an  irrational fear that their disease was somehow contagious. In fact this is completely false. This highlights the need for education of the public, so that they understand the true causes and nature of the disease.
—Jeffrey M. Weinberg, MD (New York, New York)

Direct-to-consumer marketing (DTCM) is the promotion of health-related products or services directly to patients. Although this topic is not new to orthopedics, several emerging trends hold troubling implications for patients as well as orthopedic surgeons, particularly surgeons in training.

Orthopedics DTCM most commonly involves television and print advertisements. Supporters contend DTCM is an empowering educational tool that increases awareness of medical ailments and encourages patients to seek treatment. Opponents point to inaccuracies and misleading claims. Bhattacharyya and colleagues¹ found that about half the claims in orthopedic print advertisements were not supported by clinical evidence. Woloshin and colleagues² found that information in DTCM was vague and often was designed to act on the emotions. Patients misled by these claims and innately seeking improvement could present with unreasonable expectations and difficult discussions that can be detrimental to the patient–physician relationship.³Given changing patient demographics and the information revolution, the effects of DTCM likely will continue to grow. Total joint arthroplasty (TJA), which represents Medicare’s largest expenditure,⁴ is a classic example. Today’s TJA patients are younger, more active, and better educated, and they live longer, have higher expectations, and are more reliant on the media.⁵ Television is no longer our main medium—the internet is the source of healthcare education for 70% of adults in the United States.⁶Healthcare reform has also brought significant changes in the delivery of DTCM. In an era of competition for market share brought by increased demand and decreased reimbursement, DTCM has evolved into sales pitches by hospitals and physicians. Robotic joint replacement, minimally invasive surgery (MIS), use of the anterior hip approach, use of sex-specific or high-flexion knee implants, and other practices have become popular marketing tools for surgery centers competing for new patients. As a result, patients often present not only with a complaint but with a request for a particular procedure.^4,5 Labovitch and colleagues⁷ found that 70% of MIS information on the internet was produced by hospitals and private medical groups, and only 6% was produced by industry. Although the vast majority of the sources reported on the advantages of MIS, only 15% explained patient eligibility, and a mere 9% supplied references for examination of peer-reviewed data. Another unfortunate consequence of DCTM is “physician shopping.” Bozic and colleagues⁴ found that patients exposed to DCTM were more likely to demand a specific surgery, approach, or implant and were less open to alternatives; in addition, they saw more than one surgeon before deciding on joint arthroplasty.

The effects of DTCM on resident and fellowship training require serious consideration. An emphasis on technology has come at the expense of learning the science and art of orthopedics.⁸ Physicians in training are pressured both to produce more and to use whichever specific technique or product a patient requests.⁴ Similarly, orthopedic surgeons are seeing job advertisements that read, “Training in robotic surgery or anterior approach is preferred.” Employer pressure can have profound implications for residents and fellows, who may feel compelled to learn these techniques. To a large degree, residents and fellows learn by accompanying their mentors and closely observing their decision-making processes and interactions with patients. Decisions regarding fellowships should not be influenced by surgical techniques or implant choices but by the quality and breadth of clinical experience.

DTCM likely will continue to shape all aspects of care. Claims made by physicians and hospitals are especially troubling because patients trust these sources. We face the challenge of reaffirming our commitment to patients and orthopedic surgeons. As the leader in musculoskeletal education, the American Academy of Orthopaedic Surgeons (AAOS) not only must provide educational material that is compatible with current technological media but must address current controversies and misleading claims. Toward that end, AAOS can expand its patient website, OrthoInfo, to include information on new technologies and surgical techniques pertaining to each musculoskeletal condition. Educating the public about risk factors for poor surgical outcomes is equally important in order to moderate unrealistic expectations and stimulate discussions on risks involved in unnecessary or potentially harmful technologies. The American Association of Hip and Knee Surgeons (AAHKS) has already embarked on this approach. Orthopedic surgeons should continue to abide by the standards of professionalism—maintaining the tenet of “First do no harm,” resisting the temptations of consumerism, and giving patients accurate information. Taking these measures may help reduce physician shopping and strengthen the patient–physician relationship. We physicians are the guardians of patients’ well-being. We also owe it to orthopedic surgeons in training to provide well-balanced, unbiased education. The focus of training should not be on techniques for gaining market edge but on learning evidence-based medicine and surgical principles. In our burdened healthcare system, curbing DTCM has the potential to decrease unnecessary use of resources and improve the quality of education and patient care.

Am J Orthop. 2016;45(6):E335-E336. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

Direct-to-consumer marketing (DTCM) is the promotion of health-related products or services directly to patients. Although this topic is not new to orthopedics, several emerging trends hold troubling implications for patients as well as orthopedic surgeons, particularly surgeons in training.

Orthopedics DTCM most commonly involves television and print advertisements. Supporters contend DTCM is an empowering educational tool that increases awareness of medical ailments and encourages patients to seek treatment. Opponents point to inaccuracies and misleading claims. Bhattacharyya and colleagues¹ found that about half the claims in orthopedic print advertisements were not supported by clinical evidence. Woloshin and colleagues² found that information in DTCM was vague and often was designed to act on the emotions. Patients misled by these claims and innately seeking improvement could present with unreasonable expectations and difficult discussions that can be detrimental to the patient–physician relationship.³Given changing patient demographics and the information revolution, the effects of DTCM likely will continue to grow. Total joint arthroplasty (TJA), which represents Medicare’s largest expenditure,⁴ is a classic example. Today’s TJA patients are younger, more active, and better educated, and they live longer, have higher expectations, and are more reliant on the media.⁵ Television is no longer our main medium—the internet is the source of healthcare education for 70% of adults in the United States.⁶Healthcare reform has also brought significant changes in the delivery of DTCM. In an era of competition for market share brought by increased demand and decreased reimbursement, DTCM has evolved into sales pitches by hospitals and physicians. Robotic joint replacement, minimally invasive surgery (MIS), use of the anterior hip approach, use of sex-specific or high-flexion knee implants, and other practices have become popular marketing tools for surgery centers competing for new patients. As a result, patients often present not only with a complaint but with a request for a particular procedure.^4,5 Labovitch and colleagues⁷ found that 70% of MIS information on the internet was produced by hospitals and private medical groups, and only 6% was produced by industry. Although the vast majority of the sources reported on the advantages of MIS, only 15% explained patient eligibility, and a mere 9% supplied references for examination of peer-reviewed data. Another unfortunate consequence of DCTM is “physician shopping.” Bozic and colleagues⁴ found that patients exposed to DCTM were more likely to demand a specific surgery, approach, or implant and were less open to alternatives; in addition, they saw more than one surgeon before deciding on joint arthroplasty.

The effects of DTCM on resident and fellowship training require serious consideration. An emphasis on technology has come at the expense of learning the science and art of orthopedics.⁸ Physicians in training are pressured both to produce more and to use whichever specific technique or product a patient requests.⁴ Similarly, orthopedic surgeons are seeing job advertisements that read, “Training in robotic surgery or anterior approach is preferred.” Employer pressure can have profound implications for residents and fellows, who may feel compelled to learn these techniques. To a large degree, residents and fellows learn by accompanying their mentors and closely observing their decision-making processes and interactions with patients. Decisions regarding fellowships should not be influenced by surgical techniques or implant choices but by the quality and breadth of clinical experience.

DTCM likely will continue to shape all aspects of care. Claims made by physicians and hospitals are especially troubling because patients trust these sources. We face the challenge of reaffirming our commitment to patients and orthopedic surgeons. As the leader in musculoskeletal education, the American Academy of Orthopaedic Surgeons (AAOS) not only must provide educational material that is compatible with current technological media but must address current controversies and misleading claims. Toward that end, AAOS can expand its patient website, OrthoInfo, to include information on new technologies and surgical techniques pertaining to each musculoskeletal condition. Educating the public about risk factors for poor surgical outcomes is equally important in order to moderate unrealistic expectations and stimulate discussions on risks involved in unnecessary or potentially harmful technologies. The American Association of Hip and Knee Surgeons (AAHKS) has already embarked on this approach. Orthopedic surgeons should continue to abide by the standards of professionalism—maintaining the tenet of “First do no harm,” resisting the temptations of consumerism, and giving patients accurate information. Taking these measures may help reduce physician shopping and strengthen the patient–physician relationship. We physicians are the guardians of patients’ well-being. We also owe it to orthopedic surgeons in training to provide well-balanced, unbiased education. The focus of training should not be on techniques for gaining market edge but on learning evidence-based medicine and surgical principles. In our burdened healthcare system, curbing DTCM has the potential to decrease unnecessary use of resources and improve the quality of education and patient care.

Am J Orthop. 2016;45(6):E335-E336. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

Direct-to-consumer marketing (DTCM) is the promotion of health-related products or services directly to patients. Although this topic is not new to orthopedics, several emerging trends hold troubling implications for patients as well as orthopedic surgeons, particularly surgeons in training.

Orthopedics DTCM most commonly involves television and print advertisements. Supporters contend DTCM is an empowering educational tool that increases awareness of medical ailments and encourages patients to seek treatment. Opponents point to inaccuracies and misleading claims. Bhattacharyya and colleagues¹ found that about half the claims in orthopedic print advertisements were not supported by clinical evidence. Woloshin and colleagues² found that information in DTCM was vague and often was designed to act on the emotions. Patients misled by these claims and innately seeking improvement could present with unreasonable expectations and difficult discussions that can be detrimental to the patient–physician relationship.³Given changing patient demographics and the information revolution, the effects of DTCM likely will continue to grow. Total joint arthroplasty (TJA), which represents Medicare’s largest expenditure,⁴ is a classic example. Today’s TJA patients are younger, more active, and better educated, and they live longer, have higher expectations, and are more reliant on the media.⁵ Television is no longer our main medium—the internet is the source of healthcare education for 70% of adults in the United States.⁶Healthcare reform has also brought significant changes in the delivery of DTCM. In an era of competition for market share brought by increased demand and decreased reimbursement, DTCM has evolved into sales pitches by hospitals and physicians. Robotic joint replacement, minimally invasive surgery (MIS), use of the anterior hip approach, use of sex-specific or high-flexion knee implants, and other practices have become popular marketing tools for surgery centers competing for new patients. As a result, patients often present not only with a complaint but with a request for a particular procedure.^4,5 Labovitch and colleagues⁷ found that 70% of MIS information on the internet was produced by hospitals and private medical groups, and only 6% was produced by industry. Although the vast majority of the sources reported on the advantages of MIS, only 15% explained patient eligibility, and a mere 9% supplied references for examination of peer-reviewed data. Another unfortunate consequence of DCTM is “physician shopping.” Bozic and colleagues⁴ found that patients exposed to DCTM were more likely to demand a specific surgery, approach, or implant and were less open to alternatives; in addition, they saw more than one surgeon before deciding on joint arthroplasty.

The effects of DTCM on resident and fellowship training require serious consideration. An emphasis on technology has come at the expense of learning the science and art of orthopedics.⁸ Physicians in training are pressured both to produce more and to use whichever specific technique or product a patient requests.⁴ Similarly, orthopedic surgeons are seeing job advertisements that read, “Training in robotic surgery or anterior approach is preferred.” Employer pressure can have profound implications for residents and fellows, who may feel compelled to learn these techniques. To a large degree, residents and fellows learn by accompanying their mentors and closely observing their decision-making processes and interactions with patients. Decisions regarding fellowships should not be influenced by surgical techniques or implant choices but by the quality and breadth of clinical experience.

DTCM likely will continue to shape all aspects of care. Claims made by physicians and hospitals are especially troubling because patients trust these sources. We face the challenge of reaffirming our commitment to patients and orthopedic surgeons. As the leader in musculoskeletal education, the American Academy of Orthopaedic Surgeons (AAOS) not only must provide educational material that is compatible with current technological media but must address current controversies and misleading claims. Toward that end, AAOS can expand its patient website, OrthoInfo, to include information on new technologies and surgical techniques pertaining to each musculoskeletal condition. Educating the public about risk factors for poor surgical outcomes is equally important in order to moderate unrealistic expectations and stimulate discussions on risks involved in unnecessary or potentially harmful technologies. The American Association of Hip and Knee Surgeons (AAHKS) has already embarked on this approach. Orthopedic surgeons should continue to abide by the standards of professionalism—maintaining the tenet of “First do no harm,” resisting the temptations of consumerism, and giving patients accurate information. Taking these measures may help reduce physician shopping and strengthen the patient–physician relationship. We physicians are the guardians of patients’ well-being. We also owe it to orthopedic surgeons in training to provide well-balanced, unbiased education. The focus of training should not be on techniques for gaining market edge but on learning evidence-based medicine and surgical principles. In our burdened healthcare system, curbing DTCM has the potential to decrease unnecessary use of resources and improve the quality of education and patient care.

Am J Orthop. 2016;45(6):E335-E336. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

Treatment of patients admitted to the hospital with an upper respiratory infection is often complicated by the lack of diagnostics. Even in cases where a patient has a confirmed case of influenza, there is still the possibility that they may have, or become infected by, a secondary bacterial infection. This leads clinicians to treat patients empirically with antibiotics, which can result in unnecessary antibiotic use among patients without a bacterial infection.

Though antibiotics can be a lifesaving drug, their use is not without risks. Estimates suggest that 20% of patients taking common antibiotics experience some side effect. While most side effects are not life-threatening gastrointestinal effects, other nonnegligible side effects include anaphylactic shock, drug‐induced liver injury, increases in the risk of retinal detachment, serious arrhythmias, and superinfection with resistant bacteria. Antibiotics can also lead to secondary infections, such as Clostridium difficile.

Yet, despite these risks, there has been limited research on the percentage of patients with influenza who actually have a bacterial coinfection. A recent systematic review and meta-analysis conducted by my colleagues at Johns Hopkins University and the Center for Disease Dynamics, Economics & Policy examined the frequency of bacterial coinfection among hospitalized patients with influenza and identified the most common infecting bacterial species.

The findings, published in the journal Influenza and Other Respiratory Viruses, found that in the majority of studies, between 11% and 35% of patients with confirmed influenza had a bacterial coinfection. The most common coinfecting bacteria were found to be Streptococcus pneumoniae and Staphylococcus aureus. Combined, S. pneumoniae and S. aureus accounted for more than 60% of the identified coinfecting bacteria; however, many other bacterial species were found to cause infections as well.

The results suggest that while bacterial infection is common in influenza patients, only about a quarter of patients are likely to be infected. However, the studies were widely heterogeneous, both in patient makeup and results. Analyses of age, setting, enrollment year, study type, study size, and bacterial collection methods did not reveal a source for the heterogeneity in results. Thus, additional factors, such as patient comorbidities or prior antibiotic use, which could not be systematically assessed, may affect the likelihood of coinfection.

Given that the symptoms of influenza and bacterial infection often overlap, correctly diagnosing bacterial coinfection without a laboratory culture can present a challenge. This diagnostic uncertainty leads to significant overuse of antibiotics in patients with influenza alone. Most influenza cases will never result in serious bacterial infections (particularly in nonhospitalized patients), and thus a lot of antibiotic use is unnecessary. As mentioned earlier, unnecessary antibiotic use poses a nonnegligible risk to patients, but it also contributes significantly to rising rates of antibiotic resistance, a major public health issue.

The results from this study highlight that the majority of patients hospitalized with influenza are unlikely to be coinfected with a bacterial pathogen. Thus, it is important for clinicians to appropriately treat patients with antiviral drugs, and ensure that bacterial testing is done when presumptively starting patients on antibiotics. Based on the microbiology results, antibiotics can be stopped if no pathogen is identified or altered to be more appropriate depending on the pathogen found.

Although the findings of this study suggest we need a more thorough analysis of the issue, the results should still aid clinicians by improving their understanding of the likelihood of bacterial coinfection in hospitalized patients with influenza, and thus help them balance the need to minimize patient risks as well as the individual and societal risks of nonessential antibiotic use.

Eili Klein, PhD, is assistant professor in the department of emergency medicine at Johns Hopkins Medicine, Baltimore.

Treatment of patients admitted to the hospital with an upper respiratory infection is often complicated by the lack of diagnostics. Even in cases where a patient has a confirmed case of influenza, there is still the possibility that they may have, or become infected by, a secondary bacterial infection. This leads clinicians to treat patients empirically with antibiotics, which can result in unnecessary antibiotic use among patients without a bacterial infection.

Though antibiotics can be a lifesaving drug, their use is not without risks. Estimates suggest that 20% of patients taking common antibiotics experience some side effect. While most side effects are not life-threatening gastrointestinal effects, other nonnegligible side effects include anaphylactic shock, drug‐induced liver injury, increases in the risk of retinal detachment, serious arrhythmias, and superinfection with resistant bacteria. Antibiotics can also lead to secondary infections, such as Clostridium difficile.

Yet, despite these risks, there has been limited research on the percentage of patients with influenza who actually have a bacterial coinfection. A recent systematic review and meta-analysis conducted by my colleagues at Johns Hopkins University and the Center for Disease Dynamics, Economics & Policy examined the frequency of bacterial coinfection among hospitalized patients with influenza and identified the most common infecting bacterial species.

The findings, published in the journal Influenza and Other Respiratory Viruses, found that in the majority of studies, between 11% and 35% of patients with confirmed influenza had a bacterial coinfection. The most common coinfecting bacteria were found to be Streptococcus pneumoniae and Staphylococcus aureus. Combined, S. pneumoniae and S. aureus accounted for more than 60% of the identified coinfecting bacteria; however, many other bacterial species were found to cause infections as well.

The results suggest that while bacterial infection is common in influenza patients, only about a quarter of patients are likely to be infected. However, the studies were widely heterogeneous, both in patient makeup and results. Analyses of age, setting, enrollment year, study type, study size, and bacterial collection methods did not reveal a source for the heterogeneity in results. Thus, additional factors, such as patient comorbidities or prior antibiotic use, which could not be systematically assessed, may affect the likelihood of coinfection.

Given that the symptoms of influenza and bacterial infection often overlap, correctly diagnosing bacterial coinfection without a laboratory culture can present a challenge. This diagnostic uncertainty leads to significant overuse of antibiotics in patients with influenza alone. Most influenza cases will never result in serious bacterial infections (particularly in nonhospitalized patients), and thus a lot of antibiotic use is unnecessary. As mentioned earlier, unnecessary antibiotic use poses a nonnegligible risk to patients, but it also contributes significantly to rising rates of antibiotic resistance, a major public health issue.

The results from this study highlight that the majority of patients hospitalized with influenza are unlikely to be coinfected with a bacterial pathogen. Thus, it is important for clinicians to appropriately treat patients with antiviral drugs, and ensure that bacterial testing is done when presumptively starting patients on antibiotics. Based on the microbiology results, antibiotics can be stopped if no pathogen is identified or altered to be more appropriate depending on the pathogen found.

Although the findings of this study suggest we need a more thorough analysis of the issue, the results should still aid clinicians by improving their understanding of the likelihood of bacterial coinfection in hospitalized patients with influenza, and thus help them balance the need to minimize patient risks as well as the individual and societal risks of nonessential antibiotic use.

Eili Klein, PhD, is assistant professor in the department of emergency medicine at Johns Hopkins Medicine, Baltimore.

Treatment of patients admitted to the hospital with an upper respiratory infection is often complicated by the lack of diagnostics. Even in cases where a patient has a confirmed case of influenza, there is still the possibility that they may have, or become infected by, a secondary bacterial infection. This leads clinicians to treat patients empirically with antibiotics, which can result in unnecessary antibiotic use among patients without a bacterial infection.

Though antibiotics can be a lifesaving drug, their use is not without risks. Estimates suggest that 20% of patients taking common antibiotics experience some side effect. While most side effects are not life-threatening gastrointestinal effects, other nonnegligible side effects include anaphylactic shock, drug‐induced liver injury, increases in the risk of retinal detachment, serious arrhythmias, and superinfection with resistant bacteria. Antibiotics can also lead to secondary infections, such as Clostridium difficile.

Yet, despite these risks, there has been limited research on the percentage of patients with influenza who actually have a bacterial coinfection. A recent systematic review and meta-analysis conducted by my colleagues at Johns Hopkins University and the Center for Disease Dynamics, Economics & Policy examined the frequency of bacterial coinfection among hospitalized patients with influenza and identified the most common infecting bacterial species.

The findings, published in the journal Influenza and Other Respiratory Viruses, found that in the majority of studies, between 11% and 35% of patients with confirmed influenza had a bacterial coinfection. The most common coinfecting bacteria were found to be Streptococcus pneumoniae and Staphylococcus aureus. Combined, S. pneumoniae and S. aureus accounted for more than 60% of the identified coinfecting bacteria; however, many other bacterial species were found to cause infections as well.

The results suggest that while bacterial infection is common in influenza patients, only about a quarter of patients are likely to be infected. However, the studies were widely heterogeneous, both in patient makeup and results. Analyses of age, setting, enrollment year, study type, study size, and bacterial collection methods did not reveal a source for the heterogeneity in results. Thus, additional factors, such as patient comorbidities or prior antibiotic use, which could not be systematically assessed, may affect the likelihood of coinfection.

Given that the symptoms of influenza and bacterial infection often overlap, correctly diagnosing bacterial coinfection without a laboratory culture can present a challenge. This diagnostic uncertainty leads to significant overuse of antibiotics in patients with influenza alone. Most influenza cases will never result in serious bacterial infections (particularly in nonhospitalized patients), and thus a lot of antibiotic use is unnecessary. As mentioned earlier, unnecessary antibiotic use poses a nonnegligible risk to patients, but it also contributes significantly to rising rates of antibiotic resistance, a major public health issue.

The results from this study highlight that the majority of patients hospitalized with influenza are unlikely to be coinfected with a bacterial pathogen. Thus, it is important for clinicians to appropriately treat patients with antiviral drugs, and ensure that bacterial testing is done when presumptively starting patients on antibiotics. Based on the microbiology results, antibiotics can be stopped if no pathogen is identified or altered to be more appropriate depending on the pathogen found.

Although the findings of this study suggest we need a more thorough analysis of the issue, the results should still aid clinicians by improving their understanding of the likelihood of bacterial coinfection in hospitalized patients with influenza, and thus help them balance the need to minimize patient risks as well as the individual and societal risks of nonessential antibiotic use.

Eili Klein, PhD, is assistant professor in the department of emergency medicine at Johns Hopkins Medicine, Baltimore.

Many patients with diabetic foot infections receive methicillin-resistant Staphylococcus aureus antibiotics unnecessarily, according to Kelly Reveles, PharmD, and her associates.

Among the 318 patients with diabetic foot infections (DFIs) in the study, S. aureus was the most common pathogen, accounting for 146 cases. MRSA accounted for 47 of S. aureus cases, and 15% of overall cases. Although MRSA accounted for a relatively small number of cases, MRSA antibiotics were administered to 86% of all patients, resulting in 71% of all patients receiving the treatment unnecessarily.

Independent risk factors for MRSA DFI were male sex and bone involvement. Other risk factors included previous MRSA infection, more severe infection, and a higher white cell count. The most common comorbidities of DFI were hypertension, dyslipidemia, and obesity.

“The improper use of antibiotics unnecessarily exposes the patient to potential complications of the therapy. Furthermore, the overuse of antibiotics drives antimicrobial resistance and is likely to increase the health care burden,” the investigators wrote.

Find the full study in PLoS One (doi: 10.1371/journal.pone.0161658).

lfranki@frontlinemedcom.com

Many patients with diabetic foot infections receive methicillin-resistant Staphylococcus aureus antibiotics unnecessarily, according to Kelly Reveles, PharmD, and her associates.

Among the 318 patients with diabetic foot infections (DFIs) in the study, S. aureus was the most common pathogen, accounting for 146 cases. MRSA accounted for 47 of S. aureus cases, and 15% of overall cases. Although MRSA accounted for a relatively small number of cases, MRSA antibiotics were administered to 86% of all patients, resulting in 71% of all patients receiving the treatment unnecessarily.

Independent risk factors for MRSA DFI were male sex and bone involvement. Other risk factors included previous MRSA infection, more severe infection, and a higher white cell count. The most common comorbidities of DFI were hypertension, dyslipidemia, and obesity.

“The improper use of antibiotics unnecessarily exposes the patient to potential complications of the therapy. Furthermore, the overuse of antibiotics drives antimicrobial resistance and is likely to increase the health care burden,” the investigators wrote.

Find the full study in PLoS One (doi: 10.1371/journal.pone.0161658).

lfranki@frontlinemedcom.com

Many patients with diabetic foot infections receive methicillin-resistant Staphylococcus aureus antibiotics unnecessarily, according to Kelly Reveles, PharmD, and her associates.

Among the 318 patients with diabetic foot infections (DFIs) in the study, S. aureus was the most common pathogen, accounting for 146 cases. MRSA accounted for 47 of S. aureus cases, and 15% of overall cases. Although MRSA accounted for a relatively small number of cases, MRSA antibiotics were administered to 86% of all patients, resulting in 71% of all patients receiving the treatment unnecessarily.

Independent risk factors for MRSA DFI were male sex and bone involvement. Other risk factors included previous MRSA infection, more severe infection, and a higher white cell count. The most common comorbidities of DFI were hypertension, dyslipidemia, and obesity.

“The improper use of antibiotics unnecessarily exposes the patient to potential complications of the therapy. Furthermore, the overuse of antibiotics drives antimicrobial resistance and is likely to increase the health care burden,” the investigators wrote.

Find the full study in PLoS One (doi: 10.1371/journal.pone.0161658).

lfranki@frontlinemedcom.com

There is ample evidence in the medical literature, as well as clinical experience, that patients seeking help for chemical dependency benefit from pharmacotherapy. It is common, however, for physicians, patients, and family to balk at the idea. Even within the psychiatry community, where there should be better understanding of substance use disorders, many practitioners hesitate to employ medications, especially for alcohol use disorder (AUD).

Efficacy for such FDA-approved medications has been demonstrated in well-designed, randomized controlled trials, but many trainees, and even experienced professionals, have never seen these medications used effectively and appropriately. Medication-assisted treatment (MAT) is not an alternative to biopsychosocial approaches but is an augmentation that can (1) help stabilize the patient until he (she) can be educated in relapse prevention skills and (2) allow the brain to rewire and heal until he regains impulse control.

Diverse presentations

Do you remember that patient who often arrived for appointments intoxicated, promising that he plans to cut down? How about the man you saw in the emergency department with an elevated blood alcohol level, who was constantly endorsing suicidal thoughts that subsided when he reached clinical sobriety? What about the college student who often was treated for alcohol poisoning after binge drinking on weekends, but who never considered this behavior problematic? And, how about the elderly woman who was evaluated for anxiety, but had been drinking 4 beers nightly for the past 30 years?

Despite the diverse presentations, these patients all have a chronic disease and we fail them when we do not apply evidence-based medicine to their treatment.

As psychiatrists, we encounter many patients with AUD as a primary or comorbid diagnosis. This is a global problem associated with significant human and financial cost. With 80% of American adolescents having reported using alcohol in the past year, the problem will continue to grow.¹ Furthermore, a greater prevalence of AUD is noted in clinical populations undergoing psychiatric treatment.² Ongoing alcohol abuse complicates the course of medical and psychiatric conditions and incites significant societal exclusion.

Pharmacotherapy is underutilized

Despite an increase in the use of psychotropic medications for treating psychiatric illness, pharmacotherapy for AUD is under­utilized: only 3% of patients have received an FDA-approved treatment.^2,3 Nearly one-third of adults are affected by AUD during their lifetime, yet only 20% seek help.³ Management today remains limited to episodic, brief inpatient detoxification and psychosocial therapy.

Recovery rates are highest when addiction treatment that monitors abstinence is continuous; yet, for most part, alcohol addiction is treated in discrete episodes upon relapse. Although MAT is recommended by experts for “moderate” and “severe” substance use disorders, practitioners, in general, have demonstrated considerable resistance to using this modality as part of routine practice.^4,5 This is regrettable: Regardless of terminology used to describe their condition, these people suffer a potentially fatal disease characterized by high post-treatment recidivism.

Neuroscience supports the brain disease model of addiction, with neuro­plasticity changes being made during phases of drug use. Medications are shown to assist in preventing relapse while the brain is healing and normal emotional and decision-making capacities are being restored.⁶

Why hesitate to use pharmacotherapeutics?

There are diverse pharmacotherapeutic options that can be pursued for treating AUD with minimal disruption to home and work life. Alarmingly, many trainees have never prescribed or even considered such medications. Despite modest effect sizes in randomized controlled trials, efficacy has been demonstrated in reducing relapse rates and overall severity of drinking days.^4,5 So, from where does the ambivalence of patients and providers about using these treatments to achieve lasting recovery stem?

Starting MAT certainly requires both parties to be in agreement. A patient might decline medication because of a fear of dependence or because he overestimates his ability to achieve remission on his own. There also may be financial barriers in a current alcohol treatment system that is traditionally non-medically oriented. Prescribers also fail to offer medications because of:

• lack of familiarity with available agents
• absence of guidelines for use
• disbelief that the condition is treatable.

Given that treatment often is based on a 12-step approach, such as Alcoholics Anonymous (AA), providers might hesitate to prescribe medication for an illness that is thought to be managed through psychosocial interventions, such as group and motivational therapy.

Therapeutic options

Choice of medication depends on the prescriber’s comfort level, reputation of the medication, potential side-effect profile, medical contraindications, and affordability; the most important consideration, however, should be the overall goals and expectations of the patient.

There are 4 FDA-approved medications for AUD (Table); many others are off-label. It is advisable to start with an FDA-approved medication such as disulfiram for the motivated patient who has a collaborator and desires complete abstinence; naltrexone for a patient who wants to cut down on intake (a long-acting formulation can be used for poorly adherent patients); and acamprosate for a patient with at least some established sobriety who needs help with post-withdrawal sleep disturbances.

Psychosocial interventions

Medications are just 1 tool in recovery; patients should be engaged in a program of counseling. Encourage attendance at AA meetings. An up-and-coming concept is the use of smartphone applications to prevent relapse (or even induce remission); apps that provide an accurate blood alcohol tracking systems and integrated psychosocial therapies are in the pipeline. The novel Reddit online forum r/StopDrinking is a 24-hour peer-support community that relies on
fellowship, accountability, monitoring, and anonymity; the forum can compete with
motivational interviewing for efficacy in increasing abstinence and preventing relapse.

There is ample evidence in the medical literature, as well as clinical experience, that patients seeking help for chemical dependency benefit from pharmacotherapy. It is common, however, for physicians, patients, and family to balk at the idea. Even within the psychiatry community, where there should be better understanding of substance use disorders, many practitioners hesitate to employ medications, especially for alcohol use disorder (AUD).

Efficacy for such FDA-approved medications has been demonstrated in well-designed, randomized controlled trials, but many trainees, and even experienced professionals, have never seen these medications used effectively and appropriately. Medication-assisted treatment (MAT) is not an alternative to biopsychosocial approaches but is an augmentation that can (1) help stabilize the patient until he (she) can be educated in relapse prevention skills and (2) allow the brain to rewire and heal until he regains impulse control.

Diverse presentations

Do you remember that patient who often arrived for appointments intoxicated, promising that he plans to cut down? How about the man you saw in the emergency department with an elevated blood alcohol level, who was constantly endorsing suicidal thoughts that subsided when he reached clinical sobriety? What about the college student who often was treated for alcohol poisoning after binge drinking on weekends, but who never considered this behavior problematic? And, how about the elderly woman who was evaluated for anxiety, but had been drinking 4 beers nightly for the past 30 years?

Despite the diverse presentations, these patients all have a chronic disease and we fail them when we do not apply evidence-based medicine to their treatment.

As psychiatrists, we encounter many patients with AUD as a primary or comorbid diagnosis. This is a global problem associated with significant human and financial cost. With 80% of American adolescents having reported using alcohol in the past year, the problem will continue to grow.¹ Furthermore, a greater prevalence of AUD is noted in clinical populations undergoing psychiatric treatment.² Ongoing alcohol abuse complicates the course of medical and psychiatric conditions and incites significant societal exclusion.

Pharmacotherapy is underutilized

Despite an increase in the use of psychotropic medications for treating psychiatric illness, pharmacotherapy for AUD is under­utilized: only 3% of patients have received an FDA-approved treatment.^2,3 Nearly one-third of adults are affected by AUD during their lifetime, yet only 20% seek help.³ Management today remains limited to episodic, brief inpatient detoxification and psychosocial therapy.

Recovery rates are highest when addiction treatment that monitors abstinence is continuous; yet, for most part, alcohol addiction is treated in discrete episodes upon relapse. Although MAT is recommended by experts for “moderate” and “severe” substance use disorders, practitioners, in general, have demonstrated considerable resistance to using this modality as part of routine practice.^4,5 This is regrettable: Regardless of terminology used to describe their condition, these people suffer a potentially fatal disease characterized by high post-treatment recidivism.

Neuroscience supports the brain disease model of addiction, with neuro­plasticity changes being made during phases of drug use. Medications are shown to assist in preventing relapse while the brain is healing and normal emotional and decision-making capacities are being restored.⁶

Why hesitate to use pharmacotherapeutics?

There are diverse pharmacotherapeutic options that can be pursued for treating AUD with minimal disruption to home and work life. Alarmingly, many trainees have never prescribed or even considered such medications. Despite modest effect sizes in randomized controlled trials, efficacy has been demonstrated in reducing relapse rates and overall severity of drinking days.^4,5 So, from where does the ambivalence of patients and providers about using these treatments to achieve lasting recovery stem?

Starting MAT certainly requires both parties to be in agreement. A patient might decline medication because of a fear of dependence or because he overestimates his ability to achieve remission on his own. There also may be financial barriers in a current alcohol treatment system that is traditionally non-medically oriented. Prescribers also fail to offer medications because of:

• lack of familiarity with available agents
• absence of guidelines for use
• disbelief that the condition is treatable.

Given that treatment often is based on a 12-step approach, such as Alcoholics Anonymous (AA), providers might hesitate to prescribe medication for an illness that is thought to be managed through psychosocial interventions, such as group and motivational therapy.

Therapeutic options

Choice of medication depends on the prescriber’s comfort level, reputation of the medication, potential side-effect profile, medical contraindications, and affordability; the most important consideration, however, should be the overall goals and expectations of the patient.

There are 4 FDA-approved medications for AUD (Table); many others are off-label. It is advisable to start with an FDA-approved medication such as disulfiram for the motivated patient who has a collaborator and desires complete abstinence; naltrexone for a patient who wants to cut down on intake (a long-acting formulation can be used for poorly adherent patients); and acamprosate for a patient with at least some established sobriety who needs help with post-withdrawal sleep disturbances.

Psychosocial interventions

Medications are just 1 tool in recovery; patients should be engaged in a program of counseling. Encourage attendance at AA meetings. An up-and-coming concept is the use of smartphone applications to prevent relapse (or even induce remission); apps that provide an accurate blood alcohol tracking systems and integrated psychosocial therapies are in the pipeline. The novel Reddit online forum r/StopDrinking is a 24-hour peer-support community that relies on
fellowship, accountability, monitoring, and anonymity; the forum can compete with
motivational interviewing for efficacy in increasing abstinence and preventing relapse.

There is ample evidence in the medical literature, as well as clinical experience, that patients seeking help for chemical dependency benefit from pharmacotherapy. It is common, however, for physicians, patients, and family to balk at the idea. Even within the psychiatry community, where there should be better understanding of substance use disorders, many practitioners hesitate to employ medications, especially for alcohol use disorder (AUD).

Efficacy for such FDA-approved medications has been demonstrated in well-designed, randomized controlled trials, but many trainees, and even experienced professionals, have never seen these medications used effectively and appropriately. Medication-assisted treatment (MAT) is not an alternative to biopsychosocial approaches but is an augmentation that can (1) help stabilize the patient until he (she) can be educated in relapse prevention skills and (2) allow the brain to rewire and heal until he regains impulse control.

Diverse presentations

Do you remember that patient who often arrived for appointments intoxicated, promising that he plans to cut down? How about the man you saw in the emergency department with an elevated blood alcohol level, who was constantly endorsing suicidal thoughts that subsided when he reached clinical sobriety? What about the college student who often was treated for alcohol poisoning after binge drinking on weekends, but who never considered this behavior problematic? And, how about the elderly woman who was evaluated for anxiety, but had been drinking 4 beers nightly for the past 30 years?

Despite the diverse presentations, these patients all have a chronic disease and we fail them when we do not apply evidence-based medicine to their treatment.

As psychiatrists, we encounter many patients with AUD as a primary or comorbid diagnosis. This is a global problem associated with significant human and financial cost. With 80% of American adolescents having reported using alcohol in the past year, the problem will continue to grow.¹ Furthermore, a greater prevalence of AUD is noted in clinical populations undergoing psychiatric treatment.² Ongoing alcohol abuse complicates the course of medical and psychiatric conditions and incites significant societal exclusion.

Pharmacotherapy is underutilized

Despite an increase in the use of psychotropic medications for treating psychiatric illness, pharmacotherapy for AUD is under­utilized: only 3% of patients have received an FDA-approved treatment.^2,3 Nearly one-third of adults are affected by AUD during their lifetime, yet only 20% seek help.³ Management today remains limited to episodic, brief inpatient detoxification and psychosocial therapy.

Recovery rates are highest when addiction treatment that monitors abstinence is continuous; yet, for most part, alcohol addiction is treated in discrete episodes upon relapse. Although MAT is recommended by experts for “moderate” and “severe” substance use disorders, practitioners, in general, have demonstrated considerable resistance to using this modality as part of routine practice.^4,5 This is regrettable: Regardless of terminology used to describe their condition, these people suffer a potentially fatal disease characterized by high post-treatment recidivism.

Neuroscience supports the brain disease model of addiction, with neuro­plasticity changes being made during phases of drug use. Medications are shown to assist in preventing relapse while the brain is healing and normal emotional and decision-making capacities are being restored.⁶

Why hesitate to use pharmacotherapeutics?

There are diverse pharmacotherapeutic options that can be pursued for treating AUD with minimal disruption to home and work life. Alarmingly, many trainees have never prescribed or even considered such medications. Despite modest effect sizes in randomized controlled trials, efficacy has been demonstrated in reducing relapse rates and overall severity of drinking days.^4,5 So, from where does the ambivalence of patients and providers about using these treatments to achieve lasting recovery stem?

Starting MAT certainly requires both parties to be in agreement. A patient might decline medication because of a fear of dependence or because he overestimates his ability to achieve remission on his own. There also may be financial barriers in a current alcohol treatment system that is traditionally non-medically oriented. Prescribers also fail to offer medications because of:

• lack of familiarity with available agents
• absence of guidelines for use
• disbelief that the condition is treatable.

Given that treatment often is based on a 12-step approach, such as Alcoholics Anonymous (AA), providers might hesitate to prescribe medication for an illness that is thought to be managed through psychosocial interventions, such as group and motivational therapy.

Therapeutic options

Choice of medication depends on the prescriber’s comfort level, reputation of the medication, potential side-effect profile, medical contraindications, and affordability; the most important consideration, however, should be the overall goals and expectations of the patient.

There are 4 FDA-approved medications for AUD (Table); many others are off-label. It is advisable to start with an FDA-approved medication such as disulfiram for the motivated patient who has a collaborator and desires complete abstinence; naltrexone for a patient who wants to cut down on intake (a long-acting formulation can be used for poorly adherent patients); and acamprosate for a patient with at least some established sobriety who needs help with post-withdrawal sleep disturbances.

Psychosocial interventions

Medications are just 1 tool in recovery; patients should be engaged in a program of counseling. Encourage attendance at AA meetings. An up-and-coming concept is the use of smartphone applications to prevent relapse (or even induce remission); apps that provide an accurate blood alcohol tracking systems and integrated psychosocial therapies are in the pipeline. The novel Reddit online forum r/StopDrinking is a 24-hour peer-support community that relies on
fellowship, accountability, monitoring, and anonymity; the forum can compete with
motivational interviewing for efficacy in increasing abstinence and preventing relapse.

Despite staff and budget reductions, local health departments (LHDs) are finding ways to expand services in some areas, according to a survey by the National Association of County and City Health Officials (NACCHO). One-third of LHDs reported reducing services of at least 1 program area, such as immunization, diabetes screening, and high blood pressure screening. However, one-fourth said they were expanding population-based preventive programs for obesity, drug, alcohol, and tobacco.

The association has periodically surveyed LHDs since 2008 to assess the impact of the economic recession. In 2014, NACCHO renamed the survey “The Forces of Change” and expanded it to take in a wider range of factors. The 16-question online survey, distributed during January-February 2015, went to 948 LHDs in the U.S. (excluding Rhode Island and Hawaii, which have no LHDs), representing one-third of all LHDs. Of the 690 top executives who responded, 353 represented small, 271 medium, and 66 large LHDs.

Related: Meta-Analysis Examines Quality of VA Health Care

At the peak of budget cuts, in 2009, 45% reported budget decreases. Since then, about 1 in 4 LHDs is still reporting budget cuts compared with the previous year; 27% expect budget decreases to continue into the next year.

Since 2008, NACCHO says, 51,700 jobs have been lost. More than half the 3,400 lost in 2014 were due to attrition; the rest to layoffs. The number of lost jobs was “most marked” among large LHDs: Sixty-one percent of those reported at least 1 job lost, followed by 41% of medium and 26% of small LHDs.

Related: Pharmacists in the Emergency Department: Feasibility and Cost

For many LHDs, “the cumulative effects of budget cuts and job losses” have not been reversed as the economy recovered. Some are trying creative workarounds, such as collaborations with primary care providers (PCPs). For example, 61% report actively encouraging PCPs to use evidence-based public health services, such as interventions to reduce asthma triggers.

However, < 10% of LHDs were actively engaged in new systems of care with PCPs, such as State Innovation Models (multipayer health care payment and service delivery models), patient-centered medical homes, or accountable care organizations (networks of health care providers voluntarily responsible for providing coordinated care). And < 70% are engaged in or exploring partnerships with nonprofit hospitals, which NACCHO says “might benefit multiple stakeholders and the community at large.”

Related: Implementing the EQUiPPED Medication Management Program at 5 VA Emergency Departments

Despite staff and budget reductions, local health departments (LHDs) are finding ways to expand services in some areas, according to a survey by the National Association of County and City Health Officials (NACCHO). One-third of LHDs reported reducing services of at least 1 program area, such as immunization, diabetes screening, and high blood pressure screening. However, one-fourth said they were expanding population-based preventive programs for obesity, drug, alcohol, and tobacco.

The association has periodically surveyed LHDs since 2008 to assess the impact of the economic recession. In 2014, NACCHO renamed the survey “The Forces of Change” and expanded it to take in a wider range of factors. The 16-question online survey, distributed during January-February 2015, went to 948 LHDs in the U.S. (excluding Rhode Island and Hawaii, which have no LHDs), representing one-third of all LHDs. Of the 690 top executives who responded, 353 represented small, 271 medium, and 66 large LHDs.

Related: Meta-Analysis Examines Quality of VA Health Care

At the peak of budget cuts, in 2009, 45% reported budget decreases. Since then, about 1 in 4 LHDs is still reporting budget cuts compared with the previous year; 27% expect budget decreases to continue into the next year.

Since 2008, NACCHO says, 51,700 jobs have been lost. More than half the 3,400 lost in 2014 were due to attrition; the rest to layoffs. The number of lost jobs was “most marked” among large LHDs: Sixty-one percent of those reported at least 1 job lost, followed by 41% of medium and 26% of small LHDs.

Related: Pharmacists in the Emergency Department: Feasibility and Cost

For many LHDs, “the cumulative effects of budget cuts and job losses” have not been reversed as the economy recovered. Some are trying creative workarounds, such as collaborations with primary care providers (PCPs). For example, 61% report actively encouraging PCPs to use evidence-based public health services, such as interventions to reduce asthma triggers.

However, < 10% of LHDs were actively engaged in new systems of care with PCPs, such as State Innovation Models (multipayer health care payment and service delivery models), patient-centered medical homes, or accountable care organizations (networks of health care providers voluntarily responsible for providing coordinated care). And < 70% are engaged in or exploring partnerships with nonprofit hospitals, which NACCHO says “might benefit multiple stakeholders and the community at large.”

Related: Implementing the EQUiPPED Medication Management Program at 5 VA Emergency Departments

Despite staff and budget reductions, local health departments (LHDs) are finding ways to expand services in some areas, according to a survey by the National Association of County and City Health Officials (NACCHO). One-third of LHDs reported reducing services of at least 1 program area, such as immunization, diabetes screening, and high blood pressure screening. However, one-fourth said they were expanding population-based preventive programs for obesity, drug, alcohol, and tobacco.

The association has periodically surveyed LHDs since 2008 to assess the impact of the economic recession. In 2014, NACCHO renamed the survey “The Forces of Change” and expanded it to take in a wider range of factors. The 16-question online survey, distributed during January-February 2015, went to 948 LHDs in the U.S. (excluding Rhode Island and Hawaii, which have no LHDs), representing one-third of all LHDs. Of the 690 top executives who responded, 353 represented small, 271 medium, and 66 large LHDs.

Related: Meta-Analysis Examines Quality of VA Health Care

At the peak of budget cuts, in 2009, 45% reported budget decreases. Since then, about 1 in 4 LHDs is still reporting budget cuts compared with the previous year; 27% expect budget decreases to continue into the next year.

Since 2008, NACCHO says, 51,700 jobs have been lost. More than half the 3,400 lost in 2014 were due to attrition; the rest to layoffs. The number of lost jobs was “most marked” among large LHDs: Sixty-one percent of those reported at least 1 job lost, followed by 41% of medium and 26% of small LHDs.

Related: Pharmacists in the Emergency Department: Feasibility and Cost

For many LHDs, “the cumulative effects of budget cuts and job losses” have not been reversed as the economy recovered. Some are trying creative workarounds, such as collaborations with primary care providers (PCPs). For example, 61% report actively encouraging PCPs to use evidence-based public health services, such as interventions to reduce asthma triggers.

However, < 10% of LHDs were actively engaged in new systems of care with PCPs, such as State Innovation Models (multipayer health care payment and service delivery models), patient-centered medical homes, or accountable care organizations (networks of health care providers voluntarily responsible for providing coordinated care). And < 70% are engaged in or exploring partnerships with nonprofit hospitals, which NACCHO says “might benefit multiple stakeholders and the community at large.”

Related: Implementing the EQUiPPED Medication Management Program at 5 VA Emergency Departments